The facility had a census of 31 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to ensure staff identified an allegation of rough care as potential abuse and reported immediately to the Licensed Nursing Home Administrator (LNHA). The facility further failed to report the allegation of abuse to the State Agency (SA) as required. This placed the resident at risk for ongoing abuse and mistreatment. Findings included: - R1's Electronic Medical Record (EMR) recorded diagnoses of hypertension (HTN-elevated blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), generalized osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), personal history of malignant neoplasm (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) of the breast, and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The Annual Minimum Data Set dated 09/01/24, documented R1 had severe cognitive impairment. R1 had verbal behaviors directed toward others and rejected care for one to three days of the observation period. R1 was dependent on staff for oral, personal, and toileting hygiene, and dressing. The MDS further documented R1 was always incontinent of bladder and bowel. The resident received scheduled pain medication, an antianxiety medication (a class of medications that calm and relax people), and an antidepressant (a class of medications used to treat mood disorders). The Behavioral Symptoms Care Area Assessment (CAA), dated 09/13/24, documented a care plan would be developed related to the resident having verbal behaviors due to dementia, HTN, and depression. The CAA further documented R1 had a risk for increased confusion, falls, agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), and injury. R1's Care Plan dated 03/11/24, directed one to two staff members to assist R1 with bed mobility, transfers, walking, toileting, grooming, personal hygiene, and bathing. The plan further documented R1 would refuse care, become combative, and yell at staff. The plan directed staff to ensure resident safety, then leave R1 with her call light in reach and try to reapproach and attempt talking again later. The Physician Orders dated 07/27/24, directed staff to administer Ativan (an antianxiety) one milligram (mg) twice weekly before showers and one to two mg every two hours as needed for mild to moderate anxiety or agitation for generalized anxiety disorder. The Skin Evaluation dated 10/22/24 and 10/29/24, documented no issues. The Interdisciplinary Note (ID) dated 10/25/24 at 09:04 PM, documented R1 hollered out with care, however, R1 was fine after lying down in bed. On 11/12/24 at 12:45 PM, observation revealed CMA S and CMA R wheel R1 back to her room in a wheelchair. CMA S and CMA R explained to R1 that they were going to assist R1 onto the mechanical lift and take her to the bathroom. The staff proceeded to provide incontinent care; R1 yelled Ouch and Stop. CMA S and CMA R reported it was common for R1 to yell out especially when cares involved something wet like wipes and showers. On 11/12/24 Administrative Nurse D was unavailable for an interview. On 11/12/24 at 10:44 AM, Administrative Staff A reported she was informed by Certified Medication Aide (CMA) R on 11/05/24 of an occurrence with R1 and CMA T that took place on 10/25/24. Administrative Staff A stated CMA R reported to her that Certified Nurse Aide (CNA) M saw CMA T place her hand on R1's arm while R1 was being assisted for transfer and care prior to supper and reported that CMA T had potentially handled R1 roughly. Administrative Staff A confirmed that CMA T was suspended on 11/07/24 pending an investigation of alleged physical abuse. Administrative Staff A stated Administrative Nurse D was aware of the allegation on 10/25/24 and should have informed her of the 10/25/24 allegation of possible physical abuse to R1. On 11/12/24 at 01:55 PM, CMA R stated she was told by CNA M she had witnessed CMA T squeezing R1's arm while R1 was yelling out and being assisted with a lift transfer. CMA R further stated when she had inquired about the status of the investigation regarding the 10/25/24 occurrence, Administrative Nurse D stated it had been taken care of. CMA R further reported that on 11/05/24 she called Administrative Staff A and reported the alleged physical abuse of R1 by CMA T, and Administrative Staff A told CMA R she had no knowledge of the incident. CMA R said that since then, Administrative Staff A has called her several times inquiring about the 10/25/24 situation. On 11/12/24 at 03:05 PM, CNA M stated on 10/25/24 prior to the evening meal, she heard R1 yelling out and went to see if CMA T needed assistance with R1. CNA M stated when she had entered R1's room, CMA T had her hand on R1's left arm. CNA M then proceeded to assist CMA T in providing incontinent care and transfers for the evening meal. CNA M reported after the meal she had noticed R1's left arm was red. CNA M reported the redness on R1's left arm to Licensed Nurse (LN) G and said that CMA T may have handled R1 roughly prior to the evening meal. On 11/12/24 at 01:30 PM, Administrative Staff A provided an email sent to Administrative Nurse D on 10/25/24 at 08:31 PM by LN G which stated at about 05:55 PM on 10/25/24 CNA M reported a concern she witnessed prior to the evening meal of CMA T being more rough than necessary and CNA M felt she should bring it to the nurses' attention. The email continued to state when LN H came on duty, both nurses took R1 into her room and examined her. LN G stated R1 had bruising to her arms, typical per her normal and none stood out, R1 was pleasant and cooperative, and there was no new bruising. LN G stated she and LN H had a conversation with CMA T in the email regarding CMA T asking for help when necessary and what to expect when caring for R1. The facility's Abuse, Neglect, Exploitation and Crime Prevention and Management policy, dated 05/2023, documented the facility must ensure that all allegations of abuse, neglect, injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the facility, the State Survey Agency, to other officials in accordance with state law, and take all necessary corrective actions depending on the results of the investigation. The facility failed to ensure staff identified an allegation of rough care as potential abuse and reported it immediately to the LNHA. The facility further failed to report the allegation of abuse to the SA as required. This placed the resident at risk for ongoing abuse and mistreatment.

The facility had a census of 31 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to initiate protective measures and fully investigate an allegation of abuse for Resident (R) 1. This placed the resident at risk for ongoing abuse. Findings included: - R1's Electronic Medical Record (EMR) recorded diagnoses of hypertension (HTN-elevated blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), generalized osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), personal history of malignant neoplasm (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) of the breast, and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The Annual Minimum Data Set dated 09/01/24, documented R1 had severe cognitive impairment. R1 had verbal behaviors directed toward others and rejected care for one to three days of the observation period. R1 was dependent on staff for oral, personal, and toileting hygiene, and dressing. The MDS further documented R1 was always incontinent of bladder and bowel. The resident received scheduled pain medication, an antianxiety medication (a class of medications that calm and relax people), and an antidepressant (a class of medications used to treat mood disorders). The Behavioral Symptoms Care Area Assessment (CAA), dated 09/13/24, documented a care plan would be developed related to the resident having verbal behaviors due to dementia, HTN, and depression. The CAA further documented R1 had a risk for increased confusion, falls, agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), and injury. R1's Care Plan dated 03/11/24, directed one to two staff members to assist R1 with bed mobility, transfers, walking, toileting, grooming, personal hygiene, and bathing. The plan further documented R1 would refuse care, become combative, and yell at staff. The plan directed staff to ensure resident safety, then leave R1 with her call light in reach and try to reapproach and attempt talking again later. The Physician Orders dated 07/27/24, directed staff to administer Ativan (an antianxiety) one milligram (mg) twice weekly before showers and one to two mg every two hours as needed for mild to moderate anxiety or agitation for generalized anxiety disorder. The Skin Evaluation dated 10/22/24 and 10/29/24, documented no issues. The Interdisciplinary Note (ID) dated 10/25/24 at 09:04 PM, documented R1 hollered out with care, however, R1 was fine after lying down in bed. On 11/12/24 at 12:45 PM, observation revealed CMA S and CMA R wheel R1 back to her room in a wheelchair. CMA S and CMA R explained to R1 that they were going to assist R1 onto the mechanical lift and take her to the bathroom. The staff proceeded to provide incontinent care; R1 yelled Ouch and Stop. CMA S and CMA R reported it was common for R1 to yell out especially when cares involved something wet like wipes and showers. On 11/12/24 Administrative Nurse D was unavailable for an interview. On 11/12/24 at 10:44 AM, Administrative Staff A reported she was informed by Certified Medication Aide (CMA) R on 11/05/24 of an occurrence with R1 and CMA T that took place on 10/25/24. Administrative Staff A stated CMA R reported to her that Certified Nurse Aide (CNA) M saw CMA T place her hand on R1's arm while R1 was being assisted for transfer and care prior to supper and reported that CMA T had potentially handled R1 roughly. Administrative Staff A confirmed that CMA T was suspended on 11/07/24 pending an investigation of alleged physical abuse. Administrative Staff A stated Administrative Nurse D was aware of the allegation on 10/25/24 and should have informed her of the 10/25/24 allegation of possible physical abuse to R1. On 11/12/24 at 01:55 PM, CMA R stated she was told by CNA M she had witnessed CMA T squeezing R1's arm while R1 was yelling out and being assisted with a lift transfer. CMA R further stated when she had inquired about the status of the investigation regarding the 10/25/24 occurrence, Administrative Nurse D stated it had been taken care of. CMA R further reported that on 11/05/24 she called Administrative Staff A and reported the alleged physical abuse of R1 by CMA T, and Administrative Staff A told CMA R she had no knowledge of the incident. CMA R said that since then, Administrative Staff A has called her several times inquiring about the 10/25/24 situation. On 11/12/24 at 03:05 PM, CNA M stated on 10/25/24 prior to the evening meal, she heard R1 yelling out and went to see if CMA T needed assistance with R1. CNA M stated when she had entered R1's room, CMA T had her hand on R1's left arm. CNA M then proceeded to assist CMA T in providing incontinent care and transfers for the evening meal. CNA M reported after the meal she had noticed R1's left arm was red. CNA M reported the redness on R1's left arm to Licensed Nurse (LN) G and said that CMA T may have handled R1 roughly prior to the evening meal. On 11/12/24 at 01:30 PM, Administrative Staff A provided an email sent to Administrative Nurse D on 10/25/24 at 08:31 PM by LN G which stated at about 05:55 PM on 10/25/24 CNA M reported a concern she witnessed prior to the evening meal of CMA T being more rough than necessary and CNA M felt she should bring it to the nurses' attention. The email continued to state when LN H came on duty, both nurses took R1 into her room and examined her. LN G stated R1 had bruising to her arms, typical per her normal and none stood out, R1 was pleasant and cooperative, and there was no new bruising. LN G stated she and LN H had a conversation with CMA T in the email regarding CMA T asking for help when necessary and what to expect when caring for R1. The facility's Abuse, Neglect, Exploitation and Crime Prevention and Management policy, dated 05/2023, documented the facility must ensure that all allegations of abuse, neglect, injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the facility, the State Survey Agency, to other officials in accordance with state law, and take all necessary corrective actions depending on the results of the investigation. The facility ' s Abuse, Neglect, Exploitation and Crime Prevention and Management policy, dated 05/2023, documented the facility must ensure that all allegations of abuse, neglect, injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the facility, the State Survey Agency, to other officials in accordance with state law, and take all necessary corrective actions depending on the results of the investigation. For protection, as soon as it is reported that there was alleged abuse of a resident by an employee, the employee is to be immediately suspended pending the outcome of the investigation and asked to leave the premises until they are called in for review of the findings upon completion of the investigation. The facility failed to fully investigate and initiate protective measures for R1 after an allegation of abuse. This placed the resident at risk for continued abuse.

The facility had a census of 37 residents. The sample included 15 residents with one reviewed for dignity. Based on observation, record review, and interview the facility staff failed to treat Resident (R) 29 with dignity when staff checked his blood glucose level at the dining room table with two other residents able to view the procedure. This placed the resident at risk for an undignified experience. Findings included: - On 03/05/24 at 10:57 AM, observation revealed in the 300-House dining room, Certified Medication Aide (CMA) R used a glucometer (an instrument used to calculate blood glucose) to check R29's blood glucose level at the dining room table during the meal service and dining. There were two other residents present and able to view the procedure. On 03/11/24 at 10:46 AM, Administrative Nurse D stated she expected staff to take R29 to his room or a private area when they checked his blood glucose level. The facility's Supporting the Resident's Right to Privacy and Confidentiality Policy, revised 02/2009, documented it was the responsibility of each employee of the community to ensure that the privacy and confidentiality of each resident was protected. The facility staff failed to treat R29 with dignity when staff checked his blood glucose level at the 300-House dining room table during meals. This placed the resident at risk for an undignified experience.

The facility had a census of 37 residents. The sample included 15 residents, with three reviewed for Medicare Liability Notices. Based on record review and interview, the facility failed to provide the resident (or their representative) a fully completed Advanced Beneficiary Notice (ABN) for skilled services for Resident (R) 16, R17, and R190 which included the estimated cost of services. This placed the resident at risk for uninformed care decisions. Findings included: - The Medicare Advanced Beneficiary Notice (ABN) informed the beneficiary that Medicare may not pay for skilled services and provided a cost estimate of continued services. The form included an option for the beneficiary to (1) receive the specified skilled services listed, and bill Medicare for an official decision on payment. The recipient understands if Medicare does not pay, the recipient is responsible for payment but can appeal to Medicare. (2) receive therapy listed, but do not bill Medicare, the recipient is responsible for payment for services. (3) the recipient does not want the listed therapy services. The Center of Medicare (CMS)-10055 form provided to R16 when the skilled services ended on 01/16/24, lacked the estimated costs of services. The Center of Medicare (CMS)-10055 form provided to R17 when the skilled services ended on 10/13/23 lacked the estimated costs of services. The Center of Medicare (CMS)-10055 form provided to R19 when the skilled services ended on 03/01/24 lacked the estimated costs of services. On 03/12/24 at 10:50 AM, Administrative Nurse D and Social Services X verified there was no estimated cost of continued services on the CMS-10055. The facility's Medicare Coverage policy, dated 12/2000, documented Medicare will cover 100 percent (%) of service from one to 29 days of the resident's stay in the Skilled Nursing Unit. The resident is responsible for covering the cost of the co-pay for skilled nursing care for days 21 to 100. The amount varies from year to year. If the resident disagrees with the determination, the resident can ask for a Demand Bill. The facility failed to provide the resident (or their representative) the completed CMS-10055 form when discharged from skilled services for R16, R17, and R190 which included the estimated cost of continued services. This placed the residents at risk of making uninformed decisions for their skilled services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 37 residents. The sample included 15 residents, with five reviewed for accidents. Based on observation, record review, and interview, the facility failed to revise the care plan with interventions to prevent avoidable accidents. This placed the resident at risk for further accidents due to uncommunicated care needs. Findings included: - The Electronic Medical Record (EMR) for R7 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance, macular degeneration (progressive deterioration of the retina), epilepsy (brain disorder characterized by repeated seizures), glaucoma (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow), falls, and pain. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R7 had severely impaired cognition. R7 was dependent on staff for toileting and required substantial/maximum assistance for dressing and bathing. R7 required partial/moderate assistance for mobility and transfers and set-up assistance for eating. R7's Hot Liquid Assessment, dated 01/28/24, documented R7 was cognitively impaired but was deemed safe to handle and ingest hot liquids. R7's Care Plan dated 02/07/24, initiated on 09/27/23 documented R7 had impaired decision-making skills and directed staff to offer R7 simple choices and monitor for changes in her behavior, appetite, and health needs. The care plan directed staff to monitor for fatigue, weakness, altered muscle tone or strength, involuntary movements, and contractions of muscles or muscle groups related to her seizure disorder. The care plan directed staff to cut up R7's meat into bite-size pieces, provide a regular diet, and use an insulated cup. The Nurse's Note, dated 03/03/24 at 11:39 AM, documented R7 spilled hot tea on her lap at lunch. The note documented R7 used a Kennedy cup (an adaptable drinking cup designed to prevent spills) with a lid, but the resident removed the lid. The note further documented R7's pants were removed immediately and there was no sign of erythema (redness) or burns. The Nurse's Note, dated 03/07/24 at 03:02 PM, documented R7 was steeping her hot tea and she reported it was on the edge of the table and tipped onto her lap. The note documented R7 pulled at her pants to keep the warmth off her thighs and the nurse used a towel to get some of the hot water off her. A skin assessment was performed and the area to the inner right thigh was light red but blanchable (when the skin becomes white or pale in appearance). The staff applied a cool washcloth to the area. R7's EMR lacked documentation R7 was assessed for safety with hot liquids after she spilled her hot tea on 03/03/24 and 03/07/24 and lacked evidence of interventions to address the hot liquid spills. On 03/11/24 at 07:45 AM, observation revealed R7 at the dining room table with a regular coffee cup and no lid and R7 was able to drink the coffee without incident. On 03/06/24 at 11:06 AM, Certified Nurse Aide (CNA) N stated she was unaware of any problems with R7 drinking and said she did not know of any accidents with R7 and hot liquids. On 03/11/24 at 09:29 AM, Administrative Nurse E stated she had not completed another hot liquid assessment and did not update R7's Care Plan because R7 did not receive any injury with the recent hot tea incident. Administrative Nurse E further stated the cup was on the edge of the table when it fell onto R7's lap; the area on R7's inner thigh was pink and blanchable. On 03/11/24 at 11:15 AM, Administrative Nurse D stated staff should make sure R7's cup was away from the edge of the table. Administrative Nurse D said she expected staff to complete a new hot liquid assessment and care plan interventions to prevent further incidents for R7. The facility's Skin and Wound Prevention Management policy, dated 01/21, documented that skin integrity would be maintained at the optimum level for the duration of the resident's stay. The care plan would be reviewed and revised as needed to manage treatment and identify prevention approaches. The facility failed to revise R7's care plan with interventions to prevent further accidents with her hot beverages. This placed the resident at risk for further injury due to uncommunicated care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 37 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to assess and treat Resident (R) 32's alteration in bowel movements, which placed the resident at risk of ongoing constipation and possible fecal impaction (accumulation of hardened feces in the rectum that the individual was unable to move) complications. Findings included: - R32's Electronic Medical Record (EMR) included diagnoses of acute respiratory failure with hypoxia or hypoxia (inadequate supply of oxygen), dementia (a progressive mental disorder characterized by failing memory, and confusion), and constipation. The admission Minimum Data Set (MDS), dated [DATE], documented R32 had moderately impaired cognition, disorganized thinking which fluctuated, and other behavioral symptoms not directed to others which occurred daily that significantly disrupted care or living environment. R32 required set-up and clean-up assistance with eating and partial to moderate assistance with toileting, upper and lower body dressing, personal hygiene, and mobility. The MDS further documented R32 had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) and was always continent of bowel. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 02/09/24, documented the facility would care plan for an indwelling catheter to reduce the risk for injury and infection. R32's Care Plan, dated 02/15/24, documented R32 did not have continence issues and had an indwelling catheter due to bladder outlet obstruction. The care plan directed staff to monitor R32's bowel movements and treat for constipation per provider orders. The Physician Order, dated 01/30/24, directed staff to administer polyethylene (medication used to treat constipation) 17 grams by mouth once daily for other functional intestinal disorders. The Physician Order, dated 02/04/24, directed staff to administer Milk of Magnesia (MOM) 1200 mg, 30 cubic centimeters (cc) by mouth as needed (PRN) every 12 hours, with a maximum of two doses in 24 hours for constipation. The Physician Order, dated 02/29/24, directed staff to administer bisacodyl suppository 10 milligrams (mg) rectally PRN daily for constipation, if no bowel movement for three days. On 01/30/24 at 02:31 PM the Interdisciplinary Note documented R32 was admitted to the facility from a hospital. The note further documented R32's last bowel movement on 01/28/24. On 02/04/24 at 04:18 PM, the Interdisciplinary Note documented R32's abdomen was soft, non-tender with active bowel sounds in four quadrants. R32 had a bowel movement that morning and was on the three-day no bowel movement list so MOM was administered. On 02/07/24 the Physician Note documented R32 required enemas (introduction of a solution into the rectum for cleansing or therapeutic purposes) for constipation while hospitalized from [DATE] to 01/30/24. On 02/07/24 at 01:50 AM, the Interdisciplinary Note documented R32's abdomen was soft, non-tender with active bowel sounds in four quadrants. R32 had no bowel movement and was on the bowel movement list for day two. On 02/10/24 at 01:38 PM, the Interdisciplinary Note documented R32's normal active bowel sounds and R32 had no bowel movement that evening. On 02/11/24 at 06:58 PM, the Interdisciplinary Note documented R32 had normal active bowel sounds and had no bowel movement. The EMR lacked further documentation of bowel movement or treatment. R32's February 2024 Bowel Movement Record revealed R32 did not have a bowel movement on February 5-9 (five days), 11-17 (seven days), 19-22 (four days), and 24-28 (five days). R32's EMR revealed MOM had been administered on the following dates: 02/04/24 02/09/24 After five days with no bowel movement. 02/15/24 After four days with no bowel movement and again on 02/17/24 with now seven days with no bowel movement. 02/23/24 After four days with no bowel movement. On 03/11/24 at 10:43 AM, Administrative Nurse D reported that R32 continued to decline and that the staff should utilize the use of bowel protocols and PRN medication and treatments to manage R32's bowels. The facility's Constipation Standing Protocols-PRN Medication and Treatment orders reviewed 01/03/24, documented the use of: Milk of magnesium 30 cc by mouth every 12 hours PRN, no more than two doses in 24 hours. Senna (bowel stimulant) 8.6 one or two tablets by mouth twice a day as needed. Bisacodyl suppository per rectum if no stool for three days. Fleets enema for distention or hard stool, repeat one time if no results. Fiber stat 15 to 30 cc as directed per nurse judgment. The facility's Bowel Management policy, dated 08/01/11, documented bowel monitoring, and management will be followed to minimize any bowel problems such as constipation or fecal impaction by actively employing all preventative options possible. The facility failed to treat R32's lack of bowel movements which placed the resident at risk of ongoing constipation and fecal impaction complications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 37 residents. The sample included 15 residents, with one reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to implement nutritional interventions to promote healing for one resident, Resident (R) 11, after development of a Stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed) pressure ulcer. This placed the resident at risk for complications from pressure injuries and delayed healing. Findings included: - The Electronic Medical Record (EMR for R11 documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough sepsis made, or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breath), pressure ulcer, and nutritional deficiency (severely reduced levels of one or more nutrients). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R11 had intact cognition and required extensive assistance from one staff for bed mobility, dressing, toileting, and personal hygiene. The MDS documented R11 was at risk for pressure ulcers and had pressure-relieving devices for his bed and chair. The MDS documented R11 had no skin breakdown. R11's Quarterly MDS, dated 01/20/24, documented R11 had intact cognition and was dependent on staff for toileting and transfers. R11 required substantial/maximum assistance for mobility. R11 had frequent bladder incontinence. R11 was at risk for pressure ulcers and had pressure-relieving devices for his bed and chair. R11 had two Stage 2 pressure ulcers and received pressure ulcer care. The Braden Scale Assessment, (a formal assessment for predicting pressure ulcer risk) dated 06/26/23, 09/21/23, and 12/21/23, documented R11 was at high risk for pressure ulcers. R11's Care Plan, dated 02/01/24, initiated on 12/31/20, directed staff to remind R11 to lie down to get off his bottom and to change positions every two hours. The plan directed R11 should wear heel protectors at night and take off his incontinence pull-up at night. The update, dated 06/25/22, directed staff to make sure his cushion was moved from chair to chair. The update, dated 09/27/23, documented R11 had two Stage 2 pressure ulcers on his right and left buttocks. The plan directed staff to assess R11's skin weekly and ensure R11 had a pressure-reducing mattress on his bed. The update dated 02/29/24 directed staff to encourage R11 to use a rolled-up towel under his hips to offload pressure, alternating sides. The Skin Evaluation Record, dated 09/13/23, documented R11 had an open sore on his left buttock which measured 0.4 centimeters (cm) x 0.8 cm x 0.2. The Physician's Order, dated 09/20/23, directed staff to apply Triad wound dressing paste (a paste that covers moist, weeping wounds), apply a small amount to the wound as needed, and leave it open to air. The Skin Evaluation Record, dated 10/23/23, documented R11 had a Stage 2 pressure ulcer on his left buttock that measured 0.4 cm x 0.8 cm x 0.2 cm. The note documented the pressure ulcer was macerated (prolonged exposure to moisture) and directed staff to bandage after showers. The Nutritional Assessment, dated 10/31/23, documented R11 had skin breakdown on his left buttock. The note documented the Registered Dietician (RD) recommended Vitamin C 500 milligrams (mg) twice per day, a multivitamin daily, and Arginaide (supplement to aid in wound healing) twice per day. The EMR lacked evidence R11 was provided the recommendations from the RD and lacked evidence the physician was presented with the recommendations and /or declined the recommendations. The Skin Evaluation Record, dated 11/15/23, documented R11 had a Stage 2 pressure ulcer on his left buttock which measured 1.4 cm x 0.5 cm x 0.2 cm. The Physician's Order, dated 11/30/23, directed staff to apply Fibracol Plus Collagen (absorbent dressing with protein) and alginate (promotes wound healing) to the wound bed. Cover with a bandage and change every other day or sooner if soiled. The Skin Evaluation Record, dated 12/21/23, documented R11 had a Stage 2 pressure ulcer on his left buttock which measured 0.4 cm x 0.3 cm x 0.2 cm, and a new pressure ulcer on his right gluteal fold (the horizontal skin crease that forms below the buttocks, separating the upper thigh from the buttocks) which measured 0.7 cm x 0.7 cm. The evaluation documented that Fibracol Plus was applied to both wounds. The Skin Evaluation Record, dated 01/05/24, documented R11 had a Stage 2 pressure ulcer on his left buttock which measured 0.5 cm x 0.4 cm x 0.2 cm, and a Stage 2 pressure ulcer on his right gluteal fold which measured 0/7 cm x 0.5 cm. The Skin Evaluation Record, dated 01/25/24, documented R11 had a Stage 2 pressure ulcer on his left buttock which measured 0.8 cm x 1.3 cm x 0.2 cm, and a Stage 2 pressure ulcer on his right gluteal fold which measured 1.0 cm x 0.8 cm x 0.2 cm. The Nutritional Assessment, dated 01/29/24, documented R11 had skin breakdown on his left buttock and right gluteal fold and recommended Vitamin C 500 mg twice per day, a multivitamin daily, and Arginaide twice per day. The Physician's Order, dated 02/02/24, directed staff to administer Vitamin C 500 mg by mouth twice per day, a multivitamin daily, and Arginaide, one serving daily for wound healing. On 03/06/24 at 07:30 AM, R11 stated he had pressure ulcers off and on. R11 stated the wounds would heal but after the treatment was finished, nothing was done to it to protect it, and it would open again. R11 further stated that he had staff place a sign on the wall to remind them to move the cushion from his wheelchair to the recliner because it was often forgotten. R11 stated he usually slept in his recliner except for on shower days, then he would lie down in bed. On 03/06/24 at 09:30 AM, observation revealed Consultant GG and her assistant, Consultant HH, were in R11's room to provide wound care. Consultant HH sanitized her hands, gloved and cleansed the pressure ulcer with wound cleanser, and measured the wound at 1.6 cm x 1.3 cm. Further observation revealed Consultant GG changed places with Consultant HH to look at the wound and to measure the depth of the wound, which was 0.2 cm. Consultant HH stated the wound had improved and said it was much smaller. Consultant HH applied the antibiotic ointment, placed a foam dressing on top of the wound, and placed a bandage over the top. On 03/06/23 at 09:45 AM Consultant GG stated the wound was avoidable and that R11 needed to make sure he was offloading several times per day. On 03/06/24 at 10:15 AM, Certified Nurse Aide (CNA) N stated staff reminded R11 to reposition often and tried to encourage him to sit in his recliner. On 03/11/24 at 09:31 AM, Administrative Nurse E stated she was unsure why the facility did not implement the recommendations from the RD on 10/31/23 and said it may have been overlooked. On 03/11/24 at 11:15 AM, Administrative Nurse D stated she did not receive the email regarding the RD recommendations on 10/31/23. Administrative Nurse D said if she had the recommendations would have been implemented. The facility's Skin and Wound Prevention Management policy, dated 01/21, documented that skin integrity would be maintained at the optimum level for the duration of the resident's stay. A comprehensive prevention plan would be initiated for all residents who had intact skin and were at risk. The dietician would be notified and a follow-up on any recommendations made when there was a development of skin injury. The facility's Pressure Injury Prevention and Management policy, dated 01/20, documented the facility was committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries, The facility should establish and utilize a systemic approach for pressure injury prevention and management including prompt assessment and treatment, intervening to stabilize, reduce or remove the underlying risk factors, monitoring the impact of the interventions, and modifying the interventions as appropriate. The facility failed to implement nutritional interventions to promote healing for R11's pressure injuries. This placed the resident at risk for complications related to pressure injuries and delayed healing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 37 residents. The sample included 15 residents, with five reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure an environment free from preventable accident hazards for Resident (R) 7, who spilled her hot tea onto her lap twice in one week. This placed the resident at risk for injury. Findings included: - The Electronic Medical Record (EMR) for R7 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance, macular degeneration (progressive deterioration of the retina), epilepsy (brain disorder characterized by repeated seizures), glaucoma (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow), falls, and pain. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R7 had severely impaired cognition. R7 was dependent on staff for toileting and required substantial/maximum assistance for dressing and bathing. R7 required partial/moderate assistance for mobility and transfers and set-up assistance for eating. R7's Hot Liquid Assessment, dated 01/28/24, documented R7 was cognitively impaired but was deemed safe to handle and ingest hot liquids. R7's Care Plan dated 02/07/24, initiated on 09/27/23 documented R7 had impaired decision-making skills and directed staff to offer R7 simple choices and monitor for changes in her behavior, appetite, and health needs. The care plan directed staff to monitor for fatigue, weakness, altered muscle tone or strength, involuntary movements, and contractions of muscles or muscle groups related to her seizure disorder. The care plan directed staff to cut up R7's meat into bite-size pieces, provide a regular diet, and use an insulated cup. The Nurse's Note, dated 03/03/24 at 11:39 AM, documented R7 spilled hot tea on her lap at lunch. The note documented R7 used a Kennedy cup (an adaptable drinking cup designed to prevent spills) with a lid, but the resident removed the lid. The note further documented R7's pants were removed immediately and there was no sign of erythema (redness) or burns. The Nurse's Note, dated 03/07/24 at 03:02 PM, documented R7 was steeping her hot tea and she reported it was on the edge of the table and tipped onto her lap. The note documented R7 pulled at her pants to keep the warmth off her thighs and the nurse used a towel to get some of the hot water off her. A skin assessment was performed and the area to the inner right thigh was light red but blanchable (when the skin becomes white or pale in appearance). The staff applied a cool washcloth to the area. R7's EMR lacked documentation R7 was assessed for safety with hot liquids after she spilled her hot tea on 03/03/24 and 03/07/24 and lacked evidence of interventions to address the hot liquid spills. On 03/11/24 at 07:45 AM, observation revealed R7 sat at the dining room table with a regular coffee cup and no lid. R7 was able to drink the coffee without incident. On 03/06/24 at 11:06 AM, Certified Nurse Aide (CNA) N stated she was unaware of any problems with R7 drinking and said she did not know of any accidents with R7 and hot liquids. On 03/11/24 at 09:29 AM, Administrative Nurse E stated she had not completed another hot liquid assessment and did not update R7's Care Plan because R7 did not receive any injury with the recent hot tea incident. Administrative Nurse E further stated the cup was on the edge of the table when it fell onto R7's lap; the area on R7's inner thigh was pink and blanchable at first and ultimately had no injury. On 03/11/24 at 11:15 AM, Administrative Nurse D stated staff should make sure R7's cup was away from the edge of the table. Administrative Nurse D said she expected staff to complete a new hot liquid assessment and care plan interventions to prevent further incidents for R7. The facility's Skin and Wound Prevention Management policy, dated 01/21, documented that skin integrity would be maintained at the optimum level for the duration of the resident's stay. The care plan would be reviewed and revised as needed to manage treatment and identify prevention approaches. The facility's Accident and Incident Reporting policy, dated 09/18, documented, that the facility strived to have the best quality of life for the residents to prevent accidents and incidents and any accident or incident would be reviewed and investigated timely. If an accident or incident that resulted in no apparent injury, or minor injury would be investigated, and the report would be reviewed with the administrator and risk team within seven calendar days. The facility failed to ensure an environment free from preventable accident hazards for R7. This placed the resident at risk for preventable injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 37 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 32 with sanitary indwelling catheter (tube placed in the bladder to drain urine into a collection bag) care and treatment which placed the resident at risk for urinary tract infections (UTI). Findings included: - R32's Electronic Medical Record (EMR) included diagnoses of acute respiratory failure with hypoxia or hypoxia (inadequate supply of oxygen), dementia (a progressive mental disorder characterized by failing memory, and confusion), constipation (difficulty passing stools), retention of urine, delirium (sudden severe confusion, disorientation and restlessness), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid, pain, and encephalopathy (broad term for any brain disease that alters brain function or structure). The admission Minimum Data Set (MDS), dated [DATE], documented R32 had moderately impaired cognition, disorganized thinking which fluctuated, other behavioral symptoms not directed to others which occurred daily that significantly disrupted care or living environment, required set up and clean up assistance with eating and partial to moderate assistance with toileting, upper and lower body dressing, personal hygiene and mobility. The MDS further documented R32 had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) and was always continent of bowel, had shortness of breath or trouble breathing with exertion and sitting at rest. R32 weighed 164 pounds, had a weight loss of five percent (%) or more in the last month or 10 % in six months, and was not on a physician-prescribed weight loss regimen. R32 took a diuretic (medication to promote the formation and excretion of urine) during the observation period. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 02/09/24, documented the facility would care plan for the indwelling catheter to reduce risk for injury and infection. R32's Care Plan, dated 02/15/24, documented R32 had an indwelling catheter due to bladder outlet obstruction. The care plan directed staff to provide catheter care twice a day (BID) and as needed (PRN), ensure tubing is secure to reduce pulling, monitor for symptoms of UTI, and notify the provider of symptoms. The Physician Order, dated 02/07/24, directed staff to provide R32 peri catheter care, to pull back the foreskin, and clean thoroughly BID for disorder of the skin and subcutaneous (beneath the skin) tissue. The Physician Order, dated 02/16/24, directed staff to apply a small amount of Nystatin (antifungal) topical cream at the end of the penis three times a day for tinea cruris (fungal infection in the skin of genitals, inner thigh, and buttocks). On 02/16/24 at 06:14 PM an Interdisciplinary (ID) Note documented that staff communicated with the physician regarding R32's penis lesions that were bleeding and got worse since the order of Nystatin. The physician ordered to send R32 to the emergency room. On 02/18/24 at 03:46 PM an ID Note documented R32's physician ordered the resident to be sent to the emergency room due to the resident not eating, moaning, and unable to communicate what he needed or feeling. On 02/19/24 at 12:49 AM an ID Note documented R32 had returned to the facility from the emergency room with a prescription for an antibiotic for a UTI. On 03/06/24 at 07:41 AM observation revealed Licensed Nurse (LN) H provided catheter care by cleansing the catheter insertion site with disposable wipes. LN H then applied the prescribed ointment without changing gloves. On 03/11/24 at 10:43 AM, Administrative Nurse D stated LN H should have changed gloves after cleansing the catheter and before applying the medicated ointment. The facility's Medication Administration policy, dated 05/2020, documented that if your hands have become soiled, i.e., touching a resident's mouth, contacting saliva, if you touch their spoon or glass, you must use alcohol gel or wash your hands. The facility failed to provide R32 with sanitary indwelling catheter care and treatment, which placed the resident at risk for continued complications of UTIs and fungal skin conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 37 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to provide appropriate respiratory care and services when staff failed to store oxygen cannula and tubing in a sanitary manner for Resident (R) 14. This placed the resident at risk for respiratory infections. Findings included: - R14's Electronic Medical Record (EMR) documented R14 had diagnoses of pneumonia (inflammation of the lungs), Crohn's disease (chronic inflammatory bowel disease), acute and chronic respiratory failure with hypoxia (inadequate supply of oxygen), and hypercapnia (high levels of carbon dioxide in the blood), and major depressant disorder (major mood disorder which causes persistent feelings of sadness). R14's Quarterly Minimum Data Set (MDS), dated [DATE], documented R14 had intact cognition. R14 required partial to moderate assistance with toileting hygiene, upper and lower body dressing, rolling side to side, sitting from lying, and transfers. R14 was always incontinent of urine and frequently incontinent of bowel. R14 had two or more falls with injury and had weight loss. The MDS further documented R14 received an antidepressant (class of medications used to treat mood disorders), diuretic (medication to promote the formation and excretion of urine), and opioid (medication to treat pain). R14's Care Plan initiated on 08/18/23 documented R14 had oxygen therapy via nasal cannula at three liters per minute (LPM) and directed staff to administer oxygen as ordered by the medical doctor and adhere to safety as per facility protocol. The plan directed staff to maintain an oxygen saturation of 90 percent (%) or above. The Physician Order, dated 02/29/24, directed staff to administer oxygen continuously to keep oxygen saturations at 90% or above. The Interdisciplinary (ID) Note, dated 02/26/24 at 02:37 AM, documented R14 had complaints of not being able to breathe. R14 was diaphoretic (sweaty) and had tachypnea (abnormally rapid breathing) with an oxygen saturation of 67% at times. Staff administered treatments and the oxygen flow rate was increased. The note further documented R14 was sent to the emergency room. The ID Note, dated 02/29/24, documented R14 admitted back to the facility with oxygen at two LPM. On 03/05/24 at 11:18 AM, observation revealed Certified Nurse Aide (CNA) M assisted R14 with morning care. R14 had oxygen via a nasal cannula which was attached to a concentrator placed in the bathroom/shower. During the shower process, CNA M removed the nasal cannula, which then fell to the floor in the bathroom. Once CNA M finished the showering process and assisted the resident in dressing for the day, CNA reapplied the oxygen cannula that was on the floor. Once R14 was in her wheelchair and preparing to go to the dining room for a meal, CNA M retrieved a portable oxygen machine from a bedside table where the nasal cannula was draped over the top of the machine and not stored inside a bag or other sanitary container. On 03/06/24 at 01:40 PM, Observation revealed R14 laid in bed with oxygen via a nasal cannula from the oxygen concentrator. The portable oxygen machine sat on the overbed table with the nasal cannula draped over the side of the machine. Licensed Nurse (LN) H verified the nasal cannula should be stored in a bag when not in use and the oxygen nasal cannula should not touch the floor. On 03/11/24 at 08:34 AM observation revealed R14 laid in bed and received oxygen administration vial nasal cannula and oxygen concentrator. The portable oxygen machine sat on the bedside table with the nasal cannula draped over the top, uncovered. LN G verified the nasal cannula should be stored in a bag when not in use. On 03/11/24 at 10:43 AM, Administrative Nurse D verified oxygen cannulas should be stored in a sanitary bag when not in use. The facility's Oxygen Administration policy, dated 11/2013, directed staff to place extra oxygen tubing on a hook on the concentrator, do not leave it on the floor if possible. Place a clean bag on the concentrator to hold the cannula when not in use and the cannula should not lay on furniture. The facility failed to provide appropriate respiratory care and services when staff failed to store oxygen cannula and tubing in a sanitary manner for R14. This placed the resident at risk for respiratory infections.

The facility had a census of 37 residents. The sample included 15 residents. Based on observation, record review, and interview the facility failed to prepare a nourishing well well-balanced pureed diet that followed the menu and included a vegetable for Resident (R)190, who requested vegetables. This placed the resident at risk for dissatisfaction and impaired nutrition. Findings included: - On 03/06/24 at 09:50 AM, observation in the main kitchen revealed Dietary Staff (DS) BB stated the facility had one resident (R190) who received a pureed diet. Observation revealed DS BB placed five half-ounce (oz) meatballs with sauce into a blender and blended to the consistency of pudding. DS BB used a spatula to transfer the pureed meatballs to a metal pan and placed the pan in the warmer. When asked how R190 would receive her vegetables, DS BB stated R190 had not requested any. On 03/06/24 at 10:41 AM, observation of R190's noon meal dietary order sheet revealed that R190 had soft-cooked vegetables circled. DS CC verified R190 had circled soft, cooked vegetables and stated it meant she had requested them. On 03/06/24 at 11:50 AM, Administrative Staff A stated when staff prepared R190's pureed diet, she expected staff to prepare all food items requested on R190's dietary order sheet. The facility's Dining-Pureed Food Policy, revised 07/2021, documented for those residents who have orders to have pureed food, the regular menu item that the resident chooses would be pureed in the resident dining area to allow the same options as all other residents. The facility failed to prepare R190's requested pureed diet food items. This placed the resident at risk for dissatisfaction and impaired nutrition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - On 03/06/24 at 08:00 AM, observation revealed Licensed Nurse (LN) H prepared and administered R4's morning inhalation, nasal, and ophthalmic (pertaining to the eye) treatments. LN H retrieved the medications from the locked cabinet in R4's room. LN H donned gloves and placed the medication and treatments on the overbed table in front of the resident. LN H primed the inhalation medication and handed it to the resident for inhaling, which R4 completed. LN H then removed the cover from the nasal spray and handed it to R4, who then administered the nasal spray to each nostril. LN H then adjusted the head of the bed from the bed controls positioned by a urinal that hung on the same rail. LN H's gloved hand touched the urinal and bed controls, without changing gloves LN H administered the ophthalmic wipes and drops to both eyes. LN H then took the treatments and placed them back into the locked cabinet. On 03/11/24 at 10:43 AM, Administrative Nurse D verified staff should have changed gloves with different administrations of treatments. The facility's Medication Administration policy, dated 05/2020, documented that if your hands have become soiled during the medication pass, i.e., touching a resident's mouth, contacting saliva, touching their personal spoon or glass, you must use alcohol gel or wash your hands. The facility failed to ensure sanitary administration of R4's treatments which placed the resident at risk for contaminated possible infectious process. The facility had a census of 37 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to ensure adequate infection control measures when staff did not practice appropriate hand hygiene when providing incontinence care for Resident (R) 12, or for R4 during medication administration. This placed the residents at risk for infection. Findings included: - The Electronic Medical Record (EMR) for R12 documented diagnoses of benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), atrial fibrillation (rapid, irregular heartbeat), and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R12 had moderately impaired cognition and was dependent upon staff for toileting, substantial/maximum assistance for dressing, personal hygiene, and transfers. The MDS documented R12 was continent of bowel. The Care Plan, dated 03/01/24, initiated on 02/28/24 documented R12 used incontinent products and directed staff to apply a protective skin barrier after each incontinent episode. On 03/06/24 at 09:40 AM, observation revealed Certified Nurse Aide (CNA) N assisted R12 in the sit-to-stand lift and placed him on the toilet. CNA N applied gloves and pulled down R12's pants and incontinent brief which revealed R12 had a large, loose bowel movement (BM) that had also gotten on R12's pants. CNA N removed and discarded the soiled brief into the trash and wearing the same gloves, retrieved a new brief and clean pants. Continued observation revealed CNA put the new brief and pants on, stood R12 up in the lift, provided peri care, looked through R12's drawers for barrier cream, applied the barrier cream, and pulled up the brief and pants while wearing the same soiled gloves. CNA N transferred R12 with the sit-to-stand lift with the soiled gloves on, wiped off the toilet seat, and then removed the soiled gloves. CNA N removed her gloves and took the trash out of the room without washing her hands. On 03/06/24 at 09:50 AM, CNA N stated she should have removed her gloves after she removed the soiled incontinence product and applied clean gloves. On 03/11/24 at 03:30 PM, Administrative Nurse D stated the CNA should change her gloves multiple times during toileting and should have disinfected the lift afterward. The facility's Perineal Care for the Incontinent and UTI Prevention policy, dated 10/03, directed staff to use perineal wipes over the entire soiled area of skin, wipe from front to back, repeat if necessary, allowing cleansers to further soften stool, and change gloves after working with bowel movement. The facility staff failed to use adequate hand hygiene when she did not change gloves and wash her hands when providing R12 incontinent care. This placed the resident at risk for infection.

The facility had a census of 37 residents. The facility had one main kitchen and three kitchenettes. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the 37 residents who received their meals from the facility's kitchens when staff stored unlabeled, undated food in the refrigerators. Staff did not sanitize the thermometer between food items when checking food temperatures and failed to ensure clean and sanitary preparation areas. This placed the 37 residents at risk for foodborne illness. Findings included: - On 03/05/24 at 08:05 AM, observation in the kitchen revealed the following: An updated, unlabeled plastic bag with liquid coffee. 12 uncovered, undated, and unlabeled slices of cheese. An undated, unlabeled plastic container of barbeque sauce. On 03/05/24 at 08:05 AM, Dietary Staff (DS) BB verified the above finding and stated food items placed in the refrigerator should be labeled, dated, and completely covered. DS BB disposed of the food items in the trash. On 03/06/24 at 09:55 AM, observation in the kitchen revealed DS BB checked the food temperatures of the noon food items without cleansing or disinfecting the thermometer between different food items. DS BB stated he should have cleaned the thermometer between the different food items. On 03/06/24 at 10:00 AM, observation in the kitchen revealed the following: Two unlabeled, undated flour containers. Three ceiling vents had four inches of a gray-colored substance around them. A three-quarter full 5-gallon bucket filled with a black greasy substance on the floor by the three-well sink in the dishwashing area. The floor underneath the three-well sink had an area of brown substance approximately six inches by three feet long. On 03/06/24 at 10:15 AM, DS DD verified the above findings and stated maintenance staff were responsible for cleaning the ceiling vents. DS DD said she would put in a requisition to have them cleaned. DS DD stated staff should not store the bucket of fryer grease in the kitchen, staff should take it outside every time they empty grease into the bucket after it cooled down. DS DD stated the dietary staff had a daily cleaning schedule and the floor should be clean underneath the sinks. On 03/06/24 at 10:41 AM, observation in the 100-House kitchenette refrigerator revealed the following: Two undated chocolate Mighty shakes. Eight undated strawberry Mighty shakes. One undated fast-food chocolate shake and one fast-food chocolate and vanilla shake. An undated plastic bag with four ice cream sandwiches and another one with seven ice cream sandwiches. An undated, unlabeled one-quarter-full bag of shredded cheddar cheese. An undated, nine-ounce (oz) plastic container of black forest ham. An undated package (pkg) of ham slices. An undated, unlabeled one-quarter-full plastic bag of bacon toppings. Two undated pkg of sliced yellow cheese. One undated pkg of mozzarella cheese slices. An unlabeled, undated bowl of shredded turkey. An unlabeled, undated bowl of orange slices. An unlabeled, undated pkg of cherry tomatoes. On 03/06/24 at 10:412 AM, DS CC verified the above findings in the 100-House kitchenette and stated dietary staff should label and date food when they receive it from the kitchen. DS CC discarded all food items listed above in the trash. On 03/07/24 at 11:50 AM, Administrative Staff A stated staff should not keep a bucket of grease in the kitchen. Administrative Staff A said staff should take the bucket out and pour it into the container by the dumpster. Administrative Staff A stated the closing dietary staff were supposed to check for outdated and unlabeled food in the refrigerators daily. Administrative Staff A stated when staff obtained food items from the kitchen, they should label and date them before placing them in the refrigerator. The facility's Food Storage Chart Policy, revised 07/2013, documented that food must be stored in a way in which quality is preserved and in a way that ensures proper rotation. This means that food must be sealed to reduce the growth of bacteria and date marked to ensure that the oldest items are used first. The facility's Cleaning of Work Surfaces, Utensils, and Equipment Policy revised 04/2013 documented utensils and equipment would be cleaned routinely to help prevent cross-contamination and food-borne illnesses. The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the 37 residents who received their meals from the facility's kitchen and one of three kitchenettes. This placed the 37 residents at risk for foodborne illness.

The facility had a census of 37 residents. Based on observation, record review, and interview, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (YR) 2023 Quarter 2 indicated the facility did not have a Registered Nurse (RN) on 5 dates, FY 2023 Quarter 3 indicated no RN for on 91 dates and FY 2023 Quarter 4 for 26 dates. The PBJ also indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on multiple days in FY 2023: Quarter 3 for 91 dates and Quarter 4 for 31 dates. The PBJ further indicated Fiscal YR 2024 Quarter 1 did not have an RN for 26 days and did not have a licensed nurse coverage 24 hours a day, seven days a week for 46 dates. A review of the facility licensed nurse payroll data for the dates listed on the PBJ revealed an RN for eight consecutive hours daily and a licensed nurse on duty for 24 hours a day seven days a week. On 03/06/24 at 09:30 AM, observation revealed an RN and a licensed practical nurse on duty in the facility. On 03/11/24 at 11:15 AM, Administrative Nurse D stated the facility staff were not sure how to submit the PBJ information and knew that they had submitted it incorrectly. Administrative Nurse D further stated that the facility administration would contact the appropriate people to make sure it was done correctly. Upon request a policy for PBJ was not provided by the facility. The facility failed to submit accurate PBJ data which placed the residents at risk for unidentified and ongoing inadequate staffing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 37 residents. The sample included three residents. Based on observation, record review and interview the facility failed ensure Resident (R) 1 remained free from staff to resident abuse and neglect when the facility failed to ensure the necessary number of staff as directed by R1's care plan, which directed staff to have two staff assistance for use with the sit to stand lift (a device used to assist a resident to rise from the seated position but does not support the resident's entire body weight) and staff then used their foot to kick R1's foot into place on the lift. The deficient practice left R1 at risk of injury and psychosocial impairment. Findings included: - The electronic medical record (EMR) for R1 documented diagnoses of cerebral infarction ( stroke-disruption of blood and oxygen to the brain causing brain cell death), and cerebrovascular disease (a condition that affects the flow of blood to the brain). The Significant Change Minimum Data Set (MDS) dated [DATE] documented R1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R1 required extensive assistance of two staff for bed mobility, transfers, dressing, and toileting activities of daily living (ADLs). R1 had impairment of both upper and lower extremities on one side. R1 required a wheelchair for mobility. R1 was on hospice services. The Quarterly MDS dated 04/10/23 for R1 documented a BIMS score of 15 indicated intact cognition. R1 required extensive assist of two staff for most ADLs and was total dependence on staff of two for transfers. R1 had impairment of both upper and lower extremities on one side. R1 required a wheelchair for mobility. R1 was on hospice services. The ADL Care Area Assessment dated 01/10/23 for R1 documented to proceed to the care plan with the amount of assistance required for resident. R1's ADL Care Plan dated 11/15/22 directed staff R1 required assistance of two staff members for transfers, bed mobility and toileting. The care plan directed staff to use the sit to stand lift with two staff for transfers. With a start date of 11/15/22 the care plan directed staff that R1 required the assistive device of full lift. A Grievance Form with a date of 01/10/23 by Social Services X, as reported by R1, documented R1 reported a staff member was rough with him during transfers. Social Services X notified Administrative Nurse D and facility vice president who completed an investigation and interviewed staff and other residents. The investigation was completed by Administrative Nurse D and Administrative Staff B. Social Services X was notified on 01/13/23 by Administrative Nurse D that she (Administrative Nurse D) had spoken with the involved staff member, Certified Medication Aide (CMA) R, and provided additional training and in-service. Social Services X followed up with R1 on 01/13/23 and he reported the situation had gotten better. Social Services X informed R1 of her follow up and R1 agreed to let Social Services X know if an issue arises again. A Witness Statement of Facts dated 02/10/23 signed by CMA R documented R1 used the sit to stand lift. R1 had issues standing upright to be safe while on the lift. CMA R had prompted R1 repeatedly to stand tall while on the lift and explained that it was unsafe to use the sit to stand lift if R1 cannot bear weight and stand. CMA R used a full sling lift to transfer R1 in a safer manner. R1 reported to other staff he felt like CMA R punished him by using the full lift. R1 also made comments to CMA R about how she should find another job. Thes incidents were reported by CMA R's charge nurse. A Witness Statement of Facts dated 02/10/23 by Consultant GG documented the nurse asked R1 how he was feeling and R1 stated he was cold last night. R1 stated that CMA R turned off his heat. R1 went on to say that CMA R was also rough when he was in the lift, if his foot was in the wrong place CMA R kicks it into place. R1 said CMA R had bumped him into the wall while in the lift and when CMA R removed the lift strap, she pulled it roughly and yanks it off and caused him pain. R1 further stated CMA R was mean to him and said CMA R abuses him. R1 continued saying it had been getting worse over the last few weeks. Consultant GG then notified Administrative Nurse D. A Witness Statement of Facts dated 02/10/23 by Certified Nurse Aide (CNA) M documented when CNA M was getting R1 up after CMA T and her put on R1's jacket, R1 asked how to get an aide to transfer to another house. R1 then told CMA T and CNA M that CMA R told him yesterday to button up his own shirt and kicked his foot. R1 had also told them that CMA R told R1 to wheel himself to breakfast. CNA M recorded CMA R had not answered any of R1's lights that day, in fact CMA R told CNA M she was avoiding R1. A Witness Statement of Facts dated 02/10/23 by CMA T documented she was assisting R1 up for the day with another aide CNA M. R1 asked if there was any way to get someone moved out of the house. CMA T asked if R1 wanted to move and R1 said no. R1 said he wanted a certain staff out of there (CMA R). CMA T asked what happened and R1 said CMA R told him to button his own shirt. R1 also stated the CMA R kicked his foot because it was not on the lift correctly. A typed statement dated 02/10/23 from Administrative Nurse D documented Consultant GG came to her that morning to discuss some concerns brought to her attention by R1. Consultant GG told Administrative Nurse D that R1 stated CMA R had been short with him and rough with cares. Consultant GG stated R1 had used the term abuse. Consultant GG completed a witness statement. Administrative Nurse D went to speak with R1 and asked him what was going on. R1 said every time CMA R walked in, she goes to the thermostat and turns his heat off. R1 states this type of thing had been going on a couple of months and then stated that it has always been bad. R1 stated he thought CMA R and him were friends and he had her as an aide the first time he was at the facility. R1 reported CMA R hits the wall with the lift when she takes him in and out of the bathroom; CMA R yanks the sling off to remove it after transfers and it pulls his skin. R1 denied ever having a bruise or skin issue related to cares from CMA R. R1 also reported that CMA R kicks him when he was on the lift to get his feet in the right position if they were not in the correct spots. R1 also reported that CMA R made him attempt to button his own shirt and that was something he could not do on his own due to limited dexterity. R1 also reported CMA R put him in the hall after getting him ready for meals and encouraged him to wheel out independently. R1 mentioned twice that he did not want CMA R fired but did not want her in the house. R1 denied any issues with any other staff members. Administrative Nurse D encouraged R1 to let staff know immediately if there were any staff concerns or he felt like he was being treated with respect or dignity in any way. CMA R was sent home at the beginning of investigation by the administrator pending investigation. A Witness Statement of Facts dated 02/12/23 by Licensed Nurse (LN) H documented CMA R had mentioned to that nurse that R1 was giving her a hard time and was not standing in the lift. CMA R told the nurse that she told R1 that if he did not stand, she was going to use the full lift on him. CMA R told this nurse that when standing R1 in the lift, he would not stand up and would hang and not attempt to stand. CMA R said R1 would tell her he was an old man and he had two strokes. CMA R said that a few times while R1 was on the lift, she would use her feet to move R1's feet as they would start to move while standing in the lift. LN H spoke with R1 who said he did not like CMA R because she was always in a bad mood and threatened to use the full lift on him when he could not stand. On 05/15/23 at 12:40 PM R1 sat in his wheelchair in his room, with a lift sling under him in the wheelchair. R1 stated on the day of that incident, CMA R thought he should be advancing more in the lift and she used her foot to move his leg onto the lift. R1 stated he has had two strokes and was weak from the most recent one. R1 stated CMA R was the only staff assisting him that day with the sit to stand lift. On 05/15/23 at 12:46 PM CNA M stated R1 had complained to her and the hospice nurse about CMA R. CNA M told the charge nurse about the incident. CNA M said CMA R was not allowed to do any cares with R1 anymore. CNA M stated she had not heard or had any complaints from other resident about CMA R. CNA M stated R1 was not happy after being switched to the full lift after physical therapy (PT) re-evaluated the need to use the full lift. On 05/15/23 at 01:44 PM LN H stated via phone conversation that R1 complained about CMA R being rough at times with his cares and when he was not able to move his foot or leg when CMA R wanted him too she would use her foot/leg the kick his foot into the right place. R1 had told LN H that he felt CMA R was being mean to him. LN H stated CMA R told her about the incident with R1. On 05/15/23 at 02:50 PM Administrative Nurse D stated usually the sit to stand lift only required one staff assist with its used and the full lift required two staff and she was not aware that R1's care plan directed staff to have two staff with his transfers with the sit to stand lift. Administrative Nurse D stated she did an investigation regarding the incident with R1 and CMA R but did not report the incident to the state because after investigation the facility found there to be no evidence of abuse. Administrative Nurse D stated R1 was upset and felt like he was being degraded when he was changed to having to use the full lift. Administrative Staff D stated that herself and PT staff both further explained in depth the need of the full lift use for his safety and his inability to stand as needed when using the sit to stand lift. On 05/15/23 at 04:02 PM LN G stated she had worked at the facility since April but had worked at the facility prior to that when R1 first came to the facility. LN G stated R1 had used the sit to stand lift, but a few months ago and ever since she had been back R1 used a full lift with two staff. LN G stated the aides did have access to resident care plans and were available also in a book at the nurse's station. LN G stated the facility just had a big training about the lifts a couple of months ago. On 5/15/23 at 04:10 PM CMA S stated R1 was care planned to have two staff with him for the sit to stand lift for a short time, but R1 now has to use the full lift after he was evaluated by PT. CMA S stated R1 did not like the full lift and felt like he was being picked on and he felt staff just didn't want to help him anymore to use the sit to stand lift. The Abuse, Neglect, Exploitation and Crime Prevention and Management Policy last revised 12/16 documented: As soon as it is reported that there was alleged abuse of a resident by an employee, the employee was to be immediately suspended pending the outcome of the investigation and asked to leave the premises until they were called in for review of the findings upon completion of the investigation. Any employee that had knowledge of, was suspicious of, or was witness to an incident of abuse, shall immediately report their concerns to their supervisor, DON, and/or Administrator. The Supervisor will report the incident to the DON and the Administrator immediately. Upon completion of the investigation, administration would discuss the outcome with any involved employees. If the accusation was validated administration would complete disciplinary action and/or termination at that time. The Administrator or designee will report to Kansas Department for Aging and Disability Services (KDADS) injuries of an unknown source immediately and investigate. Evidence of these investigations will be made to KDADS with five working days of the incident. Proof of investigation will be provided on appropriate state forms. The facility failed to ensure R1 remained free from staff to resident abuse and neglect. The deficient practice left R1 at risk of injury and psychosocial impairment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 37 residents. The sample included three residents. Based on observation, record review and interview, the facility failed to identify an allegation as potential abuse and neglect and failed to report to the State Agency (SA) as required when R1 reported that Certified Medication Aide (CMA) R was being rough with cares and kicked R1's leg/foot. This placed R1 at risk for ongoing neglect and abuse. Findings included: - The electronic medical record (EMR) for R1 documented diagnoses of cerebral infarction (stroke-disruption of blood and oxygen to the brain causing brain cell death), and cerebrovascular disease (a condition that affects the flow of blood to the brain). The Significant Change Minimum Data Set (MDS) dated [DATE] documented R1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R1 required extensive assistance of two staff for bed mobility, transfers, dressing, and toileting activities of daily living (ADLs). R1 had impairment of both upper and lower extremities on one side. R1 required a wheelchair for mobility. R1 was on hospice services. The Quarterly MDS dated 04/10/23 for R1 documented a BIMS score of 15 indicated intact cognition. R1 required extensive assist of two staff for most ADLs and was total dependence on staff of two for transfers. R1 had impairment of both upper and lower extremities on one side. R1 required a wheelchair for mobility. R1 was on hospice services. The ADL Care Area Assessment dated 01/10/23 for R1 documented to proceed to the care plan with the amount of assistance required for resident. R1's ADL Care Plan dated 11/15/22 directed staff R1 required assistance of two staff members for transfers, bed mobility and toileting. The care plan directed staff to use the sit to stand lift with two staff for transfers. With a start date of 11/15/22 the care plan directed staff that R1 required the assistive device of full lift. A Grievance Form with a date of 01/10/23 by Social Services X, as reported by R1, documented R1 reported a staff member was rough with him during transfers. Social Services X notified Administrative Nurse D and facility vice president who completed an investigation and interviewed staff and other residents. The investigation was completed by Administrative Nurse D and Administrative Staff B. Social Services X was notified on 01/13/23 by Administrative Nurse D that she (Administrative Nurse D) had spoken with the involved staff member, Certified Medication Aide (CMA) R, and provided additional training and in-service. Social Services X followed up with R1 on 01/13/23 and he reported the situation had gotten better. Social Services X informed R1 of her follow up and R1 agreed to let Social Services X know if an issue arises again. A Witness Statement of Facts dated 02/10/23 signed by CMA R documented R1 used the sit to stand lift. R1 had issues standing upright to be safe while on the lift. CMA R had prompted R1 repeatedly to stand tall while on the lift and explained that it was unsafe to use the sit to stand lift if R1 cannot bear weight and stand. CMA R used a full sling lift to transfer R1 in a safer manner. R1 reported to other staff he felt like CMA R punished him by using the full lift. R1 also made comments to CMA R about how she should find another job. These incidents were reported by CMA R's charge nurse. A Witness Statement of Facts dated 02/10/23 by Consultant GG documented the nurse asked R1 how he was feeling and R1 stated he was cold last night. R1 stated that CMA R turned off his heat. R1 went on to say that CMA R was also rough when he was in the lift, if his foot was in the wrong place CMA R kicks it into place. R1 said CMA R had bumped him into the wall while in the lift and when CMA R removed the lift strap, she pulled it roughly and yanks it off and caused him pain. R1 further stated CMA R was mean to him and said CMA R abuses him. R1 continued saying it had been getting worse over the last few weeks. Consultant GG then notified Administrative Nurse D. A Witness Statement of Facts dated 02/10/23 by Certified Nurse Aide (CNA) M documented when CNA M was getting R1 up after CMA T and her put on R1's jacket, R1 asked how to get an aide to transfer to another house. R1 then told CMA T and CNA M that CMA R told him yesterday to button up his own shirt and kicked his foot. R1 had also told them that CMA R told R1 to wheel himself to breakfast. CNA M recorded CMA R had not answered any of R1's lights that day, in fact CMA R told CNA M she was avoiding R1. A Witness Statement of Facts dated 02/10/23 by CMA T documented she was assisting R1 up for the day with another aide CNA M. R1 asked if there was any way to get someone moved out of the house. CMA T asked if R1 wanted to move and R1 said no. R1 said he wanted a certain staff out of there (CMA R). CMA T asked what happened and R1 said CMA R tells him to button his own shirt. R1 also said if he does not do it, CMA R will not do it for him. R1 also stated the CMA R kicked his foot because it was not on the lift correctly. R1 said CMA R leaves him in his wheelchair in the hall and refuses to push him to/from his room. A typed statement dated 02/10/23 from Administrative Nurse D documented that Consultant GG came to her that morning to discuss some concerns brought to her attention by R1. Consultant GG told Administrative Nurse D that R1 stated CMA R had been short with him and rough with cares. Consultant GG stated R1 had used the term abuse. Consultant GG completed a witness statement. Administrative Nurse D went to speak with R1 and asked him what was going on. R1 said every time CMA R walked in, she goes to the thermostat and turns his heat off. R1 states this type of thing had been going on a couple of months and then stated that it has always been bad. R1 stated he thought CMA R and him were friends and he had her as an aide the first time he was at the facility. R1 reported CMA R hits the wall with the lift when she takes him in and out of the bathroom; CMA R yanks the sling off to remove it after transfers and it pulls his skin. R1 denied ever having a bruise or skin issue related to cares from CMA R. R1 also reported that CMA R kicks him when he was on the lift to get his feet in the right position if they were not in the correct spots. R1 also reported that CMA R made him attempt to button his own shirt and that was something he could not do on his own due to limited dexterity. R1 also reported CMA R put him in the hall after getting him ready for meals and encouraged him to wheel out independently. R1 mentioned twice that he did not want CMA R fired but did not want her in the house. R1 denied any issues with any other staff members. Administrative Nurse D encouraged R1 to let staff know immediately if there were any staff concerns or he felt like he was being treated with respect or dignity in any way. CMA R was sent home at the beginning of investigation by the administrator pending investigation. A Witness Statement of Facts dated 02/12/23 by Licensed Nurse (LN) H documented: CMA R had mentioned to that nurse that R1 was giving her a hard time and was not standing in the lift. CMA R told the nurse that she told R1 that if he did not stand, she was going to use the full lift on him. CMA R told this nurse that when standing R1 in the lift, he would not stand up and would hang and not attempt to stand. CMA R said R1 would tell her he was an old man and he had two strokes. CMA R said that a few times while R1 was on the lift, she would use her feet to move R1's feet as they would start to move while standing in the lift. LN H spoke with R1 who said he did not like CMA R because she was always in a bad mood and threatened to use the full lift on him when he could not stand. On 05/15/23 at 12:40 PM R1 sat in his wheelchair in his room, with a lift sling under him in the wheelchair. R1 stated on the day of that incident, CMA R thought he should be advancing more in the lift and she used her foot/leg to move his leg onto the lift. R1 stated he has had two strokes and was weak from the most recent one. R1 stated CMA R was the only staff assisting him that day with the sit to stand lift. On 05/15/23 at 02:50 PM Administrative Nurse D stated she did an investigation regarding the incident with R1 and CMA R but did not report the incident to the state because after investigation the facility found there to be no evidence of abuse. Administrative Nurse D stated R1 was upset and felt like he was being degraded when he was changed to having to use the full lift. Administrative Staff D stated that herself and PT staff both further explained in depth the need of the full lift use for his safety and his inability to stand as needed when using the sit to stand lift. The Abuse, Neglect, Exploitation and Crime Prevention and Management Policy last revised 12/16 documented: Residents were to be protected from any physical and mental mistreatment, involuntary seclusion and misappropriation of resident property through the actions of staff, other residents, family members and other visitors. The Abuse coordinator in the facility was the Director of Nursing, Administrator, or facility appointed designee. Report allegations or suspected abuse, neglect or exploitation immediately to the Administrator, other officials in accordance with state law, and state survey and certification agency through established procedures. The Administrator or designee will report to the Kansas Department for Aging and Disability Services (KDADS) injuries of an unknown source immediately and investigate. Evidence of these investigations will be made available to KDADS within five working days of the incident. Proof of investigation will be provided on appropriate state forms. The facility failed to report an allegation of abuse and neglect to the state agency as required. This placed R1 at risk for ongoing neglect and abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 51 residents. The sample included 13 residents with one reviewed for abuse. Based on observation, record review, and interview, the facility failed to prevent an incident of abuse and/or retaliation for Resident (R)23, when agency Licensed Nurse (LN) G refused to give R23 his evening medications then took the residents cell phone out of his hand, threw it in the recliner, refused to let the resident to call the police and then transferred R23 using a lift whereas R23 sustained a skin tear during the transfer. This deficient practice placed R23 at risk for physical injury and impaired psychosocial wellbeing. Findings included: - R23's Physician Order sheet, dated 08/16/22 documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), chronic obstructive pulmonary disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), dry eye syndrome, facial dermatitis (a condition of the skin in which the skin becomes red swollen, and sore, sometimes with small blisters, resulting from direct irritation of the skin by an external agent or allergic reaction to it) and chronic pain. The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition, with a Brief Interview for Mental Status (BIMS) score of 15. The resident required extensive staff assistance with bed mobility, transfers, personal hygiene, and toileting. The resident received dialysis (the process of removing excess water, solutes, and toxins from the blood in people who can no longer perform these functions naturally) treatment. The Activities of Daily Living (ADLs) Care Plan, dated 07/20/22, directed staff to assist R23 with all ADLs and self-cares. The care plan documented the resident used an electric scooter for mobility and a sit to stand lift for transfers with assistance of one staff. The Psychosocial Wellbeing Care Plan, dated 07/20/22, directed staff to provide emotional support and validate R23's concerns and feelings. The care plan documented the social worker and chaplain were available as needed. The Nurse Note, date 07/03/22 at 11:26 AM, recorded the resident complained of discomfort to his left shin where a small skin tear was obtained on 07/02/22 evening shift. LN H documented the skin tear was bandaged and clean. The Nurse's notes lacked any further documentation of the incident. The facility completed an Investigation on 07/03/22 regarding an incident on 07/02/22. Information obtained revealed on 07/02/22 R23 stated LN G refused to give him his evening medications. R23 became very upset and stated that he was going to call the police. R23 stated LN G took R23's cell phone from him and threw it in the chair so he could not call the police. R23 reported he received a skin tear when LN G was rough with him when she put him to bed afterwards. On 07/03/22 LN H was instructed to complete a head to toe assessment regarding R23's allegations and noted the resident had a skin tear to his left shin. LN H cleansed the area and placed a bandage to the open skin tear. The investigation documented Administrative Staff A, the primary care physician, and R23's Durable Power of Attorney (DPOA) were notified of the incident. The investigation documented LN H was not allowed to return to the facility. The 07/04/22 at 09:38 AM, Witness Statement documented LN G stated R23 asked for his evening medication several times and stated he had not received his medications. LN G stated she looked at the electronic medical record and R23's medications were signed off by another agency employee, Certified Medication Aide (CMA) R. LN G explained to the resident he had already received his medications and she would not be able to administer them again. LN G stated R23 said if he did not get his medications he would call the police, LN G stated she would not be able to do anything for him and she would not give him the medications he had already received. LN H stated she asked the resident if he needed anything else and went to move his bedside table. R23's cell phone fell to the ground and the back part of the screen protector fell off, LN G put it back on and placed the cell phone on his bedside table. LN G stated later that night, towards the end of the shift, it was shared with her that R23's eye drops and inhaler were kept at the resident's bedside in a locked box and the agency CMA was not aware there were additional medications in a locked box in the resident's room. LN G then administered the resident's remaining medications and apologized to R23 for not understanding that there were additional medications. LN G stated she assisted the resident to bed with a sit to stand lift and was not aware he sustained a skin tear during the transfer. On 8/23/22 at 10:45 AM R23 stated the incident on 07/02/22 with LN G caused him distress and he felt threatened when LN G denied him the cell phone to call the police to resolve the issue. On 08/25/22 at 02:30 PM, Administrative Staff A stated on 07/03/22 she became aware of R23's allegation of not receiving some of his evening medications and the incident that took place. Administrative Staff A terminated agency LN G from working at the facility after she completed the investigation. The facility's Abuse, Neglect, and Exploitation policy, undated, recorded the facility would protect the residents from any physical and mental mistreatment, involuntary seclusion and misappropriation of resident property through the action of the staff, other residents, family members and other visitors. The facility failed to protect R23 from abuse and/or retaliation when LN G refused to provide the resident his evening medications, took his cell phone away, denied him access to call police for help, and transferred him roughly. This deficient practice placed the resident at risk for pain and suffering.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 51 residents. The sample included 13 residents with one reviewed for quality of life. Based on observation, record review, and interview, the facility failed to ensure all staff honored and responded to Resident (R)23's preferences, requests and choices to ensure R23's quality of life. This deficient practice placed R23 at risk for decreased psychosocial wellbeing and impaired dignity and autonomy. Findings Included: - R23's Physician Order sheet, dated 08/16/22 documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), chronic obstructive pulmonary disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), dry eye syndrome, facial dermatitis (a condition of the skin in which the skin becomes red swollen, and sore, sometimes with small blisters, resulting from direct irritation of the skin by an external agent or allergic reaction to it) and chronic pain. The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition, with a Brief Interview for Mental Status (BIMS) score of 15. The resident required extensive staff assistance with bed mobility, transfers, personal hygiene, and toileting. The resident received dialysis (the process of removing excess water, solutes, and toxins from the blood in people who can no longer perform these functions naturally) treatment. The Activities of Daily Living (ADLs) Care Plan, dated 07/20/22, directed staff to assist R23 with all ADLs and self-cares. The care plan documented the resident used an electric scooter for mobility and a sit to stand lift for transfers with assistance of one staff. The Psychosocial Wellbeing Care Plan, dated 07/20/22, directed staff to provide emotional support and validate R23's concerns and feelings. The care plan documented the social worker and chaplain were available as needed. The facility completed an Investigation on 07/03/22 regarding an incident on 07/02/22. Information obtained revealed on 07/02/22 R23 stated agency Licensed Nurse G refused to give him his evening medications. R23 got very upset and stated that he was going to call the police. R23 stated LN G took his cell phone from him and threw it in the chair so he could not call the police. The investigation documented Administrative Staff A, the primary care physician, and R23's Durable Power of Attorney (DPOA) were notified of the incident. The investigation documented LN H was not allowed to return to the facility. The 07/04/22 at 09:38 AM, a Witness Statement documented LN G stated R23 asked for his evening medication several times and stated he had not received his medications. LN G stated she had looked at the electronic medical record and R23's medications were signed off by another agency employee, Certified Medication Aide (CMA) R. LN G explained to the resident he had received his medications and she would not be able to administer them again. LN G stated R23 said if he did not get his medications he would call the police, LN G stated she would not be able to do anything for him and she would not give him the medications he had already received .LN H stated she asked the resident if he needed anything else and went to move his bedside table. R23's cell phone fell to the ground and the back part of the screen protector fell off , LN G put it back on and placed the cell phone on his bedside table. LN G stated later that night, towards the end of the shift, it was shared with her R23's eye drops and inhaler, were kept at the resident's bedside in a locked box and the other agency personnel was not aware there were additional medications in a locked box in the resident's room. LN G then administered the resident's remaining medications and apologized to R23 for not understanding that there were additional medications On 8/23/22 at 10:45 AM, R23 stated on the 07/02/22 evening shift he did not get all of his medications and had explained to agency LN G the medication aide had not given him his eye drops, inhaler, or face cream. R23 stated he asked for the medication's multiple times throughout the evening and the nurses denied him the medication, stated he had received it, and the medication aide had signed off he received it. The resident stated he told the nurse if he did not get it he would call the police and stated LN G took the cell phone out of his hand and threw it in a bedside chair and he was unable to reach the phone. R23 stated this incident cause him distress and he felt threatened when they denied him the cell phone to call the police to resolve the issue. R23 stated he had never felt threatened or fearful in the three years he lived at the facility, and stated the involved staff were agency, not the regular staff. On 08/25/22 at 02:30 PM, Administrative Staff A stated on 07/03/22 she became aware of R23's allegation of not receiving some of his evening medications and the incident that took place. Administrative Staff A terminated agency LN G from working at the facility after she completed the investigation. The facility's Resident Right's policy, dated 7/19, documented the resident would be treated with respect, dignity and consideration, and would be free from discrimination, coercion or reprisals in the exercise of resident rights. The policy documented the resident would receive services for the resident's special needs and responses to requests and receive adequate health care and appropriate support services. The facility failed to ensure all staff honored R23's preferences, requests and choices to support and maintain R23's quality of life when LN G refused to follow up on R23's requests. This deficient practice placed R23 at risk for decreased psychosocial wellbeing, and impaired dignity and autonomy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 51 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to ensure staff possessed the appropriate skills and competencies when staff failed to complete post-fall neurological assessments for one of three residents reviewed for accidents, Resident (R) 9. This placed R9 at increased risk for unrecognized fall related injury and delayed treatment. Findings included: -The Medical Diagnosis section within R9's Electronic Medical Record (EMR) included diagnoses of transient cerebral ischemic attack (TIA-episode of cerebrovascular insufficiency), epilepsy (brain disorder characterized by repeated seizures), dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance, fall trip with strike against object and depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R9 had severe cognitive impairment, required limited assistance of one staff for activities of daily living, was not steady, but able to stabilize without staff assistance with balance and transitions. The MDS further documented R9 had no falls since prior assessment. The Care Plan, dated 06/07/22, documented R9 had actual falls related to hypertension (elevated blood pressure), dementia and seizures. The Care Plan directed staff to assist the resident to get ready for bed right after supper meal, cluster cares so R9 did not have to turn around and she could focus on ambulation, keep walker close, and staff were to assist with ambulation. The Physician Order Sheet (POS), dated 08/01/22, documented R9 routinely took Plavix (medication used to prevent blood clots), aspirin, and Keppra (used to treat seizures). The Interdisciplinary (ID) Note, dated 07/19/22 at 06:18 PM, documented at 05:30 PM R9 was on her buttocks in front of her closet. The note further documented R9 lost her balance attempting to get into pajamas for the evening. The physician was notified via fax of the unwitnessed fall. A Neurological Assessment Tool initiated on 07/19/22 at 05:30 PM directed staff to complete a neurological check every 15 minutes for one hour, every 30 minutes for one hour, then every two hours for six hours, every four hours for eight hours, and then every eight hours for 56 hours. The ID Note dated 07/20/22 at 05:13 AM, documented R9 had been sleeping all night. The (agency) nurse did not obtain vital signs (neurological checks) at 11:30 PM (07/19/22), 01:30 AM (07/20/22) and 05:30 AM (07/20/22). The note recorded the agency nurse did not obtain the vital sign measurements because she was told not to disturb the residents while they slept. On 08/29/22 at 10:10 AM, Licensed Nurse (LN) I stated the facility's policy directed staff to perform neurological checks for resident's who had an unwitnessed fall. LN I stated staff should have woke R9 for vital sign and neurological checks. LN I also verified R9 took blood thinning medications: Plavix and aspirin. On 08/29/22 at 11:00 AM, Administrative Nurse D stated she expected nursing staff to make at least one attempt to check the resident's neurological status and document information related to not completing the assessment. The facility's Fall Management policy, dated 07/2022, documented the charge nurse will initiate the Fall Incident-Immediate Care Plan which will identify immediate care plan changes and include neuro checks when indicated per protocol. The policy further documented to continue follow up assessment, monitoring, documentation for actual and/or potential complication or harm and care plan effectiveness. The facility failed to complete neurological assessments for R9 who received blood thinners and had an unwitnessed fall which placed the resident at risk for unrecognized injury and delayed treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R16's Physician Order Sheet (POS), dated 08/25/22, documented diagnoses of dementia (group of symptoms that affects memory, thinking and interferes with daily life) with behavioral disturbance, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear,) Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and major depressive disorder (major mood disorder.) The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had severely impaired cognition. The MDS documented R16 had disorganized thinking, was easily annoyed, and had behaviors which fluctuated. R16 required extensive assistance with all activities of daily Living (ADLs). The MDS documented the resident received antipsychotic and antidepressant medication six days of the look back period. The Psychotropic Care Area Assessment (CAA), dated 08/22/22, documented to proceed to the care plan with management of psychotropic (medications which alter mood or thought) medication during therapeutic use. The Cognitive/Dementia CAA, dated 08/22/22, documented to proceed to the care plan, no additional information provided. The Medication Care Plan, dated 07/15/22, documented R16 had the potential for drug related complications associated with the use of psychotropic medication. The care plan directed staff to monitor the resident for targeted behaviors/symptoms such as physically abuse, drug related complications, and document per facility protocol. The care plan documented the resident took Seroquel (antipsychotic) and the resident's family has been educated on the risk versus benefits of the resident receiving antipsychotic medications for treatment of his dementia related. The care plan directed the staff to consult the pharmacy and the medical director to consider dosage reduction when clinically appropriate. The Consultant Pharmacist Review, dated 06/14/22, documented an inappropriate diagnosis for the use of Seroquel and requested a risk versus benefit statement. The Nurse's Notes, date 06/21/22, at 02:45 PM, documented Administrative Nurse D contacted the primary care physician to discuss psychotropic regimen regarding Seroquel was not an approved treatment for residents with dementia related psychosis. The primary care physician stated she was frustrated by this guidance and stated she cannot diagnosis a resident with an illness that he did not have. The primary care physician stated the only other option is to send the resident to a behavioral health unit where the resident will potentially be inappropriately diagnosed and given antipsychotic medication anyway. The facility was unable to provide documentation this situation was referred to the facility Medical Director for physician consult and review. The Physician's Order, dated 06/30/22, directed the staff to administer Seroquel 50 milligrams (mg), daily for a diagnosis of dementia with behavioral disturbance. The Physician's Order, dated 07/07/22, directed staff to administer Seroquel 25 mg, daily for a diagnosis of dementia with behavioral disturbance. On 08/24/22 at 11:25 AM, observation revealed R16 sat at the dining room table, in a wheelchair. Certified Medication Aid (CMA) S crushed the resident's Seroquel 25 mg tablet and mixed it in pudding, then administered the spoonful to the resident at the dining room table. On 08/29/22 at 01:00 PM, Administrative Nurse D verified the diagnosis of dementia for the use of Seroquel was inappropriate. Administrative Nurse D verified the facility had been in contact with R16's primary care physician who refused to change the diagnosis for the use of the medication stating it was for dementia with behavioral disturbance. The facility's Antipsychotic Medication Use, policy, dated 06/19, documented residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. All physician orders for antipsychotic medications will be clear and accurate and will include an appropriate diagnosis, condition or indication for use; and the consultant pharmacist will review the appropriateness of all medication orders for medications to be administered by clinical staff. An Informed Consent Agreement would be initiated and reviewed with the resident/resident representative. The ordering physician will outline the risks and the benefits of administration of the medication. The dispensing pharmacy or consultant pharmacist will be instructed by the facility to complete a drug regimen review related to possible behavioral symptoms as an adverse side effect of another drug or a drug-to- drug interaction side effect, appropriate indication for antipsychotic drug, and the pharmacist discusses the medication order with the facility's DON/Administrator/Nurse Manager. The facility's Pharmacy Review policy, dated 08/18, stated the pharmacist would review resident medications at least monthly and recommend changes to the physician and facility. The pharmacist shall document in the medical records the drug regimen review has been performed and including review of unnecessary medication. Attending providers are required to document in the medical records this has been reviewed and what, if any action has been taken to address the concern. If no change, the attending provider should document the rationale which would be placed in the resident's medical record. The facility failed to act upon the Consultant Pharmacist's report regarding an inappropriate diagnosis for the use of Seroquel which included involving the Medical Director as needed, placing the resident at risk for inappropriate use of an antipsychotic medication. The facility had a census of 51 residents. The sample included 13 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to follow up on the consultant pharmacist recommendations to ensure the facility obtained a risk versus benefit statement annually for the continued use of Seroquel (antipsychotic drug) for R42 and an appropriate diagnosis for the use of Seroquel for R16. This deficient practice placed R16 and R42 at risk for unnecessary drugs. Findings included: - R42's Physician Order Sheet (POS), dated 08/04/22, documented diagnoses of anxiety disorder (disorder characterized by feelings of worry, anxiety) and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. R42 required supervision for eating and one to two staff assistance for all other activities of daily living. The MDS documented R42 had no pain, one non-injury fall, one minor injury fall, and received antipsychotic (class of medicines used to treat psychosis and other mental and emotional conditions), antidepressant (prescription medicines to treat depression), and anticoagulant (chemical used to prevent and treat blood clots in blood vessels and the heart) medications seven days of the lookback period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 08/01/22, documented the CAA triggered secondary to use of psychotropic (medication which alters mood or thoughts) medication to manage psychiatric condition and contributing factors included diagnoses of dementia and acute psychosis (mental disorder characterized by a disconnection from reality) episode. The Medication Care Plan, 06/23/22, documented R42 had potential for drug related complications associated with use of psychotropic medications and directed staff to monitor for target behaviors and document per facility protocol. Observe, document, report to the physician as needed, signs of drug related complications. Consult with pharmacist and physician to consider dosage reduction when clinically appropriate. The Consultant Pharmacist Reviews reviewed for the past year documented on 11/11/21 and 12/08/21 recommendations noted the need for a review of Seroquel use. The physician did not respond to the 11/11/21 recommendation. The Pharmacist Consultant Note, dated 12/08/21, documented he resent a note to R42's physician (second attempt) on 12/08/21 requesting he assess R42 for possible gradual dose reduction (GDR) to Seroquel and/or Trazodone (antidepressant). The physician response, dated 12/08/21, ordered a GDR of Trazodone. The physician did not respond to the recommendation for a GDR for Seroquel and did not write a risk versus benefit statement for continuing it. The Physician Order, dated 08/23/22, directed staff to administer Seroquel 50 milligrams (mg) at bedtime, for psychosis. Review of the medical record revealed R42 had received Seroquel since 03/24/21(17 months) and lacked evidence of an attempted GDR or risk versus benefit statement. The Psychiatric Visit Note, dated 04/30/22, documented R42 was cooperative, had no agitation, disorganized thought, delusions, no hallucinations or paranoia and not reported to have any recent target symptoms. The psychiatrist documented a diagnosis of dementia with behavioral problem. The Psychiatric Visit Note, dated 08/20/22, documented during a follow up psychiatry visit R42 was cooperative, no agitation, delusions, possible hallucinations, no paranoia. The psychiatrist documented a diagnosis of dementia with behavioral problem and directed staff to continue to provide care with physical activity, offer toileting, hygiene, snacks may be helpful for wandering or restlessness, and to contact psychiatry if hallucinations become distressing. On 08/24/22 at 07:45 AM, observation revealed R42 sat in a chair in the dining room and Certified Nurse Aide (CMA) R assisted her to walk to her room. R42 walked with small steady steps and cooperated well. CMA R offered toileting assistance, R42 declined, and CMA R assisted her to bed. On 08/25/22 at 03:20 PM, CMA S stated R42 wandered some days, especially when agitated or needed to use the bathroom. CMA S stated R42 had not attempted to open doors for the past three weeks, as she tried to open doors a year ago. She stated R42 used to hallucinate or have delusional thoughts but slept a lot now. On 08/29/22 at 03:08 PM, Administrative Nurse D verified the physician had not initiated a gradual dose reduction (GDR) or written a risk versus benefit statement for the continued use of Seroquel during the 17 months the resident received the antipsychotic. She stated the consultant pharmacist had attempted twice to obtain a GDR or risk versus benefit statement from the physician. The facility's Pharmacy Services Policy and Procedure, dated 08/2018, documented Resident-specific recommendations are documented in the resident's active medical record. Attending providers are required to document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending provider should document the rationale and placed in the resident's medical record. The director of nursing, or designated individual, will track physician responses. If the attending provider fails to respond to an irregularity within fourteen (14) business days of the initial requested review, the attending provider will be contacted by the director of nursing or designated facility agent to obtain a response and the attempted contact will be documented in the resident's medical record. If no response is received from the attending provider within twenty-one (21) business days of the initial requested review, the facility's medical director will be contacted by the director of nursing or designated facility agent for requested responses/recommendations and the attempted contact will be documented in the resident's medical record. The facility failed to follow up on the consultant pharmacist's recommendation to attempt GDR of R42's Seroquel or obtain a statement from the physician weighing the risk versus benefit for the continued use of Seroquel, placing R42 at risk for adverse effects from the antipsychotic drug.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R16's Physician Order Sheet (POS), dated 08/25/22, documented diagnoses of dementia (group of symptoms that affects memory, thinking and interferes with daily life) with behavioral disturbance, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear,) Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and major depressive disorder (major mood disorder.) The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had severely impaired cognition. The MDS documented R16 had disorganized thinking, was easily annoyed, and behaviors which fluctuated. R16 required extensive assistance with all activities of daily Living (ADLs). The MDS documented the resident received antipsychotic (class of medicines used to treat psychosis and other mental and emotional conditions), and antidepressant (prescription medicines to treat depression) medication six days of the look back period. The Psychotropic Care Area Assessment (CAA), dated 08/22/22, documented to proceed to the care plan with management of psychotropic medication during therapeutic use. The Cognitive/Dementia CAA, dated 08/22/22, documented to proceed to the care plan, no additional information provided. The Medication Care Plan, dated 07/15/22, documented R16 had the potential for drug related complications associated with the use of psychotropic medication. The care plan directed staff to monitor the resident for targeted behaviors/symptoms such as physically abuse, drug related complications, and document per facility protocol. The care plan documented the resident took Seroquel and the resident's family has been educated on the risk versus benefits of the resident receiving antipsychotic medications for treatment of his dementia related. The care plan directed the staff to consult the pharmacy and the medical director to consider dosage reduction when clinically appropriate. The Physician's Order, dated 06/30/22, directed the staff to administer Seroquel 50 milligrams (mg), daily for a diagnosis of dementia with behavioral disturbance. The Physician's Order, dated 07/07/22, directed staff to administer Seroquel 25 mg, daily for a diagnosis of dementia with behavioral disturbance. The Consultant Pharmacist Review, dated 06/14/22, documented an inappropriate diagnosis for the use of Seroquel and requested a risk versus benefit statement. The Nurse's Notes, date 06/21/22, at 02:45 PM, documented Administrative Nurse D contacted the primary care physician to discuss psychotropic regimen regarding Seroquel was not an approved treatment for residents with dementia related psychosis. The primary care physician stated she was frustrated by this guidance and stated she cannot diagnosis a resident with an illness that he does not have. The primary care physician stated the only other option is to send the resident to a behavioral health unit where the resident will potentially be inappropriately diagnosed and given antipsychotic medication anyway. The facility was unable to provide documentation this situation was referred to the facility Medical Director for physician consult and review. On 08/24/22 at 11:25 AM, observation revealed R16 sat at the dining room table, in a wheelchair. Certified Medication Aid (CMA) S crushed the resident's Seroquel 25 mg tablet and mixed it in pudding, then administered the spoonful to the resident at the dining room table. On 08/29/22 at 01:00 PM, Administrative Nurse D verified the diagnosis of dementia for the use of Seroquel was inappropriate. Administrative Nurse D verified the facility had been in contact with R16's primary care physician who refused to change the diagnosis for the use of the medication stating it was for dementia with behavioral disturbance. The facility's Antipsychotic Medication Use, policy, dated 06/19, documented residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. All physician orders for antipsychotic medications will be clear and accurate and will include an appropriate diagnosis, condition or indication for use; and the consultant pharmacist will review the appropriateness of all medication orders for medications to be administered by clinical staff. An Informed Consent Agreement would be initiated and reviewed with the resident/resident representative. The ordering physician will outline the risks and the benefits of administration of the medication. The dispensing pharmacy or consultant pharmacist will be instructed by the facility to complete a drug regimen review related to possible behavioral symptoms as an adverse side effect of another drug or a drug-to- drug interaction side effect, appropriate indication for antipsychotic drug, and the pharmacist discusses the medication order with the facility's DON/Administrator/Nurse Manager The facility failed to ensure R16 did not receive antipsychotic medication without an appropriate diagnosis or clinical justification for its use, placing R16 at risk for adverse side effects related to the use of Seroquel. The facility had a census of 51 residents. The sample included 13 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to ensure two sampled Residents (R) did not receive unnecessary psychotropic medications (class of medications which alter mood or thought) when they failed to obtain a risk versus benefit statement for the continued use of Seroquel (antipsychotic drug) for R42 and an appropriate diagnosis for the continued use of Seroquel for R16. This deficient practice placed R16 and R42 at risk to receive unnecessary psychotropic drugs. Findings included: - R42's Physician Order Sheet (POS), dated 08/04/22, documented diagnoses of anxiety disorder (disorder characterized by feelings of worry, anxiety) and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. R42 required supervision for eating and one to two staff assistance for all other activities of daily living. The MDS documented R42 had no pain, one non-injury fall, one minor injury fall, and received antipsychotic (class of medicines used to treat psychosis and other mental and emotional conditions), antidepressant (prescription medicines to treat depression), and anticoagulant (chemical used to prevent and treat blood clots in blood vessels and the heart) medications seven days of the lookback period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 08/01/22, documented the CAA triggered secondary to use of psychotropic (medication which alters mood or thoughts) medication to manage psychiatric condition and contributing factors included diagnoses of dementia and acute psychosis (mental disorder characterized by a disconnection from reality) episode. The Behavior Care Plan, dated 06/23/22, documented R42 had impaired decision making related to dementia. Social worker available as needed. Observe for any changes in resident's psychosocial/mood state and report changes to resident's nurse or facility social worker as needed. Intervene as necessary to ensure safety of resident and others, divert attention from stimulus. Talk with the resident in a calm voice when behavior is disruptive and redirect. Leave and reapproach when resident has calmed down. Document any observed behaviors and notify the physician. Wandering or pacing will be managed to allow freedom but support safety. The care plan documented R42 had a history of demonstrating physically violent behaviors towards others related to dementia with behavioral disturbance. R42 sometimes believed that she was in her 20's and that she had young children. Do not attempt to re-orient R42 by proving otherwise, as this has been known to potentially increase her agitation and anxiety. The Medication Care Plan, 06/23/22, documented R42 had potential for drug related complications associated with use of psychotropic medications and directed staff to monitor for target behaviors and document per facility protocol. Observe, document, report to the physician as needed, signs of drug related complications. Consult with pharmacist and physician to consider dosage reduction when clinically appropriate. The Pharmacist Consultant Note, dated 12/08/21, documented he resent a note to R42's physician (second attempt) on 12/08/21 requesting he assess R42 for possible gradual dose reduction (GDR) to Seroquel and/or Trazodone (antidepressant). The Physician Response, dated 12/08/21, ordered a GDR of Trazodone. The physician did not respond to the recommendation for a GDR for Seroquel and did not write a risk versus benefit statement for continuing it. The Physician Order, dated 08/23/22, directed staff to administer Seroquel 50 milligrams (mg) at bedtime, for psychosis. Review of the medical record revealed R42 had received Seroquel since 03/24/21(17 months) and lacked evidence of an attempted GDR. The Psychiatric Visit Note, dated 04/30/22, documented R42 was cooperative, had no agitation, disorganized thought, delusions, no hallucinations or paranoia and not reported to have any recent target symptoms. The psychiatrist documented a diagnosis of dementia with behavioral problem. The Psychiatric Visit Note, dated 08/20/22, documented during a follow up psychiatry visit R42 was cooperative, no agitation, delusions, possible hallucinations, no paranoia. The psychiatrist documented a diagnosis of dementia with behavioral problem and directed staff to continue to provide care with physical activity, offer toileting, hygiene, snacks may be helpful for wandering or restlessness, and to contact psychiatry if hallucinations become distressing. On 08/24/22 at 07:45 AM, observation revealed R42 sat in a chair in the dining room and Certified Nurse Aide (CMA) R assisted her to walk to her room. R42 walked with small steady steps and cooperated well. CMA R offered toileting assistance, R42 declined, and CMA R assisted her to bed. On 08/25/22 at 03:20 PM, CMA S stated R42 wandered some days, especially when agitated or needed to use the bathroom. CMA S stated R42 had not attempted to open doors for the past three weeks, as she tried to open doors a year ago. She stated R42 used to hallucinate or have delusional thoughts, but slept a lot now. On 08/29/22 at 03:08 PM, Administrative Nurse D verified the physician had not initiated a gradual dose reduction (GDR) or written a risk versus benefit statement for the continued use of Seroquel during the 17 months the resident received the antipsychotic. The facility's Antipsychotic Medications policy dated 06/2019, documented any resident who uses an antipsychotic drug receives a gradual dose reduction and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs to ensure the resident does not receive unnecessary medications and the lowest possible dose is administered for the shortest amount of time. The policy stated each resident who has an order for an antipsychotic drug will be assessed and periodically reassessed during their residency to determine the effectiveness of the medication. The facility failed to ensure a GDR of R42's Seroquel or a statement from the physician weighing the risk versus benefit for the continued use of Seroquel, placing R42 at risk for adverse effects from the antipsychotic drug. Surveyor: Ravenkamp, Pat

The facility had a census of 51 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to ensure one of seven residents reviewed during medication administration pass remained free of medication errors. This deficient practice placed Resident (R) 23 at risk for adverse reaction from the medication. Findings included: - R23's Physician Order sheet, dated 08/16/22 documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), chronic obstructive pulmonary disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), dry eye syndrome, facial dermatitis (a condition of the skin in which the skin becomes red swollen, and sore, sometimes with small blisters, resulting from direct irritation of the skin by an external agent or allergic reaction to it,) chronic kidney disease Stage 4 (kidneys are severely damaged and are not working to clear filter waste from your blood) and chronic pain. R23's Physician Order, dated 01/29/22 instructed staff to administer Renvela (medication used to control phosphorus levels for resident's who received dialysis [the process of removing excess water, solutes, and toxins from the blood in people who can no longer perform these functions naturally]), 0.8 grams (g) oral powder one packet, three times a day with meals. On 08/23/22 at 04:20 PM, observation revealed License Nurse (LN) H administered Renvela 2.4 g, hydroxyzine (antihistamine) 500 milligrams (mg,) and carvedilol (medication for high blood pressure and heart failure) 12.5 mg tablet (crushed) in jelly. R23 ingested all of the medication. On 08/23/22 at 04:25 PM, LN H stated staff crushed R23's medications, and mixed the medications with the powder medication [Renvela]. LN H said R23 liked the medications mixed with jelly. On 08/29/22 at 09:30 AM, Administrative Nurse D verified the physician ordered Renvela 0.8 grams three times a day. Administrative Nurse D confirmed the pharmacy sent out Renvela 2.4 mg packets on 06/03/22 and the nurses had administered the incorrect dose for 12 weeks. Administrative Nurse D said the nurse was expected to check the five rights for medication administration (the right patient, the right drug, the right dose, the right route, and the right time) and the nurses failed to do that. The facility's Medication Administration policy, dated 05/21, documented staff would dispense medication according to the residents Medication Administration Record (MAR), read the medication label, dispense it into a cup, and read the medication label again when it was placed back in the medication cart. The facility failed to prevent a significant medication error when staff administered the incorrect dose of medication to R23. This placed the resident at risk for adverse reaction from the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 63 residents. The sample included 16 residents. Based on observation, record review and interview, the facility failed to report Resident (R) 37's missing Fentanyl (narcotic) patch to the state agency. Findings included: - R37's Annual Minimum Data Set (MDS), dated [DATE], documented the resident had severe cognitive impairment and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS documented the resident received scheduled opioid (class of pain-relieving medication including fentanyl) pain medication two times a week. Review of the resident's Electronic Medical Record (EMAR) lacked a Pain Care Plan The Physician Order, dated 06/07/21, directed staff to apply Fentanyl 25 micrograms/hour (mcg/hr) transdermal (applied to the skin and medication penetrates thru the skin layer and exert their effects on deeper or more distant tissue) patch, topically (application to body surface) every three days for pain, cover with Tegaderm (a medical dressing used to cover and protect wounds) and Fentanyl 100 mcg/hour transdermal patch apply every three days for pain, cover with Tegaderm, and ensure both patches were in place The Nurse's Note, dated 04/21/21 at 09:34 PM, documented Certified Medication Aide (CMA) R checked the location of R37's Fentanyl patch, could not find the patch, and notified Administrative Nurse D. On 06/29/21 at 08:10 AM, observation revealed the resident sat at the dining room table . On 06/23/21 at 10:20 AM, Licensed Nurse (LN) G stated the resident had an order for the Fentanyl patch to be changed every three days, and staff observed for facial grimacing to determine her pain level. On 06/29/21 at 02:00 PM, Administrative Nurse D verified she had not reported the missing Fentanyl patch to the state agency and realized she should have. Administrative Nurse D stated CMA R contacted the charge nurse and reported the missing patch. On 06/29/21 at 02:15 PM, Administrative Staff A verified she received a text and a picture of the missing Fentanyl patch from CMA S on 04/26/21. The text documented the patch was found in the resident's night gown. Administrative Staff A verified she had not reported the missing patch to the state agency or law enforcement and had not completed an investigation but would start an investigation now. The facility's Abuse, Neglect, and Exploitation policy, dated December 2020, recorded the facility would protect the residents from any physical and mental mistreatment, involuntary seclusion and misappropriation of resident property through the action of the staff, other residents, family members and other visitor. Administrator or designee will report to Kansas Department for Aging and Disability Services (KDADS) injuries of unknown source immediately and investigate. Any complaint which alleges a possible criminal act requires immediate, written notification to a law enforcement agency. The facility failed to report R37's missing Fentanyl patch to the state agency, placing the resident at risk for increased pain, and abuse and neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 63 residents. The sample included 16 residents. Based on observation, interview, and record review, the facility failed to investigate Resident (R) 37's missing Fentanyl (narcotic) Patch. Findings included: - R37's Annual Minimum Data Set (MDS), dated [DATE], documented the resident had severe cognitive impairment and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS documented the resident received scheduled opioid (class of pain-relieving medication including fentanyl) pain medication two times a week. Review of the resident's Electronic Medical Record (EMAR) lacked a Pain Care Plan The Physician Order, dated 06/07/21, directed staff to apply Fentanyl 25 micrograms/hour (mcg/hr) transdermal (applied to the skin and medication penetrates thru the skin layer and exert their effects on deeper or more distant tissue) patch, topically (application to body surface) every three days for pain, cover with Tegaderm (a medical dressing used to cover and protect wounds) and Fentanyl 100 mcg/hour transdermal patch apply every three days for pain, cover with Tegaderm, and ensure both patches were in place The Nurse's Note, dated 04/21/21 at 09:34 PM, documented Certified Medication Aide (CMA) R checked the location of R37's Fentanyl patch, could not find the patch, and notified Administrative Nurse D. On 06/29/21 at 08:10 AM, observation revealed the resident sat at the dining room table . On 06/23/21 at 10:20 AM, Licensed Nurse (LN) G stated the resident had an order for the Fentanyl patch to be changed every three days, and staff observed for facial grimacing to determine her pain level. On 06/29/21 at 02:00 PM, Administrative Nurse D verified she had not reported the missing Fentanyl patch to the state agency and realized she should have. Administrative Nurse D stated CMA R contacted the charge nurse and reported the missing patch. On 06/29/21 at 02:00 PM, Administrative Staff A verified the facility had not investigated R37's missing Fentanyl patch. On 06/29/21 at 02:15 PM, Administrative Staff A verified she received a text and a picture of the missing Fentanyl patch from CMA S on 04/26/21. The text documented the patch was found in the resident's night gown. Administrative Staff A verified she had not reported the missing patch to the state agency or law enforcement and had not completed an investigation but would start an investigation now. The facility's Abuse, Neglect, and Exploitation policy, dated December 2020, recorded the facility would protect the residents from any physical and mental mistreatment, involuntary seclusion and misappropriation of resident property through the action of the staff, other residents, family members and other visitor. Investigation procedure should include the following: verified witness statements, review of facility policies and procedures, resident care records, including care plans, ID notes and the latest MDS, employee counseling and disciplinary records, interview with the resident (s) involved when possible, and any other material deemed relevant to the factual and legal issues involved. Administrator or designee will report to Kansas Department for Aging and Disability Services (KDADS) injuries of unknown source immediately and investigate. Any complaint which alleges a possible criminal act requires immediate, written notification to a law enforcement agency. The facility failed to investigate R37's missing Fentanyl patch, placing the resident at risk for inadequate pain control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 63 residents. The sample included 16 residents, with one reviewed for hospice (end of life care). Based on observation, record review and interview, the facility failed to develop a comprehensive care plan for one of one sampled resident, Resident (R) 53. Findings included: - R53's Significant Change Minimum Data Set (MDS), dated [DATE], recorded the resident had short- and long-term memory loss with severely impaired cognition. The MDS recorded the resident required extensive staff assistance with bed mobility and transfers and received Hospice services. The Cognitive Loss Care Plan, dated 06/04/21, recorded the resident declined in condition with weight loss and skin breakdown, and dehydration expected. The care plan documented the goal was to keep the resident comfortable. Review of R53's Care Plans lacked a care plan for hospice care and services. On 06/24/21 at 10:00 AM, observation revealed R53 sat in a recliner with her eyes closed and the TV on in room. Review of the facility's Hospice Services Agreement/Contract , dated 08/28/17 stated hospice staff and facility staff were to collaborate and coordinate care for a hospice resident. On 06/29/21 at 02:10 PM, Administrative Nurse D stated she expected the facility to have a hospice care plan for R53 to be able to coordinate care with hospice services. Administrative Nurse D verified the facility lacked a hospice care plan for R53. The facility's Hospice Services Provided in the Nursing Facility policy, dated 08/21/17, documented the hospice provider's plan of care is integrated with the facility's comprehensive care plan. The facility's Hospice Care Plan policy, dated May 2021, documented it is the policy of the facility to improve quality and consistency of care between hospice and the facility in the provision of hospice care to the resident in order to attain or maintain the highest physical mental and psychosocial well-being of each resident. The policy documented the facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the facility to attain or maintain the resident's highest practical, physical, and mental, and psychosocial well-being. The facility failed to develop a comprehensive care plan for R53 who received hospice services, placing the resident at risk for inappropriate care.

The facility had a census of 63 residents. The sample included 16 residents. Based on observation, interview, and record review, the facility failed to maintain an environment free of accident hazards for two of five households. Findings included: - On 06/23/21 at 09:38 AM, observation revealed house 807's soiled linen closet unlocked and contained an unopened quart squirt bottle of Ecolab Degreaser, and an unopened bottle of Betco-Quat Stat five disinfectant. Both bottles labels documented, Keep out of reach of children can be hazardous to humans. On 06/23/21 at 10:00 AM, observation revealed house 805's soiled linen closet unlocked and contained an opened quart spray bottle of Glitz no rinse sanitizer. The bottle's label documented, Keep out of reach of children can cause eye irritation. On 06/23/21 at 10:20 AM, Administrative Nurse D verified the soiled linen closets in house 807 and house 805 should be locked at all times and a total of three cognitively impaired independently mobile residents resided in those houses. The facility's Chemical Storage policy, dated January 2021, documented it is the intent of the facility to keep all chemicals out of reach of cognitively impaired residents. Locked storage areas will be available for securing supplies that could be harmful to residents. The facility failed to adequately secure harmful chemicals in two of five households, placing the cognitively impaired, independently mobile residents at risk for injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 63 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, seven days a week, and utilized the Director of Nursing (DON) as the charge nurse for the 63 residents who resided in the facility. Findings included: - Review of the Registered Nursing Staffing Schedule for May and June 2021, recorded the Director of Nursing worked as the registered charge nurse on the floor on May 30, from 6:00 PM until 6:00 AM (12 hours) census 64 residents, June 3, from 6:00 PM until 6:00 AM (12 hours) census 63 residents, and June 8, from 6:00 PM until 10:00 PM (4 hours) census 62 residents. On 06/23/21 at 08:30 AM, observation revealed 63 residents resided in the facility. On 06/29/2021 at 02:30 PM, Administrative Staff A verified the DON worked as the registered charge nurse on the above documented dates. The Director of Nursing Job Description recorded the Registered Nurse would work a minimum of 40 hours a week and would be responsible to develop and maintain programs that support The [NAME] mission. The DON is responsible for the overall function of the nursing department and is a support for the partnering Director of Nursing in other areas. The DON is responsible for the overall function for working as a team member with other departments of The [NAME] to ensure the wellbeing of the residents and staff. The DON is responsible for overseeing the quality of care provided, meeting regulatory requirements, participating in the Quality Assurance Programs and overseeing staffing and staff educational needs. The DON is responsible to provide quality services and maintain financial standards. The DON also serves as a liaison with the community. The facility failed to provide a registered charge nurse for the 63 residents who resided in the facility, without utilizing the DON, placing the facility and residents at risk for inadequate nurse guidance and leadership.

The facility had a census of 63 residents. The sample included 16 residents. Based on observation, record review and interview, the facility failed to correctly prepare a pureed diet for one resident, Resident (R) 3. Findings included: - On 06/28/21 at 11:15 AM, observation revealed Dietary Staff (DS) CC prepared a pureed diet. DS CC placed two ounces of tuna salad in the ninja (a small blender) then blended the tuna salad, DS CC then added a packet of mayonnaise, blended, and emptied the blended tuna into a divided plate. Observation revealed DS CC then placed two ounces of hummus (a thick paste made from ground chickpeas) in the ninja and blended, then emptied the blended hummus onto the divided plate. Observation revealed DS CC then placed two ounces of creamed peas in the ninja and blended, then emptied the peas onto the divided plate. On 06/28/21 at 11:25 AM, DS CC stated, the pureed food looked like baby food, she was unaware she needed to follow a recipe, and stated she just blended it and added stuff. On 06/28/21 at 11:40 AM, DS BB verified DS CC did not follow a pureed recipe. DS BB stated she expected DS CC to follow a recipe, and verified the household did not have a pureed recipe book. The facility's Recipe Guideline for Pureed foods policy, dated February 2015, documented to measure the required amount of food needed for the pureed item according to the daily spreadsheet and recipe. Add required amount of liquid as directed by the recipe to obtain the correct consistency of the food item. The facility failed to prepare a pureed diet using professional standards for food service safety for R3, placing the resident at risk for impaired nutrition.

The facility had a census of 63 residents. Based on observation, interview, and record review, the facility failed to maintain clean kitchen equipment, in accordance with professional standards for food service safety, in four of the five households. Findings included: - On 06/28/21 at 11:35 AM, observation of household 801's kitchen revealed the two-door oven with numerous dried food particles on the oven door and the foil lined bottom of the oven, and large amounts of dark stains on the inside of the oven door. Dietary Staff (DS) CC stated staff were to clean the oven every Sunday but looked like it had not been cleaned in a while. On 06/28/21 at 11:50 AM, observation of household 803's kitchen revealed the two-door oven with numerous dried food particles on the oven door and the foil lined bottom of the oven, and large amounts of dark stains on the inside of the oven door. DS DD stated she was unsure who was responsible for cleaning the oven, but thought it might be maintenance. On 06/28/21 at 12:10 PM, observation of household 805's kitchen revealed the two-door oven with numerous dried food particles on the oven door and the foil lined bottom of the oven, and large amounts of dark stains on the inside of the oven door. DS EE stated the oven needed cleaned but staff did not have time to clean it. On 06/28/21 at 12:30 PM, observation of household 807's kitchen revealed the two-door oven with numerous dried food particles on the bottom of the oven and the oven door with large amounts of dark stains. DS FF stated she only worked part time and was unsure when the oven was to be cleaned. On 06/28/21 at 01:50 PM, DS BB verified the ovens in all four houses needed to be cleaned. The facility's undated Dining and Cleaning of Services policy documented all surfaces for intended use of food preparation must be clean and sanitized. Heavy soiled equipment is to be cleaned of dried foods and liquids. The facility failed to clean the ovens for all four houses, placing the residents at risk for food borne illnesses.