Based on observation, interview, review of the United States Department of Agriculture (USDA) web site, and review of the facility's policies, it was determined the facility failed to store and serve food in a safe manner which had the potential to affect 126 residents who received food from the kitchen.The findings include:Review of the USDA web site https://www.fsis.usda.gov, undated, revealed when checking food temperatures, a food thermometer was to be placed in the thickest part of the food, away from bone, fat or gristle. Continued review revealed for thin foods, the food thermometer was to be inserted through the side until it reached the center of the food. Further review revealed always check each piece of food to ensure it reached the safe internal temperature.Observation of the [NAME] on 07/22/2025 at 11:25 AM, during the lunch meal tray line, revealed the [NAME] pushed the food thermometers through the plastic wrap of the creamed corn, pureed enchilada casserole and kernel corn on the steam table.In interview with the Interim Dietary Manager on 07/24/2025 at 10:05 AM, she stated staff were not to pierce food with the thermometer through the plastic wrap or foil, as there was a potential for cross contamination. She said doing that could also cause a choking hazard. In interview with the [NAME] on 07/24/2025 at 10:20 AM, he stated the proper way to take the food temperature was by pulling back the plastic or foil covering the food. The [NAME] stated taking food temperatures that way would prevent the potential for cross contamination of the food.In interview with the Director of Nursing (DON) on 07/25/2025 at 1:09 PM, she stated her expectation was for staff to follow best practices for food service. She further stated, Plastic wrap or saran wrap over food, if you punch it, could be a potential aspiration risk or choking hazard. The DON further stated staff were to ensure the thermometer is clean and dry and inspected prior to use. In interview with the Administrator on 07/25/2025 at 3:18 PM, he stated his expectation was for staff to follow best practices for food service. He reported, When it comes to temping food in the kitchen, if there is a barrier like plastic wrap over the food, first of all, food should be uncovered and temped correctly. The Administrator further stated, I hope that wouldn't happen. In the event that should occur, I would hope staff would remove plastic wrap, if contamination, food should be replaced. I could foresee outcomes like choking or aspiration if served.

Based on interview, record review, and facility policy review, the facility failed to ensure its abuse prohibition policy was implemented by failing to verify and maintain documentation of screening and training, including criminal record checks required for pre-employment for 9 of 12 personnel files reviewed. The criminal background check, the nurse aide abuse registry check, and/or the Kentucky Adult Caregiver Misconduct Registry (KACMR) check was not completed for newly hired employees. Additionally, there was not documented evidence to support newly hired staff had received the abuse training required at the beginning of employment. The findings include: Review of the facility's policy titled, Abuse, Neglect, Exploitation, revised 03/05/2024, revealed, Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident's property. 1. Background, reference, and credential checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Further review of the policy revealed the pre-employment checks were to be completed before the employee came to the facility for orientation. Further review of the policy revealed new employees would be educated on abuse, neglect, exploitation, and misappropriation of the resident's property during initial orientation. Existing staff would receive annual education through planned in-services and as needed. Review of the Kentucky Revised Statutes (KRS) 209.032, effective 07/15/2014 and amended on 07/15/2024, revealed a vulnerable adult services provider, such as a long-term care facility was to, Query as to whether prospective or current employee has validated substantiated finding of adult abuse, neglect, or exploitation - Administrative regulations - Central registry of substantiated findings made on or after July 15, 2014. Continued review of the Statute revealed an employee included a person hired directly or through contract by a vulnerable adult services provider with duties that involved or might involve one-on-one contact with a resident. Further review revealed a vulnerable adult services provider was to query the cabinet as to if a validated substantiated finding of adult abuse, neglect, or exploitation was entered against an individual who was a prospective employee of the provider. 1. Review of the personnel file for Registered Nurse (RN)4 revealed a hire date of 01/28/2025, but the nurse aide abuse registry and KACMR check was not completed until after RN4's hire date, on 01/30/2025. Also, there was no documentation to support RN4 had completed abuse training. 2. Review of the personnel file for RN9 revealed a hire date of 01/24/2025, but the nurse aide abuse registry and KACMR check were not completed until after RN9's hire date, on 02/05/2025. Also, there was no documentation to support RN9 had completed the abuse training. 3. Review of the personnel file for Certified Nursing Assistant (CNA)23 revealed a hire date of 01/24/2025, however, her nurse aide abuse registry and KACMR checks were not completed until 02/13/2025. Additionally, there was no documentation to support CNA23's abuse training was completed. 4. Review of the personnel file for CNA24 revealed a hire date of 01/24/2025, however, there was no evidence to support the employee's criminal background check or the nurse aide abuse registry check were completed. Further review revealed no documentation to support the KACMR was checked. Also, review of CNA24's personnel filed showed no documentation that the abuse training had been completed. 5. Review of the personnel file for CNA25 revealed a hire date of 02/04/2025. Continued review revealed no documentation to support the CNA had completed abuse training. 6. Review of the personnel file for CNA26 revealed a hire date of 02/11/2025. Further review revealed no documentation to support the CNA had completed the abuse training. 7. Review of the personnel file for CNA14 revealed a hire date of 11/13/2024. Continued review revealed no documentation to support a criminal background check, nurse aide abuse registry check, or KACMR check were completed. Also, there was no documentation to support the CNA had completed the abuse training. 8. Review of the personnel file for CNA19 revealed a hire date of 03/24/2024 with no documentation to support the facility had completed a criminal background check, nurse aide abuse registry check, or KACMR check. Further, there was no documented evidence to support the CNA had completed abuse training. 9. Review of the personnel file for the former administrator revealed no hire date was provided. Further review revealed no documented evidence to support the nurse aide abuse registry check was completed. Continued review of the personnel file revealed the facility had completed the KACMR check on 01/17/2024 with the criminal background check completed on 01/04/2024. Additionally, there was no documentation to support the administrator had received abuse training. In an interview with the Administrator, on 02/13/2025 at 11:00 AM, she stated the two staff persons in Human Resources were responsible for completing the required pre-employment checks for newly hired employees. The Administrator stated there was a background check, a CNA abuse registry check, and one other check required for all newly hired employees. She stated the reason for these checks was to ensure there was no one working in the facility who was convicted in a court of law for abuse, a felony, or certain drug charges. The Administrator stated her expectation of the staff was for these checks to be completed prior to the new employee stepping foot inside the building. She stated if these checks were not completed prior to a new employee reporting to work at the facility, it was possible for them to potentially hurt one or more of the residents. She stated the current owners of the facility took over on 09/01/2024, thus had no knowledge of the employees background checks who were hired before then Further, the Administrator stated abuse training was completed upon hire, during orientation. In an interview with the Regional [NAME] President of Talent and Acquisition, who was currently filling the Human Resources role until they hired a permanent Human Resources person, on 02/13/2025 at 11:05 AM, regarding the pre-employment checks required for newly hired employees, she stated she and the other Human Resource staff person were responsible for completing the required pre-employment checks. She stated they completed a criminal background check that included the Office of Inspector General (OIG) exclusions check, and she stated it was outsourced through a contracted agency. The Regional [NAME] President of Talent and Acquisition stated there was also a KBN misconduct check completed, along with a license verification. She stated these checks were required to be completed before the new employee was allowed to walk inside the building. Further, she stated if the checks were not completed before the orientation, the new employee would be sent home until all the proper checks were completed. In continued interview, she stated any employee who was hired prior to 09/01/2024 would have had their background checks completed by the previous owner of the facility and anyone hired after 09/01/2024 was processed through them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, the facility failed to ensure an allegation of abuse was reported immediately, but no later than two hours after the allegation was made for one of five sampled residents (Resident (R) 79). On12/09/2024, Certified Nursing Assistant (CNA) 14 alleged that while changing R79, the resident become combative and CNA13 was observed to have choked the resident at approximately 5:20 AM. CNA 14 reported the alleged abuse at 8:37 PM to administration, which was approxmiately 15 hours after the incident was observed and delayed the facility's investigation of abuse. The findings include: Review of the Facility's policy titled, Abuse, Neglect, and Exploitation, date implemented 02/01/2024 and date revised 02/01/2024, revealed it was the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Further review of the policy revealed the facility would have written procedures that included reporting of all alleged violation to the Administrator, state agency, adult protective services, and all other required agencies (e.g., law enforcement when applicable) within specified time frames: Immediately, but not later than two hours after the allegation was made, if the events that cause the allegation involved abuse. Review of the Facility Investigation Initial Report dated 12/09/2024, revealed the incident occurred on 12/09/2024 at 5:24 AM but was not reported to the Administrator until 12/09/2024 at 8:37 PM. Family Member (F)4 was notified on 12/2024 at 9:00 PM (no day specified on the form). In a description of the incident, the Interim Administrator (IA) reported that at 8:37 PM on 12/09/2024, she received a call from the Staffing Coordinator (SC)19 who had a brief conversation with CNA14 CNA14 stated on the morning of 12/09/2024 around 5:20 AM she witnessed CNA13 choke R79, while providing care. CNA14 stated R79 had soiled her clothing and was being changed when she grabbed onto CNA13. CNA14 stated this made CNA13 angry and she reached over and forcibly choked R79. R79 gasped for air when the choke hold was released. CNA13 was not at work and was unable to be reached by phone. CNA13 was placed on suspension once reached. CNA14 was in-serviced after the reporting about the procedures on abuse identification and immediate reporting. Police were notified at 9:20 PM and arrived at the facility around 9:30 PM to take CNA14's statement. R79 was assessed at 10:30 PM on 12/09/2024 and there was no evidence of injury (bruising, scratches, bleeding, change in voice, hoarseness, or shortness of breath). The initial report was filed on 12/09/2024 (no time indicated) by IA. Review of the Facility's Five (5) day follow up investigation, dated 12/13/2024, revealed that R79 was examined by the Administrator, a CNA, and a Police Officer and there were no physical signs of abuse. The IA interviewed all staff on shift the night of the incident and Social Services (SS) reviewed all residents to be interviewed on the night shift assignments. The Director of Nursing (DON) with her team performed skin assessments on all vulnerable residents on the unit. No residents indicated any concerns and skin assessments were free from bruising or injury. Further review of the investigation packet only contained the interview sheets and not the skin assessments. There was only one witness to the incident (R14) who stated that CNA13 was cleaning up R79 and R79 began to fight. CNA13 stated she did not choke R79 and did not know why someone would report her as doing so. She stated that R79 had a bowel movement and that CNA14 came in to help her clean up R79. They bathed and dressed R79. The two nurses (no names given in the report) that normally supervised CNA13 and CNA14 stated that there were no known or alleged complaints against either CNA. Both nurses stated they were in and out of residents' rooms all night and never witnessed any concerns with resident care. Per a statement made by an unnamed nurse and CNA13, she was in the room while CNA13 was giving R79 a bed bath. All staff working the night of the incident were trained again on abuse and immediate reporting requirements. The Incident Investigation packet had a list of all staff that received this training on 12/09/2024. Review of R79's Electronic Medical Record (EMR) revealed R79 was admitted to the facility on [DATE] with the medical diagnoses of dementia, hypertension, and hyperparathyroidism. Review of R79's quarterly Minimum Data Set (MDS) from 10/10/2024 revealed that R79 had a Brief Interview for Mental Status (BIMS) of 03, severe cognitive impairment. The State Survey Agency (SSA) surveyor requested the Police Investigation Report from responding police department on 02/10/2025 at 11:28 AM. However, no report was provided for review. Observation of R79 on 02/04/2025 at 10:37 AM revealed the resident was sitting in the common area of the locked women's unit, dressed and clean. There were no signs of bruising or injury noted. She was not able to be interviewed. She only smiled when the SSA surveyor spoke with her. In an interview with F4 on 02/06/2025 at 9:12 AM he stated the facility called and notified him that R79 was placed in the shower by her caregiver when the resident became agitated and aggressive. He stated the facility reported the resident's caregiver choked R79. Further, he stated he was not aware of any mistreatment of the resident since. On 02/10/2025 at 10:54 AM, the State Survey Agency (SSA) surveyor attempted to call the witness, CNA14. The CNA no longer worked at the facility and the phone number provided was no longer in service. On 02/10/2025 at 10:56 AM in a phone interview with CNA13 she stated that she took care of R79 the entire thirteen (13) months she was employed at the facility. CNA13 stated that R79 was often combative with staff when they were trying to change her after incontinence or when she was getting a shower. She stated she was suspended over an incident that occurred with R79 and was not allowed to return to work until the incident was investigated. Per the interview, she stated the CNA (CNA14) reported to staff that she had been rough and hit the resident. CNA13 stated the facility had unsubstantiated the incident. On 02/10/2025 at 2:01 PM in a phone interview with the Interim Administrator (IA), she stated she remembered making the report. She stated the original verbal report of the choking incident went to Staffing Coordinator (SC). She stated the SC called her at approximately 8:30 PM on 12/09/2024 to report the incident of abuse. The IA stated she had just arrived home and turned around and went back to the facility and took the statement from CNA14. The IA stated she then called the police, and they came and did an exam of R79 with the IA. Per the interview, she stated the police looked for marks that would signify any abuse. The officer used a flashlight to look at R79's neck. She further stated that once the police officer left the facility, she instructed her staff to complete another exam to make sure nothing was missed. The IA stated she could not found any evidence of the abuse. In continued interview, with the Interim Administrator (IA), on 02/10/2025 at 2:01 PM, she stated she talked to all the staff and no one reported they saw or heard anything (on the day of the alleged incident). The IA stated that after this incident they suspended a couple of CNAs. CNA13 was also placed on suspension. She stated that she left before the investigation was completed on CNA13. The Administrator stated the police officer contacted her on her last day at the facility and stated he did not believe the abuse occurred but thought that staff made up allegations to get back at the other. The IA stated CNA14 delayed her reporting of the incident. On 02/12/2025 at 9:38 AM in an interview with the Director of Nursing (DON), she said that CNA14 reported she was in the room with another CNA (CNA13) when R79 became combative. She stated CNA14 reported CNA13 had placed her hands on R79's neck and choked her. Per the interview, the DON stated her expectation of the staff was for staff to report allegations of abuse immediately. The DON stated staff should ensure the resident was out of harms way. Then, after ensuring the safety of the resident, the nurse , DON, or Administrator should be contacted. Further, she stated the reporting CNA (CNA14) was sent home and CNA13, the alleged perpetrator, was put on leave. She stated the allegation was not substantiated and CNA13 was brought back on day shift at the recommendation of Human Resources (HR). On 02/13/2025 at 8:18 AM in an interview with the Administrator she stated that she was not employed at the facility when the incident with CNA13 and R79 occurred. Her expectation was if there was an allegation of abuse staff should make sure the resident was safe and tell the nurse about the allegation immediately. Then the nurse would make her aware of the situation. The staff member that was the alleged perpetrator would be taken off work until the allegations were investigated.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 22 sampled residents, (Resident (R) 22). The facility failed to develop R22's comprehensive care plan regarding a SoftPro Ambulating ankle foot orthoses (AFO) Boot (an ankle foot orthoses used to treat mild to moderate lost range of motion of the ankle/foot and to facilitate assisted weight bearing). The finding include: Review of the facility's policy, Comprehensive Care Plan Guideline, dated 05/22/2018, revealed the facility ensured appropriateness of services and communication that met the resident's needs, severity/stability of condition, impairment, disability, or disease in accordance with state and federal guidelines. Review of the facility's policy, Resident Rights Guidelines, dated 02/15/2024, revealed the facility ensured resident rights were respected and protected and provided an environment on which they could be exercised. Review of R22's electronic medical record (EMR) Face Sheet revealed the facility admitted the resident on 05/25/2020, with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, cerebral infarction and dementia. Review of R22's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 01/02/2025, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated he was cognitively intact. Review of the comprehensive-person centered care plan for R22, dated 01/02/2025, revealed no documented evidence of a care plan to address the resident wearing a SoftPro Ambulating AFO boot on his left foot. Observation on 02/03/2025 at 1:35 PM, revealed R22 could not self-ambulate in his wheelchair due to wearing a broken SoftPro Ambulating AFO Boot on his left foot. Further observation revealed R22's wheelchair footrest was not elevated to keep the resident's foot from dragging on the floor. Observation on 02/03/2025 at 3:15 PM, revealed R22 was wearing a SoftPro Ambulating AFO boot on his left foot, asking staff to lift his foot and place it on the footrest of his wheelchair. Observation between 02/03/2025 and 02/12/2025 at various times revealed R22 was wearing the SoftPro Ambulating AFO boot around the facility. In interview with R22 on 02/06/2025 at 9:10 AM, he stated his SoftPro Ambulating AFO boot was broken, and the Director of Nursing (DON) informed him she was going to order him a new boot. In interview with the DON on 02/06/2025 at 9:23 AM, she stated she was aware R22's SoftPro Ambulating AFO Boot was broken, and she had ordered another boot. The DON stated she was unaware of Resident 22 not being care planned for the boot. The DON stated she assumed the resident was care planned for the boot as he had been wearing it for sometime. In an interview with Minimum Date Set Coordinator (MDSC) on 02/12/25 at 10:37 AM stated she has been at the facility for almost two years. The MDSC stated she completes the care plans and that all nurses in facility have access to complete a care plan. The MDS Coordinator stated if a resident was admitted she completed the care plan the next day. The MDS Coordinator stated nurses could complete the care plan under evaluations then select the admission assessment located where they could complete a baseline care plan. The MDS Coordinator stated the facility's version of baseline consist of basic activities of daily living, support need, and anything a resident may be at risk. In interview with the Administrator on 02/13/2025 at 9:38 AM, she stated comprehensive care plans should be updated within 24 hours of admission, so the correct care could be provided for the resident. The Administrator stated baseline and comprehensive care plans were very important for patient care. She stated the facility provided the best quality of care to all residents and R22's care plan not being developed (to include the AFO) could just possibly be an oversight. In additional interview with the DON on 02/13/2025 at 10:23 AM, she stated it was very critical any resident's baseline and comprehensive care plans were developed or updated in a timely manner. The DON stated comprehensive care plans should be completed seven days after the completed comprehensive (MDS) assessment. Additionally, the DON stated documentation in the progress notes for R22 should have included any occupational and physical therapy notes regarding the use of the SoftPro Ambulating AFO Boot the resident was issued and wearing.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure all drugs were labeled in accordance with professional standards. Observations revealed undated, opened, unlabeled and expired medications in 1 of 5 medication carts and 1 of 2 treatment carts. Those medications included topical creams, and one oral pill. The findings include: Review of the facility's policy titled, Medication Storage, dated 02/01/2024, revealed The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. The medications are destroyed in accordance with our Destruction of Unused Drugs Policy. The policy did not address documenting on open/expiration dates, unlabeled medications, or the long-term storage of ointments/creams in the labeled, pharmacy supplied protective plastic storage bag. Review of the facility's policy titled, Medication Administration, dated 02/02/2024, revealed, Identify expiration dates. If expired, notify nurse manager. 1. During observation on 02/04/2025 at 10:57 AM of the men's memory care unit's treatment cart revealed one tube of Silvasorb gel topical medication used to treat a variety of skin wounds with an expiration date of 07/2024. This medication was not labeled and had no identifier. Additional observation revealed one tube of Diclofenac 1% topical medication used to treat arthritic pain without an open date and was not in a storage bag for Resident (R) 87. During an interview on 02/04/2025 at 10:57 AM with Registered Nurse (RN) 1, she stated that pharmacy usually go through the carts about once a month. 2. During observation of the medication cart for the B hall on 02/04/2025 at 3:50 PM, revealed a pill separated from the pack in the top drawer of the medication cart. Further observation revealed the medication was Cyclobenzaprine (a muscle relaxant) 5 milligrams (mg). The medication was unlabeled and had no resident identifier. During an interview on 02/04/2025 at 3:50 PM with Licensed Practical Nurse (LPN) 2, she stated that night shift must have left it and that she would destroy it immediately. During an interview on 02/06/2025 at 2:05 PM with the Unit Manager, she stated that expired medications were not to be in the carts and were to be discarded according to the facility's policy. She stated that the nursing staff were to go through the medication carts weekly and monthly, and that included the treatment carts. She stated medications were to be labeled with the open date and initials, and kept in their bag and separated individually. She stated that random or floating pills were expected to be wasted. She stated medications should be patient (resident) identifiable and in their individual containers. The Unit Manager stated there was too much of an opportunity for a negative outcome. During an interview on 02/06/2025 at 2:40 PM with Staff Development, she stated it was difficult to discern a medication for a resident if it was left unlabeled in the medication cart, which could result in a potential medication error. She stated that education was provided annually during the skills fair on medication administration and ordering medication from the pharmacy. She stated medications come prepackaged individually with the resident's name. She stated she teaches the rights of medication administration, locking the med carts, how to properly open medications, and how to properly discard medications. During an interview on 02/06/2025 at 2:15 PM with the Director of Nursing (DON), she stated it was her expectation that expired medications were not to be in the carts. She stated the nurses were expected to look at the dates prior to use and reorder the medication and dispose the expired medications. She stated that open dates and expiration dates should be written on the medications with either the 30 day after open date or the manufacture's date, whichever comes first. The DON stated the nurses were to look at the medications in the carts daily for expiration dates and the unit managers were to check once a week. She stated random pills in the medication carts were expected to dispose the medications. The DON stated medications were to be in their separate container with a resident identifier. During an interview on 02/06/2025 at 2:33 PM with the Administrator, she stated it was her expectation that expired medications should not be in the medication or treatment carts. She stated any nurse could check at least once a week and review the carts. She stated medications have to have open dates according to policy. The Administrator stated that loose, random medications in the carts must be destroyed. She stated medications could not be in medication carts without personal containers with identifiers needed. She stated a negative outcome could be death, the right medications needed to go to the right resident.

Based on observation, interview, record review and review of facility documentation, policies, and Plan of Correction (POC), the facility failed to ensure it was administered in a manner that enabled it to use its' resources effectively and efficiently to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. During the Revisit Survey from 04/01/2025 through 04/04/2025, the State Survey Agency (SSA) identified continued non-compliance for the facility in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F607); 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656); and 42 CFR 483.45 Pharmacy Services (F761). Review of the facility's Plan of Correction (POC), which alleged substantial compliance as of 03/05/2025, revealed the facility's Administrator failed to have an effective process in place to address the systemic failures through the Quality Assurance Performance Improvement (QAPI) process. As a result, the facility failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. The facility was recited for the continued non-compliance at the highest Scope and Severity (S/S) of a D. (Refer to F607, F656, and F761). The findings include: Review of the facility's, Position Description: Executive Director, (more commonly referred to as Administrator), revised 02/01/2024, revealed the Administrator, was responsible for assuring the center operates in full compliance with Federal and State regulations, which will result in high levels of performance . Continued review of the Administrator's position description revealed the Administrator was responsible for planning and was accountable for all activities and departments. Further review revealed the Administrator was also subject to rules and regulations promulgated by government agencies to ensure the proper health care services for residents. Review additionally revealed the Administrator was to administer, direct, and coordinate all activities of the center (facility) to assure the highest degree of quality of care was consistently provided to residents. Review of the facility's POC for the Recertification/Abbreviated/Extended Survey, concluded on 02/13/2025, revealed the facility's Administrator failed to have an effective process in place to address the systemic failures in the facility through its Quality Assurance Performance Improvement (QAPI) process. Therefore, the facility continued to have noncompliance in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F607); 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656); and 42 CFR 483.45 Pharmacy Services (F761), following the Revisit Survey concluded on 04/04/2025. 1. Based on interview, record review, and facility policy review, the facility failed to ensure freedom from abuse, neglect, and exploitation regarding not completing the required pre-employment checks, specifically the criminal background, nurse aide abuse registry and Kentucky Vulnerable Adult Maltreatment Registry (KVAMR) checks for two of five personnel files reviewed. (Refer to F607). 2. Based on observation, interview, and record review, the facility failed to ensure the development and implementation of comprehensive resident centered care plans for three of 23 sampled residents. (Refer to F656). 3. Based on observation, interview, and record review, the facility failed to ensure all drugs were labeled in accordance with professional standards regarding expired ophthalmic drops and a loose, unlabeled pill found in two separate medication carts. (Refer to F761). In interview with the Assistant Director of Nursing (ADON) on 04/03/2025 at 4:11 PM, she stated the facility's POC was a team effort which was overseen by the Administrator and nursing team. She stated it was her expectation staff would find and discard any expired medications on the medication carts during the audits being performed. The ADON reported any loose medications were a definite issue and the breakdown in the process of implementing the facility's POC fell on the managers. In interview on 04/03/2025 at 4:54 PM, the Administrator stated she was responsible for ensuring all staff were educated and for ensuring all audits were completed as per the facility's POC. The Administrator said she expected education of staff to be performed, for staff to follow the facility's policies and perform all audits as required in the POC. She further stated she was ultimately responsible for making sure all sections of the facility's POC were followed.

Based on observation, interview, record review, and review of the facility's documentation and policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases and infections for 2 of 3 sampled residents (Resident (R) 20 and R67). Observations of Licensed Practical Nurse (LPN)6 of R20 and R67 during wound care revealed the LPN failed to perform hand hygiene when moving from a dirty task to a clean task. Additionally, the LPN failed to ensure a barrier was in place before placing supplies on the table. In an interview with the Wound Doctor, she stated this practice could contaminate the wound and cause an infection. The findings include: Review of the facility's policy titled, Wound Treatment and Management, with a date implemented of 02/01/2024 and a date revised of 02/14/2024, revealed the purpose of the policy was to promote wound healing of various types of wounds by providing evidence-based treatments in accordance with current standards of practice and physicians orders. Review of the facility's policy titled, Hand Hygiene, revised on 02/16/2024, revealed that all staff would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The policy outlined the technique for hand hygiene with alcohol based hand rub (ABHR), soap and water, and listed under what conditions each should be performed. Further review of the policy revealed the use of gloves did not replace hand hygiene. If the task required gloves, hand hygiene should be performed prior to donning gloves and immediately after removing gloves. Review of the facility's policy titled, Enhanced Barrier Precautions, revised on 02/01/2024, revealed that it was the practice of the facility to implement Enhance Barrier Precautions (EBP) for the prevention and transmission of multidrug resistant organisms. Further review of the policy stated that clear signage should be posted on the resident's door stating the type of personal protective equipment (PPE) needed for high contact resident care activities. PPE, such as gown and gloves, would be made immediately available outside the room's door and ABHR should be both inside and immediately outside the resident's door. The policy outlined who would be placed on EBP and defined what activities were considered high contact resident care activities. 1. Review of R20's Electronic Medical Record (EMR) revealed the facility admitted the resident on 11/15/2022 with the medical diagnoses of chronic obstructive pulmonary disease (COPD), schizoaffective disorder, chronic pain syndrome, and fibromyalgia. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/07/2025 revealed R20 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R20's Comprehensive Care Plan (CCP), undated, revealed the resident was care planned for the focus of altered skin integrity related to an abscess of left leg (resolved) and a wound on the left hip. The goal for this focus was R20's altered skin integrity would show signs of healing. R20 was also care planned for the focus of enhanced barrier precautions (EBP) due to altered skin integrity. The goal of this focus was resident would have a reduced likelihood of transmission of resistant organisms through target date. The interventions for this focus were to educate resident and/or family on the need for enhanced barrier precautions; enhanced barrier precautions implemented during high touch care activities; and staff must wear a gown and gloves when providing high touch care. Review of R20's Physician Orders in her EMR revealed she had an order for the abscess of the left hip/leg to cleanse with normal saline, pat dry, and apply calcium alginate with silver. The wound was to be covered with border gauze. Wound care was to be done daily. She also has an order for Enhanced Barrier Precautions (EBP) related to her wound. Observation of wound care for R20 on 02/07/2025 at 2:44 PM provided by Licensed Practical Nurse (LPN) 6 revealed that she hand sanitized and put on PPE prior to entering R20's room. Once in the resident's room, the LPN raised the resident's bed and moved other items in the room on the bedside table without washing her hands or changing her gloves. The table and sink that LPN6 placed her items on were not cleaned and a barrier was not placed. LPN6 then removed the dressing from the resident's wound and did not wash her hands or change her gloves prior to opening the sterile items needed for the wound care. After opening the bandages, she washed her hands and changed gloves, then reached into her pocket to remove her bottle of normal saline used to do the wound cleansing. She did not wash her hands or change her gloves. The wound was smaller than a dime in size and had yellow drainage. She cleaned the wound and only changed her gloves, however, did not wash her hands. Her gown touched against the open dressings on the table multiple times during wound care. She placed the calcium alginate on the wound and then put on the border gauze. She touched the resident's bed controls and bedside table prior to taking off her gloves and washing her hands. She then threw away the Normal Saline(NS) and all the other items left from the wound care. On 02/03/2025 at 2:43 PM in an interview with R20, she stated that she had a boil on her left hip, adding she has had one in the past, which had healed. In an interview with LPN4 on 02/06/2025 at 3:33 PM she said R20 had a boil on her left hip and was getting wound care for it. She stated she had only seen it once, so she was unable to state if it was healing or not. Per the interview, she stated the wound had drainage but no offensive odor. LPN4 stated R20's treatments were provided on day shift. She stated the resident's wound was cleaned with calcium alginate with border dressing. 2. Review of R67's Electronic Medical Record (EMR) revealed the facility admitted her on 10/14/2022 with medical diagnoses including cerebral infarction due to embolism of the left middle cerebral artery, dementia, type II diabetes mellitus, chronic diastolic heart failure, and chronic kidney disease stage 3A. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/2024 revealed the facility did not conduct a BIMS score for the resident. The facility assessed R67 as having a pressure ulcer and at risk for developing pressure ulcers/injuries. Additionally, the record indicated R67 had one stage 2 and one stage 4 pressure ulcer. Further review revealed the facility assessed R67 as having 2 unstageable deep tissue injuries. Treatment for the PUs: pressure reducing device for bed, nutrition and hydration interventions, PU injury care, and applications of ointments/medications (other than to feet). Review of R67's current Comprehensive Care Plan (CCP) from 01/15/2025 revealed the facility care planned her for the focus of potential skin impairment related to incontinence, diabetes mellitus, current skin impairment, and limited mobility. The interventions for this focus were incontinence care every shift and as needed for incontinence episodes. Further review revealed the facility would ensure the resident received her treatments as ordered; complete observation of the resident's skin during care and report any concerns to the nurse. Review of a Wound Care Note from 02/06/2025 revealed a stage IV pressure ulcer on her sacrum that was 0.8-centimeter (cm) x 0.3 cm x 0.1 cm. The pressure ulcer on the sacrum was assessed as having a surface area of 0.24 cm squared, with moderate serous exudate. It had 90% granulating tissue and 10% slough. The pressure ulcer was noted to have improved as evidenced by the decreased surface area. The current treatment plan for the pressure ulcer was to cleanse with normal saline, pat dry and apply alginate rope and Leptospermum honey. Further review of the note revealed staff were to use a gauze island with border to cover the pressure ulcer. Further review of the note revealed that the pressure ulcer was not likely to heal and the wound physician had recommended an assessment for ultrasound mist therapy. Observation of wound care performed on 02/07/2025 at 2:05 PM by licensed practical nurse LPN6 for R67 revealed Certified Nursing Assistant (CNA) 9 and CNA11 were in the room to help roll R67. Both CNAs performed hand hygiene and put on gown and gloves. Continued observations revealed LPN6 performed hand hygiene and donned (put on) a gown and gloves prior to entering R67's room. She did not wipe off the bedside table nor place a barrier on the bedside table prior to placing the supplies for the wound treatment onto the table. An unopened dressing fell to the floor and LPN6 retrieved the package placed it back onto the table. LPN6 indicated she forgot to bring the normal saline for cleansing R67's wound. She removed her personal protective equipment (PPE) and left the room. When she returned, she had donned a new gown and had gloves in her hands and proceeded to put the gloves on inside the room and then lowered the head of R67's bed and uncovered R67. There was no dressing over the sacral wound as LPN6 explained it was removed just prior during incontinence care. LPN6 did not change her gloves or wash her hands after lowering the head of R67's bed and removing the resident's bed covers and brief. She proceeded to open the sterile wound care supplies with the same contaminated gloves. Continued observations revealed LPN6 wiped the wound with gauze moistened with NS and patted it dry. She did not change gloves or wash her hands after cleaning the wound; and then she used her gloved fingers to wipe the Leptospermum honey onto the wound. She then took off her gloves, washed her hands, and placed new gloves on. After donning new gloves, LPN6 pressed the silence button on the tube feed pump, and did not perform hand hygiene or change her gloves. She packed the calcium alginate rope into the wound and placed a border gauze undated and unlabeled over the wound. LPN6 labeled and dated the dressing after it was adhered to R67. In an interview on 02/07/2025 at 2:40 PM with LPN6 regarding the wound care treatment she provided to both R20 and R67, she stated she forgot to do some things during the wound treatment such as performing hand hygiene when she returned to the room after leaving to go and get the normal saline for the wound cleansing. LPN6 did not comment regarding her not washing her hands or changing gloves when she moved from a dirty task to a clean task (such as after cleaning the wound and then immediately putting the Leptospermum honey and calcium alginate onto the wound without washing her hands and changing her gloves). LPN6 stated she should remove her gloves, perform hand hygiene, and then put on new gloves when moving from dirty to clean in a wound care, such as after removing an old dressing. Further, LPN6 stated hand hygiene and a glove change should be done after cleansing the wound. Additionally, LPN6 stated she typically placed a barrier before placing supplies on a table and that she should have performed hand hygiene and donned fresh gloves after touching resident equipment and before opening clean wound care supplies. In an interview with the Director of Nursing (DON) on 02/12/2025 at 9:38 AM, she stated her expectation for wound care was for staff to have a clean field on which to do wound care. She stated there should be a barrier placed and staff should clean the table prior to placing the barrier. Further, she stated staff should clean their hands and put on new gloves after touching items in the room such as the bed controls, tube feed pump, or the resident. She stated staff should change gloves after cleaning the wound and wash their hands and/or use hand sanitizer each time their gloves were changed. The DON stated that she expected staff to wash their hands and sanitize after any dirty task and change gloves. In an interview with the Wound Care Nurse/Staff Development Coordinator (WCN/SDC) on 02/12/2025 at 1:17 PM, she stated it was her expectation of staff performing would care to clean the surface they were placing their barrier on with bleach wipes and allow it to dry the specified time before putting down a barrier like a chux. Then wound care supplies should be put on the clean chux. She stated staff should hand sanitize and/or hand wash before putting on PPE (gloves and gown) to enter the room for the wound treatment. Further, she stated staff should also change gloves and wash their hands when touching anything that was not clean or sterile. The SDC stated her expectation was that the Leptospermum honey would be applied to the wound with an applicator to prevent contaminating the wound and the Leptospermum honey bottle. She stated if proper hand hygiene and changing of gloves did not occur this could cause contamination of the wound and possible infection. In an interview on 02/13/2025 at 9:17 AM with the Wound Doctor, she stated she had been seeing R67 weekly for her pressure ulcer since she inherited the facility from the previous wound doctor. She stated her expectations for wound care was that nurses go into the resident's room with PPE on. She stated staff should perform hand hygiene and wear gloves for all wound care. Further, she stated gloves should be changed in between each wound. The Wound Doctor stated that if staffs' hands were soiled staff should wash their hands, otherwise, they could use hand sanitizer for hand hygiene. She stated she expected staff to change their PPE between residents. The Wound Doctor stated she expected staff to use hand sanitizer and put on new gloves after they clean the wound. Per the interview, she stated if staff touched anything in the room that was not clean or sterile, staff should complete hand hygiene and change gloves. Further, she stated barriers should be down when completing wound care, to put the supplies on. She stated if staff did not perform hand hygiene and change gloves appropriately, staff could contaminate the wound and cause an infection.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to provide residents and/or guardians with resident personal funds account quarterly statements for 5 of 5 residents sampled for personal funds accounts, (Residents (R) 1, R6, R8, R22, and R49). The findings include: Review of the facility's policy, Resident Rights, dated 02/15/2024, revealed the facility must furnish to each resident a written description of (their) legal rights which included a description of a manner in protecting personal funds. Review of the facility's policy, Resident Personal Funds, dated 01/09/2024, revealed the facility was to ensure individual financial records were available to the resident through quarterly statements and upon request. 1. Review of R1's, Resident Statement dated 02/10/2025, revealed the resident had a credit of $1,344.00 at the end of the business day on 02/01/2025. Review of the facility's Surety Bond Certification dated 08/30/2024, revealed the facility was licensed and certified for $145,000.00. In interview with Representative 1 on 02/10/2025 at 10:19 AM, he stated he did not receive quarterly statements from the facility concerning R1's personal funds. Representative 1 stated he used an old quarterly statement, changed the date and mailed his payment in with the old quarterly statement. He stated he did receive a statement with what he owed the facility; however, the amounts never were the same each month. Representative 1 stated he just sent in $1,344.00 per month and he had no idea if he had any credits or owed money at that date and time. 2. In interview with R6 on 02/13/2025 at 10:45 AM, she stated she did not receive her quarterly statement unless she asked the Business Office Manager (BOM) for the statement. R6 stated when she withdrew money from her Resident Fund Account, she signed to confirm she received her money; however, the receipt did not give the balance of her account. 3. In interview on 02/09/2025 at 3:25 PM, R8 stated he had not received a quarterly statement. He stated he had to call the BOM to inquire about his balance. 4. In interview on 02/03/2025 at 1:52 PM, R22 stated he did not receive a quarterly statement from the Business Office. 5. In interview with R49's Representative on 02/10/2025 at 10:17 AM, she stated for some months she had not received a quarterly statement from the facility. Representative 49 stated she went to the facility to pick up the quarterly statement due to not receiving them by mail, as she requested. In interview with the BOM on 02/10/2025 at 1:37 PM, she stated she transferred to the current facility from a sister facility in June 2023. The BOM stated October 2024 was when the facility should have had quarterly statements. She stated however, the facility was bought by another company in August 2024 and did not transfer resident funds accounts until November 2024. The BOM stated the quarterly statements were mailed from the corporate office to residents and/or their guardian at the address on file with the facility. In interview with the Director of Nursing (DON) on 02/13/2025 at 10:23 AM, she stated residents could request to receive their quarterly statements at any time. She stated she was unaware residents were not receiving their quarterly statements. The DON stated not providing quarterly statements to the residents violated their rights. She stated the business office was responsible for sending out quarterly statements to the residents and guardians. The DON stated the facility had been bought by another company in August 2024. In interview with the Administrator on 02/13/2025 at 9:38 AM, she stated residents had issues with receiving quarterly statements. However, residents had been receiving their statements since her hire date, 12/18/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility policy, the facility failed to ensure the residents' environment was safe, clean, comfortable, and homelike. The facility failed to provide a functional and comfortable environment for residents related to cold water temperatures for 14 out of 19 resident rooms. (Rooms 101, 102, 103, 105, 106, 107, 108, 109, 110, 121, 122, 124, 125, and 126). The findings include: Review of the facility's policy titled, Resident Rights, revised 02/15/2024, revealed the residents had a right to a safe, clean, comfortable, homelike environment, including but not limited to receiving treatment and support for daily living. Review of the facility's policy titled, Safe and Homelike Environment, revised 03/09/2024, revealed housekeeping and maintenance services were provided as necessary to maintain a sanitary, orderly, and comfortable environment. Further review of the policy revealed under General Considerations to report any unresolved environmental concerns to the Administrator. Observation on 02/03/2025 at 2:43 PM of the temperature of the sink's water in room [ROOM NUMBER] revealed when only the hot water was turned on it was cold to the touch. Further observation revealed that despite running the water for approximately five (5) minutes, there was no change in the temperature. Observation on 02/03/2025 at 3:16 PM of the temperature of the sink's water in room [ROOM NUMBER] revealed it was cold when only the hot water was turned on and ran for greater than five (5) minutes without any change in temperature. Observation on 02/03/2025 at 9:10 AM of the temperature of the sink's water in room [ROOM NUMBER] revealed it was cold if only the hot water tap was on and ran consistently for five (5) minutes. Observation of room water temperature in room [ROOM NUMBER], on 02/07/2025 at 2:44 PM revealed despite Licensed Practical Nurse (LPN) 6 allowing the water to run for eight (8) minutes during R20's wound care, the water never got warm. On 02/07/2025 at 9:43 AM an observation of the Hall A Shower room revealed the shower did not turn on and the water in the sink was cold and did not get hot despite letting it run for over five (5) minutes. Observation of room water temperatures on 02/09/2025 at 4:01 PM revealed the following: room [ROOM NUMBER]'s hot water temperature was 55 degrees Fahrenheit (F); room [ROOM NUMBER]'s hot water temperature was 50.4 degrees F; and, room [ROOM NUMBER]'s hot water temperature was 52 degrees F. Observation of the water temperature in Hall A Shower Room on the East Unit on 02/10/2025 at 10:00 AM revealed the hot water temperature for the sink was 48.7 degrees F and for the shower was 44 degrees F. Observation of the water temperatures for Hall B on the East Unit on 02/10/2025 at 10:03 AM revealed for rooms 121 through 126, no water temperatures were over 50 degrees F. Respectively in room number order they were: 48.4 F, 47.2 F, 44 F, 44.5 F, 44.1 F, and 46.1 F. On 02/09/2025 at 3:53 PM the water temperatures of the hot water in multiple rooms were checked. room [ROOM NUMBER]'s hot water temperature after running for 5 minutes was 55 degrees F. The hot water in room [ROOM NUMBER] after running for 5 minutes was 52 degrees F. The hot water in room [ROOM NUMBER] after running for 5 minutes was 50.4 degrees F. The hot water for the shower room on the 100 Hall sink, after running for 5 minutes was 56.8 degrees F, and the hot water from the shower after running for 5 minutes was 57.4 degrees F. In an interview with Resident (R) 20 on 02/03/2025 at 2:43 PM she stated she had no hot water in her sink for over a month. R20 stated this was why she had not been able to get her hair washed. In an interview with R6 on 02/03/2025 at 3:55 PM she stated she had met the new owner of the facility, and she made him aware of the lack of hot water in their rooms. R6 stated she had met with the Ombudsman over some issues as well, including the lack of hot water in the room. In an interview with R50 on 02/04/2025 at 9:01 AM he stated it took a long time for his water to get hot, if it ever did get hot. In an interview with R43 on 02/04/2025 at 9:10 AM he stated his water in his sink was always cold. In an interview with R83 on 02/04/2025 at 11:15 AM she stated they have had no hot water in their room for a month. In an interview with R72 on 02/04/2025 at 12:10 PM she stated was no hot water in their room for months. In an interview with R73 on 02/04/2025 at 12:30 PM she stated they have no hot water in their room, have not had any hot water for months. In an interview with R14 on 02/04/2025 at 4:00 PM she stated they have not had any hot water in their room for at least a month. In an interview with R51 on 02/04/2025 at 4:05 PM she stated they had no hot water in their room and haven't had any for a month. On 02/07/2025 at 9:47 AM in an interview with the Maintenance Director (MD) and the Assistant Maintenance Director (AMD) it was revealed they did not know that Hall A Shower Room shower was not working; nor did they know there was no hot water in rooms on Hall B. The MD said he did the water temperature checks last Friday, and they were fine. When asked how he does the water temperatures he stated that he picks a room on each hallway and takes the temperature of that room only. Each week he picks a different room for that hallway. He stated that he then records that number for the hallway in the facility's electronic maintenance record. The MD and AMD stated they had pipes burst and ceiling caved in due to extreme cold temperatures in January. He stated no residents lost heat or hot water during the incident. On 02/07/2025 at 10:07 AM the night shift unit manager for the East Unit, Registered Nurse (RN)1 stated she was not sure how long Hall A Shower Room had not worked or had hot water. On 02/07/2025 at 1:25 PM in an interview with the day shift Unit Manager (UM)10 for the East Unit, she stated Hall A Shower Room did not have hot water and that was why the staff used Hall D Shower Room. She stated Hall C Shower Room was currently being remodeled and was unsure how long it had been closed. She thought that both had been down since November or December. On 02/12/2025 at 9:38 AM in an interview with the Director of Nursing (DON), she stated they have had no hot water off and on for the last few weeks. The DON stated she understood why Hall A Shower Room could not be used due to the cold water. She stated she did think it was an issue that 72 residents were using the one shower room on the East Unit that worked. On 02/12/2025 at 10:31 AM in an interview with Social Services (SS), when the pipes burst some residents ran out of hot water due to the high demand for the one shower room and he would have to tell them to wait a half an hour until the water heated back up and try getting a shower again. He stated that for the female residents who were able to walk, the Certified Nursing Assistants (CNA) took them to the locked women's unit for a shower instead. On 02/13/2025 at 8:18 AM in an interview with the Administrator she stated renovations were ongoing and they were currently working on three of the six shower rooms: [NAME] Unit Shower, East Unit Hall A Shower, and East Unit Hall C Shower. The reason there was no hot water was due to these renovations, but this issue had been fixed. She stated she was unaware of the cold water in residents' rooms and in Hall A Shower Room until this past Sunday when they were made aware and since then a plumber had come and fixed the issue. When asked if she felt one shower was sufficient for 72 residents, she stated the facility had three other showers residents could utilize.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a performance review was completed for every Certified Nursing Assistant (CNA) at least once every 12-months for five out of five CNAs' personnel records reviewed, CNA #2, #18, #20, #31, and #32. Additionally, the facility failed to provide evidence of regular in-service education based on the outcome of these reviews for three of five records reviewed, CNA #18, #31, and #32. The findings include: The State Survey Agency requested a staffing policy on 02/11/2025 at 3:05 PM; however, the facility did not provide a policy. During an interview, at that time, with the Executive Director he stated the facility did not have a staffing policy. He stated they based staffing off the facility's assessment. Review of the facility's policy titled, Job Description; Certified Nursing Assistant, dated 02/01/2024, revealed CNAs were to attend a minimum of 12 hours of continuing education programs provided by the center in order to maintain certification. Review of CNA2's personnel file revealed a hire date of 02/25/2022 and 13.41 annual training hours completed. However, there was no documentation of a performance evaluation in the previous 12 months. Review of CNA18's personnel file revealed a hire date of 01/18/2021 and only 5.63 annual training hours completed. Further review revealed no performance evaluation documented in the previous 12 months. Review of CNA20's personnel file revealed a hire date of 11/01/2019 and 22.75 annual training hours completed but no documentation of a performance evaluation in the previous 12 months. Review of CNA31's personnel file revealed a hire date of 08/25/2023 and no annual training hours were documented. Further review revealed no documentation of a performance evaluation within the previous 12 months. Review of CNA32's personnel file revealed a hire date of 05/09/2022 and only one annual training hour was documented. Further review revealed no performance evaluation documented within the previous 12 months. In an interview with [NAME] President of Regional Clinical Operations (VPRCO), on 02/13/2025 at 3:04 PM, she stated the facility had acquired new ownership, and trainings and education were provided through in-services, and skill fairs to ensure staff were meeting training needs. She stated the prior owners had provided the training/education documents but they had failed to provide the performance evaluations. In an interview with the Administrator, on 02/13/2025 at 4:00 PM, she stated she was new in her position and was still learning her role during the change in ownership and facility processes. She stated if the performance evaluations were not completed, staff could not benefit from the provided feedback regarding the tasks they performed well or what areas that needed improvement. Additionally, she stated her expectations were that CNAs were evaluated when hired and annually to assess their competencies, skills, and knowledge and their required training would be met annually.

Based on observation, interviews, and record review the facility failed to ensure it electronically submitted complete and accurate direct care staffing information, to the Centers for Medicare and Medicaid Services (CMS) for one of four quarters in 2024. The facility failed to submit direct care staffing information for the third quarter (July-September) of 2024 which triggered for no RN [registered nurse] Hours, and failure to have Licensed Nursing Coverage 24 Hours/Day Four or More Days Within the Quarter, specifically August and September 2024. The findings include: Review of the facility's provided CMS Payroll Based Journal (PBJ) report which was based on the staffing data submitted by the facility revealed excessively low weekend staffing, no RN hours, and a failure to have licensed nursing coverage 24 Hours/Day triggered for August and September 2024. A request for the facility's staffing data submitted for the third quarter (July, August, September) PBJ was requested but no verification that it had been reported successfully was provided. The facility provided an Excel spreadsheet for August and September 2024 which included payroll data for all staff; however, no verification the information was submitted or received by CMS system was provided. Further, the facility could not provide the facility's assessment completed for 2024. In an interview with the [NAME] President of Regional Clinical Operations (VPRCO), on 02/13/2025 at 3:04 PM, she stated the [NAME] President of Finance (VPF) advised her that the requested PBJ staffing data had not been submitted. She stated the VPF indicated that she (the VPF) had attempted to submit the data unsuccessfully. In an interview with the VPF, on 02/13/2025 at 3:30 PM, she stated she was responsible for submitting the payroll data to CMS for the PBJ Staffing Data Report. She stated during the third quarter there was a change of ownership and the data was entered into a new software program and could only conclude that there was an error in the software. She stated she submitted the information on 10/14/2024 but received an error message on 10/15/2024 which indicated the data was not submitted. She stated there was a lot of confusion with the third quarter because the data for July 2024 was submitted by the previous owners, but the new owners would submit the August and September 2024 data. She stated she had not contacted CMS because the error was realized after the deadline of 10/15/2024. In an interview with the Administrator, on 02/13/2025 at 4:00 PM, she stated she was new in her position and was still learning her role during the change in ownership. She stated she was made aware the staffing data had not been submitted due to a software error. She stated she understood the importance of submitting the payroll data timely to CMS because it had affected the facility's survey outcome and also decreased the facility's star rating. She stated her expectation was that the facility submitted the required data timely to ensure the facility was in compliance.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (1) of twenty-seven (27) sampled residents (Resident #31). The findings include: Review of the facility's policy titled, Resident Rights, revised 02/2021, revealed in Section (1)(p), the resident had the right to be informed of, and participate in, his or her care planning and treatment. Further review of the policy revealed in Section (1)(e) Self-Determination (g), the resident had the right to exercise his or her rights as a resident of the facility and as a resident of the United States, (h) be supported by the facility in exercising his or her rights, (i) exercise his or her rights without interference, coercion, discrimination or reprisal from the facility, and (s) choose an attending physician and participate in decision-making regarding his or her care. Review of the facility's policy titled, Homelike Environment, revised 02/2021, revealed in Section (1) that staff should provide person-centered care that emphasized the residents' comfort, independence, and personal needs and preferences. Review of Resident #31's admission Record revealed the facility admitted the resident, on 10/26/2017, with diagnoses to include Delusional Disorder, Heart Failure, and Dysphagia. Review of Resident #31's Quarterly Minimum Data Set (MDS) Assessment, dated 06/23/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), indicating the resident was cognitively intact. Review of Resident #31's Comprehensive Care Plan, dated 04/26/2017 and revised on 03/20/2023, revealed the facility developed a care plan for Resident #31 stating that the resident and his/her son had requested a female Certified Nursing Assistant (CNA) only, for bathing and showering. Review of an intervention revealed to assign a female aide for showers. However, in an interview on 08/07/2023 at 4:02 PM, CNA #21 stated, on 07/28/2023, he and another male CNA, CNA #22, entered Resident #31's room to transfer Resident #31 to bed for the night. CNA #21 stated Resident #31 refused any assistance from them. He stated Resident #31 wore briefs and would require assistance with incontinence care at bedtime. During an interview on 08/07/2023 at 4:37 PM, Family Member #2 stated Resident #31 had told him/her that the resident did not like for male CNAs to provide his/her care. During an interview on 08/10/2023 at 11:15 AM, Resident #31 stated he/she preferred only female aides for his/her care. During an interview on 08/08/2023 at 11:10 AM, the Director of Nursing (DON) stated if a male staff member were to go into a residents' room, and the resident refused care, she would expect the staff to report it to the nurse and for her to be notified. Furthermore, the DON stated that she expected staff to follow the facility's policies. During an interview on 08/10/2023 at 6:42 PM, the Executive Director (ED) stated if a resident made a request regarding his/her personal preference to staff, it should be reported to the Unit Manager or the DON when the request was made, to ensure the resident did not feel uncomfortable. Furthermore, the ED stated she expected staff to follow care plans and the facility's policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to implement or develop a comprehensive person-centered care plan for seven (7) of twenty-seven (27) sampled residents (Residents #5, #31, #35, #48, #81, #90, and #821). Resident #31 was care planned to have a preference of female care givers. However, interview and record review revealed the facility failed to implement the care plan related to Resident #31's preferences. Residents #5, #35, #48, #81, #90, and #821 were assessed by the facility to be at risk for falls and had a history of falls. Review of the care plans for these residents revealed the facility had care planned the residents for their fall risks. However, there was no documented evidence the care plans had person-centered interventions to include supervision and monitoring to prevent falls. The findings include: Review of the facility's policy titled, Comprehensive Care Plan, dated 01/13/2018, stated the purpose was to ensure that the resident or resident representative was included in all aspects of person-centered care planning and that this planning included the provision of services to enable the resident to live with dignity and supported the residents goals, choices, and preferences including, but not limited to goals related to their daily routines and goals to potentially return to a community setting. Further review of the policy revealed a section titled Procedure (3), the comprehensive care plan must be prepared with input from the Interdisciplinary Team (IDT) including to the extent practicable, the resident and resident representative. Section (4a) revealed the Comprehensive Care Planning would describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being. Continued review revealed in Section (5a) the care planning process would facilitate the inclusion of the resident and/or representative. Section (5c) incorporated the resident's personal and cultural preferences in developing goals of care. Further review of the policy revealed Section (10c) stated that approaches described staff action, must be individualized, based on the resident's interest and past/customary routine, should be interdisciplinary, proactive-to prevent problems, and reactive to respond to problems and needs. Review of the facility's policy titled, Resident Rights, revised date 02/2021, Section 1 (p) revealed the resident had the right to be informed of, and participate in, his or her care planning and treatment. Further review of the policy revealed Section 1 (e) was the resident had to right to self-determination. 1. Review of Resident #31's admission Record revealed the facility admitted the resident, on 10/26/2017, with diagnoses to include Delusional Disorder, Heart failure, and Dysphagia. Review of Resident #31's Quarterly Minimum Data Set (MDS) Assessment, dated 06/23/2023, revealed the facility assessed Resident #31 to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), indicating the resident was cognitively intact. Review of the Comprehensive Care Plan, dated 04/26/2017 and revised on 03/20/2023, revealed the facility developed a care plan for Resident #31 stating that Resident #31 and his/her son had requested female Certified Nursing Assistants (CNA) only for bathing and showering. The intervention was to assign female aide for showering assistance. However, the care plan did not specify female caregivers for routine care which would include incontence care. However, in an interview on 08/07/2023 at 4:02 PM, CNA #21 stated, on 07/28/2023, he and another male CNA, CNA #22, entered Resident #31's room to transfer Resident #31 to bed for the night. CNA #21 stated Resident #31 refused any assistance from them. He stated Resident #31 wore briefs and would require assistance with incontinence care at bedtime. During an interview on 08/10/2023 at 11:15 AM, Resident #31 stated that he/she preferred only female aides for his/her care. During an interview on 08/08/2023 at 11:10 AM, the Director of Nursing (DON) stated that if a male staff member were to go into a resident's room and the resident refused care, she would expect the staff to report it to the nurse and to be notified. During an interview on 08/10/2023 at 6:42 PM, the Executive Director (ED) stated that if a resident made a request regarding their personal preference to staff it should be reported to the Unit Manager or the DON when the request was made to ensure the facility focused on the resident's preference, and the care plan could be further developed and implemented. 2. Review of Resident #90's closed record revealed the facility re-admitted the resident, on 04/05/2023, with diagnoses which included: Traumatic Subdural Hemorrhage with Loss of Consciousness, Alzheimer's Disease, and Frontotemporal Neurocognitive Disorder. Continued review of the closed record revealed Resident #90 suffered a fall on 07/05/2023 and another fall on 07/07/2023. Review of Resident #90's Quarterly Minimum Data Set (MDS) Assessment, dated 07/06/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), which indicated the resident was not cognitively able to complete the exam. Continued review revealed the facility assessed Resident #90 as requiring a two (2) person assist with transfers and bed mobility. Review of Resident #90's Comprehensive Care Plan (CCP), developed on 09/15/2022, revealed the facility care planned the resident with a focus for risk for falls related to impaired safety awareness. Continued review revealed the care plan goal included risk for falls reduced through interventions. Per the care plan review, the interventions included: Resident #90 liked to sleep in the chair; Resident #90 sat with her/his back at the back of the chair when she/he slept; Resident #90 at times yelled out, so staff could offer the resident individualized diversional activities in an effort to keep the resident from yelling; Resident #90 had impaired vision, causing her/his hearing to be more sensitive to loud noises; and Resident #90 had bed against the wall and non-skid strips around the bed. Review of the facility's Fall Risk Investigation Reports for Resident #90's falls, dated 07/05/2023 and 07/07/2023, revealed the facility noted Resident #90 to have confusion, memory impairment, and poor ambulation without assistance. Review of Resident #90's Progress Note, dated 07/05/2023 at 4:00 PM, revealed the resident was walking around the unit. Per the note, staff observed the resident was trying to sit and there was no chair. The note stated staff then went to the resident, and the resident sat on staff, with no injuries. Review of Resident #90's Progress Note, dated 07/06/2023 at 9:58 AM, revealed there was an Interdisciplinary Team (IDT) meeting about using the brightly colored tape (used on arm rests of chairs) to prevent falls and therapy. However, review of the care plan revealed no documented evidence the facility increased supervision for Resident #90. Review Resident #90's Progress Note, dated 07/07/2023 at 6:07 PM, revealed the resident had an intercepted fall, where staff intervened and prevented the fall. Per the note, the resident was placed on one-to-one (1:1) supervision. Review of Resident #90's Progress Note, dated 07/07/2023 at 9:18 PM, revealed Licensed Practical Nurse (LPN) #4 documented the resident was having increased behaviors. The note stated the Physician was notified and ordered a one (1) time dose of Haldol (an antipsychotic) and stat (immediate) labs to be drawn. Per the note, the Haldol injection was given, and stat labs were drawn. The note stated Resident #90 was to be sent to the ED. Review of Resident #90's Discharge summary, dated [DATE], from the acute care hospital, revealed Resident #90 had a Subdural Hematoma (blood collected between two (2) membranes that covered the brain). It stated the resident was sent back to the facility at discharge. In an interview on 08/03/2023 at 2:37 PM, the Neuroradiologist from the acute care hospital stated he was unsure if Resident #90's subdural hematoma was new or chronic. 3. Review of Resident #5's clinical record revealed the facility admitted the resident, on 05/10/2021, with diagnoses of Difficulty in Walking, Dementia, Muscle Weakness, Unsteadiness on Feet, and Unspecified Mental Disorder due to Known Physiological Condition. Review of Resident #5's Quarterly Minimum Data Set (MDS) Assessment, dated 06/22/2023, revealed the resident's ability to make decisions regarding tasks of daily life was severely impaired. Further review revealed the resident required a one (1) person physical assist for ambulation. Review of Resident #5's CCP, developed on 06/03/2021, revealed a goal and a target date for 07/27/2023 for a problem of the resident had a clinically unavoidable risk for falls related to severe cognitive impairment. The goal stated the resident would have risk for falls reduced through interventions. The interventions directed the staff to have dycem (a non-slip fabric) in the wheelchair, fall mat to the right side of the bed, bed in low position, non-skid socks, and refer to therapy for wheelchair positioning. Review of Resident #5's Fall Investigation Report, dated 08/07/2023 at 9:30 AM, revealed Resident #5 attempted to stand and walk from the wheelchair unassisted and fell, hitting the left side of his/her head, which resulted in a hematoma and two (2) lacerations with bleeding noted. Per the report, the resident was oriented to person, confused, had a gait imbalance, impaired memory, and ambulated without assistance. In an interview with CNA #20 on 08/07/2023 at 3:10 PM, she stated she was sitting at a table in the common area/room, and another resident was sitting between her and Resident #5. She stated she sometimes charted on the computer when in the common room watching the residents. She stated the two (2) other CNAs assigned to the unit were in the common room but were providing care to another resident. She stated, she saw Resident #5 stand and attempt to ambulate, but was attending to another resident, even though Resident #5 was assessed to require assistance with ambulation. Observation of the common area/room on 08/07/2023 at approximately 3:10 PM, revealed the room was about nineteen (19) feet by nineteen (19) feet. There were nine (9) residents in the room during the interview with CNA #20. Further observation revealed CNA #20 was sitting at a table adjacent to the right wall if looking out the window from the nurses' station. A resident was sitting in a wheelchair in front of her. The observation revealed CNA #20 had a computer on the desk which she patted as she explained she charted on the computer when in the room monitoring the residents. Review of Resident #5's ED Discharge Note, dated 08/07/2023, revealed Resident #5 presented with an uncomplicated closed head injury with reassuring workup in the ED. The ED Discharge Note stated Resident #5 had a negative computed tomography (CT) scan of the head and cervical spine. Also, the note stated the resident returned to the facility on [DATE]. 4. Review of Resident #821's clinical record revealed the facility admitted the resident, on 12/21/2022, with diagnoses of Dementia, Mild, with Mood Disturbance; Pulmonary Disease; Resistance to Multiple Antibiotics; and Repeated Falls. Review of Resident #821's Quarterly MDS Assessment, dated 07/25/2023, revealed the facility assessed the resident to have a BIMS score of nine (9) of fifteen (15), indicating the resident was moderately cognitively impaired. Review of Resident #821's CCP, developed on 12/22/2022, revealed a focus/problem stated the resident was at risk for falls related to diminished safety awareness and dementia. Per the CCP and prior to the fall, Resident #821 had a perimeter mattress to define edges of mattress/bed, created on 04/17/2023; fall mat to right side of bed, created on 02/19/2023; wheelchair with roll backs with dycem (non-slip material) on the seat, created on 03/25/2023; bed in low position, created on 03/04/2023; and encourage to wear non-skid socks or shoes without slippery bottoms as he/she tolerated and chose; and 1:1 staff supervision, created on 04/18/2023. Review of Resident #821's Fall Investigation Report, dated 07/21/2023 at 6:21 AM, revealed the resident's sitter called the nurse to the room. Per the report, Resident #821 was resistant to care and pulled away from the sitter, falling back and hitting his/her head on the footboard of the bed. The report stated there was an abrasion to the back of the head with a scant amount of blood. Per the report, the provider was notified and ordered the resident to be sent to the hospital ED for treatment and evaluation. Review of Resident's #821's fall RCA form, not dated, revealed on 07/21/2023, a Friday, the resident was on one-to-one (1:1) supervision, with the sitter in the room. The root cause of the fall was that the one-to-one (1:1) sitter was not immediately attentive. Per the RCA, the intervention was the sitter received education on following one-to-one (1:1) supervision. Review of the hospital ED note, dated 07/21/2023, revealed the CT scan of the head and cervical spine showed no evidence of fracture or intracranial hemorrhage. The resident returned to the facility on [DATE]. 5. Review of Resident #35's clinical record revealed the facility admitted the resident, on 09/09/2021, with diagnoses of Dementia, Psychotic Disorder with Delusions due to Known Physiological Condition, and Osteoarthritis. Review of Resident #35's Quarterly MDS Assessment, dated 06/19/2023, revealed the resident's ability to make decisions regarding tasks of daily life was severely impaired. Review of Resident #35's CCP, developed on 09/10/2021, revealed a focus/problem of the resident was at risk for falls related to weakness and diminished safety awareness due to dementia. The goal stated the resident would have risk for falls reduced through interventions. Per the CCP, on 07/12/2022, the intervention was initiated to provide a defined perimeter mattress to aid in establishing boundary of mattress; and to keep frequently used items within reach, and non-skid socks. A revision occurred on 06/07/2023 to assist resident to stand when showering if desired. However, the resident was not care planned for increased supervision or monitoring. Review of Resident #35's Fall Investigation Report, dated 07/26/2023 at 2:15 PM, revealed Resident #35 was ambulating without assistance in the day area, tripped over another resident's walker, falling onto his/her bottom. Review of Resident #35's fall RCA, not dated, revealed the resident was anxious in a small, crowded area; confused; and unaware of physical limitations. The RCA stated the root cause was wandering related to Dementia, and the intervention was to provide a busy blanket/pad to use when in wheelchair. 6. Review of Resident #48's clinical record revealed the facility admitted the resident, on 02/18/2022, with diagnoses of Stroke, Lung Cancer, and Dementia. Review of Resident #48's Quarterly MDS Assessment, dated 07/13/2023, revealed the facility assessed the resident to have a BIMS score of three (3) of fifteen (15), indicating the resident was severely cognitively impaired. Review of Resident #48's CCP, developed on 02/18/2022, revealed a focus/problem of the resident was at risk for falls related to confusion and unaware of safety needs related to Dementia. The goal stated the resident would have risk for falls reduced through interventions. The approaches directed the staff to place a defined perimeter mattress to help define bed boundaries related to poor safety awareness, and fall mat beside the bed. Review of Resident #48's Fall Investigation Report, dated 07/12/2023 at 3:23 AM, revealed Resident #48 slid out of the wheelchair and went to the floor in a sitting position. Review of Resident #48's Fall Investigation Report, dated 07/19/2023 at 8:04 PM, revealed Resident #48 fell while attempting to sit in a wheelchair. Review of Resident #48's fall RCA, not dated, revealed the root cause was the wheelchair rolled backward when the resident attempted to sit in it. The intervention was for therapy to evaluate for anti-tippers/anti-rollbacks for the wheelchair. Review of Resident #48's Fall Investigation Report, dated 07/21/2023 at 11:59 PM, revealed Resident #48 had an unwitnessed fall with no apparent injuries and was lying on the floor of the common room. Review of Resident #48's RCA, not dated, revealed the root cause was the resident was drowsy and weak related to medications. The intervention was the resident needed to lie down after medication administration. However, there was no documented evidence the facility care planned Resident #48 for increased supervision and monitoring. 7. Review of Resident #81's clinical record revealed the facility admitted the resident, on 01/22/2020, with diagnoses of Dementia, Bipolar Disorder, and Repeated Falls. Review of Resident #81's Quarterly MDS Assessment, dated 07/11/2023, revealed the facility assessed the resident to have a BIMS score of six (6) of fifteen (15), indicating the resident was severely cognitively impaired. Further, the assessment stated the resident was independent in walking. Review of Resident #81's CCP, developed for falls on 02/01/2021, revealed a focus/problem of the resident was at risk for falls related to weakness, impaired cognition, and incontinence. The goal stated the resident would have risk for falls reduced through fall interventions. The approaches were resident to wear non-skid socks or shoes with soles that were not slippery; encourage the resident to ask for assistance when needing items or to get out of bed; and the chair in the resident's room was changed to a chair that had a firmer seat. Review of Resident #81's Fall Investigation Report, dated 07/04/2023 at 9:02 PM, stated the resident was found sitting on the floor. Per the report, the roommate reported the resident sat on the floor in front of her/his chair, and the resident stated he/she did not fall. Review of Resident #81's Fall Investigation Report, dated 07/05/2023 at 6:30 AM, revealed the resident's roommate reported to a nurse aide that the resident sat on the floor beside the bed and went to sleep. Per the report, the resident stated he/she wanted to sleep on the floor. However, there was no documented evidence the facility developed care plan intervetions to include increased supervision or monitoring of the resident after the resident went to his/her room after either incident, even though there was a history of finding the resident on the floor in his/her room. In an interview with CNA #1 on 08/01/2023 at 11:50 AM; CNA #5 on 08/01/2023 at 1:30 PM; CNA #17 on 08/04/2023 at 3:43 PM; CNA #30 on 08/09/2023 at 8:37 AM; and CNA #19 on 08/10/2023 at 10:44 AM, they all stated they looked at the resident's care plan to determine the needs of the resident and how to care for the resident. In an interview with the Assistant Director of Nursing (ADON) on 08/01/2023 at 1:15 PM, she stated she entered resident's needs in the care plan and revised if needed. In an interview with the Director of Nursing (DON) on 08/08/2023 at 11:10 AM, the DON stated that nurses could update care plans at any time, and she expected staff to follow facility policies and follow the care plans. She also stated sometimes she added information if needed. She said the ADON was also involved in updating care plans. She stated she and the ADON review the residents that were on fifteen (15) minute checks. She stated they tried to add intervetions after each fall to prevent further falls. In an interview with the Executive Director (ED) on 08/10/2023 at 6:38 PM, she stated she was not aware of any problem concerning supervision of residents to prevent falls. She stated she thought one (1) nursing assistant could safely monitor the residents on the memory care unit. She stated she worked with the scheduler to assure they had adequate staff. The ED stated after one-to-one (1:1) supervision was discontinued, the next monitoring to use was based on the individual resident. She stated she felt there was enough staff to supervise the residents to prevent falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the fall investigation reports, and review of the facility's policy, it was determined the facility failed to ensure it had a system in place for adequate supervision and monitoring to prevent accidents/falls, to determine the root cause of falls, to evaluate falls and implement individualized interventions, and to monitor the effectiveness of interventions to prevent additional falls for six (6) of twenty-seven (27) sampled residents, Resident #5, #35, #48, #81, #90, and #821. 1. Resident #90 was not provided adequate supervision to prevent a fall. Resident #90 was care planned to be impulsive and had decreased safety awareness related to Dementia. Resident #90 fell on [DATE], and the resident exhibited increased anxiousness, wandering, and fatigue. However, there was no documented evidence the facility increased monitoring or supervision. Then, on 07/07/2023, Resident #90 had another fall, was sent to a hospital's emergency department (ED), and was admitted for observation due to several falls at the facility. 2. Resident #5, who had a history of falls, fell on [DATE] while in the common area. The two (2) direct care staff assigned to the unit were providing care. Therefore, one (1) staff member was monitoring the residents in the common area while completing documentation for medication administration. Resident #5 attempted to stand from the wheelchair, hitting her/his head, which resulted in a raised area to the head that was bleeding, requiring hospital evaluation. 3. Resident #821, who had a history of falls and was on one-to-one (1:1) supervision related to falls, sustained a fall on 07/21/2023. The resident got out of bed, fell back hitting her/his head on the headboard, and was sent to the ED for evaluation. Record review revealed the staff assigned to Resident #821 was re-educated about one-to-one (1:1) supervision. 4. Resident #35, who was assessed by the facility to require a one (1) person physical assist with ambulation, fell on [DATE] while ambulating without assistance in the common area, tripping over another resident's walker and falling onto her/his bottom. 5. Resident #48 who was assessed by the facility to be at risk for falls and to require a two (2) person assist, fell three (3) times, on 07/12/2023, 07/19/2023, and 07/21/2023. There was not documented evidence the facility implemented increased supervision or monitoring. 6. Resident #81, who was assessed to have a history of being found on the floor in her/his room, was found on the floor on 07/04/2023 and again on 07/05/2023 after the resident's roommate alerted staff that the resident was on the floor. There was no evidence the facility implemented increased supervision and monitoring for Resident #81 after these incidents. The findings include: Review of the facility's policy titled, Fall Management, dated 09/01/2022, revealed a fall risk observation was used to identify individuals who were at high risk for falls, as well as those individuals who had any risk factors for falls. Per policy review, the observation (assessment) would be completed on a resident's admission to the facility, Quarterly, Annually, and with any Significant Change in Condition. Continued review revealed fall prevention would be achieved through an interdisciplinary approach of managing risk factors and implementing appropriate interventions to reduce risk for falls. The policy stated responses to a resident's fall were to include evaluating and monitoring the resident for seventy-two (72) hours post fall; assess the resident's level of consciousness, vital signs and range of motion; and look for lacerations, abrasions, and obvious deformities. Further review revealed additional responses to a resident's fall included: if an emergency situation existed, initiate the Emergency Medical System (EMS) response; contact the provider and resident's family; remain with the resident until EMS arrived; complete a root cause analysis (RCA) and determine an intervention based on the determined root cause; and implement interventions (immediately) after the fall. Additionally, the policy stated, as the investigation of the fall continued, the root cause analysis might trigger other interventions to the resident's plan of care; and update the care plan and Certified Nursing Assistant (CNA) communication form with the new intervention(s). Continued review of the Fall Management policy revealed fall prevention was achieved through an interdisciplinary approach of managing risk factors and implementing appropriate interventions to reduce the risk for falls. 1. Review of Resident #90's closed record revealed the facility re-admitted the resident, on 04/05/2023, with diagnoses which included: Traumatic Subdural Hemorrhage with Loss of Consciousness, Alzheimer's Disease, and Frontotemporal Neurocognitive Disorder. Continued review of the closed record revealed Resident #90 suffered a fall on 07/05/2023 and another fall on 07/07/2023. Review of Resident #90's Quarterly Minimum Data Set (MDS) Assessment, dated 07/06/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), which indicated the resident was not cognitively able to complete the exam. Continued review revealed the facility assessed Resident #90 as requiring a two (2) person assist with transfers and bed mobility. Further review revealed the facility assessed Resident #90 was always incontinent of bladder and bowel. Review of Resident #90's Comprehensive Care Plan (CCP), developed on 09/15/2022, revealed the facility care planned the resident with a focus for risk for falls related to impaired safety awareness. Continued review revealed the care plan goal included risk for falls reduced through interventions. Per the care plan review, the interventions included: Resident #90 liked to sleep in the chair; Resident #90 sat with her/his back at the back of the chair when she/he slept; Resident #90 at times yelled out, so staff could offer the resident individualized diversional activities in an effort to keep the resident from yelling; Resident #90 had impaired vision, causing her/his hearing to be more sensitive to loud noises; and Resident #90 had bed against the wall and non-skid strips around the bed. Review of the facility's Fall Risk Evaluation for Resident #90, dated 07/07/2023, revealed the facility assessed the resident to have a score of eleven (11), which indicated the resident was at risk for falls. Per the Director of Nursing (DON), any score over ten (10), meant the resident was at risk for falls. Continued review revealed Resident #90's level of consciousness/mental state was assessed as having intermittent confusion. Further review revealed the facility assessed Resident #90 as ambulatory. Review of the facility's Fall Risk Investigation Reports for Resident #90's falls, dated 07/05/2023 and 07/07/2023, revealed the facility noted Resident #90 to have confusion, memory impairment, and poor ambulation without assistance. Review of Resident #90's CCP, updated on 07/26/2023, revealed new interventions of the resident had a medication review and Depakote (an anti-seizure medication) was increased; assist resident out of bed as needed; and wear non-skid socks. Per the CCP, the resident would take non-skid socks off at times and did not like to lie in bed with the non-skid socks on at all times. Review of Resident #90's Progress Note, dated 07/05/2023 at 4:00 PM, revealed the resident was walking around the unit. Per the note, staff observed the resident was trying to sit and there was no chair. The note stated staff then went to the resident, and the resident sat on staff, with no injuries. Review of Resident #90's Progress Note, dated 07/06/2023, revealed the resident was seen by the Nurse Practitioner (NP). Review of Resident #90's Progress Note, dated 07/06/2023 at 9:58 AM, revealed there was an Interdisciplinary Team (IDT) meeting about using the brightly colored tape (used on arm rests of chairs) to prevent falls and therapy. Review of Resident #90's Progress Note, dated 07/06/2023 at 3:00 PM, revealed a follow-up nursing note that stated the resident had no pain and was walking around the unit. Review of Resident #90's Progress Note, dated 07/07/2023 at 9:58 AM, revealed the resident had a straight back chair with vinyl covering on the seat and brightly colored tape on the arm rests, in which the resident sat in the common area. The note stated an observation revealed the chair met right at the handrail level. Per the note, the nurse would monitor to determine if chairs were the same height as the handrail and interfered with the resident's safety when sitting in the chair. Review of Resident #90's Progress Note, dated 07/07/2023 at 12:14 PM, revealed the resident was restless and hit a Nursing Assistant. Per the note, the resident was closely monitored by staff, with medications given, and vital signs taken. Review of Resident #90's Fall Investigation Report, dated 07/07/2023 at 4:41 PM, revealed the resident's condition was reviewed by the Physician and NP, who recommended to increase the resident's dose of Depakote. Review Resident #90's Progress Note, dated 07/07/2023 at 6:07 PM, revealed the resident had an intercepted fall, where staff intervened and prevented the fall. Per the note, the resident was placed on one-to-one (1:1) supervision. The note stated the NP was present and reviewed medications. Review of Resident #90's Progress Note, dated 07/07/2023 at 9:18 PM, revealed Licensed Practical Nurse (LPN) #4 documented the resident was having increased behaviors. The note stated the Physician was notified and ordered a one (1) time dose of Haldol (an antipsychotic) and stat (immediate) labs to be drawn. Per the note, the Haldol injection was given, and stat labs were drawn. The note stated Resident #90 was to be sent to the ED. In an interview with Registered Nurse (RN) #1 on 08/02/2023 at 8:05 PM, she stated she did not remember Resident #90's fall, even though she had written the fall note. She also stated what she wrote in the fall note was what happened. Review of Resident #90's Discharge summary, dated [DATE], from the acute care hospital, revealed Resident #90 had a Subdural Hematoma (blood collected between two (2) membranes that covered the brain). It stated the resident was sent back to the facility at discharge. In an interview on 08/03/2023 at 2:37 PM, the Neuroradiologist from the acute care hospital stated he was unsure if Resident #90's subdural hematoma was new or chronic. 2. Review of Resident #5's clinical record revealed the facility admitted the resident, on 05/10/2021, with diagnoses of Difficulty in Walking, Dementia, Muscle Weakness, Unsteadiness on Feet, and Unspecified Mental Disorder due to Known Physiological Condition. Review of Resident #5's Quarterly Minimum Data Set (MDS) Assessment, dated 06/22/2023, revealed the resident's ability to make decisions regarding tasks of daily life was severely impaired. Further review revealed the resident required a one (1) person physical assist for ambulation. Review of Resident #5's Fall Risk Evaluation, dated 08/07/2023, revealed the resident had a score of thirteen (13), indicating the resident was at risk for falls. Review of Resident #5's CCP, developed on 06/03/2021, revealed a goal and a target date for 07/27/2023 for a problem of the resident had a clinically unavoidable risk for falls related to severe cognitive impairment. The goal stated the resident would have risk for falls reduced through interventions. The interventions directed the staff to have dycem (a non-slip fabric) in the wheelchair, fall mat to the right side of the bed, bed in low position, non-skid socks, and refer to therapy for wheelchair positioning. Review of Resident #5's Fall Investigation Report, dated 08/07/2023 at 9:30 AM, revealed Resident #5 attempted to stand and walk from the wheelchair unassisted and fell, hitting the left side of his/her head, which resulted in a hematoma and two (2) lacerations with bleeding noted. Per the report, the resident was oriented to person, confused, had a gait imbalance, impaired memory, and ambulated without assistance. Review of Resident #5's Root Cause Analysis (RCA) for the fall, not dated, revealed the resident was unaware of physical limitations due to Dementia. The RCA stated the resident was incontinent of urine and needed assistance with all activities of daily living. The root cause was determined to be Dementia and unaware of physical limitations. The RCA stated the intervention was to refer to therapy for wheelchair positioning. In an interview with Certified Nursing Assistant (CNA) #19 on 08/07/2023 at 3:05 PM, she stated she came in at 7:00 AM and was in the shower room. She stated when she came out of the shower room, Resident #5 was on the floor in the common area, and the NP and the Activities Director were with the resident. In an interview with CNA #20 on 08/07/2023 at 3:10 PM, she stated she was sitting at a table in the common area/room, and another resident was sitting between her and Resident #5. She stated Resident #5 backed her/his chair up to the middle of the room and attempted to stand. She stated, at that time, the Activities Director was coming down the hall, but Resident #5 fell before she could reach the resident. She stated Resident #5 fell, hitting his/her head on the left side. She stated she sometimes charted on the computer when in the common room watching the residents. She stated the two (2) other CNAs assigned to the unit were in the common room but were providing care to another resident. Also, she stated she did not attempt to reach Resident #5 because she was trying to keep the resident who was in front of her safe. She stated LPN #1 came into the room, assessed Resident #5, and took the resident's vital signs. CNA #20 stated Resident #5 had a raised area on the left side of his/her head with some bleeding. Observation of the common area/room on 08/07/2023 at approximately 3:10 PM, revealed the room was about nineteen (19) feet by nineteen (19) feet. There were nine (9) residents in the room during the interview with CNA #20. Further observation revealed CNA #20 was sitting at a table adjacent to the right wall if looking out the window from the nurses' station. A resident was sitting in a wheelchair in front of her. The observation revealed CNA #20 had a computer on the desk which she patted as she explained she charted on the computer when in the room monitoring the residents. In an interview with the Activities Director on 08/07/2023 at 3:15 PM, she stated after the morning clinical/IDT meeting, as she was coming into the unit, she looked to the left and saw Resident #5 trying to stand. She stated Resident #5 fell on his/her left side. She stated she saw Resident #5's head hit the ground. She stated she rolled Resident #5 onto her/his back. She stated CNA #20 came over and put a pillow under Resident #5's head, LPN #1 took the resident's vital signs, and someone got the NP. She stated LPN #1 got a towel and ice and held it to Resident #5's head. She stated the NP evaluated the resident and decided the resident needed to go to the hospital. In an interview with LPN #1 on 08/07/2023 at 3:40 PM, she stated she was standing in the nurses' station with her back to the window that looked out on the unit. She stated she heard some noise and turned around. She said the Activities Director tried to catch Resident #5 but failed, and Resident #5 fell hitting the left side of his/her head. She stated she saw the fall but did not hear a noise when Resident #5's head hit the floor. She stated CNA #20 and the Activities Director stayed with the resident, and she got the blood pressure machine and took the resident's vital signs. She stated she saw blood, got a towel, and held it to Resident #5's head. She stated she then called the NP. Observation of Resident #5, on 08/08/2023 at 9:40 AM, revealed the resident was sitting in a wheelchair, and there was an approximate one (1) inch raised area on his/her left forehead. Further observation revealed the resident's left eye was swollen shut, and the area including the check was bruised. When the resident was asked if he/she hurt, resident replied, Yes. In an interview with the NP on 08/08/2023 at 3:21 PM, she stated she was in the morning clinical/IDT meeting when her pager alarmed. She stated she went into the unit, and Resident #5 was on the floor. She stated the Activities Director and CNA #20 were with the resident. She stated there was a large, raised area on the left side of Resident #5's head. She stated, due to the head injury, she sent the resident to the hospital ED for evaluation. Review of Resident #5's ED Discharge Note, dated 08/07/2023, revealed Resident #5 presented with an uncomplicated closed head injury with reassuring workup in the ED. The ED Discharge Note stated Resident #5 had a negative computed tomography (CT) scan of the head and cervical spine. Also, the note stated the resident returned to the facility on [DATE]. In an interview with the Director of Nursing (DON) on 08/09/2023 at 8:37 AM, she stated after Resident #5 fell on [DATE], she spoke with the [NAME] President of Clinical Operations. She stated they put the five (5) Whys together for the fall (method to determine the root cause). She stated they determined the root cause of Resident #5's fall was her/his diagnosis of Dementia. Because of the resident's Dementia, she stated, he/she was unaware of his/her physical limitations, and he/she attempted to stand. The DON stated the only action taken was referring the resident to therapy; no other interventions were implemented related to supervision and/or monitoring for Resident #5. 3. Review of Resident #821's clinical record revealed the facility admitted the resident, on 12/21/2022, with diagnoses of Dementia, Mild, with Mood Disturbance; Pulmonary Disease; Resistance to Multiple Antibiotics; and Repeated Falls. Review of Resident #821's Quarterly MDS Assessment, dated 07/25/2023, revealed the facility assessed the resident to have a BIMS score of nine (9) of fifteen (15), indicating the resident was moderately cognitively impaired. Review of Resident #821's CCP, developed on 12/22/2022, revealed a focus/problem stated the resident was at risk for falls related to diminished safety awareness and dementia. Per the CCP and prior to the fall, Resident #821 had a perimeter mattress to define edges of mattress/bed, created on 04/17/2023; fall mat to right side of bed, created on 02/19/2023; wheelchair with roll backs with dycem (non-slip material) on the seat, created on 03/25/2023; bed in low position, created on 03/04/2023; encourage to wear non-skid socks or shoes without slippery bottoms as he/she tolerated and chose; and 1:1 staff supervision, created on 04/18/2023. Review of Resident #821's Fall Investigation Report, dated 07/21/2023 at 6:21 AM, revealed the resident's sitter called the nurse to the room. Per the report, Resident #821 was resistant to care and pulled away from the sitter, falling back and hitting his/her head on the footboard of the bed. The report stated there was an abrasion to the back of the head with a scant amount of blood. Per the report, the provider was notified and ordered the resident to be sent to the hospital ED for treatment and evaluation. Review of Resident's #821's fall RCA form, not dated, revealed on 07/21/2023, a Friday, the resident was on one-to-one (1:1) supervision, with the sitter in the room. The root cause of the fall was that the one-to-one (1:1) sitter was not immediately attentive. Per the RCA, the intervention was the sitter received education on following one-to-one (1:1) supervision. However, there was no documented evidence the facility provided education to all staff related to the expectations of one-to-one (1:1) supervision. Review of Resident #821's Fall Risk Evaluation, dated 07/24/2023 at 10:46 AM, revealed the resident had intermittent confusion, three (3) or more falls in the past three (3) months, balance problems with standing and walking, and decreased muscular coordination. The evaluation stated the resident required assistive devices and medications and had predisposing diseases. Review of the hospital ED note, dated 07/21/2023, revealed the CT scan of the head and cervical spine showed no evidence of fracture or intracranial hemorrhage. The resident returned to the facility on [DATE]. 4. Review of Resident #35's clinical record revealed the facility admitted the resident, on 09/09/2021, with diagnoses of Dementia, Psychotic Disorder with Delusions due to Known Physiological Condition, and Osteoarthritis. Review of Resident #35's Quarterly MDS Assessment, dated 06/19/2023, revealed the resident's ability to make decisions regarding tasks of daily life was severely impaired. Review of the Significant Change in Status MDS Assessment, date 07/05/2023 revealed the facility assessed Resident #35 to be fully dependent on staff for mobility and walking up to ten (10) feet, requiring substantial/maximal assistance. Further review of the MDS revealed the resident was assessed to be at risk for falls and had a care plan developed for falls risk. Review of Resident #35's CCP, developed on 09/10/2021, revealed a focus/problem of the resident was at risk for falls related to weakness and diminished safety awareness due to dementia. The goal stated the resident would have risk for falls reduced through interventions. Per the CCP, on 07/12/2022, the intervention was initiated to provide a defined perimeter mattress to aid in establishing boundary of mattress; and to keep frequently used items within reach, and non-skid socks. A revision occurred on 06/07/2023 to assist resident to stand when showering if desired. Further review of the care plan revealed the facility resolved the intervetion for fifteen (15) minutes checks on 07/05/2023; however, review of the care plan revealed no intervention related to supervision or monitoring of the resident. Review of Resident #35's Fall Risk Evaluation, dated 07/26/2023 at 2:48 PM, revealed Resident #35 had a score of eleven (11), indicating the resident was at risk for falls. Per the evaluation, the resident was disoriented times three (3), to person, place, and time at all times and had a history of three (3) or more falls in the past three (3) months. In addition, the evaluation stated the resident was ambulatory and incontinent, required assistive devices for ambulation, and was on no medications that increased risk for falls. Review of Resident #35's Fall Investigation Report, dated 07/26/2023 at 2:15 PM, revealed Resident #35 was ambulating without assistance in the day area, tripped over another resident's walker, falling onto his/her bottom. Review of Resident #35's fall RCA, not dated, revealed the resident was anxious in a small, crowded area; confused; and unaware of physical limitations. The RCA stated the root cause was wandering related to Dementia, and the intervention was to provide a busy blanket/pad to use when in wheelchair. 5. Review of Resident #48's clinical record revealed the facility admitted the resident, on 02/18/2022, with diagnoses of Stroke, Lung Cancer, and Dementia. Review of Resident #48's Quarterly MDS Assessment, dated 07/13/2023, revealed the facility assessed the resident to have a BIMS score of three (3) of fifteen (15), indicating the resident was severely cognitively impaired. Review of Resident #48's CCP, developed on 02/18/2022, revealed a focus/problem of the resident was at risk for falls related to confusion and unaware of safety needs related to Dementia. The goal stated the resident would have risk for falls reduced through interventions. The approaches directed the staff to place a defined perimeter mattress to help define bed boundaries related to poor safety awareness, and fall mat beside the bed. Review of Resident #48's Fall Risk Evaluation, dated 07/07/2023 at 11:51 PM and 07/12/2023 at 4:36 AM, revealed Resident #48 had a fall risk score of sixteen (16), indicating the resident was at risk for falls. Per the evaluation, the resident had intermittent confusion, one (1) to two (2) falls in the past three (3) months; was ambulatory and incontinent; vision was poor; the resident had a balance problem while walking; and the resident took medications that could increase risk of falls. Review of Resident #48's Fall Investigation Report, dated 07/12/2023 at 3:23 AM, revealed Resident #48 slid out of the wheelchair and went to the floor in a sitting position. Review of Resident #48's fall RCA, dated 07/12/2023 at 3:00 AM, revealed the root cause was the resident had weakness related to heart failure. The intervention was the walker was removed from the room to the east wing. Review of Resident #48's Fall Investigation Report, dated 07/19/2023 at 8:04 PM, revealed Resident #48 fell while attempting to sit in a wheelchair. Review of Resident #48's fall RCA, not dated, revealed the root cause was the wheelchair rolled backward when the resident attempted to sit in it. The intervention was for therapy to evaluate for anti-tippers/anti-rollbacks for the wheelchair. Review of Resident #48's Fall Investigation Report, dated 07/21/2023 at 11:59 PM, revealed Resident #48 had an unwitnessed fall with no apparent injuries and was lying on the floor of the common room. Review of Resident #48's RCA, not dated, revealed the root cause was the resident was drowsy and weak related to medications. The intervention was the resident needed to lie down after medication administration. Review of the CCP revealed no documented evidence the facility identifed the resident's risk factors to implemented appropriate intervetions to prevent falls to include increased supervision and/or monitoring even though Resident #48 had three falls on 07/12/2023, 07/19/2023, and 07/21/2023 as per the facility's policy. 6. Review of Resident #81's clinical record revealed the facility admitted the resident, on 01/22/2020, with diagnoses of Dementia, Bipolar Disorder, and Repeated Falls. Review of Resident #81's Quarterly MDS Assessment, dated 07/11/2023, revealed the facility assessed the resident to have a BIMS score of six (6) of fifteen (15), indicating the resident was severely cognitively impaired. Further, the assessment stated the resident was independent in walking. Review of Resident #81's CCP, developed for falls on 02/01/2021, revealed a focus/problem of the resident was at risk for falls related to weakness, impaired cognition, and incontinence. The goal stated the resident would have risk for falls reduced through fall interventions. The approaches were resident to wear non-skid socks or shoes with soles that were not slippery; encourage the resident to ask for assistance when needing items or to get out of bed; and the chair in the resident's room was changed to a chair that had a firmer seat. Review of Resident #81's Fall Risk Evaluation, dated 07/07/2023 at 11:30 PM, revealed Resident #81 had a fall risk score of ten (10), indicating the resident was at risk for falls. Per the evaluation, the resident was alert and oriented times three (3); the resident had one (1) to two (2) falls in the past three (3) months; the resident was ambulatory, with a normal gait; and the resident took three (3) to four (4) medications that might increase risk for falls. Review of Resident #81's Fall Investigation Report, dated 07/04/2023 at 9:02 PM, stated the resident was found sitting on the floor. Per the report, the roommate reported the resident sat on the floor in front of her/his chair, and the resident stated he/she did not fall. Review of Resident #81's Fall Investigation Report, dated 07/05/2023 at 6:30 AM, revealed the resident's roommate reported to a nurse aide that the resident sat on the floor beside the bed and went to sleep. Per the report, the resident stated he/she wanted to sleep on the floor. Review of Resident #81's fall RCA, undated, revealed the root cause was the chair had a soft seat with somewhat slick material. The intervention was to change out chairs in the resident's room and place a chair in the resident's room with an armrest and a firm cloth seat. However, there was no documented evidence the facility increased supervision or monitoring of the resident after the resident went to his/her room after either incident, even though there was a history of finding the resident on the floor in his/her room. During interview with the Director of Nursing (DON) on 08/09/2023 at 8:37 AM, she stated she had been at the facility since 07/10/2023, and she was educated about the current issues at the facility by the Corporate team. Further, she stated she did not know how many staff were scheduled on the memory care units, where some of the falls occurred. She stated she believed there were enough staff to care for the residents on the memory care units, but she did not know the staff to resident ratio on the memory care units. She stated she was involved with the Interdisciplinary Team (IDT) meeting where they talked about falls. She stated her main role with falls was to make sure the residents were eveluated after the falls. Observations, throughout the survey, revealed two (2) to five (5) staff members on the Men's Memory Care Unit (MCU), and two (2) to four (4) staff members on the Women's MCU. In an interview with the Executive Director (ED) on 08/10/2023 at 6:38 PM, she stated the staff reported the complaints to her or a manager. She stated she was not immediately notified of falls, but notification was done to the DON or Assistant Director of Nursing (ADON). She stated she was not aware of any problem concerning supervision of residents to prevent falls. She stated she thought one (1) nursing assistant could safely monitor the residents on the memory care unit. She stated she worked with the scheduler to assure they had adequate staff. The ED stated after one-to-one (1:1) supervision was discontinued, the next monitoring to use was based on the individual resident. She stated she felt there was enough staff to supervise the residents to prevent falls.

Based on observation, interview, record review, and review of the facility's Abuse Prevention Policy, it was determined the facility failed to protect residents from physical abuse for one (1) of nineteen (19) sampled residents (Resident #6). On 06/16/2023, during the noontime meal, Resident #69 was agitated because he/she did not have ice cream on his/her meal tray. Before staff could get the resident's ice cream, Resident #6 stated, here you can have mine. While using a curse word, Resident #6 put his/her ice cream on the table in front of Resident #69. Resident #69 perceived Resident #6 was going to hit him/her, so he/she stood, pushed Resident #6 in the chest, which resulted in Resident #6 falling to the floor. Licensed Practical Nurse (LPN) #40 assessed Resident #6. Resident #69 was placed on 1:1 immediately after the incident. The findings include: Review of the facility's policy titled, Abuse Prevention Program, revised December 2016, revealed the facility's residents had a right to be free from abuse, neglect, misappropriation of property, and exploitation. This included but was not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse. Further, the policy revealed the administration would protect residents from abuse by anyone including, but not limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Review of Resident #69's admission Record revealed the facility admitted the resident on 05/25/2020 with diagnoses of Schizoaffective Disorder, Bipolar Type, Other Schizophrenia, Anxiety Disorder, Chronic Obstructive Pulmonary Disease (COPD), and Other Dysphagia. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 06/09/2023, revealed Resident #69 scored a thirteen (13) out of a possible fifteen (15) on the Brief Interview for Mental Status (BIMS) cognitive assessment. This score indicated Resident #69 was cognitively intact and interviewable. Review of Resident #69's Comprehensive Care Plan (CCP) revealed a focus area, initiated on 05/31/2020, which indicated the resident had a history of negative behaviors towards others. He/she had a history of becoming agitated if he/she believed his/her peers were talking about him/her. The goal was for Resident #69 to have fewer episodes of physical aggression. One of the interventions directed staff to anticipate and meet the resident's needs. In addition, staff members were to encourage the resident to speak with staff if he/she had any concerns with anyone. Staff was to monitor Resident #69's behavioral episodes and attempt to determine the underlying cause. Review of Resident #69's CCP, revealed a focus area, initiated on 06/26/2020, that indicated the resident was at risk for outbursts in the community and dining room at any time related to others' behaviors, including verbal outbursts directed at others. According to the care plan, Resident #69 had been a bouncer and was always looking for others to do what was expected of them. Continued review revealed Resident #69 was quick to intervene and attempted to fix the issues at hand. Resident #69's care plan was revised to include 1:1 supervision after the incident on 06/16/2023. Interview with Resident #69 and observation on 06/23/2023 at 9:50 AM, revealed the resident resided on a locked unit, and was on 1:1. Certified Nurse Aide (CNA) #88 was observed providing the 1:1 supervision. Continued observation revealed Resident #69 was in his/her room, reclining on the bed and watching television. During an interview, Resident #69 stated he/she was not sure why he/she was still on 1:1 because he/she was fine. Resident #69 stated he/she asked staff for some ice cream and when he/she did, Resident #6, who was sitting at the same table, took his/her own ice cream, threw it down on the table, and said fuck this. Resident #69 stated he/she thought Resident #6 was trying to hit him/her with the ice cream, so he/she pushed Resident #6. When Resident #69 pushed Resident #6, Resident #6 ended up falling to the floor. Resident #69 stated he/she later apologized for pushing Resident #6, and stated, We are fine now. Review of Resident #6's admission Record revealed the facility admitted Resident #6 on 12/08/2021 with diagnoses of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance Mood Disturbance, and Anxiety, Generalized Anxiety, and Insomnia, unspecified. Review of Resident #6's Quarterly MDS assessment, dated 05/03/2023, revealed the resident scored a nine (09) out of a possible fifteen (15) on the BIMS' assessment for cognition. This score indicated the resident was moderately cognitively impaired, but was interviewable. During an interview with Resident #6, on 06/23/2023 at 11:40 AM, the resident confirmed the incident had happened. Resident #6 stated, There were no punches thrown, or anything like that. The resident stated there was just a little disagreement but he/she could not remember what the disagreement was about. Resident #6 stated he/she slipped and fell to the floor on his/her back after being touched by Resident #69. The resident stated he/she was not hurt and never hit his/her head on the floor. During an interview with Licensed Practical Nurse (LPN) #40, on 06/23/2023 at 12:47 PM, she stated the incident occurred between 12:00 PM and 1:00 PM. LPN #40 stated Resident #69 asked for ice cream after his/her meal in the 200 dining room. She stated Resident #69 was seated at a table and Resident #6 was standing by the table. LPN #40 stated Resident #6 dropped his/her ice cream on the table more or less and was doing a good deed. The LPN stated Resident #69 did not take it like that and he/she just shoved (him/her/Resident #6) down. She stated Resident #69 felt like he/she was being threatened by the actions of Resident #6. LPN #40 stated that Resident #6 landed on his/her bottom and got up and then went right to his/her room. The LPN stated she then went to the resident's room and did an assessment, and documented a change of condition note in the electronic health record (EHR). During continued interview with LPN #40, she stated Resident #69 was a bouncer at one time. She stated on the day of the incident, the electricity had gone out for twenty (20) to thirty (30) minutes, between 9:00 AM and 10:00 AM. She stated Resident #69 was a little agitated during that time because he/she could not watch television. The LPN stated Resident #69 stated, I pay for this, referring to the television. She stated Resident #69 could have anxiety sometimes, but stayed in his/her room most of the time and was not usually an agitator. Interview was attempted with Certified Nurse Aide (CNA) #121 on 06/23/2023. A voicemail message was left on her personal phone, but she did not return a call to the State Survey Agency (SSA) Surveyor. Review of the facility's investigation, dated 06/21/2023, signed by the facility's Executive Director (ED), revealed it included a statement completed by Licensed Practical Nurse (LPN) #40. Further review revealed on 06/16/2023 Residents #69 and #6 were seated at the same table for lunch on the locked unit. LPN noted that Resident #69 asked for ice cream. The LPN documented that as she turned to get some ice cream for the resident, Resident #6 stood and threw his/her ice cream on the table and said, take it! As Resident #6 started to walk away, Resident #69 put his/her hand up, pushed Resident #6, and he/she fell to the floor. LPN #40's statement also conveyed that Resident #69 stated that he/she felt threatened by Resident #6 and that was why he/she reacted that way. In an interview on 06/24/2023 at 3:16 PM, with LPN #40, she stated Resident #69 was known to become agitated about small things. She stated that earlier in the day, on 06/16/2023, the resident's television stopped working for about twenty (20) minutes. LPN #40 stated the resident liked things a certain way and did not like anyone invading his/her space. She stated it was important to anticipate Resident #69's needs/wants to prevent outbursts and avoid causing a situation where someone could get hurt. The LPN stated there were two (2) CNAs in the dining room, as well, when the incident occurred. In interview with CNA #10, he stated ice cream was a favorite menu item of the residents on the locked behavioral unit. He stated if a resident did not receive ice cream on his/her tray, it was easy enough for staff to go to the kitchen to obtain some for the resident. He stated it was important to anticipate the needs of Resident #69 to prevent him/her from becoming agitated and avoid any angry outbursts. Attempts were made to interview CNA #121 on 06/23/2023 at 4:36 PM and again on 06/24/2023 at 1:50 PM. CNA #121 was on duty, and in the dining room on the day of the incident. CNA #121 did not return the State Survey Agency (SSA) Surveyor's calls. Continued review of the facility's investigation, revealed a nursing assessment was completed on each resident, with no identified injuries. Resident #69 was placed on 1:1 observation since he/she was the aggressor. Social Services Staff followed up with each resident for seventy-two (72) hours with neither resident expressing any psychosocial harm as result of the incident. The facility's Psychiatric Advanced Practice Nurse Practitioner (APRN) conducted a tele-health visit with Resident #69 on 06/16/2023 (after the incident), and she conducted an in-center visit with the resident on 06/19/2023. Assessments of all other residents on the locked unit did not reveal any adverse outcomes for other residents. Additional review of the investigation revealed the facility determined the root cause of the altercation was Resident #69 initially did not receive ice cream on his/her meal tray as expected, and he/she became agitated before staff could get the ice cream for him/her. During an interview with the Psychiatric APRN on 06/24/2023 at 11:28 AM, she stated Resident #69 had a diagnosis of Paranoid Schizophrenia, plus anxiety. She stated the resident could be triggered by small things, but when she met with him/her, the resident said he/she regretted the incident and apologized to Resident #6. She stated the resident said he/she knew he/she overreacted. The APRN stated the resident could calm himself/herself by playing his/her guitar, watching television, or going to the therapy gym adjacent to the behavior unit to get some exercise. She stated those interventions tended to calm the resident, and she discussed them with him/her. The APRN stated since the incident occurred, she made an in-person visit with Resident #69 on 06/19/2023, and increased the resident's Sertraline (an antidepressant/mood elevating medication) dose from 50 mg (milligrams) to 75 mg per day on 06/19/2023. In interview with the Social Services Director (SSD) on 06/24/2023 at 2:17 PM, she stated she completed wellness checks starting on 06/16/2023 with Residents #69 and Resident #6. She said both residents indicated all was forgiven, and they wanted to move on. During an interview, on 06/24/2023 at 4:24 PM with the Director of Nursing (DON), she stated the staff on the locked behavior unit worked hard to keep it a low key environment. She stated staff tried to anticipate the residents' needs and overall she thought they had been doing that effectively for Resident #69, as well as other residents. She stated the staff in the dining room were supposed to check tray tickets to be sure the food items on the tray matched what was requested or required. The DON stated it was important to try to anticipate Resident #69's needs, but she said any resident on any given day could have an outburst. She stated Resident #69 did not go off all the time. The DON stated she thought supervision on the locked behavioral unit had increased greatly over the pasts four (4) weeks. She stated she did not consider it abusive if a resident pushed another resident down. The DON stated, I feel like it was an incident--just an incident. She stated she would consider it abusive if it became a repetitive act. The DON stated Resident #69 had a diagnosis of Schizophrenia, and he/she was going to have some behaviors. However, she did not think the resident was out of control. During continued interview, the DON stated that she could not be sure that Resident #69 pushing people down would cause an injury. She stated she had a discussion with Resident #69, and told the resident that he/she could not be putting his/her hands on other residents. She stated Resident #69 agreed with her, and that he/she wanted to apologize to Resident #6. The DON stated the Interdisciplinary Team (IDT) was looking at what else could be tried to prevent such altercations, but she could not say Resident #69 would never commit the action again. During an interview, on 06/24/2023 at 6:24 PM, with the Executive Director (ED), she stated Resident #69 had a tendency to become easily agitated if things were not to his/her liking. She stated if the resident had received his/her ice cream on the meal tray, then that may have prevented the situation, but she could not make that assumption because it was a locked behavioral unit, and residents there exhibited behaviors at times. She stated it was her understanding staff was trying to obtain the ice cream for Resident #69, but they may not have moved fast enough. The ED stated residents should not push each other because someone could be injured. The ED stated the incident would be considered abuse because the residents made physical and verbal contact. She stated the facility notified the police and they arrived at the facility, but neither resident wanted to press charges. The ED stated she wanted to provide more staff education on how to deal with residents with dementia and behaviors, and to ensure staff understood the importance of continuously engaging the residents in activities, and were providing care that hopefully would prevent resident-to-resident altercations from occurring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review it was determined the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain good oral hygiene for one (1) of nineteen (19) sampled residents (Resident #44). On 06/25/2023 at 1:52 PM, Resident #44 was observed with food particles/substance in his/her mouth and on his/her teeth. The findings include: Review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting, not dated, revealed residents who were unable to carry out ADLs independently would receive the services necessary to maintain good grooming and personal and oral hygiene. Further review revealed appropriate care and services would be provided for residents who were unable to carry out ADLS independently, with the consent of the resident and in accordance with the plan of care, which included appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care). Review of Resident #44's admission Record revealed the facility admitted the resident on 03/29/2023. The resident's diagnoses included Malignant Neoplasm of the Brain, Osteoarthritis, Muscle Weakness, Difficulty in Walking, Need for Assistance with Personal Care, and Unsteadiness on Feet. Review of Resident #44's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99. This score indicated the resident was severely cognitively impaired. Further review revealed the resident required extensive assistance of one (1) person for transfers and hygiene. Review of Resident #44's Comprehensive Care Plan initiated 04/11/2022, revealed the resident had an Activities of Daily Living (ADL) self-care performance deficit related to dementia, impulsive disorder, muscle weakness, and anxiety disorder. Further review revealed goals that included the resident would improve and maintain that level of function. Interventions included set up and assist with oral care daily and as needed. Observation of Resident #44, on 06/25/2023 at 1:52 PM, revealed the resident had food particles caked onto his/her teeth and crumbs were noted to be coming out of the resident's mouth while he/she was speaking. The resident did not have any food in his/her vicinity at the time of the observation. Interview on 06/25/2023 at 4:50 PM, with Certified Nurse Aide (CNA) #8, who was assigned to Resident #44, revealed the third (3rd) shift staff were responsible for getting residents up in the mornings, providing personal hygiene, including brushing residents' teeth. She further stated day shift staff assisted residents with oral care as needed. CNA #8 stated good hygiene was important for residents' dignity and to prolong how long residents could keep their teeth. Interview on 06/26/2023 at 10:36 AM, with Licensed Practical Nurse (LPN) #40, revealed she was not sure what the policy was at the facility regarding oral care. She further stated residents' dentures were soaked overnight. DON #4 stated during interview on 06/26/2023 at 11:05 AM, staff should assist residents with brushing their teeth before assisting them to the dining room in the mornings, after meals, and at bedtime. She stated staff should make sure food was not clinging to a resident's teeth and there was no build up on the teeth. The DON stated staff should follow the interventions on the Care Plan and brush the resident's teeth at the times listed above and as needed. During interview on 06/28/2023 at 5:32 PM, with Executive Director (ED) #2, revealed she expected the staff to follow the Care Plan interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to provide adequate supervision to prevent falls for seven (7) of nineteen (19) sampled residents. (Residents #5, #15, #32, #44, #81, #102, and #107). The facility failed to identify the root cause for each resident's fall. 1. Review of Resident #44's Comprehensive Care Plan revealed care plan interventions for fall prevention which included to assist the resident to bed if experiencing lethargy. On 06/21/2023, Resident #44 went to sleep in a chair in the common area, with his/her head leaning on his/her rolling walker and sustained a fall which resulted in a bruise to his/her chin. Observation of Resident #44, on 06/25/2023 revealed the resident had food particles caked onto his/her teeth and crumbs noted to be coming out of his/her mouth when he/she was speaking. 2. Review of a fall's investigation, dated 06/17/2023, revealed staff found Resident #5 sitting on the floor in his/her room. Resident #5 had a history of waking up and attempting to get out of bed. Resident #5 was not wearing his/her non-skid socks and the fall mat was not in place. 3. On 06/14/2023, Resident #81 sustained a fall and was found by staff sitting on the floor in his/her room. However, Resident #81 was not wearing nonskid socks and his/her bedside table was not in reach from the bed as per the resident's care plan. 4. On 06/17/2023, Resident #102 sustained a witnessed fall in the common area while sitting in a hard back chair in the lounge area with his/her walking cane in hand. Resident #102 was seen by a Certified Nurse Aide (CNA) to pull his/her legs back and then to slip down onto his/her knees onto the floor. 5. On 06/20/2023 and 06/21/2023, Resident #32 was found sitting on the floor in his/her room. The facility failed to provide the supervision and assistance Resident #32 required as per his/her Comprehensive Care Plan. 6. On 06/12/2023, Resident #107 sustained a witnessed fall from a wheelchair in the common area when trying to pick something up off the floor. Resident #107 sustained a small laceration to the left side of his/her forehead, and two (2) small skin tears to his/her right arm, complained of pain to his/her hip and was sent out to the emergency room for evaluation and treatment. 7. Resident #15's Comprehensive Care Plan included interventions for fall prevention such as ensuring the resident's call light was within reach, and encourage him/her to use it, and an intervention added on 06/16/2023, for the resident to have every fifteen (15) minute checks. Observation on 06/24/2023, at approximately 9:15 AM revealed Resident #5's call light lying over the arm of the resident's recliner located at the foot of the bed, out of the resident's reach, Resident #15's every fifteen (15) minute Check Sheet revealed the checks had not been completed for a four (4) hour period. The findings include: Review of the facility's policy titled, Fall Management, dated 09/01/2022, revealed the facility managed fall prevention through an interdisciplinary approach of managing risk factors and implementing appropriate interventions to reduce the risk for falls. Per review, potential interventions might include exercise, environmental modification, medication, assistive devices, footwear, etc. Further review revealed the facility was to complete a root cause analysis and determine an intervention based on the root cause. 1. Record review revealed the facility admitted Resident #44 on 03/29/2023. The resident's diagnoses included Malignant Neoplasm of the Brain, Osteoarthritis, Muscle Weakness, Difficulty in Walking, Need for Assistance with Personal Care, and Unsteadiness on Feet. Review of Resident #44's 05/09/2023 MDS revealed the facility assess the resident to have a BIMS' score of 99, which indicated the resident to be severely cognitively impaired. Further review of the 05/09/2023 MDS revealed the resident required extensive assistance of one (1) person for transfers and hygiene. Review of Resident #44's Comprehensive Care Plan, initiated on 03/30/2022, revealed the resident was at risk for falls related to severe cognitive impairment, impaired safety awareness, impaired mobility and incontinence. Interventions included to assist the resident to bed if experiencing lethargy. Review of Resident #44's Nursing Note, dated 06/21/2023 at 2:07 PM, revealed the resident was leaning forward on his/her rolling walker and fell, on 06/21/2023 at 11 AM. The resident fell to the floor on his/her left side with bruising to left side of the chin. Further review of the note revealed the resident fell asleep while leaning on the walker and fell forward into the floor. Continued review revealed no evidence staff attempted to assist the resident to bed when he/she fell asleep. Review of Resident #44's Nurses Interdisciplinary Team Note, dated 06/21/2023 at 4:59 PM, revealed the resident was leaning his/her head down on the walker and fell asleep, the walker moved, and the resident fell forward from the chair while the CNA was sitting next to the resident. Review of Resident #44's Comprehensive Encounter Note by the APRN, dated 06/22/2023 at 3:40 PM revealed the resident was seen because of a fall on 06/21/2023 which resulted in a large ecchymosis to his/her left chin. The resident had a history of a nondisplaced odontoid fracture type two (2) from a previous injury fall. During interview with CNA #28, on 06/23/2023 at 4:35 PM, she stated she was sitting in the common area beside Resident #44 when he/she fell on [DATE]. She further stated the resident had been rocking back and forth and fidgeting with the walker, leaned forward, the walker rolled, and the resident fell on his/her left side. CNA #28 stated after the fall, she notified the nurse after making sure the resident was safe, and the nurse assessed the resident's vital signs. During an interview with CNA #9, on 06/23/2023 at 4:40 PM, she stated she was standing approximately five (5) feet from Resident #44 when he/she fell on [DATE]. CNA #9 stated the resident was sitting in a chair with his/her arms on his/her knees rocking and fell forward, then the rocker rolled. She further stated she went to see if the resident was okay, then got the nurse, who came and assessed the resident. During an interview with Registered Nurse (RN) #11, on 06/24/2023 at 8:33 AM., she stated she was caring for Resident #44 on 06/21/2023. She further stated she had just finished passing medications when the CNA told her the resident was on the floor. RN #11 stated she assessed the resident with no apparent injuries. The RN stated she was told by the CNAs the resident was sitting in a chair leaning forward with his/her elbows on his/her knees and, before the CNA could catch him/her, he/she fell forward. She stated the walker was upright but pushed forward when she assessed the resident. RN #11 stated the CNA first told her the resident fell asleep like that, then changed the story to the resident was moving/twitching so he/she couldn't have been asleep. She stated DON #4 was present to hear the CNAs description of how the resident fell. During an interview with Family Member #44, on 06/25/2023 at 1:27 PM, she stated she received a phone call from the facility on 06/21/2023 and was notified the resident was trying to get up when the walker moved, the resident fell and hit his/her chin. Family Member #44 stated the facility was going to do a scan because the resident was already in a neck collar from a previous fracture. She further stated she asked to be updated if anything changed and expected a phone call after the scan but had not received any follow up calls. She stated she was unaware the resident had any injury from the fall, including bruising. 2. Observation of Resident #5, on 06/22/2023 at 4:36 PM, revealed the resident was sitting in a wheelchair dressed, wearing shoes, in the common area. Review of Resident #5's medical record revealed the facility admitted the resident on 05/10/2021, with diagnoses which included Dementia, Unsteadiness on feet, Major Depression and Cognitive Communication Deficit. Review of Resident #5's Quarterly Minimum Data Set (MDS) Assessment, dated 05/23/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 99. This score indicated the resident was not interviewable. Further review of the MDS, Section G for functional status revealed the facility assessed Resident #5 to require the physical assist of one (1) person for walking, and as not stable without human assistance. In addition, the facility assessed Resident #5 to require mobility devices of a wheelchair or walker with one (1) person physical assist. Review of Resident #5's Comprehensive Care Plan, dated 02/01/2021 and 03/24/2023, revealed the facility care planned the resident for being at risk for falls and need for assistance with activities of daily living. Review of care plan interventions revealed staff were to ensure the resident's call light was kept within reach for assistance. The bed was in low position and to ensure the resident wore proper nonskid footwear when out of bed, and a fall mat to the right side of the resident's bed. In addition, interventions directed staff to provide assistance of one person for bed mobility, transfers and ambulation with the rolling walker. Review of Resident #5's visual bedside Kardex report, (a care plan document for Certified Nurse Aides), dated 06/22/2023, revealed interventions for the resident's call light to be within reach. Further review revealed staff would respond promptly to requests for assistance; the resident's bed would be in the low position when the resident was in bed; the resident would wear non-skid footwear when out of bed; and a fall mat to be at the right side of his/her bed. Review of the facility's fall investigation, dated 06/17/2023 at 3:30 AM, revealed staff found Resident #5 sitting on the floor in his/her room. Per review, Resident #5 had a history of waking up and attempting to get out of bed. Continued review revealed Resident #5 was not wearing his/her non-skid socks and the fall mat was not in place. Further review revealed the facility identified the root cause of the fall was that the resident was ready to get up for the day. Review of the Occupational Therapy Evaluation, dated 06/21/2023, revealed Resident #5 was at risk for falls and further decline in function and immobility. Further review revealed Resident #5 had exhibited decreased muscle strength in both upper extremities, activity tolerance, standing balance, problem solving, safety awareness and judgement. In an interview on 06/23/2023 at 9:07 AM, and an additional interview on 06/27/2023 at 12:06 PM, Certified Nurse Aide (CNA) #9 stated Resident #5 required two (2) staff assist with gait belts for transferring. CNA #9 stated Resident #5's interventions were for a fall mat to the bedside, for the resident to wear non-skid socks and/or shoes, and to have anti-tippers to his/her wheelchair. In an interview on 06/27/2023 at 12:09 PM, CNA #28 stated Resident #5 required a gait belt and two (2) staff for transferring. The CNA stated Resident #5 seemed to fall mainly in the morning and staff made sure his/her precautions were in place. During the interview, CNA #28 stated staff were to redirect Resident #5 to prevent falls and place his/her items within reach. 3. Review of Resident #81's medical record revealed the facility admitted the resident on 01/03/2022, with diagnoses which included Dementia, Bipolar Disorder, and Major Depressive Disorder. Review of Resident #81's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident with a BIMS' score of seven (7) out of fifteen (15), which indicated he/she was severely cognitively impaired. Continued review of the MDS, Section G for functional status revealed the facility assessed Resident #81 as requiring set up of one (1) staff for walking, and with no assistive device for ambulation. Review of Resident #81's Comprehensive Care Plan revealed the facility care planned the resident for being at risk for falls. Interventions dated 02/01/2021, included to keep the resident's frequently used items within reach. Review of the CNA's Kardex report, dated 06/19/2023, revealed the interventions included the assist of one staff as needed for ambulating with a rolling walker for safe ambulation and transfers. Review of the facility's fall investigation, dated 06/14/2023 at 3:30 AM, revealed the facility found Resident #81 sitting on his/her bottom with his/her back against the door. Continued review revealed Resident #81 was not wearing socks and his/her bed side table was not within reach from the bed which was in the lowest position. However, further review revealed the facility identified the root cause of Resident #81's fall as his/her failure to use his/her walker to ambulate to the bedside table for the pitcher of water. Observation on 06/28/2023 at 10:15 AM, revealed Resident #81's bedside table was to the left of the resident's bed against the wall with his/her water pitcher sitting on it. In interview at the time of observation, related to the 06/14/2023 fall, Resident #81 stated when he/she reached over the ¼ bedrail with his/her right arm over his/her left side to reach the water on the bedside table, he/she slide out of bed onto the floor. In an interview on 06/28/2023 at 10:15 AM, Registered Nurse (RN) #35 stated Resident #81 was on fall precautions, had fall strips in front of his/her chair and had a walker. She stated she was not aware Resident #81 had a fall on night shift and not been informed of the fall during report. In an interview on 06/28/2023 at 10:30 AM, Certified Medication Technician (CMT) #1 stated Resident #81 was care planned for falls, had falls strip in front of his/her chair and closet. CMT #1 stated Resident #81 used a walker to ambulate and liked to move the bedside table around away from the bed. 4. Review of Resident #102's medical record revealed the facility admitted the resident on 01/28/2022, with diagnoses which included Dementia, and Major Depressive Disorder. Review of Resident #102's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to be moderately cognitively impaired. Further review of the MDS, Section G, the functional status revealed the facility assessed Resident #102 to require the assistance of one (1) person for transfers and ambulation. Continued review revealed the facility assessed Resident #102 as not steady without human assistance, and to require the assistance of a cane for ambulation. Review of Resident #102's Comprehensive Care Plan, dated 02/20/2023, revealed the facility care planned the resident as at risk for falls. Interventions included to assist him/her with proper sitting positions while in a chair. Further review revealed additional interventions included the resident was to have his/her walking cane within arm's reach, dated 01/31/2022; the resident was to sit in a chair rather than the couch, with appropriate nonskid footwear when out of bed; and ensure the resident had an unobstructed path to the bathroom, dated 02/11/2022. Review of the fall investigation, dated 06/17/2023, revealed Resident #102 had a witnessed fall in the common area. Per review, Resident #102 had been sitting in a hard back chair in the lounge area with his/her walking cane in his/her hand. Further review revealed a CNA observed Resident #102 pull his/her legs back and then slipped down onto his/her knees onto the floor. Continued review revealed the facility identified the root cause of Resident #102's fall as his/her feet slipped due to poor traction. In addition, the facility implemented an intervention to place Resident #102 on 1:1 supervision. Review of the Comprehensive Care Plan dated 06/18/2023, revealed interventions for Resident #102 to be placed on every fifteen (15) minute checks; and to assist the resident to bed when staff observed him/her falling asleep in a chair. Review of the Physical Therapy evaluation, dated 06/19/2023, revealed Resident #102 was able to complete transfers from multiple seats on the memory care unit with extra time and attempts, supervision, and cues for technique. Further review revealed Resident #102 was also able to ambulate using his/her sight cane with supervision with occasional cues for obstacles and navigation. In addition, Resident #102 was noted to be at his/her prior level of function. Review of Resident #102's bedside Kardex report, dated 06/20/2023, revealed the interventions included the resident was independent for transfers and ambulation with his/her walking stick. Continued review revealed additional interventions included to assist Resident #102 with proper sitting positions when in a chair and to wear appropriate nonskid footwear when out of bed. Review of Resident #102's bedside Kardex report dated 06/20/2023, revealed the intervention for the resident to be on every fifteen (15) minute checks. Observations of Resident #102 on 06/22/2023 at 9:05 AM and 4:20 PM, revealed the resident sitting in a hard back chair in the common area of the unit. Further observation revealed Resident #102 had his/her cane in hand, and was wearing hard sole shoes. In addition, observation revealed non-skid strips on the floor in front of the chair. Review of the facility's fall investigation dated 06/23/2023 at 1:00 AM, revealed Resident #102 had sustained an unwitnessed fall in his/her room, and was found lying on the floor on his/her right side. Continued review revealed Resident #102 stated he/she was trying to go to the bathroom. The resident stated that his/her head was hurting after the fall. Further review revealed the facility identified the root cause of the fall as the resident needed to use the restroom. In addition, the facility's immediate intervention was to place the resident on 1:1 supervision, and to make a referral to Occupational Therapy pertaining to the resident using a urinal. In an interview on 06/28/2023 at 9:20 AM, Certified Medication Technician (CMT) #85 stated Resident #102 tried to get up to go the bathroom on impulse, and had a habit of trying to clean his/her chair before sitting down. CMT #85 stated Resident #102's interventions included for him/her to wear shoes and have his/her cane in hand. The CMT stated that on 06/17/2023 Resident #102 fell when he/she went to sleep in the chair and was dreaming, then slid out of the chair onto the floor. 5. Review of Resident #107's admission Record revealed the facility admitted the resident on 09/29/2022 with diagnoses that included Unspecified Injury of the Head, Dementia without behavioral disturbance, Psychotic Disturbance, Chronic Obstructive Pulmonary Disease, Hemiplegia and Hemiparesis following Cerebral Infarction, Chronic Kidney Disease, Stage 3 and Congestive Heart Failure. Review of Resident #107's Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) examination score of 99. This score indicated the resident was not interviewable. Further review revealed the resident presented with disorganized thinking behaviors that fluctuated and varied in severity. Review of the facility incident report, dated 06/12/2023 at 9:50 AM, completed by Registered Nurse (RN) #6 revealed Resident #107 had a witnessed fall from a wheelchair in the common area. Resident #107 thought he/she saw something on the floor and was trying to pick it up. The resident was unable to tell what he/she observed on the floor. Review of Resident #107's Fall Care Plan dated 09/30/2022, Dementia/Impaired Cognition Care Plan dated 03/06/2023, and Communication Deficit Care Plan dated 10/22/2022, revealed the resident was at risk for falls related to a history of falls and impaired cognition. The care plans also revealed the resident had impaired mobility, unsteadiness on feet, and a decline in safety awareness related to dementia. Further review revealed the care plan goals were for Resident #107 to have no unidentified falls thru the next review period, would be able to make needs known and maintain current level of cognition. The interventions directed staff to provide consistent cueing and to supervise as needed. In addition, to be conscious of resident position when in groups, activities and dining room promote communication with others. Review of Resident #107's Root Cause (RC) Analysis form, dated 06/12/2023, revealed the facility used the Five Why's process in determining the RC of the resident's fall. The form stated, on 06/12/2023 the resident fell from the wheelchair (w/c) in the common area trying to pick something up off the floor. Continued review revealed the RC analysis form had Five (5) Why's listed on the page and only three (3) had responses next to them. The first Why response noted, the resident leaned forward in the w/c. The second Why response noted, the reason why the resident leaned forward was to pick something up off the floor. The third Why response noted, the resident was unable to tell the staff what he/she was seeing on the floor. The fourth and fifth Why responses were left blank. The form noted the RC of the fall, was poor balance control and that physical therapy would evaluate the resident for w/c positioning. Continued review of the form did not reveal if the facility analyzed the staff's implementation of fall prevention interventions related to supervision, cueing or monitoring of resident position interventions. Review of Registered Nurse (RN) #36's Nursing Note for Resident #107's, dated 06/12/2023 at 10:00 AM, revealed CNA #103 witnessed Resident #107 fall in the common area. The note revealed Resident #107 stated, I was trying to pick it up off the floor. Per the Note, the nurse was unable to visualize anything on the floor at the time of the incident. Resident #107 complained of pain to the left arm and a skin tear to the left hand. Continued review revealed a dry dressing was applied to the skin tear to stop the bleeding. Further review revealed, (Resident) complained of pain to the left hip. A laceration to left forehead was noted. Notified (Nurse Practitioner #1), who was in the building, observed resident and ordered to send resident to the hospital. Notified the resident's family member/emergency contact and the resident was transferred from the floor to the stretcher per two (2) Emergency Medical Technicians (EMTs) and was transported to the hospital by ambulance. The DON was notified. 1 on 1 care would be provided upon arrival back to facility. During interview on 06/25/2023 at 4:11 PM, CNA #103 stated that she did not witness Resident #107's fall. She stated when she heard someone yell, she turned around and Resident #107 was already on the floor. CNA #103 stated that she stayed with Resident #107 until someone got a towel and a nurse came. Review of Resident #107's Interdisciplinary Team (IDT) Note, dated 06/12/2023 at 12:53 PM, revealed Resident #107 was in the common area this AM when he/she leaned forward in his/her wheelchair and fell out of the chair. Resident #107 stated he/she was trying to get it. The floor was clean and dry. The resident being unable to tell me what the 'get it was. Continued review revealed staff were in the area, but were unable to reach him/her. Small laceration was noted to the left side of the resident's forehead and two (2) small skin tears were noted to the resident's right arm. Resident was sent to the emergency room for evaluation and treatment. Resident's Daughter was notified. RN #36 stated during interview on 06/29/2023 at 9:13 AM, that when she completed the fall report, CNA #103 stated she had witnessed Resident #107's fall. RN #36 stated that she went to Resident #107, and noted the resident had a small skin tear to his/her left hand, and a small laceration to the head, but no hematoma was noted. She stated Nurse Practitioner (NP) #1 was in the building and she had her assess Resident #107. 6. Record review revealed the facility admitted Resident #15, on 04/30/2020, with diagnoses which included Alzheimer's Disease, Parkinson's Disease, Cerebral Infarction (Stroke), Schizophrenia, Personal History of Traumatic Brain Injury, Psychosis, and Convulsions. Review of Resident #15's Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of eight (8), which indicated moderate cognitive impairment. Further review of the MDS revealed the resident required one-person physical assist with transfers and ambulation. Review of Resident #15's Comprehensive Care Plan for risk for falls, initiated on 05/01/2020, revealed interventions which included: to be sure the resident's call light was within reach; encourage the resident to use the call light for assistance as needed; and, the resident needed prompt response to all requests for assistance. Further review revealed an intervention, initiated on 06/16/2023, for the resident to have every fifteen (15) minute checks. Review of the SBAR (Situation-Background-Assessment-Recommendation) Note, dated 06/16/2023 at 9:35 AM, revealed Resident #15 was ambulating when he/she became dizzy and his/her knees felt weak. The facility failed to encourage the resident to use his/her call light for assistance as needed per the care plan. Observation, on 06/24/2023 at 9:15 AM, revealed Resident #15 lying in bed with his/her eyes closed and appeared to be sleeping. Further observation revealed the resident's call light was lying across the arm of the recliner at the foot of the bed out of the resident's reach. Review of the fifteen (15) minute checks revealed staff had not completed the checks since 5:15 AM on 06/24/2023. The facility failed to ensure the call light was in the resident's reach and did not complete the increased supervision of the fifteen (15) minute checks per the care plan. Review of Resident #15's Comprehensive Encounter Note, dated 06/16/2023 at 4:45 PM by the Advanced Practitioner Registered Nurse (APRN) revealed the resident wanted to go eat breakfast, and was buckling at the knees. Further review revealed she went to get a chair for him/her to sit on before he/she was lowered to the floor. After breakfast, the resident stated he/she went to the bathroom and was going to eat, but forgot his/her sugar. The resident stated he/she turned to go back to get it when he/she became dizzy and fell to the floor in the hallway. Review of Resident #15's Five (5) Why's Root Cause Analysis, dated 06/16/2023, revealed the resident was in the [NAME] Hallway returning to his/her room when he/she turned around, lost his/her balance, and fell when his/her balance was off. During interview with Certified Nursing Assistant (CNA) #10, on 06/24/2023 at 9:25 AM, he stated he had been up and down the hall and checked on Resident #15. He further stated he had not had time to complete the Fifteen (15) Minute Check Sheet but everything had been good with Resident #15. CNA #10 stated he had last checked on the resident at 9:15 AM. He stated he was unsure why the night shift staff had not completed the sheet from 5:15 AM until he started his shift at 7:00 AM. During interview with Registered Nurse (RN) #4, on 06/24/2023 at 9:28 AM, she stated she expected the CNA to complete one-on-one (1:1) and every fifteen (15) minute check duties as ordered. She stated she was unaware the every fifteen (15) minute check paperwork had not been completed since 5:15 AM. The RN stated she expected staff to do their jobs and she did not micro manage them. During an interview with Director of Nursing (DON) #4, on 06/24/2023 at 10:30 AM, she stated nurses should oversee the staff on the units to ensure the staff implemented the care plan interventions appropriately. She further stated she expected staff should encourage Resident #15 to use his/her call light for assistance. DON #4 stated Resident #15's call light was to be within reach and every fifteen (15) minute checks were to be completed and documented at the time they were due. She stated the nurse should be supervising to ensure this was done. DON #4 stated the staff needed more education and she would be auditing the fifteen (15) minute check sheets in the future. 7. Record review revealed the facility admitted Resident #32, on 10/28/2022, with diagnoses which included Dementia, Chronic Obstructive Pulmonary Disease (COPD), Osteoporosis, and Anemia. Review of Resident #32's 04/11/2023 MDS revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of four (4), which indicated severe cognitive impairment. Further review of the MDS revealed the resident required one-person physical assistance for transfers and ambulation. Review of Resident #32's Comprehensive Care Plan, initiated 10/28/2022, revealed the resident required the safety of residing on a secured unit related to dementia and impaired safety to surroundings, with an intervention for the resident to be supervised while on the secured unit. Further review of the Comprehensive Care Plan, initiated 11/13/2022, revealed the resident had osteoporosis and required assistance with physical activity and daily ambulation. Continued review of Resident #32's Comprehensive Care Plan, initiated 10/28/2022, revealed the resident was at risk for falls related to impaired safety awareness, COPD, and dementia. An intervention was initiated on 11/01/2022, to ensure appropriate footwear when out of bed. Review of the resident's SBAR note, dated 06/20/2023 at 2:31 PM, revealed Resident #32 had an unwitnessed fall. Staff found the resident sitting on the floor in his/her room on his/her bottom in front of the bed. Further review revealed Resident #32 was not wearing non-skid socks at the time of the fall. Review of Resident #32's Nurse's Note, dated 06/21/2023 at 6:08 PM, revealed Resident #32 had another unwitnessed fall on 06/21/2023 when he/she was found sitting on the floor in his/her room in front of the bed. Observation, on 06/25/2023 at approximately 9:48 AM, revealed Resident #32 lying in bed with his/her walker and overbed table on the other side of the room by his/her roommate's bed. CNA #112 was observed to come into the room and assist Resident #32 to a sitting position on his/her bed, then left the room without assisting the resident to get out of bed or handing the resident his/her walker. In an interview on 06/28/2023 at 4:45 PM, the Director of Nursing (DON) stated the facility could not keep residents from falling and did not know when or how they might fall. She stated she was tracking the falls for the day, time, staff, and the activities of the staff to identify areas concerning supervision. Per the DON, she collected the information on the falls and provided the root cause of the fall. The DON stated the facility was responsible to provide safety. However, they could not always prevent residents' falls and could not put all residents on 1:1 supervision. She further stated staff should be vigilant with resident safety. The DON stated she collected the information and provided the root cause of the fall. The falls were discussed in morning meeting during clinicals. She stated the care plans were reviewed for interventions. During an interview with Executive Director #2, on 06/28/2023 at 5:32 PM, she stated she expected nurses to use good nursing judgement. The Executive Director stated the nurses should pick up on any issues with residents. She stated a delay in care could cause the resident's condition to worsen. The Executive Director stated good documentation assisted with continuity of care and a large part of the nurses' jobs was to assess and monitor. In an interview on 06/28/2023 at 5:23 PM, the Executive Director (ED) stated sh[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the facility's document, and review of the Emergency Medical Services (EMS) run report, it was determined the facility failed to ensure physician's orders for the resident's immediate care was obtained at the time each resident was admitted for one (1) of thirty-three (33) sampled residents (Resident #821). The facility failed to obtain admission orders for Resident #821 when the resident was re-admitted to the facility on [DATE] with a heparin lock (intravenous [V] catheter that could be used to give medicine or fluids intermittently). Review of Resident #821's Progress Notes revealed the facility sent the resident to the emergency room (ER), on 04/14/2023, related to blood clots in his/her urinary catheter. The Primary Care Physician (PCP) believed this issue needed to be addressed in the ER. While the resident was treated at the emergency room (ER), he/she received IV(intravenous) fluids via a heparin lock (heplock). Resident #821 returned to the facility on [DATE] at approximately 10:30 PM. However, the PCP failed to call in an order to the facility to discontinue the heparin lock upon the resident's return on 04/14/2023. The findings include: Review of Resident #821's admission Record revealed the facility admitted the resident, on 12/21/2022, with diagnoses of Dementia, Malnutrition, Urinary Retention, and Multiple Falls. Review of Resident #821's Quarterly Minimum Data Set (MDS) Assessment, dated 04/08/2023, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of six (6) of fifteen (15) which indicated severe cognitive impairment. The facility assessed the resident for one (1) person physical assistance for bed mobility, toileting, dressing, eating and personal hygiene. The MDS Assessment also revealed the resident had an indwelling urinary catheter in place. Review of Resident #821's Progress Notes revealed on 04/10/2023, the resident had blood clots in the tubing of his/her indwelling urinary catheter which interfered with its functioning. On 04/14/2023, Resident #821's Primary Care Physician (PCP) determined the resident required the care of the Emergency Room's (ER) Urologist and had the resident sent to the hospital for a pre-arranged visit. While the resident was treated at the emergency room (ER), he/she received IV fluids via a heparin lock (heplock). However, the PCP failed to call in an order to the facility to discontinue the heparin lock upon the resident's return on 04/14/2023. Consequently, the heparin lock was not discontinued until Emergency Medical Services (EMS) personnel did so on 04/15/2023 when they went to the facility to transport Resident #821 to the hospital. Review of the After Visit document for Resident #821 from the ER, dated 04/14/2023, revealed the resident was returned to the facility with instructions that the PCP wanted the IV/heplock to be left in place, and he would follow up with an order. Further review revealed the heplock was left in for the resident to possibly receive IV fluids in the facility. Continued review revealed a handwritten note at the top of the form which noted, attempted to call report 3x, no answer, any questions call, with a phone number provided. Further review of the document revealed it had a date stamp showing the facility received it on 04/19/2023. During an interview with Licensed Practical Nurse (LPN) #15, on 05/16/2023 at 3:45 AM, she stated she was the nurse who received Resident #821 back at the facility from the ER on [DATE] about 10:30 PM. LPN #15 stated the resident did not return with any paperwork. The LPN stated she only completed a waist down assessment, and she did not find the IV in the resident's arm. LPN #15 stated if the resident was sent back without any paperwork she should call the hospital to request the papers and to get report. The LPN stated that not knowing a resident had an IV in place could result in the IV getting clogged. In an interview with the PCP, on 05/12/2023 at 9:41 AM, he stated Resident #821 was pretty fragile in health. He stated the resident was sent to the hospital on [DATE] for possible dehydration, elevated creatinine (blood chemistry reflective of kidney failure or dehydration) and urinary retention. The PCP stated Resident #821 was given IV fluids cautiously in the ER due to history of congestive heart failure (CHF). He stated the heplock was left in place with the intent of giving more IV fluids at the facility, but the decision was made not to because of the resident's history of CHF. The PCP stated he had not given an order to discontinue the heplock once the resident returned to the facility. He added the time between when Resident #812 was sent to the ER for urinary retention and the fall on 04/15/2023 was so short that the heplock was in for less than one (1) day. Further review of Resident #821's Progress Notes revealed the resident sustained a fall on 04/15/2023, which resulted in Emergency Medical Services (EMS) being called, and the resident being taken to the ER. The EMS left the facility at 8:20 PM and arrived to the ER at 8:30 PM. Review of the EMS Run Report #E4523-00004335, revealed upon making patient contact, an IV was found in the patient's L AC [left antecubital]. The staff stated they had no idea why the IV was still there, and their nurse practitioner had been made aware. In the patient's paperwork, there was no indication that patient was on IV medications so Paramedic .discontinued the IV. On 05/10/2023 at 2:46 PM, the State Survey Agency (SSA) Surveyor emailed the EMS Manager to request an interview with the Paramedic who was at the facility on 04/15/2023. The SSA Surveyor was informed by the EMS Manager that she would contact the EMS Department Attorney for approval, but the SSA Surveyor did not receive a reply. In an interview with the Assistant Director of Nursing (ADON), on 05/11/2023 at 1:00 PM, she stated when a resident arrived back to the facility after being in the hospital, the nurse who received the resident should have performed a skin assessment. However, she did not believe it was required if the resident returned the same day he/she was sent out, only during readmission. She stated, on 04/14/2023, Resident #821 was just out for a few hours. The ADON said paperwork sent back from an appointment was reviewed by the clinical team. The discharge summary should have been reviewed thoroughly and documentation done immediately. In an interview with the Director of Nursing (DON), on 05/11/2023 at 1:44 PM, she stated management reviewed the dashboard daily in the morning meetings, which included looking at incident reports, care plans, and orders; and they discussed each resident as a team. She said the paperwork did not always come back with a resident when they went out for an appointment. The DON stated the PCP decided he did not want Resident #821 to have IV fluids because of concerns of fluid overload. She stated she could not find a note about the resident's return, after his/her 04/14/2023 appointment, in the system. The DON said the IV should have been taken out. She stated she did not know why this information was missed in the morning meeting on 04/15/2023. In an interview with the Executive Director (ED), on 06/02/2023 at 1:23 PM, she stated she expected staff to follow the policies and procedures of the facility.

Based on observation, interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 User Manual,, it was determined the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for one (1) of thirty-three (33) sampled residents (Resident #48). The facility assessed Resident #48, as having a walker and wheelchair on the 05/11/2023 Minimum Data Set (MDS) assessment. However, observation and interview revealed Resident #48 did not use a wheelchair. The findings include: Review of the RAI Manual revealed the RAI process required that the assessment accurately reflected the resident's status and a registered nurse conducted or coordinated each assessment with the appropriate participation of health professionals. Observation of Resident #48, on 06/02/2023 at 1:38 PM, revealed the resident was sitting on a couch in the common area and did not have a wheelchair present. Review of Resident #48's admission Record revealed the facility admitted the resident on 02/18/2022, with diagnoses of Cerebral Infarction, Muscle Weakness, Difficulty in Walking, and Dementia. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/11/2023, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) which indicated severe cognitive impairment. The MDS also revealed the facility assessed Resident #48 for the use of a wheelchair for mobility on 03/24/2023, 04/07/2023 and 05/11/2023. Review of Resident #48's Comprehensive Care Plan (CCP), last revised 04/10/2023, revealed the facility did not care plan the resident for use of a wheelchair. During interview, on 06/02/2023 at 1:38 PM, Certified Nursing Assistant (CNA) #88 stated Resident #48 did not use a wheelchair. In an interview with MDS Coordinator #1 on 06/02/2023 at 3:12 PM, she said that she was responsible for making sure the MDS was completed. She stated she reviewed the residents' care plans as she completed quarterly and annual MDS's. MDS #1 stated she made changes as appropriate so the resident's care plan and MDS aligned. She further stated Resident #48's 05/11/2023 Quarterly MDS was completed by another nurse off site by reviewing the resident's medical record. In an interview with the Director of Nursing (DON) she stated the MDS team was responsible to ensure the care plan and the MDS matched. She stated updates could be made by any nurse or in the Interdisciplinary Team (IDT) meeting. She stated any inaccuracies should be caught during the IDT meeting. The DON said the MDS team was responsible for the comprehensive review and during that review the team could also make any updates and changes to resident's care plans. In an interview with the Executive Director on 05/19/2023 at 3:43 PM, she stated interventions were discussed daily in their clinical meetings/IDT. She stated if there was an incident the day prior, or on Monday over the weekend they look at it to determine if a new interventions was needed. She said If an intervention was not working, it should be taken off and a new one should be added. The MDS Coordinator was the one responsible to make those changes. The DON and Assistant Director of Nursing (ADON) could assist with ideas in the IDT/Clinical meeting. The ED stated the MDS Coordinator did not attend every clinical meeting, but she was not expected to attend them regularly. In continued interview with the ED on 05/19/2023 at 3:43 PM, she stated different residents required different assessments. She stated when a resident was admitted to the facility there should be an assessment completed for any type of device the resident required. The ED stated the nursing department was responsible to complete those type of assessments. She stated nurses were taught in school how to complete assessments. The ED stated the importance of accurate assessments was because those assessments determined what kind of care the residents needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review it was determined the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain good oral hygiene for one (1) of nineteen (19) sampled residents (Resident #44). On 06/25/2023 at 1:52 PM, Resident #44 was observed with food particles/substance in his/her mouth and on his/her teeth. The findings include: Review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting, not dated, revealed residents who were unable to carry out ADLs independently would receive the services necessary to maintain good grooming and personal and oral hygiene. Further review revealed appropriate care and services would be provided for residents who were unable to carry out ADLS independently, with the consent of the resident and in accordance with the plan of care, which included appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care). Review of Resident #44's admission Record revealed the facility admitted the resident on 03/29/2023. The resident's diagnoses included Malignant Neoplasm of the Brain, Osteoarthritis, Muscle Weakness, Difficulty in Walking, Need for Assistance with Personal Care, and Unsteadiness on Feet. Review of Resident #44's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99. This score indicated the resident was severely cognitively impaired. Further review revealed the resident required extensive assistance of one (1) person for transfers and hygiene. Review of Resident #44's Comprehensive Care Plan initiated 04/11/2022, revealed the resident had an Activities of Daily Living (ADL) self-care performance deficit related to dementia, impulsive disorder, muscle weakness, and anxiety disorder. Further review revealed goals that included the resident would improve and maintain that level of function. Interventions included set up and assist with oral care daily and as needed. Observation of Resident #44, on 06/25/2023 at 1:52 PM, revealed the resident had food particles caked onto his/her teeth and crumbs were noted to be coming out of the resident's mouth while he/she was speaking. The resident did not have any food in his/her vicinity at the time of the observation. Interview on 06/25/2023 at 4:50 PM, with Certified Nurse Aide (CNA) #8, who was assigned to Resident #44, revealed the third (3rd) shift staff were responsible for getting residents up in the mornings, providing personal hygiene, including brushing residents' teeth. She further stated day shift staff assisted residents with oral care as needed. CNA #8 stated good hygiene was important for residents' dignity and to prolong how long residents could keep their teeth. Interview on 06/26/2023 at 10:36 AM, with Licensed Practical Nurse (LPN) #40, revealed she was not sure what the policy was at the facility regarding oral care. She further stated residents' dentures were soaked overnight. DON #4 stated during interview on 06/26/2023 at 11:05 AM, staff should assist residents with brushing their teeth before assisting them to the dining room in the mornings, after meals, and at bedtime. She stated staff should make sure food was not clinging to a resident's teeth and there was no build up on the teeth. The DON stated staff should follow the interventions on the Care Plan and brush the resident's teeth at the times listed above and as needed. During interview on 06/28/2023 at 5:32 PM, with Executive Director (ED) #2, revealed she expected the staff to follow the Care Plan interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observations, record review, and the facility's policy it was determined the facility failed to ensure proper treatment and evaluation for assistive devices related to maintaining vision for one (1) of thirty-three (33) sampled residents (Resident #90). The facility admitted Resident #90 on 09/21/2022. However, the facility failed to arrange for the resident to be assessed for his/her vision impairment and need for eyeglasses. The findings include: Review of the facility's policy titled, Vision and Hearing Evaluations, Version #:1, dated 09/03/2017, revealed the purpose statement was to promote resident function at their highest practical level. Procedures included assess need for an evaluation, with resident or representative with Social Services or nursing staff arranging evaluation as soon as possible. Added review revealed Social Services or designee would update the resident's plan of care. Review of the facility's agreement with the contracted Optometry Service, with an effective date of 11/01/2019, revealed services available included Optometry Services. These services included vision examinations, medical eye evaluations, fall risk evaluations and fitting and ordering glasses. Review of Resident #90's admission Record revealed the facility admitted Resident #90, on 04/05/2023 with diagnoses of Alzheimer's Disease, muscle weakness, difficulty walking, dementia, vision impairment, and repeated falls. Review of Resident #90's Quarterly Minimum Data Set (MDS) Assessment, dated 04/07/2023. revealed the facility assessed the resident with a Brief interview for Mental Status (BIMS) score of three (3) out of fifteen (15). This score indicated severe impairment. Further review revealed Resident #90 had moderately impaired-limited vision. Review of Resident #90's Fall Risk assessment dated [DATE] revealed a score of eighteen (18) indicating vision status as poor. Review of the facility's Fall Risk Assessment form revealed eight (8) areas of fall risks, which included, 1-level of consciousness/mental status, 2-history of falls(past three (3) months), 3- Ambulation/elimination status, 4- Vision status, 5- Gait/balance, 6- systolic blood pressure, 7- Medication, 7-1 resident has had a change in medication or change in dosage in the past five (5) days, and 8- predisposing disease. Continued review of FRA revealed number four (4) was indicated for vision status as poor (with or without glasses) for Resident #90. Review of Resident #90's Comprehensive Care Plan (CCP), dated 09/15/2022, revealed the facility assessed the resident to reside on a secured unit related to diagnosis of dementia and impaired safety to surroundings. Interventions placed on the 01/20/2023 CCP, included the resident was to be supervised while on the secured unit. Continued review of the CCP revealed the facility assessed the resident to be at risk for falls related to impaired safety awareness and impaired vision increasing risk of injury. The date initiated was 09/15/2022 and was revised on 03/21/2023. Additional interventions included: individualized activities to reduce outside stimulation; resident had impaired vision causing hearing to be more sensitive to loud noises and outside distractions initiated on 10/21/2022 and revised on 03/09/2023. Continued review of Resident #90's CCP revealed the facility assessed the resident to have impaired visual function and uses walls as guides. Review of the CCP revealed interventions placed on 10/11/2022, which included to arrange consultation with eye care practitioner as required, assist with Activities of Daily Living (ADLs) as needed and consistently tell the resident where items were placed. Observation of Resident #90, on 05/25/2023 at 9:15 AM, revealed the resident was sitting in a chair with other residents in the common area and appeared to be dozing. Further observation revealed bruising noted to the resident's left eye orbital area. Review of Resident #90's Electronic Medical Record (EMR) revealed on 05/25/2023 at 4:15 AM the resident was found on the floor in his/her room with sheets wrapped around his/her feet. A skin assessment revealed a small area of blood from an old scab and two (2) small knots noted on the left side of his/her face. The facility did not transfer the resident to the hospital. Continued review of Resident #90's EMR revealed on 04/21/2023 at 6:45 AM, the resident attempted to sit in a chair located in the dayroom and missed the chair falling to the floor, no injuries were noted. Review of Resident #90's EMR revealed on 04/22/2023 ecchymosis (bruising) was noted to resident's buttock area. Review of the Interdisciplinary Team (IDT) meeting notes on 04/21/2023 revealed no injuries were noted after the fall, but ecchymosis was noted to the right buttock. Review of the IDT meeting notes revealed the root cause of the fall was determined to be the resident attempted to sit in chair and was not close enough to the chair, lost his/her balance and landed on his/her buttocks. Continued review of the meeting notes revealed no evidence the facility considered Resident #90's impaired vision as a root cause of the falls. Review of Resident #90 EMR revealed, on 04/15/2023 at 1:52 PM, the resident had two (2) falls within twenty (20) minutes, one in which the resident hit the back of his/her head which resulted in a small amount of blood noted. Further review revealed the facility transferred Resident #90 to the local emergency room. Review of the IDT Notes, dated 04/15/2023, revealed Resident #90 fell twice in twenty (20) minutes with no injuries noted with the first fall. However, the resident hit his/her head with the second fall with a small laceration and a small amount of blood noted to the back of the scalp. The root cause analysis concluded the resident attempted to transfer without assistance and was unable to do so. Continued review revealed no evidence the facility considered impaired vision as a possible root cause for the falls. Review of the results of the Computerized Tomography (CT) of Resident #90's head performed at a local emergency room on [DATE] were chronic subdural (membrane covering spinal cord and brain) hematomas (mass of blood) and or hygromas (sac of fluid) since study on 09/16/2022. Review of the CT of the spine revealed no fractures of the spine with final diagnosis of contusion of scalp per emergency room notes. Continued review of Resident #90 EMR revealed an active order as of 04/05/2023 which stated the resident was to see an ophthalmologist written on 09/15/2022 upon admission. Review of the EMR also revealed a Physical Therapy Evaluation and Plan of Treatment, dated 04/06/2023, which noted patient's (resident's) factors included poor scanning of environment and history of wandering around on unit. Continued review of the Physical Therapy Evaluation and Plan of Treatment, dated 05/29/2023, revealed a new goal was to provide verbal cues for use of compensatory strategies due to low/reduced vision. Review of the Physical Therapy Evaluation and Plan of Treatment revealed a functional mobility assessment for gait which included deviations of inconsistently scanning environment and difficulty with object negotiation below waist level. Review of Resident #90's EMR revealed appointments for an eye examination on 06/21/2023, with the resident listed as a new patient exam. Continued review revealed former the Medical Director, noted on 04/14/2023 for the eye doctor to evaluate Resident #90 on next visit due to vision declining. Observation on 05/30/22023 at 12:40 PM revealed another resident holding Resident #90 hand and guiding him/her as they walked down the hallway to the dining room. Additional observation revealed two (2) staff members who were already in the dining room, assisted Resident #90 to be seated in a chair at the table. Observation on 05/31/2023 at 9:25 AM revealed Resident # 90 sitting in chair with his/her head down. Resident #90 appeared to be dozing (falling asleep). Observation on 05/30/2023 at 12:40 PM revealed Speech Therapy #1 assisted the resident with his/her meal redirecting where the resident's food was located on the plate, placement of his/her drink and the amount of food to be placed in the spoon. During interview with Certified Nursing Assistant (CNA) #87 on 05/25/2023 at 9:30 AM, she stated Resident #90 was a little unsteady when walking and had sustained a fall on night shift. CNA #90 stated the resident now had bruising to the left eye. The CNA stated she had not noticed the resident wearing glasses since she has worked here. During interview with CNA #34, on 05/25/2023 at 9:20 AM, she stated she never saw the resident with glasses since he/she lived at the facility. In an additional interview with CNA #34, on 06/02/2023 at 5:05 PM, she stated Resident #90 needed assistance when trying to sit in a chair. In a interview with Licensed Practical Nurse (LPN) #9, on 05/30/2023 at 11:20 AM, she stated she never saw Resident #90 wearing glasses. She stated she recalled eye care had previously been to the facility but, she could not recall if Resident #90 had seen them. In interview with Social Service Director (SSD), on 05/31/2023 at 2:30 PM, she stated appointments were set up for routine visits for the residents, but the Optometry Service declined coming to facility since the State Survey Agency was in the building and appointments were moved to 06/21/2023. She stated that she did not know if the previous SSD made any appointments for Resident #90 to be seen by the eye doctors. Review of the CCP with the SSD, revealed the CCP was initiated on 09/15/2022 and revised on 03/21/2023 for Resident #90 to see an eye care doctor for impaired vision, which increased the risk for injury. In interview with Director of Nursing (DON), on 05/23/2023 at 2:00 PM, she stated the only time a resident was sent to outside provider for eye care was if the resident had an urgent condition.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice for one (1) of thirty-three (33) sampled residents, Resident #22. Resident #22 had a Bilevel Positive Airway Pressure (BiPAP) machine that helped the resident get more air into the lungs. There was no evidence the Licensed Nursing staff were conducting assessments of pre/post lung sounds for administration of nebulizer medications. Also there was no evidence nursing staff was conducting more frequent rounds to ensure Resident #22 wore the Bi-PAP mask while napping and at bedtime, as per Physician's Orders. Review of Resident #22's Care Plan revealed he/she was care-planned for refusal to wear the Bi-PAP when napping or sleeping. However, there were no resident centered interventions to ensure Resident #22 was wearing the Bi-PAP mask as ordered. The findings include: Review of the facility's policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised 2010, revealed the process would include documentation of the pre/post lung sounds for administration of nebulizer medications. Review of the facility's policy titled, Care of Residents with Respiratory Diseases, revised 01/24/2012, revealed staff would assess lung sounds including auscultation (listening to lung sounds with a stethoscope). Review of the facility's policy titled, Chronic Obstructive Pulmonary Disease (COPD)-Clinical Protocol, revised 11/2018, revealed the clinical protocol included assessment and documentation of vital signs to include a detailed description of respirations. Additional review revealed full lung sounds were to be assessed and documented. During an interview with the Director of Nursing (DON), on 05/18/2023 at 10:55 AM, she stated there was not a facility policy, procedure, or process to ensure residents that were care-planned for refusals of care were monitored more frequently to ensure compliance. The Executive Director (ED), on 05/18/2023 at 11:38 AM, reiterated what the DON had said by stating there was not a facility policy, procedure, or process to ensure residents that were care-planned for refusals of care were monitored more frequently to ensure compliance. Review of Resident #22's clinical record revealed the facility admitted him/her on 02/10/2020, with diagnoses that included Acute/Chronic Respiratory Failure with Hypercapnia (build-up of carbon dioxide (CO2) in the blood) and Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #22's Quarterly Minimum Data Set (MDS) Assessment, dated 04/05/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of twelve (12) of fifteen (15), indicating moderate cognitive impairment. Review of Resident #22's Care Plan, dated 03/28/2023, revealed a Focus that included at risk for decline related to his/her refusal for care as ordered, that included wearing the Bi-PAP mask; he/she understood the risk of refusing to wear the mask but did not like wearing the Bi-PAP mask. Further review revealed there were no resident centered interventions on the care plan to encourage use of the BiPAP. Observations on 05/16/2023 at 3:38 AM, revealed Resident #22 to be in bed with his/her eyes closed. Resident #22's Bi-PAP mask and Oxygen (O2) nasal cannula were both off. During an interview with Registered Nurse (RN) #15, on 05/16/2023 at 3:47 AM, she stated that she did not routinely check breath sounds unless a resident was exhibiting sounds and symptoms of respiratory distress. She stated she did assess lung sounds pre/post administration of nebulizer medications; however, there was no area to document the results on the medication administration record (MAR) or treatment administration record (TAR). She stated she would occasionally document lung sounds in the Nursing Progress Notes. RN #15 stated she would make resident rounds with medication administration and every two (2) hours; but to her knowledge, there was not a process to ensure Resident #22 received more frequent rounding to ensure compliance with wearing the Bi-PAP mask. Review of Resident #22's MAR/TAR, dated April 2023 and May 2023, revealed there was not an area to document pre/post nebulizer treatment lung sounds as per the facility's policy. Review of Nursing Progress Notes and General Notes for April 2023 and May 2023, revealed there was no documentation of Resident #22's lung sounds pre/post nebulizer treatments; nor was there documented evidence of more frequent monitoring for compliance or refusals to wear the Bi-PAP mask. During an interview with the Assistant Director of Nursing (ADON), on 05/16/2023 at 7:15 AM, she stated she was unaware if the facility had policies concerning care of residents with respiratory diseases. She also stated she was not aware if pre/post nebulizer lungs sounds should be obtained and where to document the results. In an interview with the facility's Advance Practice Registered Nurse (APRN), on 05/17/2023 at 11:39 AM, she stated it would be her expectation for staff to obtain and document pre/post nebulizer medication administration lung sounds. She also stated it would be her expectation for staff to monitor and document Resident #22's usage or refusal of the Bi-PAP mask. She stated Resident #22 needed to use the Bi-PAP machine to assist in managing his/her disease processes of Acute/Chronic Respiratory Failure with Hypercapnia and Chronic Obstructive Pulmonary Disease (COPD). RN #6, during an interview on 05/17/2023 at 1:55 PM, stated she was aware that pre/post lungs sounds with nebulizer medication administration should be assessed and documented; however, there was not a place on the MAR/TAR to document results. During the interview, RN #6 stated she was unaware if increased monitoring for Resident #22 was ordered. Agency RN #28 stated during an interview, on 05/17/2023 at 2:17 PM, that lung sounds should be assessed pre/post nebulizer medication administration, but there was nowhere to document the results. RN #28 also stated she was unaware of any increased monitoring related to Resident #22's refusal to wear the Bi-PAP mask. In an interview with the East Unit Manager, on 05/17/2023 at 2:36 PM, she stated there was a binder at the Nurses' Station that was used as a staff reminder for residents with additional needs such as nebulizer treatments, assistive devices for breathing such as Bi-PAP machines, and wounds. She stated that items in the binder would be discussed in daily clinical meetings. The East Unit Manager stated, to her knowledge, there was no increased monitoring for Resident #22. During an interview with the Director of Nursing (DON), on 05/18/2023 at 10:55 AM, she stated it was her expectation that nurses would assess a resident's lung sounds pre/post nebulizer medication administration and document the results per the policy to show the effectiveness of the treatment. She stated she was unaware there was not a place to document the results. The DON stated that ideally the results would be documented on the MAR, but nurses could also document them in the Nursing/General Notes. She stated lung sounds also should be assessed if there was a status change. The DON stated it was her expectation that baseline lungs sounds would be assessed on admission, re-admission, and with a change in condition. She stated currently there was not a process in place to monitor if lung sounds were being assessed and documented. The DON stated she was unaware if increased monitoring for compliance to wear the Bi-PAP mask was being completed for Resident #22. In an interview with the Executive Director (ED), on 05/18/2023 at 11:38 AM, she stated it was her experience that pre/post nebulizer medication administration lung sounds would be documented on the MAR. However, she stated she was unaware there was not a place on the MAR to document the lung assessment results. She stated it was her expectation for baseline lung sound assessments to be assessed on admission, re-admission, or a change in condition and for staff to follow the policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, it was determined the facility failed to obtain the most recent Hospice agency plan of care and designate a member of the facility's interdisciplinary team (IDT), who was responsible for working with the hospice representative to coordinate care of the resident for one (1) of thirty-three (33) sampled residents, Resident #35. Review of Resident #35's Electronic Medical Record (EMR) revealed no Hospice agency care plan (CP). On 06/02/2023, Nurse Consultant #1, after a request, provided this Surveyor a copy of the Hospice agency CP. In the interview with the SSD, she stated she was not aware of the facility requirement to obtain the Hospice agency's CP for incorporation into the facility's CP. She further stated she only obtained the Hospice agency CP upon request The findings include: Review of the facility's policy titled, Hospice Program, last revised July 2017, revealed the policy provided a space for the facility to identify their designated representative, who was to be a member of the Interdisciplinary Team (IDT). The policy stated the designated representative would have clinical and assessment skills and was operating within the State scope of practice act. Per the policy, this person was responsible to ensure the most recent hospice plan of care was obtained and incorporated into the facility's person-centered care plan. Review of Resident #35's admission Record revealed the facility admitted the resident on 09/09/2021 with diagnoses of Dementia, Malnutrition, Colostomy, and a History of Falls. Review of hospital records revealed Resident #35 was in the hospital from [DATE] until 03/08/2023 for Aspiration Pneumonia. Review of Resident #35's 5-day admission Minimum Data Set (MDS) Assessment, dated 03/13/2023, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of zero-zero (00), signifying the resident was severely cognitively impaired. Also, the facility assessed the resident for two (2) person physical assistance for transfers, dressing, and toileting. He/She was assessed for one (1) person physical assistance for bed mobility and personal hygiene. The resident was assessed for the use of a wheelchair only and noted to be absent of upper/lower extremity impairments. Review of Resident #35's Progress Notes, revealed the resident was placed in hospice care, on 03/14/2023. Review of Resident #35's Electronic Medical Record (EMR) on 05/10/2023, revealed no Hospice agency care plan was located in the resident's medical record. On 05/25/2023 at 4:07 PM, an email request was sent to the Director of Nursing (DON) for the facility to provide a copy of Resident #35's hospice care plan and the identity of the facility's IDT hospice representative. The DON provided a copy of the facility's hospice care plan and two (2) names of the Hospice agency staff, not a staff member from the facility. During interview on 06/02/2023 at 8:45 AM, with the facility's Nurse Consultant #1, this surveyor requested a copy of Resident #35's Hospice agency care plan. The facility Nurse Consultant #1 provided a faxed copy of the Hospice agency care plan, with a cover sheet. Review of the faxed copy revealed the Hospice agency faxed it over on 06/02/2023 at 8:58 AM. Interview on 06/02/2023 at 9:00 AM, the DON stated the facility's Hospice staff representative was the Social Service Director (SSD). Review of Resident #35's facility Hospice CP, revealed it was initiated on 03/16/2023, with interventions of administer medication as ordered, collaborate with the hospice team to optimize care, encourage support of friends and family, honor their preferences, notify Hospice agency of any changes to the resident's condition, and observe pain and discomfort. The agency's contact information was also listed as an intervention. Review of Resident #35's Hospice agency CP, dated 03/14/2023, revealed nineteen (19) interventions listed for the resident's care. These interventions were related to seven (7) problems related to the dying process and hospice care. The problem areas were anxiety, bowels, hydration/nutrition, pain related to disease progression, requirements for comprehensive assessments, ensuring all parties involved in the resident's care understood and participated in the plan of care, safety risks for the resident, and skin integrity. In an interview with the SSD, on 06/02/2023 at 12:00 PM, she stated she was the facility's hospice representative. When asked about Resident #35's hospice agency care plan, she stated she only got them upon request. She stated she was not aware of the requirement to integrate the hospice care plan with the facility's care plan. She also stated she had not read the facility's hospice policy. The SSD said she had been the hospice representative for about one (1) year. In an interview with the Director of Nursing (DON), on 06/02/2023 at 11:46 AM, she said she would have to read the hospice policy to be able to speak on it completely. She stated the facility was to communicate with the hospice agency for any changes to the resident's needs and work with them to determine if the resident needed any therapy or medication changes. She said staff members were to call hospice, and the agency would send someone in. The DON stated the SSD conducted the hospice meetings and was responsible for getting the hospice care plan. The DON also stated the hospice agency would email their care plan over or discuss it with the SSD. In an interview with the Executive Director (ED), on 06/02/2023 at 1:23 PM, when asked who the facility representative was for hospice, the ED stated she could not think of her name, right now. She stated they are invited to the meetings but if they do not come, what can they do about it? She said she was not able to identify the hospice representative at this time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure each resident had a right to a safe, clean, comfortable, and homelike environment for eight (8) of eight (8) residents' sampled rooms. Observation on 05/19/2023 at 9:41 AM, revealed room [ROOM NUMBER], Resident #23's room, revealed bleach wipes and incontinent supplies in the windowsill, drawers removed from the bedside nightstand, papers inside the nightstand frame laying on the floor, papers laying in the floor in front of nightstand, cap noted inside night stand, multiple holes noted in wall, overbed table top lying on floor against wall at end of bed, bed footboard off bed and lying on commode in bathroom, one night stand drawer facing noted laying on commode, large oval mirror in bathtub, call/alarm system in Jevity box in bathtub, bathroom light noted not to work, electrical plug-ins and vents partially pulled out from wall. Additionally, multiple resident rooms were observed to have broken or missing slats in the window blinds, and observations of furniture in residents' rooms were in disrepair (Rooms 110, 127, 140, 226, 239, 240 and 241). The findings include: Review of the facility's policy, Homelike Environment, revised February 2021, revealed staff would provide a safe, clean, and homelike environment that emphasized the residents' comfort, independence, and personal needs and preferences. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflects a personalized, homelike setting to include comfortable and safe temperatures. 1. Observation on 05/19/2023 at 9:41 AM revealed room [ROOM NUMBER] had a bedside nightstand without drawers with papers laying on the floor in front of the nightstand, and papers and a cap in the bottom of the nightstand. Further observation revealed the overbed rolling tabletop laying on the floor against the wall and the heater at the foot of the bed. Continued observation revealed vents and electrical plugs pulled partially out from the wall and a broken electric plug cover. Additional observation revealed incontinence supplies and bleach wipes on the windowsill with the curtain open. Observation revealed holes in the bedroom walls and the baseboard missing. Further observation revealed the bed was not in the locked position and the footboard was missing. Observation of the bathroom of room [ROOM NUMBER] revealed the bathroom light did not work, a call light/alarm system in a Jevity box, and a large oval mirror inside the bathtub with Advanced 350 Ultrasorb in a plastic package laying on the side of the bathtub. Further observation revealed toilet paper, a graduated cylinder, V05 shampoo, soothed cool cleanser, hand sanitizer, and a box of X-Large gloves laying on top of the toilet tank, and the bed footboard and nightstand drawer facing laying on top of the commode lid. Continued observation revealed an X-Large blue plastic gown in a plastic bag laying on the front part of the bathroom sink, and the garbage can under the edge of the sink partially in the bathroom doorway. During an interview with Certified Nursing Assistant (CNA) #89, on 05/19/2023 at 10:15 AM, she stated she thought the maintenance issues for room [ROOM NUMBER] had been reported a couple of weeks ago. She stated she was unsure how long the nightstand drawers had been missing. She further stated she had not been in the bathroom. In an interview with Registered Nurse (RN) #19, on 05/19/2023 at 10:20 AM, she stated she had not been in room [ROOM NUMBER] that day. She further stated she would expect staff to supervise the resident's room for unsafe objects as the resident was allowed to his/her belongings in his/her room and staff should maintain a safe environment for the resident. 2. Observation of room [ROOM NUMBER], on 06/01/2023 at 9:57 AM, revealed the wall casing and trim entering the bedroom from the closet entry area had paint and plaster that was scraped away. Additionally, a chest had four (4) drawers that were off-track and hanging out of the chest, and the window blind had one (1) broken slat. 3. Observation of room [ROOM NUMBER], on 06/01/2023 at 10:05 AM, revealed paint and plaster that was scraped away on the walls and window blinds that had five (5) missing or broken slats. 4. Observation of room [ROOM NUMBER], on 06/01/2023 at 10:06 AM, revealed paint and plaster that was scraped away on the walls and window blinds that had four (4) missing or broken slats. 5. Observation of room [ROOM NUMBER], on 06/01/2023 at 10:07 AM, revealed paint and plaster that was scraped away on the walls and window blinds that had four (4) missing or broken slats. 6. Observation of room [ROOM NUMBER], on 06/01/2023 at 10:13 AM, revealed paint and plaster that was scraped away on the walls and window blinds that had one (1) missing or broken slats. 7. Observation of room [ROOM NUMBER], on 06/01/2023 at 10:19 AM, revealed paint and plaster that was scraped away on the walls and window blinds that had eight (8) missing or broken slats. 8. Observation of room [ROOM NUMBER] on 06/02/2023 at 2:00 PM, revealed there was a floor mat next to the bed with about one foot covering the bottom of the nightstand. The mat was ripped in three (3) different places, one was about six (6) inches in length. The nightstand was missing the handle on the first and third drawer but there were studs sticking out in place of the handle. Also, the baseboard was pulled out around the sink. The window blind on the door window was missing four (4) slats. Interview with the Maintenance Director on 06/02/2023 at 3:00 PM, he stated the studs sticking out of the nightstand would be a concern if the resident fell and hit his/her head on them. He also stated the missing baseboard and blind slats did not represent a homelike environment. The Maintenance Director stated he had already disposed of he ripped fall mat. He said it was a trip hazard. In an additional interview, with the Maintenance Director, on 06/01/2023 at 3:45 PM, he stated he started on 05/01/2023 and there was a lot to do within the facility. He stated the Corporation had hired an assistant that started around the middle of May 2023. He said a checklist had been created to begin doing room inspections throughout the entire facility; however, this procedure of going room to room had not started yet. He further stated a lot of touch-up work was needed to make the rooms more homelike, adding, he worked for the residents and this is their home. During an interview, on 05/19/2023 at 12:55 PM, the Director of Nursing (DON) stated it was her expectation that staff provided would expect the staff to make sure the environment was safe. She continued to state possible outcomes for bleach wipes in the room could have been gastritis, dermatitis, irritation to skin and tissue, nausea, vomiting, mouth pain, coughing, abdominal pain, irritation to the mucous membranes, eye irritation, hypersalivation, drooling, dizziness, and whatever is on the MSDS sheet. She additionally stated the situation could have been avoided by keeping the bleach wipes of the resident's reach and stored properly. During an interview with the Executive Director (ED) and the Senior [NAME] President of Clinical Services (SVPCS), on 06/01/2023 at 4:05 PM, both stated the residents' rooms were not homelike when things were not in good repair. Further, the ED further stated she had seen the missing or broken blinds from the parking lot. They further stated the Maintenance Director had developed a new checklist to help in auditing each of the resident rooms, to determine what might need to be fixed, but they have not started to complete observational rounds using the checklist. In an interview, on 05/19/2023 at 3:45 PM, the [NAME] President (VP) of Maintenance, stated he had not had a work order for room [ROOM NUMBER] since March 2023. He further stated he had a 04/12/2023 signed document that all plug-ins were in good working order at that time. He continued to state he had not had any notifications for maintenance issues in April or May 2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** [NAME], [NAME] Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure an ongoing program of activities was developed to meet the individual needs of five (5) of thirty-three (33) sampled residents (Residents #35, #57, #89, #95, and #821). The facility failed to provide individualized activities based on the comprehensive assessment, the care plan, and the personal preferences of each resident as determined by the facility's Activities Assessment, to meet the needs and interests of residents with Dementia. Review of the medical records revealed Resident #35, #57, #89, #95, and #821's Activity Assessments specified daily activities. Review of each resident's Point of Care Charting (POC) revealed they were receiving activities service for only two (2) to eleven (11) days during the month of May 2023. The findings include: Review of the facility's policy titled, Activity Programs, revised June 2018, revealed activity programs were designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Further review revealed activities were offered based on the comprehensive resident-centered assessment and the preferences of each resident. Continued review revealed the activities program was ongoing, seven (7) days a week, and included facility-organized group activities, independent individual activities, and assisted individual activities. Additional review revealed activities were scheduled at hours convenient to the residents, including evenings, weekends and holidays. Additional review revealed activities could include those provided by staff, volunteers, visitors, residents, and family members. Per the policy, all activities were documented in the resident's medical record. Review of the policy revealed scheduled activities were posted on the resident's bulletin board, as well as provided individually to residents who could not access the bulletin board. Review of the facility's policy titled, Individual Activities and Room Visit Program, revised June 2018, revealed individual activities would be provided for those residents whose situation or condition prevented participation in other types of activities and for those residents who did not wish to attend group activities. Per the policy, individual activities were provided for individuals who had conditions or situations that prevented them from participating in group activities, or who did not wish to do so. Further review revealed residents' activities should be reflective of interests as identified in the Activity Assessment, Progress Notes, and the Comprehensive Care Plan (CCP). The document stated residents with in-room activities should receive, at a minimum, three (3) in-room visits per week. Continued review revealed it was the responsibility of the facility and the activity staff to make regular contact with residents who chose independent activities, to maintain appropriate records, and to offer supplies needed for activities. 1. Review of Resident #57's medical record revealed the facility admitted the resident, on 07/05/2022, with diagnoses including Alzheimer's Disease with Dementia and Psychotic Disorder with Delusions. Review of the resident's Quarterly Minimum Data Set (MDS) Assessment, dated 03/27/2023, revealed the facility assessed Resident #57 to have a BIMS score of four (4) of 15, indicating severe cognitive impact. Continued review of the assessment revealed Section F, Preferences for Routine and Activities was not completed and was marked Not Applicable. Additional review revealed Resident #57 required limited assistance or only supervision for mobility and extensive assistance for personal care activities. Review of Resident #57's CCP, initiated on 07/05/2023, revealed the resident had been care planned for a Focus of experiencing psychosocial distress related to a history of receiving aggression from his/her peers and a history of Dementia that affected his/her ability to understand social cues, including when his/her peers might be becoming agitated. The Goal included that the resident's safety would be ensured through next review date. Interventions included to provide non-pharmacological interventions such as redirect with activity, initiated on 07/11/2022. The intervention, if another resident was seen with Resident #57's baby doll, intervene, and give Resident #57 his/her baby doll, was initiated on 04/03/2023 after Resident #57 slapped Resident #146 while Resident #20 was holding Resident #57's baby doll. Review of Resident #57's Progress Notes revealed staff had documented his/her affection and love for the baby doll. On 01/04/2023 staff noted Resident #57 was happy holding my baby. On 02/27/2023 staff wrote Resident #57 said I love this baby. And on 03/01/2023 staff documented Resident #57 was fine and said my baby is good. Review of Resident #57's Quarterly ELC Activities Assessment, dated 04/13/2023, revealed his/her attendance preferences of small groups and large groups with daily attendance. Further review revealed, however, he/she often completed self-directed activities related to severely impaired cognition and that he/she often was found in common areas with peers, while passively participating in group activities. Continued review revealed Resident #57's favored activities included cognitive ones such as trivia, discussion, reading and word puzzles; creative events such as crafts, cooking, and writing; and entertainment such as television and music. Additional review revealed Resident #57 had severely impaired cognition that could affect participation. Further review indicated Resident 57's care plan was updated with the resident's preferences. Review of Resident #57's POC documentation for May 2023 revealed daily activities documented for the first seven (7) days, then activities documented on ten (10) of the remaining twenty-four (24) days. Review of the Activities department Participation and Attendance notes revealed Resident #57 attended a holiday party on 05/05/2023, coloring on 05/11/2023, television time on 05/20/2023, and karaoke on 05/21/2023. Observation of Resident #57, on 05/10/2023 at 11:20 AM, revealed the resident was seated on the sofa located outside the Nurses' Station on the memory care unit and held nothing in his/her hands. Licensed Practical Nurse (LPN) #9 sat on the couch next to Resident #57. On another sofa in the room was a baby doll not held by any resident. During an interview on 05/17/2023 at 11:20 AM, LPN #9 stated she was aware of the importance of the baby doll to Resident #57, and it should have been on her care plan. Observation of Resident #57, on 05/12/2023 at 9:00 AM, revealed Resident #57 sat on the sofa in the memory care unit. His/her eyes were closed, and the resident was not holding anything. Observation of Resident #57, on 06/02/2023 at 9:15 AM, revealed Resident #57 was in the memory care unit seated in a wheelchair holding a blanket. CNA #9 stated, during an interview on 05/12/2023 at 1:50 PM, she knew Resident #57 had a relationship with a baby doll for about the past three (3) months. Registered Nurse (RN) #27 stated, during a telephone interview on 05/10/2023 at 9:07 AM, she did not realize the baby doll was so important to Resident #57 until after the resident-to-resident physical altercation Resident #57 had with another resident on 04/01/2023. She stated extra baby dolls were then provided to the residents after the incident occurred. The facility's Minimum Data Set (MDS) Coordinator, during an interview on 05/17/2023 at 1:15 PM, stated if staff knew Resident #57 liked her baby doll, it should have been on Resident #57's care plan. In an interview with Psychiatric Nurse Practitioner (PNP) #31, on 05/11/2023 at 10:30 AM, she stated she had seen Resident #57 weekly since 03/09/2023 to monitor his/her behaviors and psychotropic medications. She stated last year Resident #57 had undergone an unsuccessful gradual dose reduction of Zyprexa (an antipsychotic medication), but it was determined the resident needed the higher dose of the medication, which the resident had been receiving. PNP #31 stated Resident #57 had been medically evaluated, and a physical condition for his/her recent agitation was ruled out. PNP #31 stated she would continue to monitor Resident #57's behaviors and psychotropic medications. During an interview with the former Medical Director, on 05/19/2023 at 1:00 PM, he stated Resident #57 was very protective of all the baby dolls. He stated most of his interventions were with medication according to the resident's symptoms and referrals to psychology. He stated he reviewed psychology's recommendations to make sure they were acceptable, usually during the sixty (60) day visit. During further interview, the former Medical Director stated most of the time he helped staff adjust interventions and the overall plan of care depending on the individual's responses to those interventions, progression of Dementia, development of new acute medical conditions or complications, changes in resident/patient or family wishes, and other relevant factors when he talked to the psychiatrist. 2. Review of Resident 95's medical record revealed the facility admitted the resident, on 10/14/2022, with diagnoses that included Embolic Cerebral Infarction, Encephalopathy, and Dementia. Review of Resident #95's Quarterly Minimum Data Set (MDS) Assessment, dated 04/07/2023, revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score to be ninety-nine (99). This score indicated the resident was unable to complete the interview. Further review revealed the facility assessed Resident #95 to require extensive assistance or was totally dependent on staff for activities of daily living (ADL). Further review revealed Preferences for Routine and Activities (Section F) assessment was not completed and marked Not Applicable. Review of Resident #95's Progress Notes, from the month prior to the assessment, reflected no documented effort to consult his/her family regarding activities. Review of the Quarterly Activities - Annual, Quarterly, Sig (Significant) Change Activity Assessment (ELC Activities Assessment), dated 04/13/2023, revealed no attendance preferences and demonstrated the need for daily individual activities as well as favored activities of television and music in room. The assessment also revealed Resident #95 required assistance turning music and the television on. Review of Resident #95's Comprehensive Care Plan (CCP) revealed a focus for altered psychosocial needs related to the diagnosis of Dementia, dated 04/09/2023, and with the goal of meeting these needs on a daily basis with intervention to encourage activities of choice. Review of Resident #95's Quarterly Activities Notes revealed there was one (1) note, the admission note, and it was dated 10/21/2022, seven (7) months ago. Review of the point of care (POC) charting in the medical record revealed activities documented in the medical record for May 2023 included two (2) entries only. Observation of Resident #95, on 05/22/2023 at 9:15 AM, revealed the resident was in bed with tube feeding infusing with the head of bed (HOB) elevated, fall mat at the bedside, bed in low position, and air mattress noted to bed. Per the observation, there were no familiar pictures, one (1) vase of flowers with balloons, and an activity calendar. Attempted interview with Resident #95 at this time revealed his/her speech was not understandable, but he/she was able to nod his/her head to questions. Resident #95 was alone, with no roommate and no staff about. Observation of Resident #95, on 05/31/2023 at 9:25 AM, revealed the resident was in the bed and appeared to be sleeping. Observation of Resident #95, on 06/01/2023 at 2:44 PM, revealed he/she was lying in bed with no engagement and no radio or television playing. Observation of Resident #95, on 06/02/2023 at 9:39 AM, revealed he/she was resting in bed, with the television sound audible but no visual picture. Further observation revealed Resident #95 did not have the capacity to adjust the sound or the picture or to use the call light for assistance. Continued observation also revealed the resident was not in the line of sight of the door or hallway in order to see staff or for them to see him/her. During interview with Social Services Director (SSD) on 06/01/2023 at 1:18 PM, she stated for Resident #95, the staff knew him/her before the resident's decline, so staff knew what he/she liked. She stated he/she got sad when out in the common area because he/she wanted to engage with other residents and staff, but could not. 3. Review of Resident #89's medical record revealed the facility admitted the resident, on 04/22/2022, with diagnoses of Acute Osteomyelitis of the Right Femur, Traumatic Brain Injury, Unspecified Dementia and Schizophrenia. Review of the resident's Quarterly MDS Assessment, dated 05/05/2023, revealed the facility assessed the resident to have a BIMS score of ninety-nine (99), indicating the interview could not be completed. Review of Section G of the assessment revealed Resident #89 was dependent on others for all ADLs and mobility. Review of Preferences for Routine and Activities assessment was not completed and marked Not Applicable. Review of Resident #89's most recent ELC Activities Assessment, dated 04/11/2023, revealed it was a quarterly evaluation. Review of Resident #89's Progress Notes, from 03/11/2023 through 04/11/2023, reflected no documented effort to consult with his/her guardian for interviews related to activity and routine preferences. Further review revealed his/her attendance preference was one-to-one (1:1), with daily individual activities including television, music, movies, visiting groups, and being read to and requiring full assistance with activities. Continued review revealed the goals were met or exceeded, and the care plan goal would continue over the next quarter. Review of Resident #89's CCP, revised 04/22/2022, revealed a Focus for altered psychosocial needs related to the diagnosis of Dementia; a goal, revised 05/16/2023, of having no increased psychosocial needs related to Dementia through the next review, and interventions to redirect with activities and assisting to activities of choice. Review of Resident #89's Quarterly Activities Note, dated 03/13/2023, revealed he/she had received one-to-one (1:1) visits to promote sensory, mental and social stimulation as well as listening to music, being read to, and sensory stimulation. Review of Resident #89's POC documentation for May 2023 revealed four (4) entries only, including an incidence of talking and conversation on 04/10/2023 and three (3) documentations of NA which had no definition in the charting legend, on 05/01/2023, 05/11/2023 and 05/21/2023. Review of the Activities Department Participation and Attendance sheets for May 2023 revealed no documentation at all for 05/01/2023 and reflected no participation for Resident #89 for either 05/11/2023 or 05/21/2023. Observations of Resident #89, on 05/09/2023 at 2:17 PM, 05/10/2023 at 3:19 PM, 05/11/2023 at 4:07 PM, 05/15/2023 at 10:11 AM, 05/16/2023 at 11:13 AM, 05/17/2023 at 2:32 PM, 05/22/2023 at 3:01 PM, 05/24/2023 at 11:37 AM and on 05/26/2023 at 12:14 PM revealed him/her to be in bed, unengaged and with no staff around. Subsequent observation, on 06/02/2023 at 3:00 PM, revealed the resident in bed, unengaged and unattended. 4. Review of Resident #821's medical record revealed the facility initially admitted the resident, on 12/21/2022, with diagnoses including Postprocedural Kidney Failure, Nontraumatic Subdural Hemorrhage, and Dementia. Review of the resident's Quarterly MDS Assessment, dated 04/24/2023, revealed the facility assessed the resident to have a BIMS score of five (5) of fifteen (15), indicating severe cognitive impact. Further review revealed the Preferences for Routine and Activities section was not completed and was marked Not Applicable. Review of the Quarterly ELC Activities Assessment, dated 04/13/2023, revealed a preference for small group activities, then the need for daily individual activities. The favored activities identified included television; music; movies; visiting groups; physical activities of walking, exercise, senior games; social activities of parties, visiting, social media; and also pet visits. Further review revealed activity goals were met or exceeded. Review of Resident #821's Progress Notes, from 03/13/2023 through 05/13/2023, reflected no documented effort to consult with his/her family for interviews related to activity and routine preferences. Review of Resident #821's most recent CCP, revealed a Focus, revised 03/06/2023, for severely impaired cognition and risk for decline related to Dementia. The goal was for reduced risk of decline, with interventions of administering medications as ordered and to approach with a calm, friendly manner. Review of Resident #821's Activities Specific Progress Notes revealed one (1) note, the new admission Note, on 12/28/2022, which indicated initial preferences of Bingo/Dominoes, fishing, parties, and watching news and sports. Review of Resident #821's POC charting for May 2023 revealed activities documentation on eleven (11) of thirty-one (31) days. The activities note included general socializing, activity room, coloring, group games, talking/conversing, and patio time. Review of the Activity Department Participation Attendance sheets for May 2023 revealed television time on 05/04/2023, Bingo on 05/08/2023, activity room on 05/09/2023, and patio time on 05/12/2023, 05/29/2023, and 05/31/2023. Observation of Resident #821, on 05/09/2023 at 1:40 PM, revealed the resident was in bed, dressed in street clothes, with his/her shoes on. The resident had a one-to-one (1:1) sitter in place because of the resident's risk of falls, and the resident was resting. Observation of Resident #821, on 05/11/2023 at 8:20 AM, revealed the resident was in bed resting, and the aide was present for one-to-one (1:1) supervision. Observation of Resident #821, on 05/12/2023 at 8:00 AM, revealed the resident had just finished breakfast, and the aide was getting him/her cleaned up. The aide stated she liked to get the resident up in his/her wheelchair after breakfast. Observation of Resident #821, on 05/18/2023 at 11:15 AM, revealed the resident was in the room with the door closed. After knocking on the door and entering, observation revealed staff present was doing one-to-one (1:1) supervision. At this time, activities were going on in the common area with nine (9) residents present. Observation of Resident #821, on 06/02/2023 at 2:51 PM, revealed the resident was resting in bed, with one-to-one supervision from Certified Nursing Assistant (CNA) #18. Resident #821 was not engaged in any particular activity. 5. Review of Resident #35's medical record revealed the facility admitted the resident, on 09/09/2021, with diagnoses that included Dementia in Other Diseases Classified Elsewhere, Severe, with Agitation; Chronic Obstructive Pulmonary Disease (COPD), and Repeated Falls. Review of Resident #35's Quarterly MDS Assessment, dated 03/21/2023, revealed the facility assessed the resident to have a BIMS score of zero (0) of fifteen (15), indicating severe cognitive impairment. Continued review of the assessment revealed the interview for Daily and Activity Preferences should not be conducted and was not. The assessment form also indicated if the resident was unable to complete the interview, staff should attempt to complete the interview with a family member or significant other. However, review of progress notes in the month prior to the assessment revealed no evidence of family consultation. Review of Resident #35's ELC Activities Assessment, dated 04/13/2023, revealed the reason for the review was quarterly, and no attendance size was marked, i.e., small group versus large group versus individual. Further review did indicate the need for daily individual activities including holding a doll and folding items and that he/she required cueing. Review of Resident #35's CCP, revised 06/28/2022, revealed a focus for severely impaired cognition related to Dementia, with goal to anticipate his/her needs and interventions of administering medications as ordered, approach him/her in calm, friendly manner and use yes/no questions to determine needs. Review of Resident #35's Progress Notes, for the past seven (7) months, revealed the one (1) Activities Note was a quarterly note dated 11/02/2022. Review of Resident #35's POC documentation for May 2023 revealed daily documented activities for the first seven (7) days, then ten (10) documented activities for the remaining twenty-four (24) days. Review of the Activities department Participation and Attendance notes revealed Resident #35 attended a holiday party on 05/05/2023, coloring on 05/11/2023, television time on 05/20/2023, and karaoke on 05/21/2023. Observation of Resident #35, on 5/19/2023 at 8:20 AM, revealed the resident was in the dining room getting assistance with breakfast. After he/she was done eating, the resident bobbed his/her head and made a humming sound. CNA #81, who assisted the resident, stated the resident loved to hear music. When breakfast was over at 8:45 AM, the nurse took the resident and placed him/her in bed. Observation of Resident #35, on 05/22/2023 at 9:20 AM, in the common area of the Memory Care Unit, revealed he/she was in the wheelchair and was pushed all the way up to the television. However, the resident was sleeping. There were two (2) aides present, CNA #62 and CNA #87. There were eight (8) residents seated in the area; some were napping and some were watching television. CNA #62 looked for something to watch on television. During an interview with Activities Assistant #1, on 05/23/2023 at 2:33 PM, she stated she had understood she was getting a new supervisor, but now she was not sure. She stated the new supervisor was not here today. In continued interview, she stated she had worked the weekend, and this was typically stressful and exhausting to carry out as there was one (1) person to do group activities, in-room activities, mail delivery, and charting for both sides of the building. She stated besides group activities, there were in-room activities scheduled for residents who needed/required it. While looking at the activities calendar, she stated the patio time activity on the weekends was really smoking breaks but was a nicer way to say it. Observation of the May 2023 activities calendar at this time revealed the Saturday activities for the month were coffee service and patio time. During another interview with Activities Assistant #1, on 06/02/2023 at 10:03 AM, she stated she turned in a copy of the Plan of Correction audit to the Executive Director (ED) every day and kept a copy in her binder and was completing audits daily until further notice. She further stated she had been working by herself mostly since mid-March when the previous director left, and then the other activities assistant for the [NAME] side left right after the director did. In continued interview, she stated the director had always completed the planning, calendars, the administrative tasks, so she was not familiar with those tasks. She stated the facility hired a new director, but she never came, and then CNA #18/Activities Assistant #5 started sometime around 5/10/2023. She stated the residents listed on the Activities Department Participation Attendance sheets, and by extension the audit sheets, were all the residents she had eyes on that day. She also stated she charted on Point Click Care (PCC), the electronic medical record, on those residents for that day. In further interview, she related she communicated scheduled activities by posted calendar and verbally, when engaged in activities like the smoking break or when delivering mail, or would just go ask residents she thought might enjoy a particular activity. She also stated there were no volunteers right now, and she did not know the previous director did individual visits once a week until it popped up on the April 2023 calendar. During continued interview, she stated she was not sure of the expectation for in room visits and/or individual activities. She stated she wondered about who was going to activities when she was not at the facility since she was the only activities staff right now. During a telephone interview with CNA #18/Activities Assistant #5, on 05/25/2023 at 7:18 PM, she stated she had worked as an aide for fourteen (14) years and had previously worked as activities assistant at a different facility. She additionally stated resident activities assessment was completed upon admission and possibly quarterly, with preference information obtained from family for residents who could not verbalize independently. She stated activities programming was important because it helped the residents emotionally. For example, she stated a resident could be staring at the wall, but when music/movie time started, they might recognize the music and engage more and were less agitated. During an interview with the Social Services Director (SSD) on 06/01/2023 at 1:18 PM, she stated activity interventions were developed with support from family regarding preferences as well as relying on staff to pay attention and pick up on what residents preferred. During an interview with CNA #88, on 06/02/2023 at 4:09 PM, she stated she was asked if she would help with activities until the facility hired someone, and she started about two (2) weeks ago. She stated residents played bingo, had ice cream parties, and went out to the patio. She also stated it was hard to get the men on either East Side Unit to do much of anything, stating they had a schedule of activities on the calendar, but they did not want to do those. She stated because of that, today staff members were asking each of them about their preferences. She stated the residents told staff they would like to go out for activities, like fishing and shopping at Wal Mart. She stated the residents, on the Downstairs Unit, also talked about going places for activities. In continued interview, she stated she just started asking because residents did not want to do the activities on the calendar. She further stated residents were supposed to have a meeting every month to determine the calendar for each unit for what they would like to do. She additionally stated she had not been told to do individual activities. She stated she documented activities and attendance on a form, which she gave to the Executive Director (ED). During an interview with CNA #6, on 06/02/2023 at 4:34 PM, she stated the activities staff split the Upstairs and Downstairs Units, but she was not sure what happened when someone was not at work; they possibly split the one (1) staff member between both sides. She further stated the residents all liked bingo, but some residents did not want to come. She additionally stated all residents were invited, but some would rather stay in their rooms; or they came to get snacks and went back their rooms. She also stated she was not aware of activities taken to individual rooms. During an interview with LPN #12, on 06/02/2023 at 11:07 AM, she stated the activities staff did work on weekends, but if they were not available, an aide was tasked to help with activities on weekends. She stated she was uncertain about in-room activities or specific activities for residents with Dementia. During an interview with RN #4, on 06/02/2023 at 10:47 AM, she stated before it was down to one (1) staff in activities, they alternated weekends, but she was not sure how they scheduled it now to cover everything. She further stated the facility had church groups that came in, and residents had drinks and snacks on the weekends too, though she was not sure about other activity options. She also said the facility had tasked an agency aide to help with activities upstairs in the memory care units until more staff was hired. During an interview with the Unit Manager (UM), on 06/02/2023 at 10:51 AM, she stated there were activities on weekends, such as churches that came for services. She also stated if activities staff members were not available for a day, she was not sure how activities were scheduled. However, she stated had seen an aide be assigned as an activities assistant. During an interview with the Director of Nursing (DON), on 06/01/2023 at 2:58 PM, she stated the process for documenting daily resident participation in activities existed, but she did not have access to that documentation. She stated activity participation was supposed to documented, whether passive or active, along with the general timeframe. She stated the Activity Department had a tool on which to record that. In continued interview, she stated the activity frequency and documentation should be done daily. During another interview with the DON, on 06/02/2023 at 11:51 AM, she stated some residents with Dementia were more engaged with activities than others, and the specifics with Dementia residents were care planned. She also stated residents who were lower functioning received individual activities with a staff member. She stated staff would go to these residents, for example, and read a book to them. During an interview with the ED, on 05/23/2023 at 4:09 PM, she stated the facility had been without an Activity Director for about two (2) months and that CNA #18/Activities Assistant #5 had just started in that role in mid-May 2023. She stated she was working to expand activities for the residents on both sides of the building, but she acknowledged these were in the planning stage at this time. During another interview with the ED, on 06/02/2023 at 1:23 PM, she stated activities were important for psychosocial well-being and that the different units had different activity needs and required separate staff for them. She also stated she was working to implement increased coverage, so there could be activities later in the evening and on weekends. She also confirmed that activities were expected to be documented in the POC section of the medical record.

Based on interview and review of the Activity Director's job description, it was determined the facility failed to ensure the Activity Program was directed by a qualified therapeutic recreation specialist or an activity professional who was licensed or registered by the State. The Executive Director (ED) stated in an interview on 05/23/2023, that the facility did not have an Activity Director in place who possessed the qualifications to serve in a Long-Term Care Facility. The findings include: Review of the Activity Director's job description, undated, revealed the required education and/or experience to fulfill the duties was an associates degree (A.A.) or equivalent from a two (2) year college or technical school, or two (2) to four (4) years related experience and/or training, or equivalent combination of education and experience, as well as meet state and federal requirements. During interview with Certified Nursing Assistant (CNA) #18/Activities Assistant #5, via telephone on 05/25/2023 at 7:18 PM, she stated she completed an Occupational Therapy Assistant degree. However, she had not taken the certification examination. She also stated she worked as an aide for fourteen (14) years, and had previously worked as an Activities Assistant at a different facility. She further stated she would be taking the Activity Director's position. Certified Nurse Aide (CNA) #18/Activities Assistant #5, stated she would apply for a temporary license and complete the post graduate field work while the board examination was pending. She stated she was not a certified Activity Director, but she was enrolled in a certification course that would begin in June 2023. During the interview, she stated the activities program was important because it helped the residents emotionally, and when residents were more engaged, they could become less agitated. During interview with the Human Resources Manager, on 06/02/2023 at 4:45 PM, she stated CNA #18/Activities Assistant #5 would no longer be taking the Activity Director position, as she she was no longer working at the facility. She stated the other new Activity Director had just started as of this date. The Executive Director (ED) stated during interview, on 05/23/2023 at 4:09 PM, that the previous Activity Director left about mid-March 2023. She stated she hired a replacement, but that person never started due to health issues. The ED stated two (2) new Activity Director hires were pending, one (1) for the upstairs unit and one (1) for the East side unit. She stated neither was currently certified as an Activity Director, but both were enrolled in the June 2023 class to receive that certification. During interview with ED, on 06/02/2023 at 1:23 PM, she stated one (1) of the new Activity Directors started today, but the other would not be filling that position after all.

Based on observations, interviews, record review, review of the facility's assessment, policies, and plan of correction, it was determined the facility failed to have an effective system in place to ensure sufficient nursing staff was provided on a twenty-four (24) hour basis to provide nursing care to meet the individual needs of the residents, considering the number and acuity of the resident population per the Facility's Assessment. Review of the facility's assessment revealed the facility was assessed to require nine (9) to twelve (12) nurses per day to ensure there were sufficient team members to meet the needs of the residents at any given time. Review of the daily nursing schedules revealed the facility had fewer than the facility's required nine (9) licensed nurses available to provide direct care to residents at all times on the following dates: 04/25/2023, 04/29/2023, 05/06/2023, 05/07/2023, 05/11/2023, 05/13/2023, 05/17/2023, and 05/21/2023. Additionally, review of the facility policy and Plan of Correction, the facility failed to have an effective system to ensure adequate supervision and monitoring to prevent falls/accidents. The facility failed to identify risks and hazards; failed to establish root cause analyses of previous falls; and failed to implement and evaluate interventions to prevent further falls for six (6) of thirty-three (33) sampled residents (Residents #20, #35, #90, #97, #146 and #821). (Refer to F689) The findings include: Review of the facility's policy Staffing, Sufficient and Competent Nursing, dated August 2022, revealed staffing numbers and the skill requirements of direct care staff was determined by the needs of the residents based on each resident's plan of care, the resident assessments, and the facility assessment. Further review of the policy revealed factors considered in determining appropriate staffing ratios and skills included an evaluation of the diseases, conditions, physical or cognitive limitations of the resident population, and acuity. Review of the facility's Standard Re-Certification/Abbreviated/Extended Survey Plan of Correction (PoC), with exit date of 04/04/2023 and correction date of 04/16/2023, revealed the Executive Director (ED) had an adHoc Quality Assurance Performance Improvement (QAPI) meeting with the Director of Nursing (DON) and the Medical Director to develop the action plan which included audits, reeducation, and compliance monitors for sufficient nursing staff. Further review of the PoC revealed the facility was aware of the requirement, that the facility must have sufficient nursing staff with the appropriate competencies and skill set to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessment and individual plans of care, considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.35. Further review revealed the ED had routine communication related to staffing daily to ensure sufficient staff were available. Further, scheduling needs were reviewed to ensure staff were available to provide care and services. Review of the Facility Assessment (FA), updated 03/2023, revealed general approaches to staffing were to ensure there was sufficient team members to meet the needs of the residents at any given time based on the resident population and their needs for care and support. Further, the FA revealed that if the resident population changed throughout the year, then the number and type of team members would change accordingly, and staffing would be adjusted to meet the facility's needs. Continued review revealed the facility's average daily census was one-hundred sixteen (116) residents, and the maximum was one-hundred forty-five (145) residents. Continued review of the Facility Assessment revealed that between fifteen (15) and twenty-two (22) nurses' aides/certified medical technicians (CNAs/CMTs) and nine (9) to twelve (12) licensed nurses were needed to provide direct care to residents. Review of the Staffing Daily Schedule from 04/16/2023 through 05/21/2023 revealed the facility scheduled eight (8) nurses, instead of the facility's assessed nine (9) nurses, on the following dates: 04/25/2023, 04/29/2023, 05/06/2023, 05/07/2023, 05/11/2023, 05/13/2023, 05/17/2023, and 05/21/2023. The facility failed to ensure its Facility Assessment was followed to meet the needs of the residents and failed to ensure the PoC for the Abbreviated Survey, with exit date of 04/04/2023, was implemented. Observation of the Staffing Daily Meeting with the Executive Director (ED), Director of Nursing (DON) and the Scheduling Coordinator, on 05/19/2023 at 1:32 PM, revealed the Scheduling Coordinator reported nurse shortages for six (6) shifts for the upcoming weekend. Continued observation revealed they discussed the facility's staffing needs and the need to ensure enough licensed nurses were scheduled for 05/20/2023, 05/21/2023, and 05/22/2023. Further observation of the discussion between the ED, DON, and the Scheduling Coordinator revealed that since the Staff Development Coordinator (SDC) was on call for the weekend, she would cover the two (2) 7:00 AM to 7:00 PM shifts, if needed. The Scheduling Coordinator continued working on the staff coverage and stated she would report back to the ED and DON. However, review of the Staffing Daily Schedule revealed that on 05/21/2023, the facility staffed eight (8) licensed nurses, instead of the Facility Assessed nine (9) licensed nurses to provide direct care to the residents. In an interview with Certified Nursing Assistant (CNA) #86, on 05/18/2023 at 11:00 AM, she stated she had to stay after her scheduled shift for oncoming staff to relieve her. Licensed Practical Nurse (LPN) #2 stated in interview, on 05/18/2023 at 2:45 PM, she must wait past her shift end time for the oncoming nurse to arrive. During an interview with the Certified Medication Technician (CMT) #1, on 05/18/2023 at 2:08 PM, she stated she had to work past her scheduled time because she was waiting on the oncoming shift to arrive. During a telephone interview, with the Scheduling Coordinator, on 06/01/2023 at 5:57 PM, revealed her process for staffing the facility was according to what the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) recommended. She stated she used the residents' acuity to staff the facility by putting the same staff on units where the residents were familiar with staff. In an interview with the Executive Director (ED) on 05/19/2023 at 3:43 PM, she stated adequate supervision meant there were enough staff present to provide care for the residents, enough aides and nurses. In continued interview the ED stated the facility worked to provide a safe environment in many different ways, and what was needed depended on the resident. The ED stated she had increased supervision a lot, and had managers completing rounds, especially during the evenings, from 8:00 PM to 8:00 AM. She stated staffing continued to be a problem for the facility as no nurses had applied in a while. In further interview the ED stated she needed to find a night supervisor; however, it was hard to find good people who could be trusted. She stated that when the facility accepted a resident as an admission, they were expected to provide a stable and safe environment for the resident. In an additional interview with the Executive Director (ED), on 06/02/2023 at 3:00 PM, the Executive Director (ED) stated staffing was reviewed and projected in a staffing meeting every morning seven (7) days a week. Per the interview, the ED stated staffing reviews/scheduling was ongoing and were conducted in the afternoons as well. Further, the ED stated that when fewer nursing staff was scheduled, as per the Facility Assessment, the facility would utilize the nurses that had administrative duties to staff the units. However, review of the schedule revealed that a total of eight (8) nurses were scheduled, to include the Staffing Development Coordinator (SDC), on 05/21/2023. Further interview with the ED revealed the facility had loss some staff and the facility considered paying over three ($3,000,000.00) million dollars to employ agency nurses.

Based on observation, interview, record review and review of the facility's policy it was determined, the facility failed to implement a process to ensure narcotics were controlled and accounted for through the process of a two-person count and signature, at the change of each shift, per the facility's policy. There were multiple omissions noted during review of the narcotic books, which revealed the count was not performed with two (2) licensed nurses at shift change. The facility's failed to ensure a two-person count and signature was observed on six (6) of the six (6) medication carts in the facility. Review of the facility's six (6) Controlled Substances Log Books Shift Count revealed fifty-four omissions of two (2) nurse signatures verifying the narcotic count was correct. Per the acceptable Plan of Correction (PoC), with an alleged compliance date of 04/16/2023, the facility would complete daily audits of the facility's procedure to ensure an account of all controlled drugs was maintained. Continued non-compliance was identified at this tag. Continued non-compliance was identified. Based on review of the facility's Plan of Correction (PoC), with an alleged compliance date of 04/16/2023, the facility failed to ensure compliance with F755. The findings include: Review of the facility's policy titled, Controlled Substances, revealed facility complied with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of controlled medications and controlled substances were reconciled upon receipt, administration, disposition and at the end of each shift. Further review of the facility's policy revealed at the end of each shift, controlled medications were counted between the coming on duty nurse and the going off duty nurse to determine the count together. Any discrepancies were to be reported to the Director of Nursing (DON) Services immediately. Review of the facility's PoC, with an alleged compliance date of 04/16/2023 for F755, revealed the facility had conducted education for all Licensed Nurses (LN) and Certified Medication Technicians (CMT) to include agency staff. The education included the on-coming nurse and the off-going nurse both signed that the count verification had been completed at the end of each shift. Further review of the PoC revealed that starting on 04/14/2023, the Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC) or the Unit managers (UM), would visually audit three (3) narcotic blue books to ensure the on coming and off going nurses signed the count verification daily. The audit information would be reported to the Quality Assurance Performance Improvement (QAPI) committee weekly. Review of the facility's Controlled Substances Log Book Shift Count for six (6) of six (6) medication carts, revealed omissions of the required two (2) signatures of either the oncoming staff or the going off duty licensed nurses on fifty-four (54) occasions between 04/16/2023 and 05/30/2023. 1. Review of the Controlled Substances Log Book Shift Count for the D Hall revealed the following dates without signatures: 04/19/2023 both on coming and off going nurse; 04/23/2023 both on coming and off going nurse; 05/02/2023 on coming nurse; 05/06/2023 on coming nurse; 05/07/2023 both on coming and off going nurse; 05/08/2023 off going nurse; 05/10/2023 off going nurse; 05/12/2023, 05/13/203, 05/14/2023 , 05/15/2023, and 05/20/2023 both on coming and off going nurses. 2. Review of documentation of shift change narcotic count per the Controlled Substances Log Book Shift Count for the Men's ACU Unit/Men's side revealed the following dates without signatures: 04/23/2023 off going nurse; 04/24/2023 on coming nurse; 05/01/2023 on coming nurse; 05/02/2023 off going nurse; 05/03/2023 off going nurse; 05/07/2023 and 05/08/2023 both on coming and off going nurses; 05/17/2023 on coming nurse; 05/21/2023 on coming nurse; 05/22/2023 off going nurse; and 05/30/2023 on coming nurse. 3. Review of the documentation of the shift change narcotic count per the Controlled Substances Log Book Shift Count for Alzheimer's Care Unit (ACU)/Women's side, revealed the following dates without signatures: 04/22/2023 on coming nurse; 04/23/2023 of going nurse; 04/24/2023 off going nurse; 04/25/2023 off going nurse; 04/29/2023 on coming and off going nurse; 05/08/2023 off going nurse; 05/26/2023 off going nurse; and 05/27/2023 and 05/30/2023 both on coming and off going nurses. 4. Review of documentation of shift change narcotic count per Controlled Substances Log Book Shift Count for the B Hall, revealed the following dates without signatures: 04/28/2023 both on coming nurse and off going nurse; 05/13/2023 on coming nurse; 05/14/2023 both on coming and off going nurse; 05/19/2023 off going nurse; and 05/22/2023 the on coming nurse. 5. Review of the documentation of the shift change narcotic count per the Controlled Substances Log Book Shift Count for the [NAME] Men's Unit revealed the following dates without signatures: 04/16/2023 and 05/01/2023 off going nurses; 05/02/2023 on coming nurse; and 05/03/2023 going off nurse. 6. Review of documentation of the shift narcotic count per Controlled Substances Log Book Shift Count for C Hall revealed the following dates without signatures: 05/09/2023 off going nurse; 05/10/2023 on coming nurse; 05/20/2023 on coming nurse; and 05/21/2023 both on coming and off going nurses. Review of the facility's document titled . Survey Education for 755 test, revealed question number four (4) which stated two (2) licensed nurses would count the narcotic medications at the beginning of each shift with the correct answer as true. Review of the test revealed twenty-eight (28) tests had 100% passing grades. During an interview with Registered Nurse (RN) #30, on 05/22/2023 at 9:35 AM, she stated she was Agency Staff and the last time she worked at the facility was sometime in May 2022. She stated she knew that she and another nurse needed to both sign the blue narcotic count book when the medication cart keys were transferred at change of shift. However, review of the Controlled Substances Log Book Shift Count for 05/22/2023, oncoming nurse signature was blank, Which was where RN #30 should have signed the book. During an interview with the Staff Development Coordinator (SDC), on 05/22/2023 at 10:00 AM, she stated she was in charge of educating Agency staff prior to working related to the Plan of Correction issues. She stated the facility had a call-in at 6:30 AM and RN #30 was needed on the floor at 7:00 AM so she had not yet educated RN #30 on counting the narcotics with two (2) nurse signatures that verified the count was correct. During an interview with Certified Medication Aide (CMT)/Certified Nursing Assistant (CNA) #1, on 05/31/2023 at 11:00 AM, she stated she did sometimes pre-sign the shift count narcotic book before count at end of shift and had been doing this for a while now. She stated she had training on the facility's process for signing at the end of shift. CMT/CNA #1 stated she had not thought about the count being incorrect at the end of the shift and she had already signed the book that the count was correct. She further stated she should follow the process to ensure control of the narcotics. During an interview with the Assistant Director of Nursing (DON), on 05/23/2023 at 3:20 PM, she stated she helped train the facility's nurses to count the narcotics between shifts and to sign the narcotic count book at shift change. She stated no concerns had been identified. The ADON stated during interview, on 06/01/2023 at 2:20 PM, that she had not received any reports of nurses signing narcotic books before the end of their shift. She stated the reason that pre-signing should not occur was to assure the count was correct, but had not physically observed any shift counts for narcotics. The ADON stated when omissions were noted in the audit tool, she asked the nurses why and they said they had forgotten. She stated she would call them to come back in to sign the narcotic book and re-educate them. The ADON could not explain why there were fifty-four (54) signature omissions that were found while the facility was supposed to be auditing this process. During an interview with Staff Development Coordinator (SDC), on 06/01/2023 at 10:30 AM, she stated she had provided training for narcotic counts to occur at the end of shift. The SDC stated she knew of no one pre-signing narcotic books. She stated the UMs were completing the audits and reporting to her. The SDC stated that she had not observed change of shift narcotic count during the audits, which started on 04/15/2023. In an interview with Licensed Practical Nurse (LPN) #3/UM on 05/23/2023 at 2:10 PM she stated she had training on signing the narcotic book between shifts. During an interview with LPN #3/UM, on 06/02/2023 at 11:20 AM, she stated she was never made aware of nurses pre-signing narcotic books. She stated that she had not observed shift change narcotic counts. LPN #3/UM stated if pre-signing was occurring there could be a discrepancy. She stated she had reported to the ADON and the DON that she was finding missing signatures when she was auditing the Controlled Substances Log Books Shift Count. During interview, on 05/31/2023 at 11:40 AM, with Registered Nurse (RN) #28, she stated she was late getting here today and had counted the medication cart with RN #6 when she arrived. She stated she would not pre-sign the narcotic book for the off going shift. However, she stated there were times when she may not have signed that she counted the control drugs. RN #28 stated she had never been observed or audited while counting narcotics at shift change. During interview with RN #4, on 05/31/2023 at 11:45 AM, she stated she had been pre-signing the narcotic book for the off going signature for a while. She stated she and could change it by answering the yes or no questions if there was a discrepancy. RN #4 stated she had never been told anything different. During interview, on 05/31/2023 at 11:40 AM, LPN #9 stated when she came on duty for her shift, she signed her name at that time on the Controlled Substances Log Book Shift Count as the nurse coming on duty and as the nurse going off duty. LPN #9 stated she signed the Controlled Substances Log Book Shift Count as the nurse going off duty not at the end of her shift, but instead at the beginning of her shift. LPN #9 stated she did this because she was so ready to go home after working twelve (12) hours and she did not want to forget to sign the book. When interviewed about the blank spaces by her name where other nursing staff had recorded the actual number of controlled drug cards counted, LPN #9 stated when she signed her name, she was verifying that she had passed the cart keys to the nurse coming on duty. During interview, on 05/31/2023 at 11:45 AM, RN #1 stated she was aware that some nursing staff did sign the Controlled Substances Log Book Shift Count as the nurse coming on duty and as the nurse going off duty at the beginning of their shifts. RN #1 stated she had tried to educate the nursing staff about the correct way to sign the Controlled Substances Log Book Shift Count, but had no documentation of the education. During interview, on 05/31/2023 at 11:30 AM, LPN #2 stated she had been trained and per facility policy she knew to sign the Controlled Substances Log Book Shift Count when she went off duty at the end of each shift to verify that all narcotic medications and other controlled substances administered by her were fully accounted for. She stated she had reported to the DON and Executive Director (ED) on several occasions that not all nurses were following this procedure. During an interview with the DON, on 05/25/2023 at 3:00 PM, she stated the facility's process for controlling narcotics was to have the narcotics counted at each shift change with the on-coming nurse and the off-going nurse. She stated they were to count the pages of narcotics and then the actual narcotic skids for each resident together, and then each of them sign the book that the count was correct. She stated this education was provided to all staff as part of the Plan of Correction (POC). The DON stated there was someone assigned to audit this process and they turned the audits into her, and she had noted no problems. She stated she had not completed any observations of this medication count process as part of the Quality Assurance (QA). The DON further stated she was surprised to find out there were so many missing signatures from the Blue Books. The DON stated during interview, on 05/31/2023 at 2:00 PM, a staff member had come forward on 05/31/2023 and told her and the Executive Director (ED) that she had been pre-signing the shift count narcotic book. In continued interview she stated disciplinary action was taken for that staff member as well as re-education. The DON stated she had no knowledge of staff pre-signing the narcotic book. She stated there were no concerns for pre-signing and the narcotic counts were being performed daily on the units. During an interview with the ED, on 05/31/2023 at 2:00 PM, she stated one (1) staff had come forward saying she had been signing the shift count narcotic book prior to end of shift. The ED stated retraining and disciplinary action had been taken. She stated she had no reports of staff pre-signing the narcotic books and the narcotic audits were on going. The ED stated she was unaware there were so many omissions in the Blue Books for signing a correct narcotic count at the beginning and end of each shift. She stated this process needed to be consistent in order to maintain and keep control of the narcotic drug counts. The ED stated they had no diversion of narcotics since alleging compliance on 04/16/2023, but if the process was not followed exactly, there was definitely the opportunity for narcotics to come up missing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to have an effective system to ensure the proper temperature ranges of the medication refrigerators were maintained for one (1) of four (4) medication refrigerators. In addition, the facility failed to ensure discontinued medications were removed from the medication refrigerators, per the facility's policy for one (1) of four (4) medication refrigerators. Observation on 05/22/2023, revealed the medication refrigerator on the B/C hall contained two (2) thermometers, one reading forty-two (42) degrees Fahrenheit (F) and the other read twenty-eight (28) degrees F. Continued observation of the refrigerator, revealed medications, including insulin, for Residents #103, #22 and #95. Continued observation revealed discontinued medications for Residents #95 and #400 were stored in the refrigerator. Additionally, observation revealed the facility's audit tool, posted on the front of the medication refrigerator, indicated the refrigerator had not been audited for proper storage and temperature, since 05/15/2023. Further, the facility failed to ensure all drugs and biological's were stored in locked compartments in accordance with State and Federal laws. Observations revealed the facility failed to ensure two (2) of the six (6) medication carts were locked when unattended. Observations on 05/22/2023, revealed the medication cart on B Hall was unlocked and unattended, and observation on 06/02/2023, revealed the medication cart on the D Hall was unlocked and unattended. Both medication carts contained drugs and biological's which were left unlocked and unattended. Based on review of the Plan of Correction (PoC), for the 04/04/2023 survey, with an alleged compliance date of 04/16/2023, it was determined the facility failed to ensure the POC was implemented through auditing and monitoring medication storage and the Quality Assurance Performance Improvement (QAPI) failed to have documented evidence of on going monitoring of the audits to ensure continued compliance. The findings include: Review of the facility's policy, Storage of Medications, revised November 2020, revealed drugs and biological's used in the facility were stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. Compartments including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes containing drugs and biological's were locked when not in use. Unlocked medication carts were not to be left unattended. Discontinued, outdated, or deteriorated drugs or biological's were returned to the dispensing pharmacy or destroyed. Review of the Food and Drug Administration's (FDA) article, Information Regarding Insulin Storage and Switching Between Products in an Emergency, dated 09/17/2017, revealed according to the product labels from all three U.S. insulin manufacturers, it was recommended that insulin be stored in a refrigerator at approximately thirty-six (36)° Fahrenheit (F) to forty-six (46)°F. Unopened and stored in this manner, these products maintain potency until the expiration date on the package. Further review revealed users should not use insulin that has been frozen. Review of the FDA Insulin Storage Policy, dated 09/17/2017, revealed according to the product labels from all three (3) United States insulin manufacturers, it was recommended that insulin be stored in a refrigerator at approximately 36°F to 46°Fahrenheit (F). Unopened and stored in this manner, these products maintained potency until the expiration date on the package. 1. Record review revealed the facility admitted Resident #95 to the facility on [DATE], with diagnosis to include Type 2 Diabetes Mellitus, Obesity, and Urinary Tract Infection. Review of the Physician's Orders, with a start date of 01/03/2023, revealed orders for Humalog KwikPen Subcutaneous Solution Pen-100 Unit/Milliliter (ml) (insulin Lispro), inject 10 units subcutaneous with meals and Lantus SoloStar Subcutaneous Solution One-Injector 100 Units/ml, inject 20 units subcutaneously one time a day. Continued review of the Physician's Orders revealed an order with a discontinue date of 05/11/2023 for Augmentin Oral Suspension 250-62.5 Milligrams (mg)/5 ml, give via G-tube every eight hours. Record review revealed the facility admitted Resident #22 to the facility on [DATE], with diagnoses to include Type 2 Diabetes Mellitus, obesity, and Long-Term Insulin Use. Review of the Physician's Orders, with a start date of 04/01/2023 revealed orders for Insulin Aspsrt FlexPen Subcutaneous Solution Pen-Injector 100 Unit/ml, inject 32 units subcutaneously with meals and an order for Insulin Glargine Subcutaneous Solution Pen-Injector 100 Unit/ml, inject 60 units subcutaneously one time a day. Record review revealed the facility admitted Resident #103 to the facility on [DATE] with diagnoses to include Type 2 Diabetes Mellitus and Obesity. Review of the Physician's Orders, with a start date 12/06/2022 revealed orders for HumaLOG KwikPen Solution Pen-Injector 200 units/ml (Insulin Lispro), inject 50 units subcutaneously with meals and Lantus SoloStar 100 Units/ml Solution Pen-Injector, inject 100 units subcutaneously in the morning. Record review revealed the facility admitted Resident #400 to the facility on [DATE] with diagnoses to include Hemiplegia and Cystitis with Hematuria. Review of the Physician's Orders, with a stop date of 05/20/2023, revealed an order for Augmentin Oral Suspension 250-62.5 mg/5 ml, give 10 ml by mouth two times a day. Observation on 05/22/2023 at 10:25 AM, of the medication refrigerator for the B/C Halls, with Registered Nurse (RN) #6, revealed there were two (2) thermometers, both in the refrigerator part, one (1) reading 44 degrees F and the other reading 28 degrees F. Further observation revealed medication stored in the refrigerator to include: a pack of three (3) Humalog KwikPen Subcutaneous Solution Pen-100 Unit/ml (insulin Lispro), a pack of three (3) Lantus SoloStar Subcutaneous Solution One-Injectors 100 Units/ml, two (2) partially filled bottles of Augmentin Oral Suspension 250-62.5 mg/5 ml, with a stop date of 05/11/2023, labeled for Resident #95; a pack of three (3) Insulin Aspsrt FlexPen Subcutaneous Solution Pen-Injector 100 Unit/ml and a pack of four (4) Insulin Glargine Subcutaneous Solution Pen-Injectors labeled for Resident #22; a pack of two (2) HumaLOG KwikPen Solution Pen-Injector 200 units/ml (Insulin Lispro) and a pack of four (4) Lantus SoloStar 100 Units/ml Solution Pen-Injectors labeled for Resident #103; and two (2) partially full bottles of Augmentin Oral Suspension 250-62.5 mg/5 ml, with a stop date of 05/20/2023, labeled for Resident #400. Continued observation revealed an audit tool, posted on the front of the refrigerator, contained no documented evidence the facility had audited the proper storage and temperature of the refrigerator. During the observation and interview, on 05/22/2023 at 10:25 AM, RN #6 stated there should only be one thermometer in the refrigerator section of the refrigerator. She confirmed the two (2) thermometers registered at 42 degrees F and 28 degrees F. She stated that insulin should be stored between 36 degrees F and 46 degrees F per the guidelines from the manufacturer and the facility's policy. She stated by looking at the audit tool on the front of the B/C halls refrigerator, it had not been checked for proper storage and temperature since 05/15/2023. She continued stating, the discontinued antibiotics for Residents #95 and #400, should have been removed from the refrigerator after the stop date, per the facility's policy. During Interview with Licensed Practical Nurse (LPN) #3, on 05/22/2023 at 1:40 PM, she stated she was the Unit Manager and she had been assigned to audit the medication refrigerators. She said she was unaware there were two (2) thermometers in the refrigerator and stated 28 degrees F would be out of range for insulin storage. She stated the discontinued antibiotics should have been removed after the stop date, and should have been done by the nurse administering the last dose of the antibiotic. She further stated she did not know why she had not signed off on the audit tool attached to the refrigerator that the storage was checked, and the temperature was in range since 05/15/2023. 2. Observation on 05/22/2023 at 9:40 AM revealed the B Hall medication cart was sitting by the nurses' station desk, unattended and unlocked. During an interview with Registered Nurse (RN) #32, on 05/22/2023 at 9:45 PM, she stated she was assigned to the B Hall medication cart. She said she was an agency staff and had not worked at the facility since last year. She stated she knew it was important to keep the medication cart locked for safety and control of the medications. She said she got to the facility at 6:55 AM and the Staff Development Coordinator (SDC) told her to go on and take the medication cart assignment and she would give her the required education, per the Plan of Correction (POC) later. During interview with the SDC, on 05/22/2023 at 10:45 AM, she stated the facility had a scheduled nurse to call off work at 6:30 AM that morning and when RN #32 arrived at 6:55 AM she did not have time to conduct the education with the agency staff prior to the start of her shift as stated in the POC. She stated she told RN #32 to go ahead and start the medication administration for the B Hall residents and she would give her the education later. She further stated keeping an unattended medication locked was important to ensure safety and control of medications. 3. Observation on 06/02/2023 at 4:26 PM revealed the D Hall medication cart was unlocked and unattended. Further observation revealed RN #4 was sitting at nurse's station. There were no residents observed in the area of the unlocked medication cart at the time of the observation. During interview with RN #4, on 06/02/2023 at 4:30 PM, she stated she was responsible for the medication cart and had just given resident medication and did not lock back. She said the cart should have been locked and she had been educated to lock the medication cart. Review of the facility's PoC for F761, with an alleged compliance date of 04/16/2023, revealed all Licensed Nurses (LN), including Agency Staff were educated by the Director of Nursing (DON, Assistant Director of Nursing (ADON), or the Staff Development Coordinator (SDC) by 04/06/2023 on the proper storage of drugs and biologicals should be stored in locked compartments and under proper temperature and that discontinued or outdated medications would be promptly returned to the pharmacy or destroyed. Further review revealed beginning 04/10/2023 the DON, ADON, SDC or Unit manager (UM) would round the facility to ensure proper storage of medications daily and report the daily audits to the Quality Assurance Performance Improvement (QAPI) Committee, which met weekly. During Interview with Licensed Practical Nurse (LPN) #3/UM, on 05/22/2023 at 1:40 PM, she stated she was the UM and she had been assigned to audit the medication refrigerators. She said she was unaware there were two (2) thermometers in the refrigerator and stated 26 degrees F would be out of range for insulin storage. She stated the discontinued antibiotics should have been removed after the stop date and that should have been done by the nurse administering the last dose of the antibiotic. She further stated she did not know why she had not signed off on the audit tool attached to the refrigerator that the storage was checked, and the temperature was in range since 05/15/2023. During an interview with the Director of Nursing (DON), on 05/25/2023 at 12:05 PM, she stated the staff assigned to complete the medication storage audits and temperature logs for medication refrigerators audits reported their findings to her. She stated there had been no issues reported to her since the facility alleged compliance on 04/16/2023. She stated she did not conduct observational rounds herself, to ensure the audits were correct and the information reported to her was correct. She stated someone should have been going behind the staff assigned to the audits to ensure compliance. During an interview with the Executive Director (ED), on 05/23/2023 at 4:00 PM, she revealed it was her expectation for all medications cart to be locked, when not attended. She said she thought the SDC was ensuring education was being provided to all agency staff prior to them starting their assigned shift. She stated the medication refrigerators should have one (1) accurate thermometer because she had replaced all of the thermometers and they should be maintained between 36 degrees F and 46 degrees F at all times to ensure medication is stored at the appropriate temperature. She stated she was not sure if Administrative staff were doing observations rounds on the units to ensure the audits of the medication's storage and refrigerator temperatures were being conducted daily as per the POC. During interview with the Senior [NAME] President of Clinical Services (SVPCS), on 05/22/2023 at 10:45 AM, she stated medication carts should be locked at all times for safety and control of medications. She stated there was no excuse for staff to leave medication carts unlocked and unattended as they had all been educated. When reviewing the audit sheet that had not been signed as completed for the B/C Hall refrigerator that had no documented evidence of the daily audit since 05/15/2023, she state that was unacceptable. She further stated medications that have been discontinued should be removed from the medication refrigerators after their stop date, as per facility policy.

Based on interview, record review, review of the facility's investigation report, and review of the facility's policy, it was determined the facility failed to ensure residents were protected from physical abuse, including resident to resident abuse for one (1) of thirty-three (33) sampled residents (Resident #57). The facility failed to provide adequate supervision to ensure Resident #146 was protected from abuse by Resident #57. On 04/01/2023 at 11:00 AM, Resident #57, who had a history of physical aggression toward staff, slapped Resident #146 once on the right arm and once across the face, while agitated about wanting his/her baby doll. The findings include: Review of the facility's policy titled, Freedom from Abuse and Neglect Policy, dated 10/30/2019, revealed the facility defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It included verbal abuse, sexual abuse, physical abuse, and mental abuse. The policy defined willful, as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy stated the facility's staff would conduct an investigation of any alleged or suspected abuse, neglect, exploitation of residents or misappropriation of property, and would provide notification of information to the proper authorities according to state and federal regulations. Per the policy, prevention of abuse included staffing levels assessed on a continuing basis; adjustments to staffing levels were to be based on the census and the individual needs of the residents. Review of Resident #57's admission Record revealed the facility admitted the resident on 07/05/2022, with diagnoses that included Alzheimer's Disease, Benign Neoplasm of Brain, and Psychotic Disorder with Delusions Due to Known Physiological Condition. Review of Resident #57's Quarterly Minimum Data Set (MDS) Assessment, dated 03/27/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4) of fifteen (15), which indicated the resident was severely cognitively impaired. Review of Resident #57's Comprehensive Care Plan (CCP), initiated on 07/05/2022, revealed the facility care planned the resident for a Focus of experiencing psychosocial distress related to a history of receiving aggression from his/her peers, and history of dementia that affected his/her ability to understand social cues, including when his/her peers might be become agitated. The Goal included that Resident #57's safety would be ensured through next review date. Interventions included: ensure the resident maintained an appropriate/safe distance from his/her peers when he/she appeared agitated, as the resident's nature was to try and help others; provide non-pharmacological interventions such as redirect with activity, offer food/fluid, offer reassurance/conversation; one-to-one (1:1) supervision; and others as needed. This was initiated on 07/11/2022. Review of Resident #57's Progress Notes, dated 04/01/2023 at 11:49 AM, revealed staff and residents were in the lounge area when they heard Resident #57 screaming, and he/she was standing beside another resident. Per the notes, before staff could get between the two (2) residents, Resident #57 slapped at the other resident making contact on his/her face and right arm. Further review revealed the residents were immediately separated, a skin assessment was completed. Resident #57 was placed on one-to-one (1:1) supervision. Review of the Facility's Investigation/Final Report, dated 04/04/2023, revealed Certified Nursing Assistant (CNA) #7 was coming up the hall when she heard Resident #57 getting loud. CNA #7 stated she was on her way to intervene. As CNA #7 was on her way, she saw another resident, Resident #20, holding Resident #57's baby doll on his/her lap. CNA #7 stated that before she could reach the residents, Resident #57 started walking towards Resident #20, and Resident #146 just happened to be in Resident #57's direct path. Per the report, Resident #57 began screaming at Resident #146 and they were yelling incoherently. Resident #57 told Resident #146 to shut up. Resident #146 yelled I will not. Further review revealed suddenly Resident #57 slapped Resident #146 with an open hand twice (once on the right arm and once across the face). CNA #7 reached both residents as Resident #146 was swatting back but did not make contact with Resident #57. Per the report, CNA #7 separated them and guided Resident #57 away from the other residents; she obtained the baby doll for Resident #57. Per the report, CNA #7 related that Resident #57 believed that his/her baby doll was his/her real baby. The report stated CNA #7 said as soon as Resident #57 was given his/her baby doll he/she was immediately calm. Per the report, a skin assessment was completed on Resident #146, and no new areas to the skin were noted. The State Survey Agency (SSA) Surveyor attempted telephone interviews with CNA #7, on 05/09/2023 at 2:22 PM and on 05/10/2023 at 10:04 AM. Voice messages were left for the CNA to make a return call; but no return call was received. During an interview with CNA #9, on 05/09/2023 at 3:45 PM, she stated if a resident took a baby doll from Resident #57, staff got him/her another baby doll. CNA #9 stated the facility had lots of baby dolls, so staff would give him/her more than one (1) doll. During telephone interview, on 05/10/2023 at 9:07 AM, Registered Nurse (RN) #27 stated she recalled Resident #57 and the baby doll incident on 04/01/2023. RN #27 stated she remembered CNA #7 came to her and said something about a baby doll. She stated Resident #57 had smacked another resident. RN #27 stated she went immediately into the memory care unit where she separated Resident #57 from Resident #146. RN #27 stated CNA #7 was close to the residents involved in the resident-to-resident physical altercation related to Resident #57's baby doll, but CNA #7 was not close enough to the two (2) residents to prevent or stop the altercation. During an interview with CNA #15 on 05/11/2023 at 1:00 PM, he stated he worked on the adjacent memory care unit (AMCU) and thought that the staff on the memory care unit (MCU) needed to pay more attention to those residents. CNA # 15 said when he got a break he would sometimes go to the MCU. He stated, when there, he had seen residents without any staff present on the unit and that concerned him. During an interview with RN #28 on 05/10/2023 at 9:07 AM, stated she recalled that on 04/01/2023, CNA #7 came to her and said a resident on the women's unit had smacked another resident, and there was something about a baby doll. RN #28, who was working on another nearby unit, stated she immediately went into the common area, where the television was located of the unit where the altercation had happened. The RN stated she first ensured all residents were safe, and then she assigned someone to stay with Resident #57 since he/she was the resident who had done the smacking. RN #28 stated the resident who had been slapped, Resident #146, was sitting in a wheelchair by the television in the common area when she arrived on the unit. RN #28 stated she placed Resident #57 on one-to-one (1:1) supervision, and called the provider and the Psychiatric Nurse Practitioner (PNP). RN #28 stated when the altercation happened, she thought CNA #7 was close by, but not close enough to prevent it from happening. Review of Resident #57's Progress Notes, dated 03/09/2023 at 11:00 PM, revealed a medical provider saw Resident #57 for a comprehensive encounter at the request of the nurse who reported that Resident #57 had increased agitation and aggression, which was not the resident's typical demeanor. The nurse noted that each time Resident #57's behaviors had increased. Further review of Resident #57's Progress Notes revealed PNP #31 conducted follow up visits from her 03/09/2023 visit with Resident #57. In an interview with PNP #31, on 05/11/2023 at 10:30 AM, she stated she had seen Resident #57 weekly since 03/09/2023 to monitor his/her behaviors and psychotropic medications. She stated that 'last year Resident #57 had undergone an unsuccessful gradual dose reduction of Zyprexa (an antipsychotic medication). The PNP stated the resident needed the higher dose of the medication, which the resident had been receiving. PNP #31 stated Resident #57 had been medically evaluated, and a physical condition for his/her recent agitation was ruled out. During interview, on 05/17/2023 at 1:15 PM, the Director of Nursing (DON) stated Resident #57 thought his/her doll was his/her baby, and the intervention to give Resident #57 a baby doll was initiated after the resident's baby doll incident with Resident #146. The Executive Director (ED), in an interview on 06/02/2023 at 1:23 PM, stated she expected staff to follow the policies and procedures of the facility.

Based on interview, review of the facility's policies, review of the Executive Director's Job Description, and review of the Plans of Correction (PoC ) submitted for the On-site Revisit/Abbreviated Survey with exit date 04/04/2023, it was determined the facility failed to ensure it was administered in a manner that enabled it to use its' resources effectively and efficiently to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The State Survey Agency (SSA) identified continued non-compliance in the areas of 42 CFR 483.10 Resident Rights (F550, F578); 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600); 42 CFR 483.20 Resident Assessments (F635, F641); 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656, F657); 42 CFR 483.24 Quality of Life (F679); 42 CFR 483.25 Quality of Care (F689); 42 CFR 483.35 Nursing Services (F725); 42 CFR 483.45 Pharmacy Services (F755, F761); and 42 CFR 483.70 Administration (F837). Additionally, the facility failed to maintain substantial compliance in the areas of 42 CFR 483.10 Resident Rights (F584); 42 CFR 483.24 Quality of Life (F680); 42 CFR 483.25 Quality of Care (F685, F695); 42 CFR 483.70 Administration (F835, F849); and 42 CFR 483.75 Quality Assurance and Performance Improvement (F867). Review of the facility's Plan of Correction (PoC) revealed its' Administration failed to have an effective process in place to address systemic failures through the Quality Assurance Performance Improvement (QAPI) process. As a result, the facility failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. The facility was recited at the highest scope and severity (S/S) of a K, for the 06/02/2023, second (2nd) revisit. (Refer to F578, F656, F657, F689, F835, and F867) The findings include: Review of the facility's, Job Title: Executive Director, undated, revealed the Executive Director (ED) was to direct the administration of the health care facility within the authority of the facility's management company. Per the review, the ED directed and performed Quality Assessment and Assurance functions including but not limited to regulatory compliance rounds to monitor the facility's performance and to continuously improve quality. Further review revealed the ED was responsible for the implementation of programs to gather and analyze data for trends and institute actions to resolve problems promptly, and report and make recommendations to the appropriate committee. Review of the facility's acceptable Plans of Correction (PoC), for the Standard Recertification/Abbreviated/Extended Survey concluded on 03/16/2023 and the On-site Revisit/Abbreviated Survey concluded on 04/04/2023, revealed the Executive Director failed to ensure the facility achieved substantial compliance. The facility remains out of compliance with repeat deficiencies following the second (2nd) revisit, concluded on 06/06/2023. 1. Review of Resident #2's, Resident #23's and Resident #89's medical records and the Plan of Correction for the survey, revealed the residents had a Do Not Resuscitate (DNR) order. However, there was no evidence that the Emergency Medical Service (EMS) DNR forms had been completed for the residents. The facility's failure to ensure the EMS DNR forms were completed for Resident #2, Resident #23, and Resident #89 has caused or is likely to cause serious harm or serious injury to residents. (Refer to F578) 2. Based on observation, interview, record review and the Plan of Correction for the survey, along with the facility's policy it was determined the facility failed to develop and implement care plans with individualized person-centered interventions to prevent falls for five (5) of thirty-three (33) sampled residents (Residents #20, #35, #97, #146, and #821) who were identified with multiple falls with injuries. (Refer to F656) 3. Based on observation, interview, record review, and facility policy review, it was determined the facility failed to have an effective system in place to ensure care plans were revised to provide proper care and supervision to residents to prevent falls/accidents for two (2) of thirty-three (33) sampled residents (Residents #146 and #821). (Refer to F657) 4. Based on observation, interview, record review, review of the facility policy and Plan of Correction, the facility failed to have an effective system to ensure adequate supervision and monitoring to prevent falls/accidents. The facility failed to identify risks and hazards; failed to establish root cause analyses of previous falls; and failed to implement and evaluate interventions to prevent further falls for six (6) of thirty-three (33) sampled residents (Residents #20, #35, #90, #97, #146 and #821). (Refer to F689) In an interview with the Minimum Data Set (MDS) Coordinator #1 on 06/02/2023 at 3:12 PM, she stated she reviewed care plans with every major assessment quarterly, annually and with a significant change. She stated she made changes as appropriate to update the care plans to the most appropriate interventions based on records found in the residents Electronic Medical Record (EMR) and through observations of the resident. She stated she was responsible for all MDS's now but some things were done by a remote team. In an interview with the Director of Nursing (DON), on 06/02/2023 at 11:46 AM, she stated the facility had not identified any trends as they related to falls. She said they did identify that the D Hall seemed to have more falls, but they could not determine a certain time, shift or staff member involved. When asked who trained her on how to do a root cause analysis (RCA), she said it was the previous [NAME] President of Clinical Operations (VPOC). In an interview with the Executive Director (ED) on 06/02/2023 at 1:20 PM she stated she was a member of the Quality Assurance Performance Improvement (QAPI) Committee and meetings were held weekly now and usually daily as the needs arose with survey, but normally they were held monthly. She stated in attendance generally were the Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Managers (UM), and all department heads naming a few such as Housekeeping, Business office and Human Resources. She added the discussions addressed old business first then new business, employee turnover, retention, orientation, marketing, point click care, infection control, and Relias training. She added mainly they discussed the survey findings and citations and the facility was working through the cited deficiencies. She stated other topics discussed in QAPI, were training of new employees, re-admissions and discharges of residents. In continued interview with the ED on 06/02/2023 at 1:20 PM she said the Medical Director would be providing In-Services for the staff on falls. Per the interview, the ED stated the care plans should have been developed initially when the residents were admitted , and revised with any change of condition and quarterly. In an interview with the Chief Operations Officer (COO) on 06/02/2023 at 3:41 PM, she stated the facility utilized audit tools and she was just made aware of the findings and the Care Plan Team would be in the facility to work on the concerns the State Survey Agency (SSA) identified on 06/03/2023, to review the care plans and Minimum Data Set (MDS), to ensure they were correct. The COO also stated the team created the audit tools based on the POC to work toward compliance. She said additional rounds were conducted with a new rounding tool, twenty-four (24) hours around the clock. Further, she stated she felt the facility was moving in the right direction and things were getting better. However, review of the PoC for surveys with exit date of 03/16/2023 and 04/04/2023, revealed the facility was recited at the Immediate Jeopardy (IJ) level.

Based on interview, record review, review of the facility's documents, the facility's Plan of Correction (PoC), and review of the facility's policies, it was determined the facility failed to ensure its' Governing Body was involved and actively engaged in establishing and implementing policies regarding the management of the facility. The State Survey Agency (SSA) identified continued non-compliance in the areas of 42 CFR 483.10 Resident Rights (F550, F578); 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600); 42 CFR 483.20 Resident Assessments (F635, F641); 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656, F657); 42 CFR 483.24 Quality of Life (F679); 42 CFR 483.25 Quality of Care (F689); 42 CFR 483.35 Nursing Services (F725); 42 CFR 483.45 Pharmacy Services (F755, F761); and 42 CFR 483.70 Administration (F837). Additional non-compliance was identified in the areas of 42 CFR 483.10 Resident Rights (F584); 42 CFR 483.24 Quality of Life (F680); 42 CFR 483.25 Quality of Care (F685, F695); 42 CFR 483.70 Administration (F835, F849); and 42 CFR 483.75 Quality Assurance and Performance Improvement (F867). Review of the facility's Plan of Correction (PoC) revealed its' Governing Body failed to provide oversight of the facility's Administration to ensure substantial compliance was achieved for the Recertification/Abbreviated/Extended Survey which concluded on 03/16/2023 and for the On-site Revisit/Abbreviated Survey which concluded on 04/04/2023. The facility was recited at the highest scope and severity (S/S) of a K for the second (2nd) revisit survey. (Refer to F578, F656, F657, F689, F835, and F867) The findings include: Review of a document the facility provided as their Governing Body policy, which did not include a header and was undated, revealed in accordance with 42 CFR Section 483.70(b), the facility must have a Governing Body, or designated persons functioning as a Governing Body, that was legally responsible for establishing and implementing policies regarding the management and operation of the facility. The Governing Body appointed the Administrator who was licensed by the State, where licensing was required. Further review revealed the Governing Body was responsible for the management of the facility. Additionally, the Governing Body reported to and was accountable to the Governing Body. Continued review of this document, undated, revealed the Governing Body was responsible and accountable for the QAPI Program in accordance with 42 CFR Section 483.75 (f). The Governing Body was comprised of the Regional Director of Operations/Vice Present of Operations, [NAME] President of Human Resources, and/or the [NAME] President of Clinical Operations/Regional Director of Operations. Further, the Governing Body fulfilled its above-referenced duties through a combination of onsite visits, Zoom or telephone conferences, and performance of audits. Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Program-Governing Body (GB) and Leadership, last revised March 2020, revealed the Governing Body was responsible for ensuring the QAPI program: was implemented and maintained to address identified priorities; was sustained through transitions of leadership and staffing; was adequately resourced and funded, to include the provisions of money, time, equipment, training, and staff coverage sufficient to conduct the activities of the program; was based on data, resident and staff input, and other information that measured performance; and focused on problems and opportunities that reflected processes, functions, and services provided to the residents. Review of a document presented by the facility included a list of Directors of Nursing (DON) and Executive Directors (ED) the facility had employed for the past three (3) years. Continued review of the document revealed the facility had thirteen (13) DON changes since 01/15/2022 and nine (9) ED changes since 11/01/2019. Review of the facility's acceptable Plans of Correction (PoC), for the Standard Recertification/Abbreviated/Extended Survey concluded on 03/16/2023 and the Onsite Revisit/Abbreviated Survey concluded on 04/04/2023, revealed the facility alleged substantial compliance on 04/16/2023. However, the State Survey Agency (SSA) has determined the facility remains out of compliance with repeat Immediate Jeopardy (IJ) deficiencies following the second (2nd) revisit, which concluded on 06/02/2023. Review of the facility's Plan of Correction (PoC), for the Standard Recertification /Abbreviated/Extended Survey that concluded on 03/16/2023 and the Onsite Revisit/Abbreviated survey which concluded on 04/04/2023, for F tag F578, revealed the facility alleged substantial compliance on 04/16/2023. Further review of the PoCs revealed all the residents' admission packets were audited to ensure the facility had assisted the residents and/or their responsible party formulate an Advanced Directive. Per review of the PoCs, no issues were identified. During the 03/16/2023 survey, the facility was cited at the highest scope and severity (S/S) of a D. However, for the second (2nd) on-site revisit with the exit date of 06/02/2023, the State Survey Agency (SSA) identified continued non-compliance at the highest S/S of a K, with the F-Tag now cited at a higher S/S of an Immediate Jeopardy (IJ), which indicated a serious adverse outcome or serious adverse outcome was likely to result in serious injury, serious harm, and serious impairment or death. Review of the facility's Plan of Correction (PoC), for the Standard Recertification/Abbreviated/Extended Survey that concluded on 03/16/2023 and review of the Onsite Revisit/Abbreviated Survey with exit date 04/04/2023, for F tag F656 and F657, for Care Plan Development, Implementation, and Revision, revealed the facility alleged substantial compliance on 04/16/2023. Further review of the PoC revealed the facility audited the residents' care plans beginning on 01/17/2023 and 03/06/2023 to determine if the residents' care plans were developed and implemented to meet the residents' preferences, goals, and addressed the residents' medical, physical, mental, and psychosocial needs to include residents with falls to ensure that safety interventions were in place for all residents at risk for falls. Further, the audits included revisions regarding the care plan related to falls. Continued review revealed visual observation/rounds were conducted to determine the care plans were implemented with any corrective action upon discovery. An additional review revealed the Executive Director (ED) or Director of Nursing (DON) reviewed the audits daily and concerns identified was corrected upon discovery. During the 03/16/2023 survey, the facility was cited at the highest scope and severity (S/S) of a L, for F656, and for F657, the highest S/S was an E. However, for the second (2nd) on-site revisit with an exit date of 06/02/2023, the SSA identified continued non-compliance at the highest S/S of a K for F656 and for F657, the highest S/S was cited at a J, reciting Immediate Jeopardy (IJ) for F656, and F657 was cited at a higher S/S of an J, which indicated a serious adverse outcome or serious adverse outcome was likely to result in serious injury, serious harm, and serious impairment or death. Review of the audit tool created to check on care plans and to make observations of staff providing care for residents, any corrective action, and the signature of the auditor, dated 04/19/2023, revealed one (1) resident was still care planned for a wheelchair and a walker that the resident no longer utilized. However, these assistive devices remained on the care plan. Another resident was care planned for a cushion on his/her wheelchair, but the resident did not have a cushion, which was not needed, and it continued to remain on the care plan. An additional resident, who did not use a cane, and had been care planned to use a cane. Review of the audit tool for 04/20/2023, revealed a resident was care planned for a walker but did not use a walker. Another resident's care plan reflected the resident had one-half (½) side rails, when in fact it was one-quarter (¼) side rails. Review of the facility's Plan of Correction (PoC), for the Standard Recertification/Abbreviated/Extended Survey that concluded on 03/16/2023 and the On-site Revisit/Abbreviated Survey with exit date of 04/04/2023 for F-tag F689, for Accidents and Supervision, revealed the Executive Director (ED), Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Manager (UM), Nurse Supervisors, or Licensed Nurses conducted visual observation audits to determine resident supervision needs were met to prevent accidents including falls. During the Standard Recertification Survey, with exit date 03/16/2023, the SSA identified non-compliance at the highest S/S of a K and the facility alleged substantial compliance on 04/16/2023. However, on the second (2nd) on-site revisit with an exit date of 06/02/2023, the SSA identified continued non-compliance at the highest S/S of a K, reciting IJ which indicated a serious adverse outcome was likely to result in serious injury, serious harm, and serious impairment or death. Review of the facility's Plan of Correction (PoC), for the On-site Revisit/Abbreviated Survey that concluded on 04/04/2023, for F-tag F837, Administration/Governing Body, revealed the Executive Director (ED) notified the Medical Director on 04/01/2023 of the survey findings for F837, and reported the facility was to have a governing body,that was legally responsible for establishing and implementing policies regarding the management and operations of the facility. Continued review of the PoC revealed an adHoc Quality Assurance Performance Improvement (QAPI) meeting was conducted on 04/01/2023 with the Senior [NAME] President of Operations, [NAME] President of Human Resources, Regional Human Resources Business Partner, Chief Compliance Officer, ED, Director of Nursing (DON) and the Medical Director to review the action plan including audits, reeducation, and compliance monitors. During the On-site Revisit/Abbreviated Survey with exit date of 04/04/2023, the SSA identified non-compliance at the highest S/S of an F and the facility alleged substantial compliance on 04/16/2023. However, on the 2nd on-site revisit with an exit date of 06/02/2023, the SSA identified continued non-compliance at the highest S/S of an F. In an interview with the Director of Nursing (DON), on 06/02/2023 at 11:46 AM, she stated the facility had not identified any trends as they related to falls. She stated the facility had identified that the D Hall seemed to have more falls, but they could not determine a certain time, shift, or staff member involved. Per the interview, the DON revealed the previous [NAME] President of Clinical Operations (VPOC) provided the education to her on how to complete a root cause analysis (RCA). In an interview with [NAME] President of Clinical Operations (VPCO) on 06/02/2023 at 3:12 PM, she stated she was part of the Governing Body and prior to January 2023, the Governing Body was the Executive Director. Further, she stated the new Governing Body was formed in March 2023 and included the [NAME] President of Operations (VPO), the Chief Operation Office (COO), and the [NAME] Present of Human Resources (VPHR). Further, she stated that as part of her role within the Governing Body, she rounded, audited, gathered/checked information, and helped develop Plans of Corrections (POC) for the facility. She stated the Governing Body gave direction to the facility and assisted them with any/all problems. Per the interview, she stated she provided oversight to the Director of Nursing (DON). Further, she stated she was physically present at the facility every day since 02/14/2023. Per the interview, she stated the deficient practice from the surveys were discussed in QAPI. Further, she stated the audit tools that were utilized were created by the pervious Interim Director of Nursing (DON) and she reviewed many of the audits. In an interview with the Chief Operations Officer (COO), on 06/02/2023 at 3:41 PM, she stated she provided oversight over the operation of the company, its' operators, and the clinicians under her. She stated she appointed the Executive Director for the facility. The COO stated she had been providing direct supervision to the Executive Director and was a member of the Governing Body. She stated further that in an effort to achieve compliance, audit tools were developed based on the the facility's Plan of Correction (POC). The COO continued by stating she was unaware of the concerns identified in the audit tools and would address the concerns with the Care Plan Team. During an interview with the Chief Executive Officer (CEO)/Owner, on 06/01/2023 at 3:02 PM, he stated he had been with the company for twenty (20) years. He stated surveys had not been going great lately and he planned to be present more at the facility.

Based on interview, record review, review of the facility's policy, and review of the Plans of Correction (PoC) submitted for the 04/04/2023 survey, it was determined the facility failed to have an effective process in place to address systemic failures through the Quality Assurance Performance Improvement (QAPI) process. As a result, the facility failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. The facility failed to effectively track adverse resident events, analyze their causes, and implement preventive action. The facility failed to ensure there was an effective system in place to regularly review and analyze audit data, including data collected under the QAPI program, and act on available data to make improvements and maintain substantial compliance. 1. Review of the facility's Form CMS-672 Resident Census and Conditions of Residents, identified forty-four (44) residents were assessed to be at risk for falls. The facility reported residents had over thirty (30) falls between 04/16/2023 and 05/26/2023. However, there was no evidence the facility was discussed the falls, reviewed previous falls, analyzed the time of day and staff patterns for each fall in order to determine the root cause of the falls and to implement person centered intervention to prevent further falls. 2. Review of the facility's audit tool for residents' Care Plans showed multiple times the care plans were inaccurate. 3. Review of the facility's audit tool for Accurate Coding revealed three (3) residents, who had inaccurate coding on the Minimum Data Set (MDS) assessments, and the care plans that did not match the coding/assessments. 4. Review of the facility's Controlled Substances Log Book Shift Count revealed multiple times two (2) Licensed Nurses' signatures were not present. This was not reflected on the audit tool. 5. Review of the audit tool for Drugs and Biologicals revealed it had not been completed for seven (7) days. Further, observation revealed unlocked medication carts; inconsistent temperatures taken by two (2) different thermometers; and insulin stored at an inappropriate temperature. 6. Review of the audit tool for 04/17/2023, 04/18/2023, and 04/19/2023 revealed they were incomplete. The findings include: Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Program-Governing and Leadership, last revised March 2020, revealed the Administrator (Executive Director) was a member and was ultimately responsible for the QAPI Program and for interpreting its results and findings to the Governing Body. The QAPI Coordinator coordinated the activities of the QAPI Committee. The policy stated the responsibilities of the QAPI Committee were to collect and analyze data, identify, evaluate, monitor, and improve the facility's systems and processes of care and services, identify and help to resolve negative outcomes and quality of care problems identified during QAPI. The committee would also determine the root cause analysis to help identify problems pointed to underlying systemic problems, help departments, consultants, and ancillary services implement a system to correct potential/actual issues of quality of care. The policy also revealed the committee was to establish benchmarks and goals to measure performance improvement projects to achieve specific goals. It also was to communicate all phases of the QAPI process to the Administrator (Executive Director) and Governing Body through sharing meeting minutes, committee activities, and results of QAPI activities. Continued review of the QAPI policy revealed the committee had full authority to oversee the implementation of the QAPI program, to establish performance and outcome indicators for quality of care and services delivered in the facility, choosing, and implementing the tools that best captured and measured the data about chosen indicators, appropriately interpreting data within the context of standards of care, benchmarks, targets and the strengths and challenges of the facility. Per the policy, the committee was responsible to communicate the information gathered and their interpretation to the Owner/Governing Body. The policy also revealed the QAPI Committee was made up of the Administrator/Executive Director or designee, the Director of Nursing (DON), the Medical Director (MD), and the Infection Preventionist. Additionally, the Administrator/Executive Director could request a representative from each department: pharmacy, social services, activities, environmental services, human services, and medical records. Per the policy, the committee must meet at least quarterly and should be reminded of the meeting day, time, and location via e-mail at least two (2) days prior to the meeting. The policy stated special meetings could be called prior to the next scheduled meeting by the Administrator/Executive Director as needed. Review of the facility's 04/17/2023 audit tool the facility created revealed it covered each tag, F550, F656, F689, F725, F726, F761, F880 and F919. Staff members were to randomly pick ten (10) residents to audit daily. They were to audit to ensure urinary catheters were covered with a dignity bag, the Kardex (an abbreviated care plan for aides) was followed by aides as the plan of care, residents were turned and repositioned, to check water temperatures, to ensure call lights were answered timely, residents' supervision needs were being met, gait belts were used during transfer, unused medication was discarded from the medication carts, and the unit medication carts were locked. Additionally, the same ten (10) residents were to be observed as staff interacted with them to ensure proper Personal Protection Equipment (PPE) was used, hand hygiene between meals, gloves were used by staff when touching food, clean trays and dirty trays were kept separate, the dining room was clean, items on the floor were disposed of, hand hygiene between carts, call lights were functional, and the toilets worked. 1. Review of the facility's Plan of Correction (PoC), with an alleged compliance date of 04/16/2023, revealed the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Staff Development Coordinator (SDC) conducted education to all Licensed Nurses (LN), starting 03/08/2023 and ongoing related to ensuring the facility provided an environment free from accident hazards and provided supervision and assistive devices to prevent accidents including falls based on the root cause of the falls. Further review revealed management staff including the Executive Director, DON, ADON, and SDC would make visual observation rounds daily to determine resident needs were met to prevent accidents including falls, and these audits would be submitted to the Quality Assurance Performance Improvement (QAPI) Committee weekly. Review of the weekly QAPI meeting documentation presented by the facility revealed a flow sheet outlining each non-compliance tag. Review of the information related to F689 (falls) revealed the QAPI was identifying the number of falls for each week; however, there was no documented evidence the facility was discussing the falls, looking at previous falls, analyzing the time of day and staff patterns for each fall in order to determine the root cause of the falls and to implement person centered intervention to prevent further falls. Review of the facility's Quality Assurance and Performance Improvement (QAPI) meeting minutes for 04/21/2023 for F689 revealed there were six (6) falls for the prior week. It was noted a Root Cause Analysis (RCA) was done for each fall and appropriate interventions were in place for all residents. However, this statement written in the minutes could not be verified because there was no other documented evidence, and the facility was not able to provide any details in interviews that this occurred. Review of the signature sheet revealed the Executive Director (ED) was present as well as the Staff Development Coordinator (SDC), the Director of Rehabilitation (DOR), Environment Services Supervisor (ESS), Admissions Coordinator (AC), the Director of Maintenance, the Business Office Manager (BOM), the [NAME] President of Maintenance (VPM), the Medical Director (MD), a nurse aide, and a licensed nurse. Review of the facility's QAPI meeting minutes for 04/28/2023 for F689 revealed it was documented there were five (5) falls for the previous week, an RCA was done for each fall, and appropriate interventions were in place for all residents. However, this statement written in the minutes could not be verified because there was no other documented evidence, and the facility was not able to provide any details in interviews that this occurred. Review of the signature sheet revealed present at the meeting was the Director of Nursing (DON), a Registered Nurse (RN), the Assistant Director of Nursing (ADON), the Social Service Director (SSD) and the [NAME] President of Clinical Education (VPCE). Review of the facility's QAPI meeting minutes for 05/05/2023 for F689 revealed it was documented the facility had thirteen (13) falls during the previous week. The minutes also documented an RCA was done for each fall, and all residents involved had appropriate interventions in place. However, this statement written in the minutes could not be verified because there was no other documented evidence, and the facility was not able to provide any details in interviews that this occurred. Review of the signature sheet revealed present for this meeting was the ED, DON, ADON, DOR, Medical Records, the Dietary Manager (DM), SSD, BOM, Minimum Data Set (MDS) Coordinator and the MD, as well as a licensed floor nurse. Review of the facility's QAPI meeting minutes for 05/12/2023 for F689 revealed it was documented the facility had seven (7) falls during the previous week, an RCA was done for each fall, and each resident had the appropriate interventions in place. However, this statement written in the minutes could not be verified because there was no other documented evidence, and the facility was not able to provide any details in interviews that this occurred. Review of the signature sheet revealed present at the meeting was the ED, DON, DOR, a Unit Manager (UM) illegible name, Environment Services Supervisor, MDS Coordinators #1 and #2, DM, and a floor CNA #18. Review of the facility's QAPI meeting minutes for 05/19/2023 for F689 revealed it was documented the facility had six (6) falls the previous week, an RCA was completed on each fall, and each resident had appropriate interventions. However, this statement written in the minutes could not be verified because there was no other documented evidence, and the facility was not able to provide any details in interviews that this occurred. Review of the signature sheet revealed present at the meeting were the ED, DM, ADON, SSD, Medical Records, and two (2) illegible names. In an interview with the Director of Nursing (DON), on 05/25/2023 at 11:55 AM, the DON stated when a fall occurred, the nurse on duty was to contact her and start the fall event in the Electronic Medical Record (EMR). She said then she came up with the root cause of the fall and made sure an intervention was implemented. She said she had received training on determining the root cause for falls but could not remember what the training was called or when she received it. She said she usually used the information provided by the reporting nurse to determine the root cause. The DON also stated the falls were discussed in the Interdisciplinary Team (IDT) meetings that included the ED, ADON, Unit Managers, Department Heads and the MD. She was unable to provide documented evidence the IDT was analyzing the falls to review staffing patterns, time of day, previous falls, or what level of monitoring/supervision was being provided at the times of the falls. She said she realized the IDT needed to do more analysis of the falls and document this. In another interview with the DON, on 05/25/2023 at 12:55 PM, she stated she did not have knowledge of Resident #90 falling in the early morning hours today. She added either she, the Assistant Director of Nursing (ADON), or the Executive Director (ED) should be notified immediately when a fall occurred, and care plan interventions should be placed immediately as well. The ED was also in the room and stated she had not been informed of Resident #90's fall. The ED stated this notification was not in the facility's policy, but they preferred to be notified. At this point, the DON contacted the ADON, and she came to the ED's office. When the ADON was asked if she had been notified of the fall, she stated she had not. All three (3) stated that perhaps one (1) of the unit managers had been notified. When asked if the process had been followed, the DON said probably not, and the nurse should have notified one (1) of them. In an interview with the ED, on 05/25/2023 at 12:15 PM, she stated the DON received a report of every fall. She stated the DON reviewed what the nurse on duty at the time documented and determined the root cause of the fall. She stated the IDT discussed the falls in their meeting each morning. She further stated she was not sure if the DON had received any training on determining the root cause of falls. The ED stated there was no set format to follow when discussing the falls. She stated they used to have a falls meeting specifically to talk about and analyze the falls, using the environment, time of day, pattern of falls, and the use of assistive devices to come up with the root cause of the falls. That way, she stated, appropriate interventions could be implemented. She said she could not put all residents with repeat falls on one-to-one (1:1) observation; the facility just did not have enough staff for that to be done. When the ED was asked how many residents the facility had that had been assessed to be a fall risk, she said she was not sure, but she thought the falls had decreased. In an interview with the DON, on 06/02/2023 at 11:46 AM, she stated the facility had not identified any trends as they related to falls. She said they did identify that the D Hall seemed to have more falls, but they could not determine a certain time, shift or staff member involved. When asked who trained her on how to do a root cause analysis (RCA), she said it was the previous [NAME] President of Clinical Operations (VPOC). In an interview with the ED, on 05/19/2023 at 3:43 PM, she stated the DON was responsible to complete an RCA of a fall. She stated once the DON had identified a root cause, it was then discussed in the clinical meetings. She said the team would give input and determine if they all agreed with the DON's analysis of the incident. The ED also stated interventions were discussed daily in the clinical meetings and with each fall that occurred. She stated the team looked over the interventions and determined if they had been effective. She stated if not, the IDT would identify a new intervention. The ED stated the facility had not determined a trend related to their falls, but if she had to pick an area, it was related to the residents' behaviors. The VPCO stated, in an interview on 06/02/2023 at 3:12 PM, facility staff was looking into a new program that would help detect a resident's movement before a fall. She stated the increased rounding, including by management staff, being done throughout shifts helped decrease the amount of falls they have had. She reported resident falls were down eighty percent (80%). 2. Review of the audit tool created to check on care plans and to make observations of staff providing care for residents, any corrective action, and the signature of the auditor, dated 04/19/2023, revealed one (1) resident was still care planned for a wheelchair and a walker that the resident no longer used. However, these assistive devices remained on the care plan. Another resident was care planned for a cushion on his/her wheelchair, but the resident did not have a cushion, which was not needed, and it still remained on the care plan. An additional resident, who did not use a cane, had been care planned to use a cane. Review of the audit tool for 04/20/2023, revealed a resident was care planned for a walker but did not use a walker. Another resident's care plan reflected the resident had one-half (½) side rails, when in fact it was one-quarter (¼) side rails. Also this resident was care planned for two (2) staff for care, which was noted as inaccurate, and it was deleted from the care plan. Additionally, the two (2) residents, who previously requested the side rails to be removed revealed they were still present. Review of the QAPI Review-Entire Survey document and meeting minutes for 04/21/2023, revealed for F656 the team discussed a wandering resident who was placed on one-to-one (1:1) supervision, and six (6) falls in which the root cause was identified, and the care plans were noted to be revised. However, there was nothing documented on any audits to show the items were addressed. For F657, it was noted they found no concerns. The signature sheet for this meeting showed the ED was present as well as the SSD, licensed floor nurse, the DOR, Admissions, Activities Assistant, the DON, the MD, the BOM, and the [NAME] President of Maintenance (VPM). Review of the QAPI Review-Entire Survey document and meeting minutes for 04/28/2023, revealed no concerns were identified for F656 and F657. However, review of the audits for 04/21/2023, revealed one (1) resident who required a perimeter mattress be added to his/her care plan; one (1) resident was noted to still not have side rails to his/her bed, and one (1) resident was noted to have a walker and bedpan on the care plan, which the resident no longer used. Review of the 04/24/2023 audit revealed a resident still had a urinal care planned but no longer used it; another was care planned for the use of a jumpsuit and binders, which the resident refused to use. Review of the 04/26/2023 audits revealed two (2) residents had perimeter mattresses but were not care planned for them. Review of the QAPI Review-Entire Survey document and meeting minutes for 05/05/2023, revealed F656 had two (2) residents that were readmitted from the hospital, with wander guards in place for both and all orders in place. The document noted F657 had no concerns noted. However, review of the 05/03/2023 audit tool, revealed one (1) resident was found to have non-skid strips next to the bed, but it was not noted on the care plan as an intervention. Another resident was found to be with the bed against the wall, but it was not noted on the care plan as an intervention; it was later added to the care plan. Review of the signature sheet for 05/05/2023, revealed the ED was present as well as the DON, the ADON, a licensed floor nurse, Medical Records, SSD, DM, BOM, an illegible name, and the MD. Review of the QAPI Review-Entire Survey document and meeting minutes for 05/12/2023, revealed no concerns were found with F656 or F657. However, on the 05/06/2023 audit tool, three (3) residents were noted to have perimeter mattresses, none of which were care planned. The audit tool noted they were added as an intervention. Review of the 05/07/2023 audit tool, revealed a resident was care planned with a rollator but no longer had one, and it was resolved on the care plan. Another resident was noted not to be walking, and the care plan had not been revised to reflect the March 2023 MDS. Another resident was identified with a perimeter mattress which had not been care planned before a staff member informed management of the finding. Review of the 05/10/2023 audit tool revealed Resident #821 did not have anti-tippers on his/her wheelchair; however he/she had an anti-rollback device, and it was not care planned. Review of the signature sheet for 05/12/2023, revealed the ED was present as well as the DOR, Minimum Data Set Coordinator (MDSC) #1, a licensed floor nurse, DON, MDSC #2, Housekeeping, Receptionist #1, Activity Assistant #5, and two (2) illegible signatures. Review of the QAPI Review-Entire Survey document and minutes for 05/19/2023, revealed F656 had a note which revealed some wandering residents had been identified, and their care plans had interventions implemented. F657 had a note which revealed some behaviors were identified, and the care plans were revised. However, review of the audit tools for F656 and F657 on 05/14/2023 revealed a resident was identified with a perimeter mattress, and it had not been care planned; later, the care plan was revised. Review of the audit tool dated 05/15/2023, revealed a resident who was care planned for dycem in the chair, but the dycem was under the chair instead of in the chair. 3. Review of the facility's PoC for F641, revealed all residents' MDS Assessments, care plans, and Kardex would be audited by 04/04/2023 by the MDS nurse to ensure accuracy of MDS coding, the care plan in place, and the Kardex to reflect use of devices. Further review revealed any MDS with coding errors had been modified to reflect accurate coding in Section G0600 Mobility Devices and care plans, and the Kardex accurately reflected the use of any mobility device, including wheelchairs. Continued review revealed the Director of Clinical Reimbursement, MDS nurse, and/or a licensed nurse would conduct a weekly audit of up to ten (10) completed MDS's to ensure any resident with a mobility device was appropriately coded on the MDS in Section G0600, and the care plan/Kardexes were up to date. This audit would continue for four (4) weeks, and if no issues were identified, the audit would decrease to monthly by the fifteenth (15th) of each month for the next six (6) months. Per the PoC, if no issues were identified after six (6) months of monthly audits, the audits would end. If issues were identified, audits would remain weekly until four (4) weeks were completed without errors. The results of the initial, weekly, and monthly audits would be reviewed by the MDS Coordinator, Director of Clinical Reimbursement, [NAME] President of Clinical Reimbursement, and Facility Executive Director (ED), and the findings and Performance Improvement Plan would be presented in the facility QAPI plan monthly until the audits were no longer required. Review of the facility's initial audit revealed multiple modifications were needed to the Care Plan and Kardex. The facility alleged compliance on 04/16/2023 with their audits. Review of the audits revealed all weekly audits were conducted by the [NAME] President of Clinical Reimbursement. A. Review of the Quarterly MDS Assessment, dated 02/10/2023, for Resident #146 revealed it was coded for a walker and wheelchair. Review of the 04/16/2023 audit for Resident #146 revealed the resident used a walker and a wheelchair during the look back period for the MDS, and the care plan and Kardex were correct. Review of the 05/07/2023 audit for Resident #146 revealed the resident used a wheelchair and walker during the MDS look back period, and the walker was not on the care plan or Kardex. Further review revealed the audit stated the walker was added to the care plan and Kardex. Review of the Quarterly MDS Assessment, dated 05/08/2023, for Resident #146 revealed it was coded for a walker and wheelchair. Review of the 05/21/2023 audit for Resident #146 revealed the resident used a walker and wheelchair during the MDS look back period and they were both on the care plan and Kardex. However, in review of Resident #146's care plan, there was no evidence it included an intervention for a walker. Further, review of Resident #146's Kardex revealed there was no evidence of a walker documented on the Kardex. B. Review of the 04/30/2023 audit for Resident #821 revealed the resident used a walker (with rehab only) and a wheelchair during the MDS look back period, and this was accurately reflected on the Care Plan and Kardex. Review of the resident's Quarterly MDS Assessment, dated 04/08/2023, and Quarterly MDS Assessment, dated 04/24/2023, revealed they were coded for a walker and wheelchair. Review of the Care Plan for Resident #821 revealed interventions for a wheelchair. However, there was no evidence of an intervention for a walker. Review of the resident's Kardex revealed the wheelchair was listed under devices, but there was no documentation the resident required a walker. Observation on 06/02/2023 at 4:10 PM, revealed Certified Nursing Assistant (CNA) #6 sitting with Resident #821 one-to-one (1:1) with a walker in the resident's room. CNA #6 stated she requested it to help the resident ambulate as he/she loves to walk. C. Review of the 05/14/2023 audit for Resident #48 revealed the resident used a walker and a wheelchair during the MDS look back period, and this was reflected accurately on the Care Plan and Kardex. Review of the resident's Quarterly MDS Assessment, dated 04/07/2023, and Quarterly MDS Assessment, dated 05/11/2023, revealed they were coded for a walker and wheelchair. Review of Resident #48's care plan revealed an intervention for a walker. However, there was no evidence of wheelchair use documented. Review of Resident #48's Kardex revealed use of a walker. However, there was no intervention documented for a wheelchair. Observation of Resident #48, on 06/02/2023 at 1:38 PM, revealed the resident was sitting on a couch in the unit's common area and did not have a wheelchair present. Upon interview, on 06/02/2023 at 1:38 PM, CNA #88 stated Resident #48 did not use a wheelchair. Upon interview, on 06/02/2023 at 3:12 PM, MDS #1 stated she was responsible for making sure MDS assessments were completed, and she reviewed residents' care plans as she completed quarterly and annual MDS assessments. She stated she made changes appropriately so the residents' care plans and MDS assessments were aligned. She further stated Resident #48's 05/11/2023 Quarterly MDS Assessment was completed by another nurse off site by reviewing the resident's medical record. She also stated she did not participate with the audit process, and the audits were completed by the [NAME] President of Clinical Reimbursement solely. During interview with the Director of Nursing (DON), on 05/30/2023 at 11:45 AM, she stated all audits for F641 were completed by the [NAME] President of Clinical Reimbursement remotely, and the DON did not participate in any way with completing or reviewing the audits. The State Survey Agency (SSA) Surveyor left voice messages per telephone to the [NAME] President of Clinical Reimbursement, on 06/02/2023 at 1:32 PM and 3:38 PM, with no call back. During interview with the ED, on 06/01/2023 at 3:46 PM, she stated she did not participate in the audit process for F641. 4. Review of the facility's PoC for F755, with an alleged compliance date of 04/16/2023, revealed the facility had conducted education for all Licensed Nurses (LN) and Certified Medication Technicians (CMT) to include agency staff on documenting that the on-coming nurse and the off-going nurse both signed that the count verification had been completed at the end of each shift by 04/15/2023. Review of the PoC further revealed starting on 04/14/2023, the Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC) or the Unit managers (UM), would visually audit three (3) narcotic blue books to ensure on-coming and off-going nurses signed the count verification daily. The audit information would be reported to the Quality Assurance Performance Improvement (QAPI) committee weekly. Review of the facility's Controlled Substances Log Book Shift Count for the six (6) of six (6) medication carts, revealed omissions of the required two (2) signatures of either coming on duty or going off duty licensed nurses on fifty-four (54) occasions between 04/16/2023 and 05/30/2023. Review of the facility's document titled Survey Education for 755 test, revealed question number four (4) was: two (2) licensed nurses count the narcotic medications at the beginning of each shift with the correct answer as true. Further review of the test revealed twenty-eight (28) tests had a one-hundred percent (100%) passing grade. During an interview with the Staff Development Coordinator (SDC), on 05/22/2023 at 10:00 AM, she stated she was in charge of educating Agency staff prior to working related to all the plans of correction issues. She stated today' the facility had a call-in at 6:30 AM, and RN #30 was needed on the floor at 7:00 AM; so she had not yet educated RN #30 on counting the narcotics with two (2) nurse signatures that the count was correct. During another interview with the SDC, on 06/01/2023 at 10:30 AM, she stated she had provided training for the narcotic count to occur at the end of shift and knew of no staff pre-signing narcotic books. She stated the UMs were completing the audits and reporting to her and that she had not observed change of shift narcotic counts during the audits starting on 04/15/2023. In an interview with Licensed Practical Nurse (LPN) #3/UM, on 05/23/2023 at 2:10 PM, she stated she had training on signing the narcotic book between shifts. In another interview with LPN #3/UM, on 06/02/2023 at 11:20 AM, she stated she was never made aware of nurses pre-signing narcotic books. She added she had not observed shift change narcotic counts and if pre-signing was occurring, there could be discrepancies in the count. She stated she had reported to the ADON and the DON that she was finding missing signatures when she was auditing the Controlled Substances Log Book Shift Count. During an interview with the DON, on 05/25/2023 at 3:00 PM, she stated the facility's process for controlling narcotics was to have the narcotics counted at each shift change by the on-coming nurse and the off-going nurse. She stated this education was provided to all staff as part of the PoC. The DON stated there was someone assigned to audit this process, who turned the audits into her, and she had noted no problems. She stated she had not completed any observations of this medication count process as part of Quality Assurance (QA). The DON further stated she was surprised to find out there were so many missing signatures from the Blue Books. 5. Review of the facility's PoC for F761, with an alleged compliance date of 04/16/2023, revealed all Licensed Nurses (LN), including Agency Staff were educated by the DON, ADON, or the SDC by 04/06/2023 on the proper storage of drugs and biologicals. This education included drugs and biologicals should be stored in locked compartments and under proper temperature and that discontinued or outdated medications would be promptly returned to the pharmacy or destroyed. Further review revealed beginning 04/10/2023 the DON, ADON, SDC or UM would round the facility to ensure proper storage of medications daily and report the daily audits to the Quality Assurance Performance Improvement (QAPI) Committee, which met weekly. Observation on 05/22/2023, revealed the medication refrigerator on the B/C Hall contained two (2) thermometers, one (1) read forty-two (42) degrees Fahrenheit (F), and the other read twenty-eight (28) degrees F. Continued observation of the refrigerator revealed it contained medications, including insulin, for Residents #103, #22 and #95. Continued observation revealed discontinued medications for Residents #95 and #400 were stored in the refrigerator. Additionally, observation revealed the facility's audit tool, posted on the front of the medication refrigerator, indicated the refrigerator had not been audited for proper storage and temperature, since 05/15/2023. Further, the facility failed to ensure all drugs and biologicals were stored in locked compartments in accordance with State and Federal laws. Observations revealed the facility failed to ensure two (2) of the six (6) medication carts were locked when unattended. Observations on 05/22/2023, revealed the medication cart on B Hall was unlocked and unattended, and observation on 06/02/2023, revealed the medication cart on D Hall was unlocked and unattended. Both medication carts contained drugs [TRUNCATED]

Based on interview, record review, and facility policy review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for residents, which included timeframes and measurable for meeting the nursing, mental, psychosocial, and medical needs identified in the comprehensive assessment for one (1) of ninety-nine (99) sampled residents (Resident #133). The facility documented Resident #133's verbal inappropriateness towards staff beginning 02/15/2022; however, the facility failed to implement care plan interventions to protect its' staff and other residents from the resident's documented historical and current verbal aggressions and inappropriateness. The facility's failure to implement necessary interventions resulted in Resident #133's continuing to have verbal aggression, inappropriateness, and disruption towards other residents and staff. The findings include: Review of the facility's Comprehensive Care Plan (CCP) Policy dated 01/13/2018, revealed its purpose was to ensure a resident or resident's representative was included in all aspects of person-centered care planning. Per policy review, Care plan included provision of services which enabled the resident to live with dignity and supported his/her goals, choices, and preferences. Continued review revealed the Care Planning/Interdisciplinary Team (IDT) reviewed and updated residents' care plans when there was a significant change in the resident's condition; when the desired outcome was not met; or when the resident had been readmitted to the facility from a hospital stay; and at least quarterly. Review of Resident #133's closed medical record revealed the facility admitted the resident on 01/13/2022, with diagnoses to include: Dementia, Anxiety Disorder, Cognitive Communication Deficit, and Cerebral Infarction. Review of the admission Minimum Data Set (MDS) assessment dated 01/20//2022 for Resident #133, revealed the facility was unable to obtain the resident's level of cognition. Further review revealed the resident exhibited behaviors to include: physical symptoms such as hitting, or scratching self, pacing, rummaging, and/or verbal/vocal symptoms. Additional behaviors revealed the resident had disorganized thoughts, rambling or irrelevant conversation, was unclear or had illogical flow of ideas, or unpredictable switching from subject to subject. Review of Resident #133's Comprehensive Care Plan (CCP) initiated on 01/14/2022, revealed no documented evidence of interventions implemented in response to the resident's history of and/or current verbally abusive behavior towards staff on 02/15/2022. Review of Resident #133's Progress Note dated 02/15/2022, revealed the former Social Services Director (SSD) heard the resident yelling, Help! Help Somebody Help! Per review of the Note, the former SSD asked Resident #133 if he/she was okay and the resident stated, What the fuck do you think! I'm ready to get out of this place! Further review of the Note revealed the SSD redirected and encouraged Resident #133 to use the call light when she/he needed assistance, with Resident #133 stating, Fuck that light! Review of Resident #133's Progress Note dated 03/06/2022, revealed Licensed Practical Nurse (LPN) #35 documented the resident's medication and treatment refusals, and that he/she became verbally abusive with all staff. Further review of the Note revealed Resident #133 screamed for his/her medicine. Continued review of the progress note revealed the resident then began to insult LPN #35 and other staff. Continued review of Resident #133's CCP revealed the facility's interventions initiated for the resident on 03/07/2022, were to: provide positive feedback for good behavior; assess the resident's understanding of the situation; assess and anticipate the resident's needs; analyze key times, places, circumstances, triggers, and what deescalated the resident's behavior and document; and administer medications as ordered. Review of the CCP revealed no documented evidence the facility developed care plan interventions related to Resident #133's verbal abuse towards staff in order to protect him/her and staff, such as having two (2) persons provide care for Resident #133. Review of Resident #133's Progress Note dated 03/19/2022, revealed LPN #36 documented the resident had been yelling and screaming during the shift. Per review of the Note, Resident #133 had been calling staff racial names and stating that she/he did not want any blacks in her/his room. Further review of the Note revealed Resident #133 had been swinging her/his legs out of bed and trying to kick at staff, and called her/his spouse and told the spouse there were blacks in the room trying to hurt her/him. Further review of Resident #133's CCP revealed no documented evidence of person-centered interventions added to his/her CCP to address protecting the resident and staff from his/her behaviors of cursing and accusing staff of abuse. Review of Resident #133's Progress Note dated 04/13/2022, revealed Registered Nurse (RN) #9 documented while assisting the resident's roommate to the bathroom, Resident #133 requested RN #9 to turn the light off. Continued review revealed RN #9 told Resident #133, I can't do that while your roommate is still eating breakfast. Further review revealed Resident #133 replied, Fuck you, to RN #9 who responded with, That's not a very kind thing to say, please don't speak to me that way, and Resident #133 again stated, Fuck you. Review of Resident #133's Statement of Witness, dated 05/03/2022, revealed Resident #133 stated she picked me up off the floor and threw me onto the bed and jumped onto my back. She hurt my esophageal track and my ribs. She didn't say anything to me so I started talking bad about her and her husband. Review of Certified Nursing Assistant (CNA) #75's Statement of Witness, dated 05/01/2022, revealed she would not have gotten on Resident #133's bed because his/her pad was wet. Per the review, the resident was a large person and took up the entire bed. CNA #75 stated Resident #133 had pushed against her and belittled her while she was changing the resident's pad. Telephonic interview with CNA #75, on 03/31/2023 at 3:46 PM, revealed she recalled Resident #133 and told the nurse she was uncomfortable around Resident #133. The CNA revealed Resident #133 talked crazy about people. Further interview revealed CNA #75 stated she did not jump on Resident #133's back or bed, especially since she was changing Resident #133's pad and there was urine in his/her bed. Review of Registered Nurse #13's Statement of Witness, dated 05/01/2022, revealed Resident #133 reported to Registered Nurse (RN) #13 that CNA #75 got on his/her bed, sometime after lunch. The State Survey Agency (SSA) Surveyor attempted a telephonic interview with RN #13 on 03/31/2023 at 3:50 PM. RN #13's automated voice messaging system was unavailable and a message could not be left. Telephonic interview with the Social Service Director (SSD), on 04/04/2023 at 2:46 PM, revealed she recalled Resident #133's verbal aggression and inappropriateness. The SSD revealed the facility had a program titled, Care in Pairs, which was an intervention used with residents who made multiple accusations or allegations against staff. Further interview revealed Care in Pairs was two (2) staff providing care for a resident, at the same time, which helped ensure residents and staff were protected from false allegations as a witness to the care provided would be present. Interview via telephone with RN #9 on 04/04/2023 at 12:23 PM, revealed she remembered Resident #133 and stated it had been very difficult to provide adequate care for him/her. Continued interview revealed it had been difficult because Resident #133 was not appropriate, and he/she frequently yelled out racist types of things. RN #9 stated Resident #133 bothered other residents with his/her inappropriate behaviors. Further interview revealed any type of intervention, such as having two (2) staff provide Resident #133's care instead of staff being solo in the room with Resident #133 would have been helpful. RN #9 further stated two (2) staff caring for Resident #133 could have helped lessen the resident's verbal aggression and inappropriateness. Interview via telephone with the Minimum Data Set Coordinator (MDS) on 04/01/2023 at 3:51 PM revealed the first intervention the facility used when residents called staff names was to let staff know the resident was verbally abusive. Further, the MDS Coordinator stated interventions for staff were to redirect and reproach the resident when he/she express such behaviors. Interview with the Executive Director (ED), on 03/16/2023 at 11:00 AM, revealed residents' care plans should be followed as well as the facility policies to ensure the residents got the best possible care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policies, it was determined the facility failed to protect residents from misappropriation of property for four (4) of ninety-nine (99) sampled residents (Resident #21, Resident #71, Resident #34, and Resident #521). The four (4) residents were found to have missing narcotics that could not be accounted for, and the facility was unable to locate them. The findings include: Review of the facility's policy, Freedom From Abuse and Neglect Policy, dated 10/30/2019, revealed misappropriation of resident's property included: the deliberate misplacement; exploitation; or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. Continued review of the policy revealed the facility was responsible for conducting an investigation of any alleged or suspected exploitation, and the Executive Director was responsible for oversight. The policy review further revealed the facility was responsible for conducting a thorough investigation of all alleged violations and taking appropriate actions, which included interviews and/or written statements from individuals with first-hand knowledge of the incident. Review of the facility's policy titled, Controlled Substances, dated 08/27/2018, revealed the storage of controlled substances must be strictly monitored. The number of controlled substances on hand must be counted and verified at the end of each shift. Further review revealed the Narcotic Sign In Sheet must be completed at the end of each shift every day and the outgoing nurse or designee was to count all controlled substances being stored while the oncoming nurse or designee watched. Continued review revealed both staff members were to sign off on the count. Further review of the policy revealed if the count did not match the controlled substances on hand, the Administrator/Designee was to be notified immediately. 1. Review of the facility's final investigation report, dated 05/13/2022, revealed on 05/08/2022, the facility identified Resident #71 and #21 were missing narcotics. Stat orders (orders that were to be done immediately) were placed by the facility to replace the residents' missing medications. Per the report, Registered Nurse (RN) #13 was identified as the nurse who signed for the missing medications. RN #13 was placed on suspension pending investigation and then resigned from her position on 05/11/2022. Further review revealed the facility notified the local police department to report the missing medications, report #0322000955. Review of the invoices from the contract Pharmacy, dated 05/31/2022, and a review of an email from the contract Pharmacist in the Account Management Department to the facility's [NAME] President of Operations, dated 05/09/2022, revealed sixty (60) tablets of Norco had been replaced for Resident #71, and thirty (30) tablets of Norco had been replaced for Resident #21 at the facility's expense. a.) Review of Resident #21's Medical Record revealed the facility admitted the resident on 03/29/2021 with diagnoses that included Chronic Post Traumatic Headache, Migraine Headaches, Peripheral Vascular Disease and Cellulitis of the Lower Limb. Review of Resident #21's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score as fifteen (15), indicating he/she was cognitively intact. Review of the Physician's Orders, with the start date of 04/12/2022 and end date of 05/16/2022, revealed the resident was ordered Norco 7.5mg-325 milligram (mg) (Hydrocodone-Acetaminophen) and was to be administered one (1) tablet by mouth every eight (8) hours as needed for pain. b.) Review of Resident #71's Medical Record revealed the facility admitted the resident on 01/21/2021, with diagnoses that included Contracture of the Right and Left elbows, Cellulitis of the Buttock, and Quadriplegia. Review of Resident #71's Quarterly MDS Assessment, dated 04/04/2022, revealed the facility assessed the resident as having a BIMS score of fifteen (15) indicating he/she was cognitively intact. Review of Resident #71's Physician's Orders, with a start date of 04/28/2022 and end date of 07/05/2022, revealed an order for Norco Tablet 7.5 mg-325 mg and was to be administered one (1) tablet by mouth every six (6) hours as needed for pain. 2. Review of the Pharmacy Manifest from the contracted Pharmacy dated 11/28/2021 revealed thirty (30) Norco 7.5 mg-325mg tablets had been delivered to the facility for Resident #34 and had been signed as received by Licensed Practical Nurse (LPN) #35. Review of the Facility's Five-Day Report, dated 11/30/2021, revealed that while completing medication administration, a full card of PRN narcotics (7.5/325 Hydrocodone) was missing from the cart that had been curried on 11/28/2021. Per the facility's investigation, an in house-wide search of the medication rooms and medication carts for the missing sleeve of thirty (30) count Norco 7.5 revealed no success in locating. Continued review revealed the facility completed interviews with the night shift staff and Licensed Practical Nurse (LPN) #35 and revealed the LPN received the narcotics from Pharmacy but failed to log the count sheets and/or count the narcotic delivery. The LPN reported she stuck the card in her medication cart and locked it up thinking that she would log the narcotic later, but got busy and forgot. The facility could not locate the missing medications and ended up replacing the resident's medications at the facility's expense. Review of the Facility's Five (5) Day Report, dated 11/30/2021 revealed the facility had not been able to locate Resident #34's missing narcotics. Further review revealed at the conclusion of the facility's investigation, LPN #35 had been placed on the do not return list for staffing. Review of Resident #34's Medical Record revealed the facility admitted the resident on 11/14/2021 with diagnoses to include Immobility Syndrome, Fibromyalgia, and Chronic Pain Syndrome. Review of Resident #34's Annual MDS Assessment, dated 10/27/2021, revealed the facility assessed the resident as having a BIMS score of fifteen (15), indicating the resident was cognitively intact. 3. Review of the Facility Initial Report Final five (5) day report dated 12/24/2021 revealed Resident #521 requested a pain pill on 12/18/2021 and was told there was none of his/her pain medication in the cart. Review further revealed the Nurse called the Pharmacy for a refill of Resident #521's medication and was told it could not be refilled because sixty (60) tablets had been delivered at the beginning of the month. Review of the Facility Five-Day Report dated 12/24/2021 revealed the facility had not been able to validate if the medication was taken by an employee or whether thirty (30) or sixty (60) tablets were missing. Further review revealed the facility obtained a replacement prescription from the Medical Director for thirty (30) tablets to be paid for by the facility. The State Survey Agency (SSA) Surveyors requested the facility's narcotic dose count sheets for Resident #521 for the timeframe of 11/01/2021 through 01/30/2022; however, the facility was unable to produce the requested narcotic dose count sheets. Review of Resident #521's Medical Record revealed the facility admitted the resident on 09/27/2021, with diagnoses that included: Malignant Neoplasm of the Left Breast, Low Back Pain, Anxiety disorder, and Arthrodesis (surgical joint fusion). Review of Resident #521's admission MDS Assessment 10/06/2021 revealed the facility assessed the resident to have a BIMS score of fifteen (15), indicating the resident was cognitively intact. Review of Resident #521's Physician's Orders, with start date of 09/30/2021 and end date 12/30/2021, revealed an order for Hydrocodone-Acetaminophen Tablet 5-325 mg, and was to be administered one (1) tablet by mouth every twelve (12) hours as needed for chronic pain. Interview with the Pharmacist in the Account Management Department, on 03/31/2023 at 5:19 PM, revealed that when there was a narcotic diversion at the facility, she would be contacted. Per the interview, she stated she would bill the facility and send the controlled substance only if the resident needed the medication. Further, she stated that in the case of a diversion, she would contact the prescriber to get a new prescription for the resident. Interview on 03/09/2023 at 8:00 PM, with the Director of Nursing (DON), revealed the facility's policy for accepting deliveries of narcotics was for the receiving nurse to compare the invoice on the bag with the contents located inside the bag to verify they matched. Per the DON, the nurse then signed the narcotics into the facility's Medline dosing record book under the appropriate resident's name. Continued interview revealed the narcotic doses were counted down as the doses were administered. She stated in cases of diversion, the staff suspected of it was suspended pending an investigation. The DON stated in the case of missing medication from 05/2022, the DON had not been employed at the facility. She further stated it was her expectation that controlled substances be handled as per the facility's policy by the nurses. Interview on 03/09/2023 at 8:10 PM, with [NAME] President (VP) of Clinical Operations #1 and the Executive Director (ED) revealed after the narcotics for Resident #21 and Resident #71 were found to be missing, RN #13 was suspended pending investigation. Further interview revealed RN #13 had resigned. During the course of the investigation, the facility identified RN #13 as the nurse that signed for the missing medication from the pharmacy and she failed to log the narcotics as received. Continued interview revealed a police report was filed with the local Police Department, and RN #13 was reported to the Kentucky Board of Nursing (KBN). They revealed the facility replaced the missing narcotics for the residents at the facility's expense. Further interview revealed they both stated it was their expectation that licensed staff handled residents' narcotic medications as per the facility's policy. In addition, they stated if any medications or property were missing due to staff negligence or theft, it was the expectation the missing items would be replaced by the facility at the facility's expense. In an additional interview with the ED on 03/16/2023 at 10:40 AM, revealed if there was an allegation of theft, the theft should be reported as required. The ED further stated it was her expectation as a leader that staff would carry out their work in accordance with the facility's policy and standards of care.

Based on interview, record review, review of the facility's investigation reports, review of the Pharmacy Services Agreement, review of Pharmacy invoices, and review of the facility's policies, it was determined the facility failed to have safeguards and systems in place to control, account for, and reconcile controlled medications to ensure all controlled medications were maintained for three (3) of ninety-nine (99) sampled residents (Residents #21, #71, and #521). Review of Resident #71's Medication Administration Record (MAR) revealed he/she was prescribed Norco (Hydrocodone-Acetaminophen, an opioid pain reliever) 7.5-325 milligram (mg). There was a discrepancy of thirty-five (35) tablets between the narcotic control sheet and the resident's MAR, from 04/20/2022 to 05/12/2022. Review of Resident #21's MAR revealed he/she was prescribed Norco 7.5-325 mg. There was a discrepancy of fifty-four (54) tablets between the narcotic control sheet and the resident's MAR, from 04/15/2022 to 04/28/2022. Review of Resident #521's MAR revealed he/she was prescribed Hydrocodone-Acetaminophen 5-325 mg, give one (1) tablet by mouth every twelve (12) hours as needed for chronic pain. However, there was a discrepancy of thirty-three (33) tablets between the narcotic control sheet and the resident's MAR, from 12/01/2021 to 12/18/2021. Further, the facility failed to determine that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. Review of multiple Controlled Medication Shift Change Log sheets, from different nursing units, revealed they were not signed off by two (2) licensed nurses. The findings include: Review of the facility's policy titled, Accepting Delivery of Medications, revised February 2021, revealed all staff shall follow a consistent procedure in accepting medications. Medications were to be delivered to and signed for by a nurse. Review of the facility's policy titled, Controlled Substances, dated 08/27/2018, revealed the storage of controlled substances must be strictly monitored. The number of controlled substances on hand must be counted and verified at the end of each shift. The Narcotic Sign In Sheet must be completed at the end of each shift every day. The Out-Going Nurse or his/her designee would count all controlled substances being stored at the community while the On-Coming Nurse or his/her designee watched. Both staff members must sign that the count and verification have been completed. Per the policy, if the count did not match the controlled substances on hand, the Administrator/Designee would be notified immediately. Review of the Pharmacy Services Agreement, signed 10/01/2021, revealed the facility retained responsibility for reconciling the applicable orders against the records supplied by Pharmacy. Continued review revealed the Pharmacy shall conduct sample audits of nursing stations, drug storage areas, and medication carts to review compliance with Pharmacy policies and procedures and Applicable Laws regarding drug handling, storage, and distribution. Per the policy, Pharmacy shall provide reports to the facility of any findings and recommendations related to such audits. 1.a. Review of Resident #71's medical record revealed the facility admitted the resident on 01/21/2021 with diagnoses of Quadriplegia, Anxiety Disorder, and Protein-Calorie Malnutrition. Review of Resident #71's Physician's Orders revealed an order for Norco tablet 7.5-325 mg, give one (1) tablet by mouth every six (6) hours as needed for pain. The medication had a start date of 04/04/2022. Review of Resident #71's Medication Administration Record (MAR) revealed he/she was prescribed Norco (Hydrocodone-Acetaminophen, an opioid pain reliever) 7.5-325 milligram (mg) to be administered every six (6) hours as needed for pain. However, there was a discrepancy of thirty-five (35) tablets between the narcotic control sheet and the resident's MAR, from 04/20/2022 to 05/12/2022. Review of Resident #71's Controlled Drug Receipt/Record/Disposition form (CDRRDF), dated 04/20/2022, revealed the resident was dispensed Hydrocodone-Acetaminophen 7.5-325 mg every six (6) hours for pain. However, the nurse's signature that received the medication was illegible, and there was only one (1) signature. Also, the quantity received was illegible. Further review of the CDRRDF from 04/20/2022 to 04/29/2022, revealed Resident #71 received twenty-nine (29) tablets from 04/20/2022 to 04/29/2022. Review of Resident #71's Medication Administration Record (MAR), dated 04/20/2022 to 04/29/2022, revealed an entry for Hydrocodone-Acetaminophen tablet 7.5-325 mg, give one (1) tablet by mouth every six (6) hours as needed for pain, with a start date of 04/18/2022 and a discontinue date of 04/28/2022; there was a new order written on 04/28/2022 with an end date of 07/05/2022. The MAR showed Resident #71 received one (1) tablet on 04/20/2022; 04/21/2022; 04/25/2022; 04/26/2022; 04/27/2022; and 04/29/2022. This was a total of six tablets taken by Resident #71 during this time. Review of the CDRRDF, from 05/01/2022 to 05/12/2022, revealed Resident #71 received twenty-eight (28) tablets of Hydrocodone-Acetaminophen 7.5-3.25 mg from 05/01/2022 to 05/12/2022. Review of Resident #71's MAR, from 05/01/2022 to 05/12/2022, revealed Hydrocodone-Acetaminophen Tablet 7.5-325 mg, give one (1) tablet by mouth every six (6) hours as needed for pain, with a start date of 04/28/2022 and a discontinue date of 07/05/2022. Further review revealed Resident #71 received two (2) tablets on 05/01/2022; one (1) tablet on 05/02/2022; one (1) tablet on 05/03/2022; two (2) tablets on 05/04/2022; one (1) tablet on 05/07/2022; three (3) tablets on 05/09/2022; one (1) tablet on 05/10/2022; three (3) tablets on 05/11/2022; and two (2) tablets on 05/12/2022. This was a total of sixteen (16) tablets taken by Resident #71 during this time. Telephone interview with Registered Nurse (RN) #17, on 03/30/2023 at 4:15 PM revealed she might have given a medication to a resident and not documented it on the MAR. She further stated this was a mistake, and it should not have occurred. Review of Resident #71's medication invoice from the pharmacy revealed Medicare A was billed on 05/13/2022 for Hydrocodone-Acetaminophen tablets 7.5-325 for a quantity of sixty (60) tablets. 1.b. Review of Resident #21's medical record revealed the facility admitted the resident on 03/29/2021 with diagnoses to include Muscle Weakness, Unsteadiness on Feet and Morbid Obesity. Review of Resident #21's Physician's Orders revealed an order for Norco 7.5-325 mg, give one (1) tablet by mouth every eight (8) hours as needed for pain, with a start date of 04/12/2022 and an end date of 05/16/2022. Review of Resident #21's CDRRDF, dated 04/15/2022, page 3 of 3, revealed a quantity received of thirty (30) tablets of Hydrocodone/Acetaminophen 7.5/325 mg, one (1) tablet by mouth three (3) times a day. It also revealed, from 04/17/2022 to 04/27/2022, the resident received twenty-eight (28) tablets. Review of Resident #21's MAR revealed Norco Tablet 7.5-325 mg, give one (1) tablet by mouth every eight (8) hours as needed for pain, with a start date of 04/14/2022 and a discontinue date of 05/16/2022. Per the MAR, from 04/17/2022 to 04/26/2022, Resident #21 received one (1) tablet on 04/23/2022 and two (2) tablets on 04/26/2022. This was a total of three (3) tablets taken by Resident #21 during this time. Review of Resident #21's MAR revealed there was a discrepancy of fifty-four (54) tablets between the narcotic control sheet and the resident's MAR, from 04/15/2022 to 04/28/2022 Review of the facility's Investigation Report, dated 05/13/2022, revealed on 05/08/2022, the facility identified Resident #71 and #21 were missing narcotics. Stat orders (orders that were to be done immediately) were placed by the facility to replace the residents' missing medications. Per the report, RN #13 was identified as the nurse who signed for the missing medications. RN #13 was placed on suspension pending investigation and then resigned from her position on 05/11/2022. Review of the pharmacy invoices, dated 05/31/2022, and an email from the Account Services Director to the facility's [NAME] President of Operations, dated 05/09/2022, revealed sixty (60) tablets of Norco had been replaced for Resident #71, and thirty (30) tablets of Norco had been replaced for Resident #21 at the facility's expense. Interview with the Pharmacy Manager, on 03/31/2023 at 3:57 PM revealed the account management department audited the medication carts monthly. He stated he did not audit the medication carts, but he monitored the trends of audits. He stated his role was the Pharmacist in Charge. In addition, after the State Survey Agency (SSA) Surveyor requested records of controlled substances and the facility's audits. The fax was sent on 03/31/2023. Telephone call follow-up to the Pharmacy Manager, on 04/04/2023 at 11:45 AM revealed they were compiling the information on controlled substances at the facility. Further interview revealed they needed approval from their cooperate compliance team prior to sending the report. Interview with the Pharmacist in the Account Management Department, on 03/31/2023 at 5:19 PM revealed if there was a narcotic diversion, the facility would contact her. She stated she would look to see how the supply was filled and if it was billed to a third party. She stated she would change the billing to the facility and send the controlled substance only if the resident needed the medication. She stated she would reach out to the prescriber and get a new prescription. She stated she looked in her computer to see if there were any narcotic diversions. Continued interview revealed there had been a diversion with Norco 7.5-325 mg in May 2022. She stated it had been billed because the resident was on Medicare. However, she stated, on 05/09/2022 the pharmacy billed ninety (90) tablets to the facility. Telephone interview with the pharmacy Account Manager, on 04/04/2023 at 5:35 PM revealed she had been the account manager for about three (3) years. She stated the last audit of the facility was March 31, 2023. She stated, since COVID, they did not inspect the carts or the narcotic sheets. She stated she did a paper audit of the narcotic sheets. Continued interview revealed they did look at the Controlled Substance Books. She stated, about a year ago, the facility stopped using the pharmacy's forms and started using blue logs instead. She stated she was not personally aware of the facility asking them to account for narcotics and billing, which would have gone through the compliance department. She stated the facility did ask her to do a narcotics audit. She stated she did one on 05/18/2022. The Account Manager stated she did a spread sheet, which she provided to the facility, and there were obviously some items missing. She stated the information was in a pharmacy report provided to the facility. Further interview revealed the previous DON received reports of the controlled substances that were dispensed and what the facility showed it had on hand. 1.c. Review of Resident #521's medical record revealed the facility admitted the resident on 09/27/2021 with diagnoses of Bipolar Disorder, Morbid Obesity, and Chronic Pain Syndrome. Review of Resident #521's Physician's Orders revealed an order for Hydrocodone-Acetaminophen Tablet 5-325 mg, give one (1) tablet by mouth every twelve (12) hours as needed for chronic pain, with a start date of 09/30/2021 at 9:15 AM and an end date of 12/30/2021. Review of Resident #521's Dispensed Controlled Medications revealed the facility received sixty (60) tablets of Hydrocodone-Acetaminophen 5-325 mg, dispensed 12/01/2021. Review of the facility's Initial Investigation Report, dated 12/19/2021, revealed Resident #521 requested a pain pill on 12/18/2021, and there were none in the cart. Per the report, the nurse called pharmacy for a refill and was told sixty (60) tablets of Hydrocodone-Acetaminophen 5-325 mg were sent at the beginning of the month. Review of Resident #521's December 2022 MAR revealed the resident had received twenty-seven (27) tablets of Hydrocodone-Acetaminophen 5-325 mg for the month of December 2021 from 12/01/2022 to 12/18/2022. Review of the facility's 5-Day Investigation Report, dated 12/24/2021, revealed the facility could not validate the medication was taken by an employee and whether thirty (30) or sixty (60) tablets were missing. Per the report, the facility obtained a replacement prescription from the Medical Director for thirty (30) tablets to be paid for by the facility. The narcotic dose count sheets for Resident #521 for 11/01/2021 to 01/30/2022 were requested, but the facility was unable to provide the sheets. 2. Review of the Controlled Substance Book, for the [NAME] Unit, revealed the instructions explained to refer to the facility's pharmacy procedure manual for specific instructions on documenting controlled substances. In general, it stated to fill out and log in all information completely; if an error was made, cross out the mistake and initial next to the error; when a refill was received, add the new quantities to the previous quantity; when completing a controlled substances shift count, examine the page and card (Front and Back) to verify the correct count; and both nurses needed to check the count. Review of the [NAME] Unit Controlled Substances Book, on 04/01/2023, which contained the unit's Controlled Medication Shift Change Logs revealed there were eighty (80) missing signatures out of four hundred twenty-four (424) signature opportunities. Review of the facility's record sheet Controlled Medication Shift Change Log, for the C Unit Medication Cart, dated 11/18/2021 to 11/27/2021, revealed seven (7) instances in which either the On-Coming or the Off-Going staff 's signature spaces were blank. Review of the facility's Controlled Medication Shift Change Log, for the East B Hall Medication Cart, dated 11/19/2021 to 11/29/2021, revealed four (4) instances in which either the On-Coming or the Off-Going staff signature spaces were blank. Additionally, the count sheet quantity from the previous sheet was not signed by either the On-Coming nurse or the Off-Going Nurse. Review of the facility's record sheet Controlled Medication Shift Change Log, for the A Hall Medication cart, dated 11/08/2021 to 11/30/2021, revealed twenty-one (21) instances in which either the On-Coming or the Off-going staff signature spaces were blank. Additionally, the count sheet quantity from the previous sheet was not signed by the On-Coming Nurse. Review of the facility's record sheet Controlled Medication Shift Change Log, for the C/D Covid Hall, dated 11/28/2021 to 11/30/2021, revealed two (2) instances in which either the On-Coming or the Off-Going staff signature spaces were blank. Interview with the Interim Director of Nursing (DON), on 03/30/2023 at 8:50 AM revealed she expected staff to verify all controlled substances when they were delivered from Pharmacy. Further, she stated she expected two (2) licensed nurses to document the receipt and count of controlled substances. Continued interview revealed she had not had any issues with controlled substances since she had been the Interim DON from December 2022 to 03/10/2023. She stated she was now the Resource Nurse at the facility. Interview with the ED, on 03/30/2023 at 10:30 AM revealed she expected the DON to make sure the nurses were educated to document and correctly give controlled substances to residents. She stated she had a discussion with the DON about controlled substances, and they were developing a plan to assure controlled substances were correctly handled. Further, she stated she had not been told of any issues with controlled substances since she had been the ED from October 2022 to today.

b) Review of Resident #125's admission Record revealed the facility admitted the resident, on 12/24/2021, with diagnoses that included Schizoaffective Disorder, Anxiety Disorder and Dementia without Behavioral Disturbance. Review of Resident #125's Significant Change Minimum Data Set (MDS) Assessment, dated 02/17/2022, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of eight (8) out of fifteen (15), indicating moderate cognitive impairment. Review of Resident #27's admission Record revealed the facility admitted the resident, on 05/03/2019, with diagnoses that included Bipolar Disorder, Generalized Anxiety Disorder and Major Depressive Disorder. Review of Resident #27's Quarterly MDS Assessment, dated 12/28/2021, revealed the facility assessed the resident as having a BIMS score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Review of the facility's investigation, for 02/20/2022, revealed Resident #125 made contact with his/her hand and the right side of Resident #27's face. Resident #125 had been yelling out near the nurse station. Resident #27 wheeled up in his/her wheelchair to Resident #125 and asked him/her to lower his/her voice. Resident #27 leaned toward Resident #125 and struck him/her. Interview with Certified Nursing Assistant (CNA) #80, on 04/04/2023 at 2:35 PM, revealed Resident #125 was seated near the nurse's station so staff could better observe him/her due to the resident being on hospice care and having a bad behavior day. Resident #125 was hollering out, and Resident #27 wheeled near the resident in his/her wheelchair and yelled at the resident to quit. Resident #125 then hit Resident #27 in the head. She further revealed the hit was not very hard and nursing staff did an assessment on Resident #27, not seeing any marks on him/her. c) Review of Resident #122's admission Record revealed the facility admitted the resident, on 02/05/2018, with diagnoses that included Cognitive Communication Deficit, Dementia with Behavioral Disturbance, Anxiety Disorder and Alzheimer's Disease with Late Onset. Review of Resident #122's Quarterly MDS Assessment, dated 02/15/2022, revealed the facility assessed the resident as having a BIMS' score of three (3) out of fifteen (15), indicating severe cognitive impairment. Review of Resident #101's admission Record revealed the facility admitted the resident, on 12/28/2021, with diagnoses that included Dementia without Behavioral Disturbance and Cognitive Communication Deficit. Review of Resident #101's admission MDS Assessment, dated 12/31/2021, revealed the facility assessed the resident as having a BIMS score of nine (9) out of fifteen (15), indicating moderate cognitive impairment. Review of the facility's investigation, for 02/22/2022, revealed Resident #101 was sitting in the television area when Resident #122 approached the resident and hit him/her in the face near his/her left eye. Resident #122's hand made contact with Resident #101's face, causing redness. Interview with CNA #30, on 04/03/2023 at 12:54 PM, revealed Resident #122 approached Resident #101, who was sitting in a chair, and hit the resident in the eye. Per interview, she separated the residents and remained with Resident #122 on one to one (1:1) staff observation. d) Review of Resident #13's admission Record revealed the facility admitted the resident, on 05/25/2020, with diagnoses that included Schizophrenia, Major Depressive Disorder and Attention-Deficit Hyperactivity Disorder. Review of Resident #13's Quarterly MDS Assessment, dated 07/11/2022, revealed the facility assessed the resident as having a BIMS' score of fourteen (14) out of fifteen (15), indicating the resident was cognitively intact. Review of Resident #23's admission Record revealed the facility admitted the resident, on 05/28/2018, with diagnoses that included Cerebral Infarction, Major Depressive Disorder and Dementia with Behavioral Disturbance. Review of Resident #23's Annual MDS Assessment, dated 05/13/2022, revealed the facility assessed the resident as having a BIMS' score of three (3) out of fifteen (15), indicating severe cognitive impairment. Review of the facility's investigation, for 07/14/2022, revealed Resident #13's wheelchair and Resident #23's wheelchair made contact. Resident #13 extended his/her arm out, and made contact with a closed fist to Resident #23's chest. Interview with CNA #30, on 04/02/2023 at 2:57 PM, revealed Resident #13's wheelchair ran into Resident #23's wheelchair, knocking off items located on the tray table. She observed Resident #13 extend his/her arm and hit Resident #23's chest with a fist. Per interview, staff immediately separated the residents to ensure their safety. e) Review of Resident #23's admission Record revealed the facility admitted the resident, on 05/28/2018, with diagnoses that included Cerebral Infarction, Major Depressive Disorder and Dementia with Behavioral Disturbance. Review of Resident #23's Quarterly MDS Assessment, dated 07/18/2022, revealed the facility assessed the resident as having a BIMS score of ninety-nine (99), indicating severe cognitive impairment. Review of Resident #96's admission Record revealed the facility admitted the resident, on 08/06/2021, with diagnoses that included Dementia with Behavioral Disturbance, Cognitive Communication Deficit and Major Depressive Disorder. Review of Resident #96's Annual MDS Assessment, dated 06/17/2022, revealed the facility assessed the resident as having a BIMS score of nine (9) out of fifteen (15), indicating moderate cognitive impairment. Review of the facility's investigation, for 07/22/2022, revealed that Maintenance Director #1 was in the hallway and observed Resident #23 grab Resident #96 and pull the resident towards him/her using his/her legs. The residents were immediately separated. Resident #96 had redness to the chest area and an x-ray revealed no injuries. Interview was attempted with Maintenance Director #1, a former employee, throughout the survey and was unsuccessful. f) Review of Resident #23's admission Record revealed the facility admitted the resident, on 05/28/2018, with diagnoses that included Cerebral Infarction, Major Depressive Disorder and Dementia with Behavioral Disturbance. Review of Resident #23's Quarterly MDS Assessment, dated 07/18/2022, revealed the facility assessed the resident as having a BIMS' score of ninety-nine (99), indicating severe cognitive impairment. Review of Resident #29's admission Record revealed the facility admitted the resident, on 03/21/2014, with diagnoses that included Alzheimer's Disease with Late Onset, Dementia with Agitation and Major Depressive Disorder. Review of Resident #29's Quarterly MDS Assessment, dated 09/09/2022, revealed the facility assessed the resident as having a BIMS score of ninety-nine (99), indicating severe cognitive impairment. Review of the facility's investigation, for 10/08/2022, revealed Resident #29 was found in the hallway laying in the floor on his/her left side next to his/her wheelchair. The resident was note to have discoloration to the head and neck area. Resident #29 also had a hematoma with an abrasion to the left eye. Continued review revealed there were no witnesses to the incident. However, video surveillance was reviewed by the facility, and it was noted that Resident #23 had grabbed Resident #29's wheelchair and shook the chair, resulting in it tipping over to the left side causing Resident #29 to fall. g) Review of Resident #13's admission Record revealed the facility admitted the resident, on 05/25/2020, with diagnoses that included Schizophrenia, Major Depressive Disorder and Attention-Deficit Hyperactivity Disorder. Review of Resident #13's Quarterly MDS Assessment, dated 09/02/2022, revealed the facility assessed the resident as having a BIMS' score of thirteen (13) out of fifteen (15), indicating the resident was cognitively intact. Review of Resident #27's admission Record revealed the facility admitted the resident, on 05/03/2019, with diagnoses that included Bipolar Disorder, Generalized Anxiety Disorder and Major Depressive Disorder. Review of Resident #27's Quarterly MDS Assessment, dated 08/15/2022, revealed the facility assessed the resident as having a BIMS score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Review of the facility's investigation, for 10/27/2022, revealed Resident #13 and Resident #27 got into a verbal altercation leading Resident #13 to hit Resident #27 in the upper right arm. Resident #27 stated that after he/she was hit in the upper arm, Resident #13 then grabbed his/her lower arm. Resident #13 admitted to hitting Resident #27. Interview with Activity Assistant #1, on 04/03/2023 at 9:25 AM, revealed she was walking to her office, and once she got to the door of her office, her back was turned to Residents #13 and #27. She heard what sounded like a hitting noise, and by the time she turned back around, Resident #13 was observed in his/her wheelchair rolling past Resident #27. Resident #13 hit Resident #27's arm as they were side by side. h) Review of Resident #92's admission Record revealed the facility admitted the resident, on 07/19/2021, with diagnoses that included Alzheimer's Disease, Cognitive Communication Deficit, Agitation and Anxiety Disorder. Review of Resident #92's Annual MDS Assessment, dated 02/24/2023, revealed the facility assessed the resident as having a BIMS score of six (6) out of fifteen (15), indicating severe cognitive impairment. Review of Resident #88's admission Record revealed the facility admitted the resident, on 03/16/2021, with diagnoses that included Cognitive Communication Deficit, Dementia and Anxiety. Review of Resident #88's Quarterly MDS Assessment, dated 01/19/2023, revealed the facility assessed the resident as having a BIMS score of three (3) out of fifteen (15), indicating severe cognitive impairment. Review of the facility's investigation, for 03/15/2023, revealed Resident #92 and Resident #88 were in the hallway when Resident #92 hit Resident #88 on the back of the head. Staff immediately intervened and separated the residents. Continued review of the facility's investigation revealed CNA #81 provided a witness statement of the incident. She was walking Resident #85 to the living room and noticed Resident #88 was turned toward the wall. She observed Resident #92 yelling at Resident #88, unprovoked, and then Resident #92 hit Resident #88 on the back of the head. The residents were immediately separated. Interview, was attempted with CNA #81 on 04/04/2023. A voicemail message was left on her personal phone, but she did not return a call to the State Survey Agency. Interview, on 03/30/2023 at 9:50 AM, with the Assistant Director of Nursing (ADON), revealed she had been at the facility for about two (2) years. Prior to becoming the ADON, she was the Unit Manager of the Dementia Unit. Per interview, staff tried to prevent residents from harming other residents by keeping the residents busy and by distracting them if they were agitated. Interview, on 03/30/2023 at 1:00 PM, with the Director of Nursing (DON), revealed she assessed the behaviors of the residents on the units to determine how many staff were needed. Per interview, if an incident occurred, it was discussed in the daily morning meetings to determine if more staff were needed on that unit. Interview, with the Executive Director (ED), on 03/29/2023 at 2:40 PM, revealed she was not working at the facility at the time of most of the reported incidents. The ED was not being able to find investigations for incidents. The ED stated her expectation was that residents should be protected from abuse, and the facility should respond to any allegation quickly and investigate them thoroughly. Per interview, it was her expectation that staff follow the facility's policy related to abuse and to provide adequate supervision to prevent resident to resident abuse. i) Review of Resident #621's admission Record revealed the facility admitted the resident on 10/29/2021 with diagnoses that included Paraplegia from a gun shot wound, Pressure Ulcer of Sacral Region Unstageable, Colostomy Status, and Acute Pancreatitis. Review of the admission MDS Assessment, dated 11/04/2021, revealed the facility assessed the resident to have a BIMS' score of twelve (12), indicating the resident had moderate cognitive function. Review of the facility's investigation, for 11/26/2021, revealed it was determined the alleged Certified Nursing Assistant (CNA) #69 did make a comment to Resident #621 about the resident getting shot in a derogatory manner. Interview, with COTA #1 on 03/31/2023 at 11:41 AM, revealed she recalled the incident between CNA #69 and Resident #621. COTA #1 was walking down the hallway and heard yelling from Resident #621's room. She then saw a food dish slide on the floor out of Resident #621'a room. COTA #1 stated CNA #69 was in Resident #621's room. The COTA stated CNA #69 was yelling at Resident #621 saying something like, if you had money, you would not be here. You would be in some fancy place. COTA #1 then diffused the situation, as she felt like this was verbal abuse to Resident #621, and reported the incident to the facility's Executive Director (ED) immediately. Interview, with CNA #69, on 03/31/2023 at 11:24 AM revealed she recalled Resident #621. CNA #69 stated the reason she got fired from employment at the facility was because she asked the resident not to throw her/his tray at the nurse because it could have hurt the nurse who was pregnant. Resident #621 started calling CNA #69 names and told her to mind her own business. 3. a) Review of the employee files revealed two (2) out of thirty-one (31) employees lacked documented evidence the facility completed a background check. Review of the employee file for Certified Nursing Assistant (CNA) #60 revealed a hire date of 07/01/2020. The facility did not have documented evidence that a background check was completed before hire, or any other time after hire. Review of the employee file for Maintenance Assistant #1 revealed a hire date of 12/27/2022 and the facility did not have documented evidence that a background check was completed before hire, or any other time after hire. b) Further review of the employee files revealed seventeen (17) out of thirty-one (31) employees lacked documented evidence the facility completed further reviews as indicated by the Client Review Required after the background check was completed by the Human Resources Business Partner (HRBP). Interview with the [NAME] President and Chief Human Resource (HR) Officer, on 03/31/2023 at 7:00 PM, revealed a background check completed by the HRBP that indicated Client Review Required would require further review by Corporate HR. Continued review of employee files revealed the HRBP indicated a further Client Review Required was needed and was not completed by the facility after the background check for the following: CNA #3's background check was completed on 11/18/2022; hired on 11/30/2022; CNA #53's background check was not completed until 11/12/2020. The CNA was hired on 09/17/2020; CNA #69's background check was completed on 07/13/2021. Hired on hired on 08/24/2021; CNA #58's background check was completed on 05/28/2022. Hired on 06/01/2022 Registered Nurse (RN) #13's background check was completed on 02/23/2022. Hired on 03/01/2022; CNA #72's background check was completed on 02/15/2022. Hired on 02/08/2022; CNA #73 was hired on 02/08/2022 and a background check was not completed until 10/19/2022; CNA #74's background check was completed on 04/07/2022. Hired on 05/03/2022 ; Activity Assistant #1 was hired on 08/25/2020 and a background was completed on 08/18/2020, with no follow up; Maintenance Director #1 was hired on 12/09/2021 and a background check was completed on 12/06/2021, with no follow up; Dietary Aide #4 was hired on 11/16/2021 and a background check was completed on 10/19/2021, with no follow up; Central Supply Clerk #1 was hired on 01/19/2023 and a background check was completed on 01/17/2023, with no follow up; Dietary Aide #5 was hired on 05/12/2021 and a background check was completed on 05/18/2021; CNA #76 was hired on 12/14/2022 and a background check was completed on 12/22/2022; CNA #2 was hired on 01/27/2023 and a background check was completed on 01/18/2023; CNA #77 was hired on 12/22/2022 and a background check was completed on 12/16/2022; CNA #71 was hired on 12/15/2022 and a background check was completed on 12/12/2022. The facility failed to follow its policy to follow up on staff that flagged Client Review Required, to ensure new employees met the hiring criteria. c) Further review of the employee files revealed three (3) out of thirty-one (31) employees lacked documented evidence the facility completed a Kentucky Nurse Aide Registry check. Review of the employee file for CNA #60 revealed a hire date of 07/01/2020 and the facility did not have documented evidence that a Kentucky Nurse Aide Registry check was completed before hire, or any other time after hire. Review of the employee file for CNA #74 revealed, a hire date of 05/03/2022. The facility did not have documented evidence that a Kentucky Nurse Aide Registry check was completed before hire, or any other time after hire. Review of the employee file for Maintenance Assistant #1 revealed a hire date of 12/27/2022 and the facility did not have documented evidence that a Kentucky Nurse Aide Registry check was completed before hire, or any other time after hire. d) Continued review of the employee files revealed thirty (30) out of thirty-one (31) employees lacked documented evidence the facility queried the Caregiver Misconduct Registry before hire: CNA #3; CNA #38; RN #8; CNA #53; CNA #69; RN #26; CNA #14; CNA #60; CNA #58; RN #13; CNA #72; CNA #73; CNA #74; CNA #75; AA #1; MD #1; Dietary Aide #4; Maintenance Assistant #1; Central Supply Clerk #1; Dietary Aide #5; CNA #76; CNA #70; CNA #2; CNA #77; AA #4; LPN #35; LPN #36; CNA #78; AA #3 and CNA #71. Based on observation, interview, record review, review of the Immediate Jeopardy (IJ) Removal Plan for F600, review of the facility's education, and review of thirty-one (31) employees' files, it was determined the facility failed to ensure the residents were free from abuse related to prevention and protection and a safe environment through employee screening. Additionally, based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure residents were protected from physical abuse, including resident to resident abuse, for eleven (11) of ninety-nine (99) sampled residents (Residents #13, #23, #27, #29, #88, #92, #96, #101, #122, #125, and #621). 1. On 02/20/2022, Resident #125 struck the right side of Resident #27's face. 2. On 02/22/2022, Resident #122 struck the left side of Resident #101's face. 3. On 07/14/2022, Resident #13 struck Resident #23's chest. 4. On 07/22/2022, Resident #23 grabbed and pulled down Resident #96. 5. On 10/08/2022, Resident #23 grabbed Resident #29's wheelchair and tipped it over to the left side. 6. On 10/27/2022, Resident #13 struck Resident #27's upper right arm. 7. On 03/15/2023, Resident #92 struck Resident #88 on the back of the head. 8. On 11/21/2021, Certified Nursing Assistant (CNA) #69 was verbally abusive to Resident #621. In addition, review of employee screenings revealed the facility failed to implement written policies and procedures that protected residents from abuse. Record review revealed thirty (30) out of thirty-one (31) employees did not have a thorough employment background screening. (Certified Nursing Assistant (CNA) #3; CNA #38; Registered Nurse (RN) #8; CNA #53; CNA #69; RN #26; CNA #14; CNA #60; CNA #58; RN #13; CNA #72; CNA #73; CNA #74; CNA #75; Activity Assistant (AA) #1; Maintenance Director (MD) #1; Dietary Aide #4; Maintenance Assistant #1; Central Supply Clerk #1; Dietary Aide #5; CNA #76; CNA #70; CNA #2; CNA #77; AA #4; Licensed Practical Nurse (LPN) #35; LPN #36; CNA #78; AA #3 and CNA #71). Further review of the thirty (30) employees revealed Maintenance Assistance #1 was currently working as of 04/04/2023. However,the facility did not present documented evidence of a background or abuse registry check after requested by the State Survey Agency (SSA). (Refer to F606 and F837) The findings include: Review of the facility's policy titled, Freedom from Abuse and Neglect Policy, dated 10/30/19, revealed the facility defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It included verbal abuse, sexual abuse, physical abuse, and mental abuse. The policy defined willful, as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility's staff would conduct an investigation of any alleged or suspected abuse, neglect, exploitation of residents or misappropriation of property, and would provide notification of information to the proper authorities according to state and federal regulations. Under Screening, the policy indicated the facility would follow all state specific requirements and pre-employment screening would include a criminal history check, background check, and applicable registry checks. Under Training, the policy indicated staff would be trained on all aspects of abuse prohibition and the identification of potential victims of abuse, interventions to prevent abuse, and understanding behavioral systems of the residents that may increase risk of abuse. Prevention of abuse included staffing levels were assessed on a continuing basis by the Executive Director (ED), and adjustments to staffing levels were to be based on the census and the individual needs of the residents. Further, under prevention it stated screening and training policies would be adhered to. Review of the facility's policy Background Screening, dated 06/14/2019, revealed the company would conduct background investigations on all candidates for employment prior to making an employment offer, and may use a third party to conduct these background checks. Further review revealed the company would not employ a person who was convicted of any offense listed on the State specific disqualifying offenses list. However, review of the policy further revealed a reported criminal offense would not necessarily disqualify a candidate from employment. The nature and seriousness of the offense, the surrounding circumstances, rehabilitation, and the relevance of the offense to the specific position(s). The Company would follow company procedures for making decisions regarding potentially adverse actions. 1. Review of the IJ Removal Plan (RP) revealed the facility alleged the immediacy of the IJ at F600 was removed on 03/26/2023. Further review of the IJRP revealed the vice President of Clinical Operations (VPCO) conducted education with the ED and Director of Nursing (DON) on 03/10/2023 on the facility's Abuse Prohibition policy. However, review of the education revealed there was no evidence the education focused on providing a safe environment for residents as related to prevention of resident to resident abuse. The IJRP indicated the ED, DON, and Staff Development Coordinator (SDC) conducted reeducation for all facility and agency staff on the policy. Further review revealed there was no indication, through review of the education, that the facility focused on prevention of resident to resident abuse, per the policy. Interview with the VPCO, on 03/30/2023 at 11:06 AM, revealed she educated the DON and ED on when to repot abuse, the types of abuse, what to do if abuse was witnessed (separate parties to ensure safety, address residents with injuries, reporting requirements, and resident-to-resident abuse that would be out of the normal for the resident to initiate 1 to 1). The interview failed to reveal education was provided related to prevention of resident-to-resident abuse. Interview, with the DON (Director of Nursing), on 03/29/2023 revealed she was trained on abuse by the ED to include the different types of abuse; who to report the abuse to; the timeframes for reporting; and when to initiate 1 to 1 for residents. She stated she initiated all staff education on 03/10/2023. The DON stated the education consisted of what to do if their was more than one (1) resident involved related to separating the residents, assessing the residents, and initiating closer supervision; but she did not state the education included methods and interventions to prevent resident to resident abuse from occurring. Interview with the ED, on 03/31/2023 at 10:04 AM, revealed she was educated by the VPCO and then began educating all facility staff on 03/10/2023. She stated the education included who and when to report the abuse, the types of abuse, and what to do if abuse was witnessed. She stated the Medical Director was informed of the IJ and wanted to be briefed on all resident-to-resident abuse that was reported. The interview did not reveal that education included interventions or actions to prevent resident-to-resident abuse. 2. a) Review of Resident #69's admission Record revealed the facility admitted the resident on 05/25/2020 with diagnoses that included Schizophrenia, Anxiety Disorder, and Dysphagia. Review of Resident #69's Quarterly Mininumum Data Set (MDS) Assessment, dated 03/10/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), indicating intact cognition. Review of Resident #69's Progress Notes, dated 03/07/2023, revealed Licensed Practical Nurse (LPN) #2 documented that Resident #69 was extremely anxious in the beginning of the shift that day and stated people kept coming into his/her room. Resident #69 was using foul language and threatening others. Resident #69 stated, I hate (him/her). (He/she) kept me up all night long. No harm was done to self or others. LPN #2 redirected Resident #69 to his/her room to calm down. Review of Resident #69's Progress Notes, dated 03/22/2023, revealed LPN #2 documented Resident #69 became frustrated during this shift regarding the bathroom shared with another resident in the next room because the toilet paper was rolled down to the floor. LPN #2 inspected the bathroom and ensured it was clean. Resident #69 believed staff members and other residents were upset with him/her and would get (him/her) in trouble. LPN #2 reviewed Resident #69's care plan and encouraged Resident #69 to discuss his/her feelings. LPN #2 reassured the resident and made sure Resident #69 knew he/she was not in trouble. Review of Resident #69's Progress Notes, dated 03/23/2023, revealed LPN #39 documented Resident #69 became frustrated with another resident and stated he/she was sick of him/her starting things and causing problems. Resident #69 also stated LPN #39 was calling the law and they were going to arrest him/her. Resident #69 was reassured that no one was calling the law and he/she was not going to jail. Review of Resident #69's Progress Notes, dated 03/26/2023, revealed the Interdisciplinary Team (IDT) reviewed Resident #69's, 03/25/2023 non-injury resident to resident event with Resident #273. Further review revealed Resident #273 was being belligerent toward staff and calling staff names. Staff was trying to verbally redirect Resident #273 to his/her room/diversional activity. Resident #273 continued to call staff names and curse. Resident #69 asked Resident #273 to stop. Resident #273 swung at Resident #69 and missed not making contact with Resident #69. Resident #273 then picked up his/her walker. Resident #69 then pushed Resident #273 down. Review of Resident #273's admission Record revealed the facility admitted the resident on 02/01/2023 with diagnoses that included Type 2 Diabetes Mellitus, Hydrocephalus, and Muscle Weakness. Review of Resident #273's Quarterly MDS Assessment, dated 03/06/2023, revealed the facility assessed the resident as having a BIMS score of fifteen (14) of fifteen (15), indicating intact/borderline cognition. Review of Resident #273's Progress Notes, dated 02/07/2023, revealed LPN #26 documented Resident #273 was verbally aggressive and threatening to staff over a water cup and used foul language with staff and other residents. LPN #26 gave Resident #273 a cup of ice water and emotional support. Review of Resident #273's Progress Notes, dated 02/13/2023, revealed the Psychiatric Nurse Practitioner (PNP) documented during his Comprehensive Encounter with Resident #273 that the resident was transferred from a sister facility due to the need for a secured unit because of his/her increasingly disruptive behaviors and inappropriate interactions with other residents. Resident #273 continued to have difficulty with impulsiveness. Continued interview revealed Resident #273 was often at the nurse's station yelling at staff and other residents, using foul language, and threatening physical harm to staff and residents. He/she could be very demanding and refused care at times. Staff redirected the resident and calmed him/her down. Further review revealed Resident #273's aggressive behaviors caused a safety risk and possible escalation of physical violence since the other residents with him/her also had a history of behavioral problems. Review of Resident #273's Progress Notes, dated 03/13/2023, revealed LPN #2 documented Resident #273 was upset because he/she did not receive coffee on his/her dinner tray and was cursing staff and stating people were trying to control him/her. LPN #2 redirected Resident #273 and ensured all his/her needs were met. Review of the facility's Self-Reported Incident Form Initial Report, dated 03/25/2023 9:24 AM, revealed Resident #273 was being belligerent with staff. Resident #69 asked Resident #273 to stop. Resident #273 swung at Resident #69, missed, and picked up his/her walker. Staff were on their way to intervene. Before staff could reach them, Resident #69 pushed Resident #273 down. Resident #273 immediately got himself/herself up and was not injured. Staff separated the residents from each other and assisted Resident #273 to his/her room. Review of the facility's Final Report, dated 03/28/2023, revealed Resident #69 and Resident #273 were evaluated and neither had any signs of injury noted. Staff placed both residents on direct line of sight observation. Neither resident had any complaints of pain. Neither resident had any signs of injuries. The PNP was contacted and recommended that direct observation could be discontinued for both residents. Further review of the Final Report revealed Resident #273 had an episode of hyperglycemia on 03/25/2023, and he/she was sent to the emergency room for evaluation and admitted to the hospital. The facility completed the investigation and neither resident was harmed, both residents expressed remorse after the event, and neither resident had any further behavior exacerbations. The facility's Final Report stated it was plausible that (Resident #273's) behavior exacerbation was related to a medical condition that he/she was currently at the hospital undergoing treatment for. Interview with the Senior [NAME] President/Chief Executive Officer (SVP/CEO), on 04/01/2023 at 1:37 PM, revealed she was in the building doing rounds on the women's unit when a staff member, whose name she did not recall, came to her saying help was needed on another unit. Upon the SVP/COO's arrival to the unit, she stated multiple people were in the area. Resident #273 was standing and yelling profanities. Resident #273 [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the facility's policy, review of 906 [NAME] (Kentucky Administrative Regulations) 1:190, Section 1(4), a disqualifying offense, and review of the Kentucky Revised Statues (KRS) 209.032, it was determined the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, exploitation, and misappropriation related to screening of new employees for thirty (30) of thirty-one (31) personnel files reviewed. Additionally, the facility failed to ensure it did not employ individuals who had been found guilty by a court of law for abuse, neglect, misappropriate of property, exploitation, or mistreatment in accordance with the facility's policy and the list of Kentucky Disqualifying Offenses, for four (4) of thirty-one (31) personnel files reviewed. (Director of Maintenance (DM) #1, Activities Assistan (AA) #4, Certified Nursing Assistant (CNA) #71, and CNA #70). The findings include: Review of the facility's policy, Background Screening, dated 06/14/2019, revealed the company would complete background investigations for all candidates for employment and would not employee a person who was convicted of any offense listed on the State specific disqualifying offenses list. However, review of the policy further revealed a reported criminal offense would not necessarily disqualify a candidate from employment. Review of the Kentucky National Background Check Disqualifying Offenses List revealed, Pursuant to 906 [NAME] 1:190, Section 1(4), a disqualifying offense is: a. Identification on the Kentucky Nurse Aide Abuse Registry, Kentucky Child Abuse and Neglect Central Registry, Kentucky Caregiver Misconduct Registry, Federal List of Excluded Individuals and Entities (LEIE), or any available abuse registry, including abuse and neglect registries of another state; b. A crime described in 42 USC 1320a-7; c. A substantiated finding of neglect, abuse, or misappropriation of property by a state or federal agency pursuant to an investigation conducted in accordance with 42 USC 1395i-3 or 1396r; d. Registration as a sex offender under federal law or under the law of any state; e. An offense under a criminal statute of the United States or of another state similar to an offense listed in the document; f. A conviction of, or plea of guilty, an [NAME] plea, or a plea of nolo contendere to: A misdemeanor offense related to: 1. Abuse, neglect, or exploitation of an adult as defined by KRS 209.020(4); 2. Abuse, neglect, or exploitation of a child; 3. A sexual offense; 4. Assault (including domestic violence) occurring less than seven (7) years from the date of the criminal background check; 5. Stalking occurring less than seven 97) years from the date of the criminal background check; 6. Theft occurring less than seven (7) years fro the date of the criminal background check; 7. Fraud occurring less than seven (7) years from the date of the criminal background check; 8. Unlawfully possessing or trafficking in a legend drug or controlled substance occurring less than seven (7) years from the date of the criminal background check; or 9. KRS 525.130, Cruelty to animal in the second degree-Exemptions-Offenses involving equines; 10. Any other misdemeanor offense relating to abuse, neglect, or exploitation that is not listed in this subsection and occurred less than seven (7) years from the date of the criminal background check. Review of KRS 209.032, revealed Long Term Care facilities shall query the Cabinet' for substantiated findings of abuse, neglect or exploitation against an individual who was a perspective employee. Review of the employee file for Activities Assistant (AA) #4, revealed she was hired on 10/04/2022. However, the facility did not complete the background check until 10/06/2022. Review of AA #4's background check revealed she had been found guilty of theft by unlawful taking and fraudulent use of credit cards on 08/14/2014 and theft on 02/19/2015, three (3) felony convictions. Review of Certified Nursing Assistant (CNA) #71's employee file revealed he was hired on 12/15/2022, and the background check remained in Client Review Required status as of 03/31/2023, without evidence of further review. Review of the background check revealed he had controlled substance and possession of Marijuana convictions, listed on the Disqualifying Offense List referenced on the facility's policy. Review of the Employee File for CNA #70 revealed he was hired on 10/19/2022 and the facility failed to complete a background check for this applicant until 03/31/2023. This background check determined he was found guilty of possession of marijuana, an offense listed on the Disqualifying Offence List. Review of the Employee File for Director of Maintenance (DM) #1 revealed he was hired on 12/09/2021. The background check identified him to have a guilty charge of Assault 4th Degree, Domestic Violence with minor injury on 06/19/2020. Interview with the Executive Director (ED) 03/30/2023 at 9:00 AM, revealed the facility forwarded all applications to Corporate Human Resources (HR) for background review. She stated she only hired an employee after final approval was given from Corporate HR. Review of the personnel files revealed thirty (30) out of thirty-one (31) employees lacked documented evidence the facility checked the Caregiver Misconduct Registry. Review of the facility's personnel files also revealed nine (9) out of thirty-one (31) staff were hired and started work prior to a completed background check and two (2) of the thirty-one (31) had no evidence of a background check. Additionally, seventeen (17) of the thirty-one (31) files reviewed revealed background checks noted, Client Review Required. When the checks were noted Client Review Required, this indicated that staff at the Corporate level would investigate further before giving the approval to hire. However, there was no evidence the facility completed further review. Interview with the Executive Director (ED), on 03/30/2023 at 9:00 AM, revealed the facility forwarded all applications to Corporate Human Resources (HR) for background review and she only hired an employee after final approval was given from Corporate HR. Continued interview with the ED on 03/31/2023 at 7:00 PM, revealed she was confident when the approval for employment came from the Corporate Office, that all of the required background checks had cleared the employ for hire. Interview with the [NAME] President (VP) of Human Resources (HR), on 03/31/2023 at 7:00 PM, revealed the applications were sent to Corporate HR to complete the background checks using a third-party vendor. She stated if the report from the vendor indicated Client Review Required, then the HR Generalist at the Corporate level would investigate further before giving the approval to hire. She stated during their audit they initiated on 02/17/2023, they found several that should not have been approved. The VP stated the HR Generalist was no longer with the company. She stated the third-party vendor reports were slow to be returned and were difficult to read and interpret, so they contracted with a different third-party vendor for the background checks on 01/12/2023. Further interview revealed she was not aware of the requirement per KRS 209.032, for the Caregiver Misconduct Registry checks. She stated the HR Generalist was trained on the disqualifying offences, that would prevent a candidate from being hired. Interview with the Chief Operating Officer (COO), on 03/30/2023, at 1:00 PM, revealed she was not aware DM #2 had a criminal background until 02/17/2023, when she was talking with a potential Corporate Level employee that indicated to her that DM #1 had a criminal background with previous assault convictions. She stated she informed the [NAME] President (VP) of Human Resources (HR) of that information, which triggered an initial audit of all employee background checks. She stated they suspended DM #1 on 02/17/2023 pending further investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of the facility's policy, and review of the facility's personnel records, it was determined the facility's Governing Body failed to ensure their Human Resources (HR) timely obtained background information, to include the requirements of 906 Kentucky Administrative Regulations ([NAME]) 1:190, Section 1(4), a disqualifying offense, and Kentucky Revised Statues (KRS) 209.032, prior to hiring for potential employees, and failed to establish and implement adequate policies related to employee screening to ensure safe management and operation of the facility as related to employing staff with adverse actions. (Refer to F606) The findings include: Review of the facility's policy Background Screening, dated 06/14/2019, revealed the company would conduct background investigations on all candidates for employment prior to making an employment offer and may use a third party to conduct these background checks. Further review revealed the company would not employ a person who was convicted of any offense listed on the State-specific disqualifying offenses list. However, review of the policy further revealed a reported criminal offense would not necessarily disqualify a candidate from employment. The nature and seriousness of the offense, the surrounding circumstances, rehabilitation, and the relevance of the offense to the specific position(s). The Company would follow company procedures for making decisions regarding potential adverse actions. Review of KRS 209.032 revealed a vulnerable adult services provider, which included long-term care facilities as defined by KRS 216.510, shall query the cabinet as to whether a validated substantiated finding of adult abuse, neglect, or exploitation has been entered against an individual who was a prospective employee of the provider. Review of the facility's Personnel Files revealed thirty (30) of thirty-one (31) employee files reviewed revealed a lack of documentation to support the facility completed thorough background checks prior to employment, to include Kentucky's Caregiver Misconduct Registry. Further review revealed the facility hired four (4) employees who had documented evidence of convictions that would be considered disqualifying offenses. Continued review revealed there were seventeen (17) employees who were noted to have Client Review Required located within their employee files, which, per interview, indicated the employee needed further review by Corporate HR before hiring would be approved. Interview with the Executive Director (ED), on 03/30/2023 at 9:00 AM, revealed the facility sent all applications to Corporate HR to complete, what she thought, was all federal and state required information and background checks, to ensure the candidates for employment were cleared for all required federal and state background checks. She stated Corporate HR would inform the facility's HR and or the ED within a few days of the decision of whether the facility could hire the potential employee. Interview with the [NAME] President (VP) of HR, on 03/30/2023 at 1:30 PM, revealed the process for hiring was for the facility HR to forward the application to Corporate HR to review and complete the third-party background check. She said she was not aware of the required check with the Kentucky Cabinet as per KRS 209.032 (the Caregiver Misconduct Registry). She stated the review of the third-party background check results was conducted by Corporate HR and if there were any questionable offenses, they would make the final decision if the applicant would be cleared for hire. She further revealed any candidate that came back from the third party with Client Review Required, or that was not 100% cleared for employment, would be reviewed by the Corporate Director of HR. Continued interview with the VP of HR, on 03/31/2023 at 7:00 PM revealed the Corporate HR Director would review the offenses, consider the timeframe and the offense, then would make the decision on whether to hire the employee. She stated she was not aware of all federal and state-required background checks. Further interview revealed the third-party reports were difficult to read, in order to determine if the applicant had a disqualifying offense, and she thought they were all inclusive of the requirements to be compliant with federal and state laws. Interview with the Chief Operating Officer (COO), on 03/30/2023 at 1:45 PM, revealed she became aware that an employee of the facility, may have convictions that would be a disqualifying offense on 02/17/2023. Further interview revealed she reached out to Corporate HR and found out the background check completed on 12/06/2021, for the Maintenance Director, at that time, contained prior convictions listed as a disqualifying offense, which prompted a sweep of all current employee files. The COO revealed she was not aware the pre-employment checks did not include the required Caregiver Misconduct Registry as per KRS 209.032.

Based on interview and record review, it was determined the facility failed to have evidence of investigations to ensure they were thoroughly investigated for five (5) of ninety-four (94) sampled residents (Residents #67, #74, #81, #122, and #144) The findings include: Review of the facility policy Freedom From Abuse and Neglect Policy, dated 10/30/19, revealed the facility was responsible for conducting an investigation of any alleged or suspected abuse, and the Executive Director was responsible for oversight. The policy stated the facility was responsible for conducting a thorough investigation of all alleged violations and taking appropriate actions, which included interviews and/or written statements from individuals with first-hand knowledge of the incident. 1. Record review revealed the facility admitted Resident #81 on 01/22/2020, with diagnoses to include Altered Mental Status and Bipolar Disorder, and Acute Kidney Failure. A diagnoses of Cognitive Communication Deficit was added on 06/23/2021. Review of Resident #81's, Quarterly Minimum Data Assessment conducted on 09/10/2021, revealed the resident scored an eleven (11) of fifteen (15) on a Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Review of facility Investigation report dated, 10/31/2021, revealed on 10/28/2021, Resident #81 was observed holding Resident #122's face for an unknown reason, prompting Resident #122 to lightly swat at Resident #81's face with his/her fingers. The Investigation report revealed neither resident could recall incident, and no residents were injured. Requests for facility documentation of this investigation were made to the Executive Director twice on 02/20/2023, and once again on 02/23/2023, but no information was provided. Review of Facility Investigation report, dated 11/16/2021, revealed minimal information regarding the specifics of what occurred on an 11/11/2021, only that Resident #81 made contact with Resident #80's area, resulting in Resident #80 reaching out and making contact with Resident #81's facial area. The report revealed there were no injuries. Continued review of investigation report revealed, although other residents were assessed or interviewed as appropriate, there were no witness statements to determine who was present or what actually occurred. This information was requested of the Executive Director (ED) on 02/21/2023, and again on 02/23/2023, but was never received. Interview with the Executive Director (ED), on 03/12/2023 at 2:40 PM, revealed she was not working at the facility at the time of facility reported incidents, involving Resident #81, and there had been a lot of changeover of staff. She expressed frustration at not being able to find investigations reports for the incidents. She stated her expectation was that residents would be protected from abuse, and the facility responded to any allegation quickly and investigated them thoroughly. She stated a thorough investigation included witness statements, and interviews with both residents and staff, so that anyone reviewing knew what happened, who was involved, and how the facility responded. 2. Record review of the Facility Reportable Incident form, dated 12/10/2022, which involved Resident #67 having a bruise to right brow bone, indicated skin assessments and staff interviews were performed. however these documents were not provided to the surveyor upon request. 3. Record review of the Facility Reportable Incident form, dated 10/12/2022, regarding Resident #144 slapping Resident #67 and #74, revealed Resident #144 was placed on 1:1 supervision. Request for the facility's investigation information revealed the facility was unable to produce all documents pertaining to the investigation, which included evidence of 1:1 supervision. Interview with Executive Director (ED), on 03/14/2023 at 3:15 PM, revealed she was ultimately responsible for investigations of allegations and was unable to locate all of the documentation pertaining to some of the investigations, but would keep looking. She also revealed she had started a new process of placing allegations in binders for easy access since coming to facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to obtain physician's orders, at the time of admission, for the resident's immediate care for one (1) of ninety-four (94) sampled residents ( Resident #70). Resident #70 was observed to be wearing oxygen (O2); however, there was no documented evidence of a Physician's Order for O2 in the resident's record. The findings include: Record review revealed the facility admitted Resident #70 on 03/22/2021, with diagnoses that included muscle weakness, unsteadiness on feet, cognitive communication deficit, unspecified symbolic dysfunctions, type 2 diabetes, essential primary hypertension, heart disease, chronic kidney disease, hypothyroidism, anemia, bradycardia and anxiety. Review of Resident #70's Quarterly Minimum Data Set Assessment (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was thirteen (13) out of fifteen (15). This score indicated the resident was cognitively intact. Review of Resident #70's Comprehensive Care Plan (CCP), dated 11/18/2022, revealed the facility care planned the resident for oxygen use. Observation on, 02/14/2023 at 9:00 AM, revealed Resident #70 was wearing oxygen via nasal cannula. Further observation revealed Resident #70 oxygen was being delivered at two (2) liters. Observations from 02/14/2023 through 03/16/2023, revealed Resident #70 was wearing oxygen daily and at all times. Interview, on 02/15/2023 at 4:00 PM with Resident #70 revealed he/she used oxygen all the time for his/her Chronic Obstructive Pulmonary Disease (COPD). Record review revealed the facility discharged the resident to the hospital, on 01/13/2023, and readmitted the resident on 01/18/2023. However, the re-admission Physician's Orders revealed no order to continue O2 or monitoring. Review of Resident #70's Physician's Orders, dated 01/18/2023 to 03/16/2023, revealed no active order for Oxygen. Interview, on 03/16/2023 at 2:00 PM, with Registered Nurse (RN) #4, revealed the Unit Manager was responsible for transcribing admission/re-admission orders for a resident entering the facility. RN #4 stated sometimes she did her own because she liked to know first hand what was happening with her residents. Interview, on 03/16/2023 at 2:15 PM, with Licensed Practical Nurse (LPN) #1, revealed the Unit Manager was responsible for transcribing admission/re-admission orders for a resident entering the facility, but if the UM was not there then the nurse receiving the resident should put the orders in. Interview, on 03/16/2023 at 2:28 PM, with Unit Manager #3 revealed it was the responsibility of the receiving floor nurse to make sure orders for a new admission or a returning resident were in the computer, but she tried to help when she could. She stated as the Unit manager, she did weekly audits to ensure residents that had entered or returned to the facility in the previous week, had orders that were correct in the computer. Interview, on 03/16/2023 at 4:00 PM, with the Interim director of Nursing (IDON), revealed admission or readmission orders should be entered into the computer by the Unit Manager or the receiving nurse for that resident. She stated it was her expectation residents receiving oxygen would have orders transcribed timely and accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility failed to update the Minimum Data Set (MDS) for one (1) of ninety-four (94) sampled residents, Resident #106. Review of the admission MDS, dated [DATE], the Quarterly MDS, dated [DATE], and the Quarterly MDS, dated [DATE], revealed no documented evidence Resident #106 utilized the assistance of a wheelchair. The findings include: Review of the medical record revealed the facility admitted Resident #106 on 08/26/2022 and readmitted on [DATE] with diagnoses of Alzheimer's Disease, Difficulty with walking, Unsteadiness of feet, and history of repeated falls. Review of the admission MDS dated [DATE], the facility assessed the resident with a Brief Interview of Mental Status (BIMS) score of ninety-nine (99) as severely cognitively impaired. Continued review of the medical record revealed the admission MDS dated [DATE], Quarterly MDS dated [DATE], and the Quarterly MDS dated [DATE], documented in Section G, Resident #106 was ambulatory and did not identify resident's use of a wheelchair. Interview with Licensed Practical Nurse (LPN) #3, on 03/04/2023 at 10:35 AM, revealed Resident #106 was admitted to East unit then moved to [NAME] memory care unit. Resident #106 used a wheelchair and ambulation was unsteady. Interview with Speech Therapist #2, on 03/07/2023 at 1:15 PM, revealed Resident #106 had cognitive and memory deficits and used a wheelchair for mobility. Interview with Occupational Therapist #1, on 03/07/2023 at 1:24 PM, revealed Resident #106 had cognitive deficits and needed maximum assistance for lower body and utilized a wheelchair for mobility. Interview with LPN #24 on 03/10/2023 at 2:40 PM, revealed she remembered Resident #106 and stated the resident utilized a wheelchair, not a walker for assistance with mobility. Interview with float Registered Nurse (RN) Minimum Data Set (MDS) Coordinator #2, on 03/14/23 at 9:21 AM, revealed information gathered for MDS Assessments, came from review of staff notes and therapy notes as well as observations of the resident. The MDS Coordinator stated the facility did not identify Resident #106, as using a wheelchair and only documented as ambulatory. Interview with Interim Director of Nursing (IDON), on 03/15/2023 at 1:45 PM, revealed the MDS Coordinator was responsible for updating and checking for accuracy of the MDS. Interview with Executive Director (ED), on 03/15/2023 at 3:30 PM, revealed the MDS should be accurate to the resident in order for the faciclity to develop a person-centered care plan for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review it was determined the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain good oral hygiene for one (1) of nineteen (19) sampled residents (Resident #44). On 06/25/2023 at 1:52 PM, Resident #44 was observed with food particles/substance in his/her mouth and on his/her teeth. The findings include: Review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting, not dated, revealed residents who were unable to carry out ADLs independently would receive the services necessary to maintain good grooming and personal and oral hygiene. Further review revealed appropriate care and services would be provided for residents who were unable to carry out ADLS independently, with the consent of the resident and in accordance with the plan of care, which included appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care). Review of Resident #44's admission Record revealed the facility admitted the resident on 03/29/2023. The resident's diagnoses included Malignant Neoplasm of the Brain, Osteoarthritis, Muscle Weakness, Difficulty in Walking, Need for Assistance with Personal Care, and Unsteadiness on Feet. Review of Resident #44's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99. This score indicated the resident was severely cognitively impaired. Further review revealed the resident required extensive assistance of one (1) person for transfers and hygiene. Review of Resident #44's Comprehensive Care Plan initiated 04/11/2022, revealed the resident had an Activities of Daily Living (ADL) self-care performance deficit related to dementia, impulsive disorder, muscle weakness, and anxiety disorder. Further review revealed goals that included the resident would improve and maintain that level of function. Interventions included set up and assist with oral care daily and as needed. Observation of Resident #44, on 06/25/2023 at 1:52 PM, revealed the resident had food particles caked onto his/her teeth and crumbs were noted to be coming out of the resident's mouth while he/she was speaking. The resident did not have any food in his/her vicinity at the time of the observation. Interview on 06/25/2023 at 4:50 PM, with Certified Nurse Aide (CNA) #8, who was assigned to Resident #44, revealed the third (3rd) shift staff were responsible for getting residents up in the mornings, providing personal hygiene, including brushing residents' teeth. She further stated day shift staff assisted residents with oral care as needed. CNA #8 stated good hygiene was important for residents' dignity and to prolong how long residents could keep their teeth. Interview on 06/26/2023 at 10:36 AM, with Licensed Practical Nurse (LPN) #40, revealed she was not sure what the policy was at the facility regarding oral care. She further stated residents' dentures were soaked overnight. DON #4 stated during interview on 06/26/2023 at 11:05 AM, staff should assist residents with brushing their teeth before assisting them to the dining room in the mornings, after meals, and at bedtime. She stated staff should make sure food was not clinging to a resident's teeth and there was no build up on the teeth. The DON stated staff should follow the interventions on the Care Plan and brush the resident's teeth at the times listed above and as needed. During interview on 06/28/2023 at 5:32 PM, with Executive Director (ED) #2, revealed she expected the staff to follow the Care Plan interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observations, record review, and the facility's policy it was determined the facility failed to ensure proper treatment and evaluation for assistive devices related to maintaining vision for one (1) of thirty-three (33) sampled residents (Resident #90). The facility admitted Resident #90 on 09/21/2022. However, the facility failed to arrange for the resident to be assessed for his/her vision impairment and need for eyeglasses. The findings include: Review of the facility's policy titled, Vision and Hearing Evaluations, Version #:1, dated 09/03/2017, revealed the purpose statement was to promote resident function at their highest practical level. Procedures included assess need for an evaluation, with resident or representative with Social Services or nursing staff arranging evaluation as soon as possible. Added review revealed Social Services or designee would update the resident's plan of care. Review of the facility's agreement with the contracted Optometry Service, with an effective date of 11/01/2019, revealed services available included Optometry Services. These services included vision examinations, medical eye evaluations, fall risk evaluations and fitting and ordering glasses. Review of Resident #90's admission Record revealed the facility admitted Resident #90, on 04/05/2023 with diagnoses of Alzheimer's Disease, muscle weakness, difficulty walking, dementia, vision impairment, and repeated falls. Review of Resident #90's Quarterly Minimum Data Set (MDS) Assessment, dated 04/07/2023. revealed the facility assessed the resident with a Brief interview for Mental Status (BIMS) score of three (3) out of fifteen (15). This score indicated severe impairment. Further review revealed Resident #90 had moderately impaired-limited vision. Review of Resident #90's Fall Risk assessment dated [DATE] revealed a score of eighteen (18) indicating vision status as poor. Review of the facility's Fall Risk Assessment form revealed eight (8) areas of fall risks, which included, 1-level of consciousness/mental status, 2-history of falls(past three (3) months), 3- Ambulation/elimination status, 4- Vision status, 5- Gait/balance, 6- systolic blood pressure, 7- Medication, 7-1 resident has had a change in medication or change in dosage in the past five (5) days, and 8- predisposing disease. Continued review of FRA revealed number four (4) was indicated for vision status as poor (with or without glasses) for Resident #90. Review of Resident #90's Comprehensive Care Plan (CCP), dated 09/15/2022, revealed the facility assessed the resident to reside on a secured unit related to diagnosis of dementia and impaired safety to surroundings. Interventions placed on the 01/20/2023 CCP, included the resident was to be supervised while on the secured unit. Continued review of the CCP revealed the facility assessed the resident to be at risk for falls related to impaired safety awareness and impaired vision increasing risk of injury. The date initiated was 09/15/2022 and was revised on 03/21/2023. Additional interventions included: individualized activities to reduce outside stimulation; resident had impaired vision causing hearing to be more sensitive to loud noises and outside distractions initiated on 10/21/2022 and revised on 03/09/2023. Continued review of Resident #90's CCP revealed the facility assessed the resident to have impaired visual function and uses walls as guides. Review of the CCP revealed interventions placed on 10/11/2022, which included to arrange consultation with eye care practitioner as required, assist with Activities of Daily Living (ADLs) as needed and consistently tell the resident where items were placed. Observation of Resident #90, on 05/25/2023 at 9:15 AM, revealed the resident was sitting in a chair with other residents in the common area and appeared to be dozing. Further observation revealed bruising noted to the resident's left eye orbital area. Review of Resident #90's Electronic Medical Record (EMR) revealed on 05/25/2023 at 4:15 AM the resident was found on the floor in his/her room with sheets wrapped around his/her feet. A skin assessment revealed a small area of blood from an old scab and two (2) small knots noted on the left side of his/her face. The facility did not transfer the resident to the hospital. Continued review of Resident #90's EMR revealed on 04/21/2023 at 6:45 AM, the resident attempted to sit in a chair located in the dayroom and missed the chair falling to the floor, no injuries were noted. Review of Resident #90's EMR revealed on 04/22/2023 ecchymosis (bruising) was noted to resident's buttock area. Review of the Interdisciplinary Team (IDT) meeting notes on 04/21/2023 revealed no injuries were noted after the fall, but ecchymosis was noted to the right buttock. Review of the IDT meeting notes revealed the root cause of the fall was determined to be the resident attempted to sit in chair and was not close enough to the chair, lost his/her balance and landed on his/her buttocks. Continued review of the meeting notes revealed no evidence the facility considered Resident #90's impaired vision as a root cause of the falls. Review of Resident #90 EMR revealed, on 04/15/2023 at 1:52 PM, the resident had two (2) falls within twenty (20) minutes, one in which the resident hit the back of his/her head which resulted in a small amount of blood noted. Further review revealed the facility transferred Resident #90 to the local emergency room. Review of the IDT Notes, dated 04/15/2023, revealed Resident #90 fell twice in twenty (20) minutes with no injuries noted with the first fall. However, the resident hit his/her head with the second fall with a small laceration and a small amount of blood noted to the back of the scalp. The root cause analysis concluded the resident attempted to transfer without assistance and was unable to do so. Continued review revealed no evidence the facility considered impaired vision as a possible root cause for the falls. Review of the results of the Computerized Tomography (CT) of Resident #90's head performed at a local emergency room on [DATE] were chronic subdural (membrane covering spinal cord and brain) hematomas (mass of blood) and or hygromas (sac of fluid) since study on 09/16/2022. Review of the CT of the spine revealed no fractures of the spine with final diagnosis of contusion of scalp per emergency room notes. Continued review of Resident #90 EMR revealed an active order as of 04/05/2023 which stated the resident was to see an ophthalmologist written on 09/15/2022 upon admission. Review of the EMR also revealed a Physical Therapy Evaluation and Plan of Treatment, dated 04/06/2023, which noted patient's (resident's) factors included poor scanning of environment and history of wandering around on unit. Continued review of the Physical Therapy Evaluation and Plan of Treatment, dated 05/29/2023, revealed a new goal was to provide verbal cues for use of compensatory strategies due to low/reduced vision. Review of the Physical Therapy Evaluation and Plan of Treatment revealed a functional mobility assessment for gait which included deviations of inconsistently scanning environment and difficulty with object negotiation below waist level. Review of Resident #90's EMR revealed appointments for an eye examination on 06/21/2023, with the resident listed as a new patient exam. Continued review revealed former the Medical Director, noted on 04/14/2023 for the eye doctor to evaluate Resident #90 on next visit due to vision declining. Observation on 05/30/22023 at 12:40 PM revealed another resident holding Resident #90 hand and guiding him/her as they walked down the hallway to the dining room. Additional observation revealed two (2) staff members who were already in the dining room, assisted Resident #90 to be seated in a chair at the table. Observation on 05/31/2023 at 9:25 AM revealed Resident # 90 sitting in chair with his/her head down. Resident #90 appeared to be dozing (falling asleep). Observation on 05/30/2023 at 12:40 PM revealed Speech Therapy #1 assisted the resident with his/her meal redirecting where the resident's food was located on the plate, placement of his/her drink and the amount of food to be placed in the spoon. During interview with Certified Nursing Assistant (CNA) #87 on 05/25/2023 at 9:30 AM, she stated Resident #90 was a little unsteady when walking and had sustained a fall on night shift. CNA #90 stated the resident now had bruising to the left eye. The CNA stated she had not noticed the resident wearing glasses since she has worked here. During interview with CNA #34, on 05/25/2023 at 9:20 AM, she stated she never saw the resident with glasses since he/she lived at the facility. In an additional interview with CNA #34, on 06/02/2023 at 5:05 PM, she stated Resident #90 needed assistance when trying to sit in a chair. In a interview with Licensed Practical Nurse (LPN) #9, on 05/30/2023 at 11:20 AM, she stated she never saw Resident #90 wearing glasses. She stated she recalled eye care had previously been to the facility but, she could not recall if Resident #90 had seen them. In interview with Social Service Director (SSD), on 05/31/2023 at 2:30 PM, she stated appointments were set up for routine visits for the residents, but the Optometry Service declined coming to facility since the State Survey Agency was in the building and appointments were moved to 06/21/2023. She stated that she did not know if the previous SSD made any appointments for Resident #90 to be seen by the eye doctors. Review of the CCP with the SSD, revealed the CCP was initiated on 09/15/2022 and revised on 03/21/2023 for Resident #90 to see an eye care doctor for impaired vision, which increased the risk for injury. In interview with Director of Nursing (DON), on 05/23/2023 at 2:00 PM, she stated the only time a resident was sent to outside provider for eye care was if the resident had an urgent condition.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice for one (1) of thirty-three (33) sampled residents, Resident #22. Resident #22 had a Bilevel Positive Airway Pressure (BiPAP) machine that helped the resident get more air into the lungs. There was no evidence the Licensed Nursing staff were conducting assessments of pre/post lung sounds for administration of nebulizer medications. Also there was no evidence nursing staff was conducting more frequent rounds to ensure Resident #22 wore the Bi-PAP mask while napping and at bedtime, as per Physician's Orders. Review of Resident #22's Care Plan revealed he/she was care-planned for refusal to wear the Bi-PAP when napping or sleeping. However, there were no resident centered interventions to ensure Resident #22 was wearing the Bi-PAP mask as ordered. The findings include: Review of the facility's policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised 2010, revealed the process would include documentation of the pre/post lung sounds for administration of nebulizer medications. Review of the facility's policy titled, Care of Residents with Respiratory Diseases, revised 01/24/2012, revealed staff would assess lung sounds including auscultation (listening to lung sounds with a stethoscope). Review of the facility's policy titled, Chronic Obstructive Pulmonary Disease (COPD)-Clinical Protocol, revised 11/2018, revealed the clinical protocol included assessment and documentation of vital signs to include a detailed description of respirations. Additional review revealed full lung sounds were to be assessed and documented. During an interview with the Director of Nursing (DON), on 05/18/2023 at 10:55 AM, she stated there was not a facility policy, procedure, or process to ensure residents that were care-planned for refusals of care were monitored more frequently to ensure compliance. The Executive Director (ED), on 05/18/2023 at 11:38 AM, reiterated what the DON had said by stating there was not a facility policy, procedure, or process to ensure residents that were care-planned for refusals of care were monitored more frequently to ensure compliance. Review of Resident #22's clinical record revealed the facility admitted him/her on 02/10/2020, with diagnoses that included Acute/Chronic Respiratory Failure with Hypercapnia (build-up of carbon dioxide (CO2) in the blood) and Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #22's Quarterly Minimum Data Set (MDS) Assessment, dated 04/05/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of twelve (12) of fifteen (15), indicating moderate cognitive impairment. Review of Resident #22's Care Plan, dated 03/28/2023, revealed a Focus that included at risk for decline related to his/her refusal for care as ordered, that included wearing the Bi-PAP mask; he/she understood the risk of refusing to wear the mask but did not like wearing the Bi-PAP mask. Further review revealed there were no resident centered interventions on the care plan to encourage use of the BiPAP. Observations on 05/16/2023 at 3:38 AM, revealed Resident #22 to be in bed with his/her eyes closed. Resident #22's Bi-PAP mask and Oxygen (O2) nasal cannula were both off. During an interview with Registered Nurse (RN) #15, on 05/16/2023 at 3:47 AM, she stated that she did not routinely check breath sounds unless a resident was exhibiting sounds and symptoms of respiratory distress. She stated she did assess lung sounds pre/post administration of nebulizer medications; however, there was no area to document the results on the medication administration record (MAR) or treatment administration record (TAR). She stated she would occasionally document lung sounds in the Nursing Progress Notes. RN #15 stated she would make resident rounds with medication administration and every two (2) hours; but to her knowledge, there was not a process to ensure Resident #22 received more frequent rounding to ensure compliance with wearing the Bi-PAP mask. Review of Resident #22's MAR/TAR, dated April 2023 and May 2023, revealed there was not an area to document pre/post nebulizer treatment lung sounds as per the facility's policy. Review of Nursing Progress Notes and General Notes for April 2023 and May 2023, revealed there was no documentation of Resident #22's lung sounds pre/post nebulizer treatments; nor was there documented evidence of more frequent monitoring for compliance or refusals to wear the Bi-PAP mask. During an interview with the Assistant Director of Nursing (ADON), on 05/16/2023 at 7:15 AM, she stated she was unaware if the facility had policies concerning care of residents with respiratory diseases. She also stated she was not aware if pre/post nebulizer lungs sounds should be obtained and where to document the results. In an interview with the facility's Advance Practice Registered Nurse (APRN), on 05/17/2023 at 11:39 AM, she stated it would be her expectation for staff to obtain and document pre/post nebulizer medication administration lung sounds. She also stated it would be her expectation for staff to monitor and document Resident #22's usage or refusal of the Bi-PAP mask. She stated Resident #22 needed to use the Bi-PAP machine to assist in managing his/her disease processes of Acute/Chronic Respiratory Failure with Hypercapnia and Chronic Obstructive Pulmonary Disease (COPD). RN #6, during an interview on 05/17/2023 at 1:55 PM, stated she was aware that pre/post lungs sounds with nebulizer medication administration should be assessed and documented; however, there was not a place on the MAR/TAR to document results. During the interview, RN #6 stated she was unaware if increased monitoring for Resident #22 was ordered. Agency RN #28 stated during an interview, on 05/17/2023 at 2:17 PM, that lung sounds should be assessed pre/post nebulizer medication administration, but there was nowhere to document the results. RN #28 also stated she was unaware of any increased monitoring related to Resident #22's refusal to wear the Bi-PAP mask. In an interview with the East Unit Manager, on 05/17/2023 at 2:36 PM, she stated there was a binder at the Nurses' Station that was used as a staff reminder for residents with additional needs such as nebulizer treatments, assistive devices for breathing such as Bi-PAP machines, and wounds. She stated that items in the binder would be discussed in daily clinical meetings. The East Unit Manager stated, to her knowledge, there was no increased monitoring for Resident #22. During an interview with the Director of Nursing (DON), on 05/18/2023 at 10:55 AM, she stated it was her expectation that nurses would assess a resident's lung sounds pre/post nebulizer medication administration and document the results per the policy to show the effectiveness of the treatment. She stated she was unaware there was not a place to document the results. The DON stated that ideally the results would be documented on the MAR, but nurses could also document them in the Nursing/General Notes. She stated lung sounds also should be assessed if there was a status change. The DON stated it was her expectation that baseline lungs sounds would be assessed on admission, re-admission, and with a change in condition. She stated currently there was not a process in place to monitor if lung sounds were being assessed and documented. The DON stated she was unaware if increased monitoring for compliance to wear the Bi-PAP mask was being completed for Resident #22. In an interview with the Executive Director (ED), on 05/18/2023 at 11:38 AM, she stated it was her experience that pre/post nebulizer medication administration lung sounds would be documented on the MAR. However, she stated she was unaware there was not a place on the MAR to document the lung assessment results. She stated it was her expectation for baseline lung sound assessments to be assessed on admission, re-admission, or a change in condition and for staff to follow the policy.

Based on observation, interview, record review and review of facility policy the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety for two (2) of ninety-four (94) sampled residents, Resident #82 and Resident #97. Review of facility Gait Belt policy, revealed staff were to use gait belts to assist in all manual transfers or ambulation of residents, unless contraindicated. Observation on 03/10/2023 at 10:30 AM, revealed Certified Nursing Assistant (CNA) #4, grabbed Resident #97 by the back of the pants, and lifted him/her from the bed during transfer from the bed to the wheelchair. Interview with CNA #42 revealed she assisted Resident #82 in transfer from his/her wheelchair to the bed and did not use a gait belt. Interviews with CNA #4 and #42, revealed the faclity had not trained them on the gait belt policy or its use. The findings include: Review of the facility's policy titled Gait Belt dated 05/05/2017, revealed its' purpose was to provide safety while transferring and ambulating by enabling staff to assist resident regain balance or lower to the floor and to provide an additional sense of security for resident. The policy's procedure was staff were to use gait belts to assist in all manual transfers or ambulation of resident unless contraindicated by the resident condition. Prior to use of gait belt, check resident's care plan or Certified Nursing Assistant (CNA) assignment sheet/Plan of Care (POC) profile or Care Needs Sign Off to assure gait belt was not contraindicated. Interview with Physical Therapy Assistant (PTA) #1, on 03/10/2023 at 1:50 PM, revealed the purpose of a gait belt was to assist the staff with resident transfers. She stated staff should not grip a resident's clothing during transfers and facility staff should use gait belts on all residents during transfers, unless contraindicated. 1. Review of the medical record revealed the facility admitted Resident #82 on 12/23/2021 with diagnoses that included muscle weakness, unsteadiness on feet, lack of coordination and need for assistance with personal care. The facility's quarterly Minimum Data Set (MDS) assessment, dated 01/30/2023 for Resident #82, revealed Resident #82 required one person to physically assist him/her when transferring between surfaces. Review of Resident #82's care plan, dated 02/10/2023, revealed the resident needed assistance, as needed, for bed mobility, transfers, and toileting, with no contraindication for gait belt use noted. Observation, on 03/10/2023 at 2:00 PM, revealed Certified Nursing Assistant (CNA) #42 released the locks on Resident #82's wheelchair, and took him/her to his/her room to provide toileting care. Privacy was requested so the State Survey Agency (SSA) Surveyor did not enter the room. When CNA #42 opened the door, Resident #82 was in bed. Interview with CNA #42, on 03/10/2023 at 2:19 PM, revealed she had worked at the facility as a CNA since mid-December. She had received training in orientation, but did not receive any training from the facility on gait belt use or policy. She stated she assisted Resident #82 in transfer from his/her wheelchair to the bed and did not use a gait belt and stated there was no gait belt available for her to use to transfer Resident #82. 2. Review of the medical record revealed the facility admitted Resident #97 on 10/26/2021 with diagnoses that included muscle weakness, unsteadiness on feet, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/23/2023 for Resident #97, revealed Resident #97 required one (1) person to physically assist him/her with transfer from bed to wheelchair. Review of Resident #97's Care Plan, dated 10/27/2021, revealed the resident required staff to assist/stand by with bed mobility, transfers, and toileting, as needed, with no contraindication for gait belt use noted. Observation on 03/10/2023 at 10:30 AM, revealed Resident #97's call light was on. The State Survey Agency (SSA) Surveyor went to Resident #97's room and observed him/her struggling to sit up. Interview at this time of observation, with CNA #4, revealed Resident #97 wanted to get out of bed. Continued observation revealed CNA #4 grabbed Resident #97, by the back of the pants, and lifted him/her from the bed to the wheelchair. Interview with CNA #4 on 03/10/2023, revealed when asked about the procedure she used to lift Resident #97 from the bed, she stated that was how she was trained. She stated she had not received training or instruction on the use of gait belts at this facility, until about one (1) week ago, when the Admissions staff handed out gait belts and instructed staff to use. The CNA continued to state no other staff used a gait belt either and she did not receive any training in orientation, nor through policy review about the facility's required use of a gait belt for transfers. Observation on 03/10/2023 at 2:10 PM, revealed the admission Concierge was holding many gait belts wrapped in plastic packaging. Interview with admission Concierge, on 03/10/2023 at 2:11 PM, revealed she was stocking the nurses' station with gait belts for all CNAs would have access to gait belts. Interview with the Staff Development Coordinator (SDC), on 03/15/2023 at 2:55 PM, revealed she had been in her position three (3) weeks. She stated she was responsible for competency oversight once she was properly trained. She expected to be properly trained soon after the facility's recertification survey was completed. She stated staff completed their competencies upon hiring and annually at a minimum. She stated she had not been in the role of SDC long enough to determine staff training needs. Interview with the Director of Nursing (DON), on 03/16/2023 at 4:00 PM, revealed gait belts were important because they provided stability and a center of gravity for staff and residents when residents stood and ambulated, but that any resident who could self-ambulate was not expected to wear a gait belt. Since the Gait Belt policy stated staff were to use gait belts to assist in all manual transfers or ambulation of residents, and did not exclude residents who could self-ambulate, the DON stated the Gait Belt policy should be updated. Interview with the Executive Director (ED), on 03/16/2023 at 9:45 AM, revealed the importance of the gait belt was to help keep residents and staff keep safe when walking. Also, after a resident fell, the gait belt made it easier for the resident and staff to get the fallen resident back up. She stated the potential outcome of gait belts not being used was that residents and/or staff could be injured.

Based on observation, interview and record review, it was determined the facility failed to ensure the Director of Nursing (DON) served as a charge nurse only when the facility had an average daily occupancy of sixty (60) or fewer residents. The findings include: Review of the facility's policy Staffing, Sufficient and Competent Nursing, dated August 2022, revealed the director of nursing services (DNS) may serve as the charge nurse only when the average daily occupancy of the facility is sixty (60) or fewer residents. Record review of the document titled Midnight Census Report dated 01/30/2023 revealed the facility's census on that date was 121 residents. Record review of the document titled Nursing Hours dated 03/07/2023 revealed the facility's census on that date was 120 residents. Interview on 03/02/2023 at 2:52 PM, with the Payroll/Human Resources staff person, revealed she was responsible for staff scheduling. She stated if staff called in, administration would cover those staff responsibilities. Observation on 03/07/2023 at 8:35 AM, revealed the Interim Director of Nursing (IDON) was administering medications to residents of the East Unit. Interview with the IDON, on 03/08/2023 at 1:15 PM, revealed if staff called in or did not report to work, the Unit Manager assigned to that Unit would administer medications to the Unit's Residents. The IDON was charge nurse only as a last resort. She had served as charge nurse until the facility could get a nurse to come in. The IDON stated she had to do that this month, but only for two (2) hours. Interview with the IDON, on 03/09/2023 at 1:30 PM, revealed she had been the Interim Director of Nursing (DON), since early December 2022. The IDON stated she had served as charge nurse on two (2) occasions. On 01/30/2023 and on 03/07/2023, she served as a charge nurse those days until replacements were found for staff who had called in or were late to work. Interview with the Executive Director (ED), on 03/08/2023 at 1:15 PM, revealed the facility was continuously looking at the staffing schedule to better meet Residents' needs. If there was a Manager administering medications, the facility would try to find a Nurse or a Certified Medication Technician to come in and take the cart from the Manager. She also stated many of her leadership staff had their Certified Nursing Assistant (CNA) certification and could work on the Unit, although they all had other jobs to do.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, it was determined the facility failed to obtain the most recent Hospice agency plan of care and designate a member of the facility's interdisciplinary team (IDT), who was responsible for working with the hospice representative to coordinate care of the resident for one (1) of thirty-three (33) sampled residents, Resident #35. Review of Resident #35's Electronic Medical Record (EMR) revealed no Hospice agency care plan (CP). On 06/02/2023, Nurse Consultant #1, after a request, provided this Surveyor a copy of the Hospice agency CP. In the interview with the SSD, she stated she was not aware of the facility requirement to obtain the Hospice agency's CP for incorporation into the facility's CP. She further stated she only obtained the Hospice agency CP upon request The findings include: Review of the facility's policy titled, Hospice Program, last revised July 2017, revealed the policy provided a space for the facility to identify their designated representative, who was to be a member of the Interdisciplinary Team (IDT). The policy stated the designated representative would have clinical and assessment skills and was operating within the State scope of practice act. Per the policy, this person was responsible to ensure the most recent hospice plan of care was obtained and incorporated into the facility's person-centered care plan. Review of Resident #35's admission Record revealed the facility admitted the resident on 09/09/2021 with diagnoses of Dementia, Malnutrition, Colostomy, and a History of Falls. Review of hospital records revealed Resident #35 was in the hospital from [DATE] until 03/08/2023 for Aspiration Pneumonia. Review of Resident #35's 5-day admission Minimum Data Set (MDS) Assessment, dated 03/13/2023, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of zero-zero (00), signifying the resident was severely cognitively impaired. Also, the facility assessed the resident for two (2) person physical assistance for transfers, dressing, and toileting. He/She was assessed for one (1) person physical assistance for bed mobility and personal hygiene. The resident was assessed for the use of a wheelchair only and noted to be absent of upper/lower extremity impairments. Review of Resident #35's Progress Notes, revealed the resident was placed in hospice care, on 03/14/2023. Review of Resident #35's Electronic Medical Record (EMR) on 05/10/2023, revealed no Hospice agency care plan was located in the resident's medical record. On 05/25/2023 at 4:07 PM, an email request was sent to the Director of Nursing (DON) for the facility to provide a copy of Resident #35's hospice care plan and the identity of the facility's IDT hospice representative. The DON provided a copy of the facility's hospice care plan and two (2) names of the Hospice agency staff, not a staff member from the facility. During interview on 06/02/2023 at 8:45 AM, with the facility's Nurse Consultant #1, this surveyor requested a copy of Resident #35's Hospice agency care plan. The facility Nurse Consultant #1 provided a faxed copy of the Hospice agency care plan, with a cover sheet. Review of the faxed copy revealed the Hospice agency faxed it over on 06/02/2023 at 8:58 AM. Interview on 06/02/2023 at 9:00 AM, the DON stated the facility's Hospice staff representative was the Social Service Director (SSD). Review of Resident #35's facility Hospice CP, revealed it was initiated on 03/16/2023, with interventions of administer medication as ordered, collaborate with the hospice team to optimize care, encourage support of friends and family, honor their preferences, notify Hospice agency of any changes to the resident's condition, and observe pain and discomfort. The agency's contact information was also listed as an intervention. Review of Resident #35's Hospice agency CP, dated 03/14/2023, revealed nineteen (19) interventions listed for the resident's care. These interventions were related to seven (7) problems related to the dying process and hospice care. The problem areas were anxiety, bowels, hydration/nutrition, pain related to disease progression, requirements for comprehensive assessments, ensuring all parties involved in the resident's care understood and participated in the plan of care, safety risks for the resident, and skin integrity. In an interview with the SSD, on 06/02/2023 at 12:00 PM, she stated she was the facility's hospice representative. When asked about Resident #35's hospice agency care plan, she stated she only got them upon request. She stated she was not aware of the requirement to integrate the hospice care plan with the facility's care plan. She also stated she had not read the facility's hospice policy. The SSD said she had been the hospice representative for about one (1) year. In an interview with the Director of Nursing (DON), on 06/02/2023 at 11:46 AM, she said she would have to read the hospice policy to be able to speak on it completely. She stated the facility was to communicate with the hospice agency for any changes to the resident's needs and work with them to determine if the resident needed any therapy or medication changes. She said staff members were to call hospice, and the agency would send someone in. The DON stated the SSD conducted the hospice meetings and was responsible for getting the hospice care plan. The DON also stated the hospice agency would email their care plan over or discuss it with the SSD. In an interview with the Executive Director (ED), on 06/02/2023 at 1:23 PM, when asked who the facility representative was for hospice, the ED stated she could not think of her name, right now. She stated they are invited to the meetings but if they do not come, what can they do about it? She said she was not able to identify the hospice representative at this time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure each resident had a right to a safe, clean, comfortable, and homelike environment for eight (8) of eight (8) residents' sampled rooms. Observation on 05/19/2023 at 9:41 AM, revealed room [ROOM NUMBER], Resident #23's room, revealed bleach wipes and incontinent supplies in the windowsill, drawers removed from the bedside nightstand, papers inside the nightstand frame laying on the floor, papers laying in the floor in front of nightstand, cap noted inside night stand, multiple holes noted in wall, overbed table top lying on floor against wall at end of bed, bed footboard off bed and lying on commode in bathroom, one night stand drawer facing noted laying on commode, large oval mirror in bathtub, call/alarm system in Jevity box in bathtub, bathroom light noted not to work, electrical plug-ins and vents partially pulled out from wall. Additionally, multiple resident rooms were observed to have broken or missing slats in the window blinds, and observations of furniture in residents' rooms were in disrepair (Rooms 110, 127, 140, 226, 239, 240 and 241). The findings include: Review of the facility's policy, Homelike Environment, revised February 2021, revealed staff would provide a safe, clean, and homelike environment that emphasized the residents' comfort, independence, and personal needs and preferences. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflects a personalized, homelike setting to include comfortable and safe temperatures. 1. Observation on 05/19/2023 at 9:41 AM revealed room [ROOM NUMBER] had a bedside nightstand without drawers with papers laying on the floor in front of the nightstand, and papers and a cap in the bottom of the nightstand. Further observation revealed the overbed rolling tabletop laying on the floor against the wall and the heater at the foot of the bed. Continued observation revealed vents and electrical plugs pulled partially out from the wall and a broken electric plug cover. Additional observation revealed incontinence supplies and bleach wipes on the windowsill with the curtain open. Observation revealed holes in the bedroom walls and the baseboard missing. Further observation revealed the bed was not in the locked position and the footboard was missing. Observation of the bathroom of room [ROOM NUMBER] revealed the bathroom light did not work, a call light/alarm system in a Jevity box, and a large oval mirror inside the bathtub with Advanced 350 Ultrasorb in a plastic package laying on the side of the bathtub. Further observation revealed toilet paper, a graduated cylinder, V05 shampoo, soothed cool cleanser, hand sanitizer, and a box of X-Large gloves laying on top of the toilet tank, and the bed footboard and nightstand drawer facing laying on top of the commode lid. Continued observation revealed an X-Large blue plastic gown in a plastic bag laying on the front part of the bathroom sink, and the garbage can under the edge of the sink partially in the bathroom doorway. During an interview with Certified Nursing Assistant (CNA) #89, on 05/19/2023 at 10:15 AM, she stated she thought the maintenance issues for room [ROOM NUMBER] had been reported a couple of weeks ago. She stated she was unsure how long the nightstand drawers had been missing. She further stated she had not been in the bathroom. In an interview with Registered Nurse (RN) #19, on 05/19/2023 at 10:20 AM, she stated she had not been in room [ROOM NUMBER] that day. She further stated she would expect staff to supervise the resident's room for unsafe objects as the resident was allowed to his/her belongings in his/her room and staff should maintain a safe environment for the resident. 2. Observation of room [ROOM NUMBER], on 06/01/2023 at 9:57 AM, revealed the wall casing and trim entering the bedroom from the closet entry area had paint and plaster that was scraped away. Additionally, a chest had four (4) drawers that were off-track and hanging out of the chest, and the window blind had one (1) broken slat. 3. Observation of room [ROOM NUMBER], on 06/01/2023 at 10:05 AM, revealed paint and plaster that was scraped away on the walls and window blinds that had five (5) missing or broken slats. 4. Observation of room [ROOM NUMBER], on 06/01/2023 at 10:06 AM, revealed paint and plaster that was scraped away on the walls and window blinds that had four (4) missing or broken slats. 5. Observation of room [ROOM NUMBER], on 06/01/2023 at 10:07 AM, revealed paint and plaster that was scraped away on the walls and window blinds that had four (4) missing or broken slats. 6. Observation of room [ROOM NUMBER], on 06/01/2023 at 10:13 AM, revealed paint and plaster that was scraped away on the walls and window blinds that had one (1) missing or broken slats. 7. Observation of room [ROOM NUMBER], on 06/01/2023 at 10:19 AM, revealed paint and plaster that was scraped away on the walls and window blinds that had eight (8) missing or broken slats. 8. Observation of room [ROOM NUMBER] on 06/02/2023 at 2:00 PM, revealed there was a floor mat next to the bed with about one foot covering the bottom of the nightstand. The mat was ripped in three (3) different places, one was about six (6) inches in length. The nightstand was missing the handle on the first and third drawer but there were studs sticking out in place of the handle. Also, the baseboard was pulled out around the sink. The window blind on the door window was missing four (4) slats. Interview with the Maintenance Director on 06/02/2023 at 3:00 PM, he stated the studs sticking out of the nightstand would be a concern if the resident fell and hit his/her head on them. He also stated the missing baseboard and blind slats did not represent a homelike environment. The Maintenance Director stated he had already disposed of he ripped fall mat. He said it was a trip hazard. In an additional interview, with the Maintenance Director, on 06/01/2023 at 3:45 PM, he stated he started on 05/01/2023 and there was a lot to do within the facility. He stated the Corporation had hired an assistant that started around the middle of May 2023. He said a checklist had been created to begin doing room inspections throughout the entire facility; however, this procedure of going room to room had not started yet. He further stated a lot of touch-up work was needed to make the rooms more homelike, adding, he worked for the residents and this is their home. During an interview, on 05/19/2023 at 12:55 PM, the Director of Nursing (DON) stated it was her expectation that staff provided would expect the staff to make sure the environment was safe. She continued to state possible outcomes for bleach wipes in the room could have been gastritis, dermatitis, irritation to skin and tissue, nausea, vomiting, mouth pain, coughing, abdominal pain, irritation to the mucous membranes, eye irritation, hypersalivation, drooling, dizziness, and whatever is on the MSDS sheet. She additionally stated the situation could have been avoided by keeping the bleach wipes of the resident's reach and stored properly. During an interview with the Executive Director (ED) and the Senior [NAME] President of Clinical Services (SVPCS), on 06/01/2023 at 4:05 PM, both stated the residents' rooms were not homelike when things were not in good repair. Further, the ED further stated she had seen the missing or broken blinds from the parking lot. They further stated the Maintenance Director had developed a new checklist to help in auditing each of the resident rooms, to determine what might need to be fixed, but they have not started to complete observational rounds using the checklist. In an interview, on 05/19/2023 at 3:45 PM, the [NAME] President (VP) of Maintenance, stated he had not had a work order for room [ROOM NUMBER] since March 2023. He further stated he had a 04/12/2023 signed document that all plug-ins were in good working order at that time. He continued to state he had not had any notifications for maintenance issues in April or May 2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, it was determined the facility failed to protect the residents from misappropriation of property for one (1) of ninety-four (94) sampled residents, Resident #371. Resident #371 had missing belongings which included a family portrait. The findings include: Review of the Missing Item Policy, undated, revealed all reports of resident missing property shall be promptly and thoroughly investigated and documented. When a resident reported a missing item, the facility should report the matter up to the administrator. The administrator shall appoint a staff member to investigate the matter. The investigation shall consist of at least the following: a. A detailed description of missing item(s) and the last time the resident or his/her personal representative reports the item(s) in their possession; b. An interview with the resident who reported the missing item(s); c. An interview with the resident missing the item(s) if not duplicative of step a; d. A review of the resident's personal inventory record to determine if the missing item(s) were recorded on the inventory; e. A search of the general use areas for the missing item; f. A search of the resident's room for the missing item; g. A search of the resident's prior rooms if applicable; h. The staff member assigned to the investigation shall document all interviews and steps taken to find the missing item(s).When/if a resident's missing item(s) were found, they should be returned immediately to the resident if found item(s) match the initial description given by the resident or his/her personal representative. When/if a resident's missing item(s) were found after a resident was discharged , facility staff shall deliver the missing item(s) to the facility administrator. The administrator would place the found item(s) in a bag, if possible, with date, time, and location item was found. The facility would attempt to contact the resident to let them know that their missing item(s) was ready for pickup. Review of Resident #371's medical record revealed the facility admitted the resident on [DATE] with diagnoses of Parkinson's Disease, Neurocognitive disorder with Lewy Bodies, and Essential Hypertension. Review of Resident #371 admission Minimum Data Assessment (MDS), dated [DATE], revealed he/she required extensive assistance with activities of daily living (ADL). Further review revealed a Brief Interview for Mental Status (BIMS) Assessment on the same date, with a score of 99, indicating his/her cognition was severely impaired. Interview with Family Member (FM) of Resident #371, on [DATE] at 9:02 PM, revealed the family went to the facility after his/her passing to collect Resident #371's belongings. He/she stated they were given clothes not belonging to Resident #371 and staff could find any of Resident #371's belongings. Further interview revealed the family spoke with the administrator and the social worker, regarding the missing items and both were rude and unhelpful. Continued interview with Resident #371's FM revealed they never received the residents belongings, after speaking with Administration. Continued interview revealed the belongings the family were most concerned about, and never received, included a sixteen-inch wide by twenty-inch-tall family portrait, a bag embroidered with the resident's spouse's name and an Air Force blanket. Interview with Registered Nurse (RN) #18, on [DATE] at 8:25 PM, revealed she had worked at the facility for a few years. Further interview revealed Resident #371 resided in the memory care unit and the normal process for belongings when brought into the faciltiy was they were tagged/labeled with an indelible marker. She further stated there was supposed to be an inventory of belongings for every resident who was admitted and it should be in the computer, in the admission documents. RN #1 revealed if a resident passed away and their belongings were left at the facility, Social Services would see to it that the resident's belongings were collected and stored. She also stated if the family did not collect belongings, they were usually donated to someone in the facility. Interview with Licensed Practical Nurse (LPN) #31, on [DATE] at 9:10 PM, revealed she no longer worked at the facility but did remember Resident #371. Record review revealed she was working at the time of his/her passing. Further interview revealed she did not remember details of the resident's belongings being collected. She stated the typical process was to call family to report passing, then family would came in to obtain their things. She stated she did not think he/she had a lot of stuff, just some clothes and such. Continued interview revealed the expectation was to complete an inventory of resident belongings, at admission using a paper form. If family brought more things in for the resident, such as clothes or personal items; ideally those would be added to the inventory form. On [DATE] at 11:40 AM, an interview Interim Director of Nursing, revealed they encourage families to label all belongings, and educated that the facility would not be responsible for unlabeled stuff. Additionally, families were educated not to bring valuable belongings into facility. She stated inventory should be done at admission or shortly after and the assumption was that if there was no inventory sheet, the resident came with nothing. Further interview revealed they tried to educate families to use judgement about what residents really needed, such as snacks rather than money for snacks. She stated they generally put belongings waiting for pick up in an office, and encouraged families to come pick up within a day or two. Further interview revealed she was not sure if the family was provided the resident's belongings at the time of passing. In addition, was not able to provide evidence of an inventory form. On [DATE] at 10:41 AM, an interview with Executive Director (ED), revealed her expectation was that Certified Nursing Assistants (CNAs) were to take inventory of resident's belongings during admission. She stated families were encouraged to let staff know if they brought things in after the initial inventory was taken, so the items could be added to the resident's list of belongings. The ED stated going forward when a resident was discharged or deceased , belongings would be packed up and an inventory sheet would go with the family.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the facility's job descriptions, it was determined the facility failed to provide activities based on the comprehensive assessment and care plan and the preferences of each resident for four (4) of ninety-four (94) sampled residents (Resident #56, Resident #62, Resident #93 and Resident #271). The findings include: Review of the Activities Director's (AD) job description, as well as the Activities Assistant's (AA) job description, neither dated, revealed both were responsible for developing, organizing and ensuring implementation of a variety of activities for social, emotional, physical and other therapeutic needs of each resident. Under Essential Duties and Responsibilities, the policy revealed both positions were responsible for assessing residents and designing the activities program to meet the functional levels, needs, interests and choices of each resident. The roles would develop and implement the comprehensive activity program, including individual and group activities. Those in these positions would maintain dialogue with residents, family members, legal representatives and significant others to develop individualized activities programs, which promoted residents' needs, preferences and rights. Observation, on 02/14/2023 at 10:36 AM, revealed eight (3) residents seated in the common area of the [NAME] Hall who were watching television (TV), at 1:00 PM. Further observation revealed the AD was on the [NAME] Hall with ice cream and cake. It was noted there were no crafts being conducted with the Behavioral Unit. Crafts were being condcuted with the Memory Care Unit and at 3:54 PM, the smokers were gathered up and taken outside to smoke. Observation, on 02/15/2023 at 9:10 AM, revealed five (5) residents were gathered in the common area and watched TV. On 02/15/2023, at 2:21 PM, observation revealed the AD came through the [NAME] Hall and announced there would be live music in about twenty (20) minutes in the Men's Memory Care Unit. However, the residents from the Behavioral Unit were not allowed to go to the live music show to watch the performance. Observation, on 02/15/2023 at 2:55 PM, revealed Residents #56 and #62, who did not residen on the Men's Memeory Care Unit, were not allowed to go onto the Men's Memory Care Unit. Resident #56 looked through the window into the Men's Memory Care Unit. Observation, on 02/16/2023 at 12:45 PM, revealed Residents #271, #56 and Resident #15 seated in the common area and watched TV. Observation, on 02/17/2023 at 3:52 PM, revealed the live musical performance was back in the MMCU and again Resident #56, Resident 62 and Resident #271 were not allowed to go over and watch. Instead they sat in the [NAME] Hall common area and watched TV. Observation, on 02/20/2023 at 1:30 PM, revealed Residents, #56, #62, #93 and #271 were seated in the common area of the [NAME] Hall and watched TV. Observation, on 02/24/2023 at 12:04 PM, revealed it was Fast Food Friday, but not all of the residents on the [NAME] Hall participated in it. Residents #56, #62, #93 and #271 had facility food for lunch Resident #69 made comments about the food coming and it was all his/her, he/she did not have to share and nobody was getting any of his/her food. Resident #93 and Resident #271 watched on as the other residents had fast food. Resident #56 and #62 did not seem to notice any difference in the food. Interview with the Activity Director revealed only resident with personal spending money could get fast food. Observations, on 02/15/2023, 02/16/2023, 02/17/2023, 02/18/2023, 02/19/2023, 02/26/2023 and 02/27/2023, from 8:30 AM to 4:00 PM, revealed no activities were done with the BU residents. Observation, on 02/26/2023 at 3:00 PM, revealed the calendar stated, Resident's Choice for the activity. At 3:30 PM, the Interim Director of Nursing I(DON) entered the [NAME] Unit with a beach ball and asked the residents if they wanted to play. Residents #56, #60, #62, #93, and #271 were present in the common area, some said, no and the others showed no interest. The DON left the unit. Observation on 03/13/2023 at 3:00 PM, of the BU Activity calendar revealed staff were to play cards with the residents, this activity did not take place. 1. Review of Resident #56's clinical record face sheet revealed the facility admitted the resident on 11/17/2022 with diagnoses of Schizophrenia, Dementia without behaviors and Dysphagia. Review of Resident #56's admission MDS, dated [DATE], revealed the facility assessed the resident to have Hallucinations and paranoia, verbal and physical behaviors towards others and other behaviors not directed toward others. The facility assessed the resident with a BIMS score of three (3) out of fifteen (15) which indicated severe cognitive impairment. Review of Resident #56's Comprehensive Care Plan (CCP), dated 11/17/2020, revealed staff were to provide the activity of the resident's choice. The resident's CCP also revealed the resident wandered aimlessly and staff were to use distraction diversion such as structured activities, food, conversation, and books (11/22/2020). The facility was too encourage the resident to ambulate daily, walking inside and outside, to provide reorientation activities such as pictures, and memory box (11/22/2020). Resident #56 was a trauma survivor and it was noted in his/her care plan the resident enjoyed therapeutic activities such as coloring and journal (12/27/2022). 2. Review of Resident #62's face sheet, revealed the facility admitted the resident on 06/01/2020 with diagnoses of Schizophrenia, Dementia and Diabetes. Review of Resident #62's Quarterly MDS revealed the facility assessed the resident with a BIMS score of three (3) out of fifteen (15) signifying severe cognitive impairment. The facility assessed the resident to have behaviors of verbal and physical aggression for one (1) to three (3) days during the review period. The facility also assessed Resident #62 to reject care for one (1) to three (3) days. The resident required one person physical assistance for dressing eating, toilet use, walking in the room/corridor and for personal hygiene. For bed mobility and transfers the resident was identified as set up only. Review of Resident #62's CCP, initiated 06/03/2020 and revised 02/12/2023, revealed the resident enjoyed sitting in the common area with his/her peers, socializing and watching TV. It was also noted the resident enjoyed coffee, outdoors, card games, bingo and horse shoes. The resident also liked to watch TV in the room alone, attending church service and listening to music. The resident was care planned to need assistance and escort to activities. 3. Review of Resident #93's clinical record revealed the facility admitted the resident on 06/28/2021 with diagnoses of Paranoid Schizophrenia, Paranoid Disorder, and Hallucinations. Review of Resident #93's Quarterly MDS, dated [DATE], revealed the resident had a BIMS' score of ten (10) out of fifteen (15) which indicated moderate cognitive impairment. The facility also assessed the resident to have delusions, verbally and physical behaviors towards others and other behaviors present for one (1) to three (3) days during look back period. On the Quarterly MDS, dated [DATE], revealed the facility assessed the resident to had a BIMS of fourteen (14) out of fifteen (15) which indicated the resident was cognitively intact. The facility assessed the resident to be absent of any behaviors at that time. On 07/19/2022, the resident was discharged to the hospital with delusions, inattention, disorganized thoughts, physical and verbal behaviors towards others. Review of Resident #93's CCP dated 01/12/2023, revealed the resident was care planned to enjoy watching TV, socializing, playing some games, going outside and coffee and snack socials. 4. Review of Resident #271's clinical record face sheet revealed the facility admitted the resident on 01/30/2023 with diagnoses of Dementia, Diabetes and Anemia. Review of Resident #271's admission MDS dated [DATE] revealed the facility assessed a BIMS' score of six (6) out of fifteen (15) signifying the resident was severely cognitively impaired. In addition, the facility assessed the resident without behaviors, but rejected care one (1) to three (3) days through the evaluation period. The facility assessed the resident with daily wandering in the facility which was identified as intrusive to others. Review of Resident #271's Baseline Care Plan, dated 02/01/2023, revealed the facility would provide diversion to wandering through structured activities, food, conversation, books and television but it should have been the reference preference. Residents #56, #60, #62 and #271 were not interviewable. Interview, with Resident #93, on 02/14/2023 at 1:26 PM, revealed the resident stated he/she eloped from the facility because he/she wanted to go somewhere. The resident stated staff did not take residents for outings. The resident stated that the residents did not get to go out shopping, as staff did the shopping for residents. Interview, with Certified Nursing Assistant (CNA), on 03/03/2023 at 9:35 AM, revealed activities were not done with the men on the Behavioral Unit. She stated Patio time was the time smokers got to go out and smoke. She stated residents got to go out for about an hour when the weather was nicer. CNA #35 stated all residents were allowed to go out during Patio time but, the non smokers needed reminding. Interview, with Licensed Practical Nurse (LPN) #2, on 02/14/2023 at 2:36 PM, revealed sometimes Activities came and played board games or cards with the residents on the [NAME] Hall. She stated she did not feel like she kept up with the activities listed on the calendar. She also stated Patio time was the time residents, who smoked, got to go outside and smoke. She stated all residents were allowed to go out, but it was usually just the smokers. LPN #2 stated activities were very important for the residents because it kept them engaged in something besides each other. The LPN stated Activities were likely to help decrease any resident to resident problems. Interview, and observation on 03/01/23 at 12:59 PM, revealed Activities Assistant #3 stated she was taking down the old activity calendars in each resident's room and putting up new ones. She stated she just started to work five (5) days per week but before, she worked Wednesday, Thursday and Friday. AA #3 stated she tried to do activities with the Behavioral Unit (BU) at least once a day. She stated on this day there were be Corn Hole' at 3:00 PM. She also stated the residents had Patio Time which was smoking time and the residents got to go out several times a day for that. AA #3 also stated all residents were welcome to go outside during Patio Time and enjoy the day. She stated the residents on the East Hall got to go out of the facility. However, the residents on the BU did not gte to go out because the facility did not have another bus driver. AA #3 stated she was trying to get licensed to drive the bus, so the residents on the BU would be able to go out too. Interview, with LPN #19 on 03/09/2023 at 10:30 AM, revealed she worked three (3) days a week on the Men's Memory Care Unit. She stated she tried to do an activity with the residents every day. Continued interview revealed on 03/09/2023, she had the residents in a circle and had them doing exercises. LPN #19 stated it was very important for residents to have daily activities, she stated this helped to keep them from wandering, prevented resident to resident altercations, and helped to keep the residents' mind working. She said nursing staff had to do their part to help the activities team because they were not always available to do it. LPN #19 said the activity should still happen because it was not the residents fault; whatever staff had going on. Interview with the AD on 03/15/2023 at 3:10 PM, revealed the problem with the lack of activities was one of the assistants were just fired right before state entered the building, making them short one (1) staff member. She stated she had to rely on CNAs to help do the activities. She stated the management team was well aware of the concerns and the Executive Director (ED) tried to get another Activity Director hired. The AD revealed she was the one who made the monthly calendar of activities. She said she had to have faith staff were doing the activities listed. She said she was not on site all of the time but would pop in to see what the team was up to. The AD said she had one (1) aide who had worked at the facility for three (3) years and she did a great job with keeping the residents busy. The AD said the importance of activities was to keep the residents intellect and social skills up. She also noted she did try to take the residents on outings, she said the Memory Care Unit got to go on two (2) outings. Continued interview with the AD on 03/15/2023 at 3:10 PM, revealed for Fast Food Friday, all resident got to be involved. She said she did not know of any residents on the [NAME] Hall who did not have money and she did not know why some of them would have been exploded in getting food. She said the Memory Care Director bought the residents food once a month too. She stated she would have to check with AA #3 to find out what happened as she was the one responsible for the Fast Food Friday on that day. The AD also said all of the residents were allowed to go outside for Patio time. She said she would make sure all residents were reminded they could go out, even if they did not smoke. Interview with the ED on 03/16/2023 at 11:00 AM, revealed she looked at hiring another AD for the [NAME] Hall specifically and through she had that resolved. She said the residents in that unit liked to go outside. She said there was another bus to use for those residents and the aide worked to get her licenses so they could take the [NAME] Unit residents out of the facility. She wanted all of the facility's residents to be about to go out and shop. She said she was working to get the residents out and about. The ED stated it was important to keep the residents busy as that would help prevent wandering, and hopefully decrease falls and cut back on resident to resident incidents. She also stated the residents' care plans should be followed as well as the facility policies to ensure the residents got the best possible care.

Based on interview and review of the Activity Director's job description, it was determined the facility failed to ensure the Activity Program was directed by a qualified therapeutic recreation specialist or an activity professional who was licensed or registered by the State. The Executive Director (ED) stated in an interview on 05/23/2023, that the facility did not have an Activity Director in place who possessed the qualifications to serve in a Long-Term Care Facility. The findings include: Review of the Activity Director's job description, undated, revealed the required education and/or experience to fulfill the duties was an associates degree (A.A.) or equivalent from a two (2) year college or technical school, or two (2) to four (4) years related experience and/or training, or equivalent combination of education and experience, as well as meet state and federal requirements. During interview with Certified Nursing Assistant (CNA) #18/Activities Assistant #5, via telephone on 05/25/2023 at 7:18 PM, she stated she completed an Occupational Therapy Assistant degree. However, she had not taken the certification examination. She also stated she worked as an aide for fourteen (14) years, and had previously worked as an Activities Assistant at a different facility. She further stated she would be taking the Activity Director's position. Certified Nurse Aide (CNA) #18/Activities Assistant #5, stated she would apply for a temporary license and complete the post graduate field work while the board examination was pending. She stated she was not a certified Activity Director, but she was enrolled in a certification course that would begin in June 2023. During the interview, she stated the activities program was important because it helped the residents emotionally, and when residents were more engaged, they could become less agitated. During interview with the Human Resources Manager, on 06/02/2023 at 4:45 PM, she stated CNA #18/Activities Assistant #5 would no longer be taking the Activity Director position, as she she was no longer working at the facility. She stated the other new Activity Director had just started as of this date. The Executive Director (ED) stated during interview, on 05/23/2023 at 4:09 PM, that the previous Activity Director left about mid-March 2023. She stated she hired a replacement, but that person never started due to health issues. The ED stated two (2) new Activity Director hires were pending, one (1) for the upstairs unit and one (1) for the East side unit. She stated neither was currently certified as an Activity Director, but both were enrolled in the June 2023 class to receive that certification. During interview with ED, on 06/02/2023 at 1:23 PM, she stated one (1) of the new Activity Directors started today, but the other would not be filling that position after all.

Based on interview, record review and review of facility policy, the facility failed to ensure a performance review of every nurse aide was completed at least once every twelve (12) months and failed to provide regular in-service education based on the outcome of those reviews for four (4) Certified Nursing Assistants (CNAs) CNA #1, CNA #6, CNA #19 and CNA #21. The findings include: Review of the facility policy titled Staffing, Sufficient Competent Nursing dated 08/2022, revealed competency was a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needed to perform work roles or occupational functions successfully. All nursing staff must have met the specific competency requirements of their respective licensure and certification requirements as defined by state law. Interview with Licensed Practical Nurse (LPN) #3, on 03/15/2023 at 10:55 AM, revealed she worked at the facility with CNA #1, CNA #6, CNA #19, and CNA #21 for more than one (1) year. Interview with the Human Resources staff person, on 03/16/2023 at 9:50 AM, revealed she could not find the completed nurse aide performance reviews, for CNA #1, CNA #6, CNA #19, and CNA #21, all of whom had been employed as CNAs by the facility for twelve (12) or more months. Interview with the Staff Development Coordinator (SDC), on 03/15/2023 at 2:55 PM, revealed she had been in her position for three (3) weeks. The SDC stated she would be responsible for competency oversight once she was properly trained. She expected to be properly trained soon after the facility's recertification survey was completed. She stated staff was evaluated when hired and annually to assess their competencies, skills, and knowledge. The SDC stated she had not been in the role of SDC long enough to determine CNA training needs. Request for records from the Executive Director, on 03/15/2023 at 1:25 PM, for the performance reviews of any and all CNAs employed by the facility for more than twelve (12) months revealed no documentation of CNA performance reviews was provided.

Based on interview, record review, review of the facility's investigation reports, review of the Pharmacy Services Agreement, review of Pharmacy invoices, and review of the facility's policies, it was determined the facility failed to have safeguards and systems in place to control, account for, and reconcile controlled medications to ensure all controlled medications were maintained for three (3) of ninety-nine (99) sampled residents (Residents #21, #71, and #521). Review of Resident #71's Medication Administration Record (MAR) revealed he/she was prescribed Norco (Hydrocodone-Acetaminophen, an opioid pain reliever) 7.5-325 milligram (mg). There was a discrepancy of thirty-five (35) tablets between the narcotic control sheet and the resident's MAR, from 04/20/2022 to 05/12/2022. Review of Resident #21's MAR revealed he/she was prescribed Norco 7.5-325 mg. There was a discrepancy of fifty-four (54) tablets between the narcotic control sheet and the resident's MAR, from 04/15/2022 to 04/28/2022. Review of Resident #521's MAR revealed he/she was prescribed Hydrocodone-Acetaminophen 5-325 mg, give one (1) tablet by mouth every twelve (12) hours as needed for chronic pain. However, there was a discrepancy of thirty-three (33) tablets between the narcotic control sheet and the resident's MAR, from 12/01/2021 to 12/18/2021. Further, the facility failed to determine that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. Review of multiple Controlled Medication Shift Change Log sheets, from different nursing units, revealed they were not signed off by two (2) licensed nurses. The findings include: Review of the facility's policy titled, Accepting Delivery of Medications, revised February 2021, revealed all staff shall follow a consistent procedure in accepting medications. Medications were to be delivered to and signed for by a nurse. Review of the facility's policy titled, Controlled Substances, dated 08/27/2018, revealed the storage of controlled substances must be strictly monitored. The number of controlled substances on hand must be counted and verified at the end of each shift. The Narcotic Sign In Sheet must be completed at the end of each shift every day. The Out-Going Nurse or his/her designee would count all controlled substances being stored at the community while the On-Coming Nurse or his/her designee watched. Both staff members must sign that the count and verification have been completed. Per the policy, if the count did not match the controlled substances on hand, the Administrator/Designee would be notified immediately. Review of the Pharmacy Services Agreement, signed 10/01/2021, revealed the facility retained responsibility for reconciling the applicable orders against the records supplied by Pharmacy. Continued review revealed the Pharmacy shall conduct sample audits of nursing stations, drug storage areas, and medication carts to review compliance with Pharmacy policies and procedures and Applicable Laws regarding drug handling, storage, and distribution. Per the policy, Pharmacy shall provide reports to the facility of any findings and recommendations related to such audits. 1.a. Review of Resident #71's medical record revealed the facility admitted the resident on 01/21/2021 with diagnoses of Quadriplegia, Anxiety Disorder, and Protein-Calorie Malnutrition. Review of Resident #71's Physician's Orders revealed an order for Norco tablet 7.5-325 mg, give one (1) tablet by mouth every six (6) hours as needed for pain. The medication had a start date of 04/04/2022. Review of Resident #71's Medication Administration Record (MAR) revealed he/she was prescribed Norco (Hydrocodone-Acetaminophen, an opioid pain reliever) 7.5-325 milligram (mg) to be administered every six (6) hours as needed for pain. However, there was a discrepancy of thirty-five (35) tablets between the narcotic control sheet and the resident's MAR, from 04/20/2022 to 05/12/2022. Review of Resident #71's Controlled Drug Receipt/Record/Disposition form (CDRRDF), dated 04/20/2022, revealed the resident was dispensed Hydrocodone-Acetaminophen 7.5-325 mg every six (6) hours for pain. However, the nurse's signature that received the medication was illegible, and there was only one (1) signature. Also, the quantity received was illegible. Further review of the CDRRDF from 04/20/2022 to 04/29/2022, revealed Resident #71 received twenty-nine (29) tablets from 04/20/2022 to 04/29/2022. Review of Resident #71's Medication Administration Record (MAR), dated 04/20/2022 to 04/29/2022, revealed an entry for Hydrocodone-Acetaminophen tablet 7.5-325 mg, give one (1) tablet by mouth every six (6) hours as needed for pain, with a start date of 04/18/2022 and a discontinue date of 04/28/2022; there was a new order written on 04/28/2022 with an end date of 07/05/2022. The MAR showed Resident #71 received one (1) tablet on 04/20/2022; 04/21/2022; 04/25/2022; 04/26/2022; 04/27/2022; and 04/29/2022. This was a total of six tablets taken by Resident #71 during this time. Review of the CDRRDF, from 05/01/2022 to 05/12/2022, revealed Resident #71 received twenty-eight (28) tablets of Hydrocodone-Acetaminophen 7.5-3.25 mg from 05/01/2022 to 05/12/2022. Review of Resident #71's MAR, from 05/01/2022 to 05/12/2022, revealed Hydrocodone-Acetaminophen Tablet 7.5-325 mg, give one (1) tablet by mouth every six (6) hours as needed for pain, with a start date of 04/28/2022 and a discontinue date of 07/05/2022. Further review revealed Resident #71 received two (2) tablets on 05/01/2022; one (1) tablet on 05/02/2022; one (1) tablet on 05/03/2022; two (2) tablets on 05/04/2022; one (1) tablet on 05/07/2022; three (3) tablets on 05/09/2022; one (1) tablet on 05/10/2022; three (3) tablets on 05/11/2022; and two (2) tablets on 05/12/2022. This was a total of sixteen (16) tablets taken by Resident #71 during this time. Telephone interview with Registered Nurse (RN) #17, on 03/30/2023 at 4:15 PM revealed she might have given a medication to a resident and not documented it on the MAR. She further stated this was a mistake, and it should not have occurred. Review of Resident #71's medication invoice from the pharmacy revealed Medicare A was billed on 05/13/2022 for Hydrocodone-Acetaminophen tablets 7.5-325 for a quantity of sixty (60) tablets. 1.b. Review of Resident #21's medical record revealed the facility admitted the resident on 03/29/2021 with diagnoses to include Muscle Weakness, Unsteadiness on Feet and Morbid Obesity. Review of Resident #21's Physician's Orders revealed an order for Norco 7.5-325 mg, give one (1) tablet by mouth every eight (8) hours as needed for pain, with a start date of 04/12/2022 and an end date of 05/16/2022. Review of Resident #21's CDRRDF, dated 04/15/2022, page 3 of 3, revealed a quantity received of thirty (30) tablets of Hydrocodone/Acetaminophen 7.5/325 mg, one (1) tablet by mouth three (3) times a day. It also revealed, from 04/17/2022 to 04/27/2022, the resident received twenty-eight (28) tablets. Review of Resident #21's MAR revealed Norco Tablet 7.5-325 mg, give one (1) tablet by mouth every eight (8) hours as needed for pain, with a start date of 04/14/2022 and a discontinue date of 05/16/2022. Per the MAR, from 04/17/2022 to 04/26/2022, Resident #21 received one (1) tablet on 04/23/2022 and two (2) tablets on 04/26/2022. This was a total of three (3) tablets taken by Resident #21 during this time. Review of Resident #21's MAR revealed there was a discrepancy of fifty-four (54) tablets between the narcotic control sheet and the resident's MAR, from 04/15/2022 to 04/28/2022 Review of the facility's Investigation Report, dated 05/13/2022, revealed on 05/08/2022, the facility identified Resident #71 and #21 were missing narcotics. Stat orders (orders that were to be done immediately) were placed by the facility to replace the residents' missing medications. Per the report, RN #13 was identified as the nurse who signed for the missing medications. RN #13 was placed on suspension pending investigation and then resigned from her position on 05/11/2022. Review of the pharmacy invoices, dated 05/31/2022, and an email from the Account Services Director to the facility's [NAME] President of Operations, dated 05/09/2022, revealed sixty (60) tablets of Norco had been replaced for Resident #71, and thirty (30) tablets of Norco had been replaced for Resident #21 at the facility's expense. Interview with the Pharmacy Manager, on 03/31/2023 at 3:57 PM revealed the account management department audited the medication carts monthly. He stated he did not audit the medication carts, but he monitored the trends of audits. He stated his role was the Pharmacist in Charge. In addition, after the State Survey Agency (SSA) Surveyor requested records of controlled substances and the facility's audits. The fax was sent on 03/31/2023. Telephone call follow-up to the Pharmacy Manager, on 04/04/2023 at 11:45 AM revealed they were compiling the information on controlled substances at the facility. Further interview revealed they needed approval from their cooperate compliance team prior to sending the report. Interview with the Pharmacist in the Account Management Department, on 03/31/2023 at 5:19 PM revealed if there was a narcotic diversion, the facility would contact her. She stated she would look to see how the supply was filled and if it was billed to a third party. She stated she would change the billing to the facility and send the controlled substance only if the resident needed the medication. She stated she would reach out to the prescriber and get a new prescription. She stated she looked in her computer to see if there were any narcotic diversions. Continued interview revealed there had been a diversion with Norco 7.5-325 mg in May 2022. She stated it had been billed because the resident was on Medicare. However, she stated, on 05/09/2022 the pharmacy billed ninety (90) tablets to the facility. Telephone interview with the pharmacy Account Manager, on 04/04/2023 at 5:35 PM revealed she had been the account manager for about three (3) years. She stated the last audit of the facility was March 31, 2023. She stated, since COVID, they did not inspect the carts or the narcotic sheets. She stated she did a paper audit of the narcotic sheets. Continued interview revealed they did look at the Controlled Substance Books. She stated, about a year ago, the facility stopped using the pharmacy's forms and started using blue logs instead. She stated she was not personally aware of the facility asking them to account for narcotics and billing, which would have gone through the compliance department. She stated the facility did ask her to do a narcotics audit. She stated she did one on 05/18/2022. The Account Manager stated she did a spread sheet, which she provided to the facility, and there were obviously some items missing. She stated the information was in a pharmacy report provided to the facility. Further interview revealed the previous DON received reports of the controlled substances that were dispensed and what the facility showed it had on hand. 1.c. Review of Resident #521's medical record revealed the facility admitted the resident on 09/27/2021 with diagnoses of Bipolar Disorder, Morbid Obesity, and Chronic Pain Syndrome. Review of Resident #521's Physician's Orders revealed an order for Hydrocodone-Acetaminophen Tablet 5-325 mg, give one (1) tablet by mouth every twelve (12) hours as needed for chronic pain, with a start date of 09/30/2021 at 9:15 AM and an end date of 12/30/2021. Review of Resident #521's Dispensed Controlled Medications revealed the facility received sixty (60) tablets of Hydrocodone-Acetaminophen 5-325 mg, dispensed 12/01/2021. Review of the facility's Initial Investigation Report, dated 12/19/2021, revealed Resident #521 requested a pain pill on 12/18/2021, and there were none in the cart. Per the report, the nurse called pharmacy for a refill and was told sixty (60) tablets of Hydrocodone-Acetaminophen 5-325 mg were sent at the beginning of the month. Review of Resident #521's December 2022 MAR revealed the resident had received twenty-seven (27) tablets of Hydrocodone-Acetaminophen 5-325 mg for the month of December 2021 from 12/01/2022 to 12/18/2022. Review of the facility's 5-Day Investigation Report, dated 12/24/2021, revealed the facility could not validate the medication was taken by an employee and whether thirty (30) or sixty (60) tablets were missing. Per the report, the facility obtained a replacement prescription from the Medical Director for thirty (30) tablets to be paid for by the facility. The narcotic dose count sheets for Resident #521 for 11/01/2021 to 01/30/2022 were requested, but the facility was unable to provide the sheets. 2. Review of the Controlled Substance Book, for the [NAME] Unit, revealed the instructions explained to refer to the facility's pharmacy procedure manual for specific instructions on documenting controlled substances. In general, it stated to fill out and log in all information completely; if an error was made, cross out the mistake and initial next to the error; when a refill was received, add the new quantities to the previous quantity; when completing a controlled substances shift count, examine the page and card (Front and Back) to verify the correct count; and both nurses needed to check the count. Review of the [NAME] Unit Controlled Substances Book, on 04/01/2023, which contained the unit's Controlled Medication Shift Change Logs revealed there were eighty (80) missing signatures out of four hundred twenty-four (424) signature opportunities. Review of the facility's record sheet Controlled Medication Shift Change Log, for the C Unit Medication Cart, dated 11/18/2021 to 11/27/2021, revealed seven (7) instances in which either the On-Coming or the Off-Going staff 's signature spaces were blank. Review of the facility's Controlled Medication Shift Change Log, for the East B Hall Medication Cart, dated 11/19/2021 to 11/29/2021, revealed four (4) instances in which either the On-Coming or the Off-Going staff signature spaces were blank. Additionally, the count sheet quantity from the previous sheet was not signed by either the On-Coming nurse or the Off-Going Nurse. Review of the facility's record sheet Controlled Medication Shift Change Log, for the A Hall Medication cart, dated 11/08/2021 to 11/30/2021, revealed twenty-one (21) instances in which either the On-Coming or the Off-going staff signature spaces were blank. Additionally, the count sheet quantity from the previous sheet was not signed by the On-Coming Nurse. Review of the facility's record sheet Controlled Medication Shift Change Log, for the C/D COVID Hall, dated 11/28/2021 to 11/30/2021, revealed two (2) instances in which either the On-Coming or the Off-Going staff signature spaces were blank. Interview with the Interim Director of Nursing (DON), on 03/30/2023 at 8:50 AM revealed she expected staff to verify all controlled substances when they were delivered from Pharmacy. Further, she stated she expected two (2) licensed nurses to document the receipt and count of controlled substances. Continued interview revealed she had not had any issues with controlled substances since she had been the Interim DON from December 2022 to 03/10/2023. She stated she was now the Resource Nurse at the facility. Interview with the ED, on 03/30/2023 at 10:30 AM revealed she expected the DON to make sure the nurses were educated to document and correctly give controlled substances to residents. She stated she had a discussion with the DON about controlled substances, and they were developing a plan to assure controlled substances were correctly handled. Further, she stated she had not been told of any issues with controlled substances since she had been the ED from October 2022 to today.

Based on observations, interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to have an effective system to ensure the proper temperature ranges of the medication refrigerators. Observation revealed six (6) residents' insulin was stored below freezing temperature, at twenty-six (26) degrees Fahrenheit (F). There were influenza vaccines and Tuberculin Purified Protein Derivative (PPD) testing solutions were also stored below 32 degrees F. Additionally, the facility failed to ensure all drugs and biologicals were stored in locked compartments in accordance with State and Federal laws. Observations and interviews revealed a medication cart and a treatment cart, which contained drugs and biologicals, were left unlocked. Residents were observed passing by the unlocked treatment cart. The findings include: Review of the facility's policy, Storage of Medications, revised November 2020, revealed drugs and biologicals used in the facility were stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. Compartments including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes containing drugs and biologicals were locked when not in use. Unlocked medication carts were not to be left unattended. Review of the Food and Drug Administration's (FDA) article, Information Regarding Insulin Storage and Switching Between Products in an Emergency, dated 09/17/2017, revealed according to the product labels from all three U.S. insulin manufacturers, it was recommended that insulin be stored in a refrigerator at approximately thirty-six (36)° Fahrenheit (F) to forty-six (46)°F. Unopened and stored in this manner, these products maintain potency until the expiration date on the package. Further review revealed users should not use insulin that has been frozen. Review of the Centers for Disease Control and Prevention's (CDC) article, Storage Best Practices for Refrigerated Vaccines - Fahrenheit (F), undated, revealed users should unpack vaccines immediately then place the vaccines in trays or containers for proper air flow, put vaccines that were first to expire in front, keep vaccines in original boxes with lids closed to prevent exposure to light and separate and label by vaccine type. Further review revealed vaccines should never be frozen, except for Measles-Mumps-Rubella vaccine which can be stored in the refrigerator or freezer and the ideal temperature was forty (40)° F with an acceptable range of 36° F to 46° F. Continued review revealed vaccine storage best practices included ensuring the refrigerator door was closed, to replace crisper bins with water bottles to help maintain consistent temperature, label water bottles Do Not Drink, leave two - three inches between vaccine containers and refrigerator walls, and post Do Not unplug signs on the refrigerator and near the electrical outlet. Record review revealed dormitory-style refrigerators should not be used; vaccines should not be stored on the top shelf, the door shelves or on the floor of the refrigerator; water bottles should not be removed or consumed; and food or beverages should not be stored in the same refrigerator. Review of the CDC's article, Vaccine Storage and Handling Toolkit, dated September 2021, revealed refrigerators should maintain temperatures between 36° F and 46° F. Further review revealed every vaccine storage unit must have a temperature monitoring device (TMD) and that an accurate temperature history that reflected actual temperatures was critical for protecting vaccines. Additional review revealed the CDC recommended a specific type of TMD called a digital data logger (DDL) because it provided the most accurate storage unit temperature information, including details on how long a unit had been operating outside the recommended temperature range, also known as a temperature excursion. Additional review revealed a DDL provided detailed information on all temperatures recorded at preset intervals. Record review revealed a refrigerator door that was not sealed properly or left open unnecessarily not only affected the temperature in a unit, it also exposed vaccines to light, which could reduce the potency of some vaccines. Users should consider using safeguards to ensure the doors of the unit remain closed-for example, self-closing door hinges, door alarms, or door locks. Review of the Tuberculin Purified Protein Derivative (PPD) package insert, undated, revealed it should be stored in a temperature range of 35° to 46° F. Further review revealed Tuberculin PPD should not be frozen and should be discarded if exposed to freezing. Continued review revealed Tuberculin PPD should be stored in the dark except when doses were being withdrawn from the vial and the solution could be adversely affected by exposure to light. Additional review revealed a vial of Tuberculin PPD which had been entered and in use for 30 days should be discarded and not used after the expiration date. 1. Observation of the [NAME] Wing medication room refrigerator, on 02/16/2023 at 10:27 AM, revealed Influenza vaccines, two (2) five (5) milliliter (ml) vials with syringes, expiration date 05/25/2023, stored on the top shelf. Observation revealed an insulin pen, 0.25 milligram (mg) - 0.5 mg, stored in the door. Further observation revealed the refrigerator held four (4) influenza vaccine vials on the door, one was opened, with no open date, and an expiration date of 05/25/2023. Observation, on 02/16/2023 at 11:20 AM, revealed the medication refrigerator temperature for the Alzheimer's Care Unit (ACU) and Acute Alzheimer's Care Unit (AACU) measured 26 °F, and there was no thermometer in the freezer, but there was nothing stored in the freezer. Continued observation revealed the refrigerator contained insulin and four (4) influenza vaccine vials in the refrigerator door. Additional review revealed the temperature log was up to date. However, there was no thermometer found in the refrigeration. Interview, with Registered Nurse (RN) #1, at the same time, revealed she would check the temperatures, but she was not sure what was safe. Observation, of the medication storage refrigerator on the East Wing by Hall D, on 02/16/2023 at 10:40 AM revealed the temperature log was up to date and the temperatures measured, at that time revealed the freezer's temperature was at 20° F and the refrigerator was at 52° F. Further observation revealed the items in stock in the refrigerator were seven (7) vials of influenza vaccine, stored on the bottom shelf. One (1) vial box was opened, but there was no open date. There was also two (2) Tuberculin Purified Protein Derivative (PPD, a solution used to test for the presence of Tuberculosis) received on 02/07/2023. Observation, of the medication storage refrigerator on the East Wing by Hall B, on 02/16/2023 at 10:55 AM, revealed the temperature log was up to date with the current temperature measured at 51° F. Continued observation revealed the refrigerator door was not sealing. The medications stored in the refrigerator, at that time included: Amoxil, delivered on 02/03/2023; Insulin Levemir; intravenous Rocephin and intravenous vancomycin, both with use by date 02/22/2023; and Tuberculin PPD, stored on the bottom shelf. Review of the Email (electronic mail) response from the manufacturer of the influenza vaccine, on 02/16/2023 at 4:20 PM, revealed the temperature excursion was anything outside the range of 34.6 °F - 46.4°F. Further review revealed any product stored outside that range should be discarded. Interview, with RN #8, who worked the B Hall, on 02/24/2023 at 7:00 AM, revealed 42°F was in range as the range should be 35-42 degrees F. She stated if the temperature was out of range, she would take the things out and put them on ice, until day shift would come into address. She also stated the potency of the meds could be destroyed if out of range. Observation, of the medication storage refrigerator by Hall D, on 02/17/2023 at 9:30 AM, revealed the current temperature was 22° F. Further observation revealed the medications in the refrigerator at that time included: an insulin pen; thirteen Novolog (type of insulin) insulin pens; eight Humalog insulin pens; three Ozempic (brand) insulin pens; two Trulicity insulin pens; nine Basaglar insulin pens; four Novolog insulin vials and two Lantus insulin vials. Further observation revealed two shingles vaccine vials, two Tuberculin PPD solution vials and seven vials of influenza vaccine, stored on the bottom shelf. Continued observation revealed the Emergency Kit, which held two 'Novolog pens, two Levemir pens, two Humalog pens and one Lantus pen. Observation, of the medication storage refrigerator by D Hall, on 02/20/2023 at 3:43 PM revealed a new refrigerator; however, the temperature shown on the thermometer was 28 degrees F, which was confirmed by Licensed Practical Nurse (LPN) #3. Continued observation with LPN #3 revealed no instruction on the log sheet of the correct temperature range or what action to take if the temperature was out of range. Further review revealed the recorded temperature for the refrigerator, on 02/19/2023 was 30 degrees F. Further observation revealed the insulins and Tuberculin PPD were discarded. Interview, with Registered Nurse (RN) #1, on 02/16/2023 at 11:20 AM, revealed she would check temperatures, but she was not sure what was safe. Interview, with RN #4, on 02/16/2023 at 10:40 AM, revealed she understood night shift nurses checked the refrigerator temperatures, crash cart supplies and changed gastrostomy tube bags and tube feeding. She stated she did not know the appropriate temperature range for the medications and vaccine storage. RN #4 stated nor did she know whether there were restrictions on where the medications could be stored inside the refrigerator. Interview, with RN #5, on 02/16/2023 at 10:55 AM, revealed high temperatures were a concern, and if high temperatures were found, she would put in a work order for the refrigerator to be repaired. Further interview revealed medication storage refrigerator temperature was important to maintain quality of medications. She also stated she would put in a work order today. Interview with the Corporate [NAME] President (VP) of Clinical Education, on 02/17/2023 at 10:13 AM, revealed if medications were stored out of temperature range, it would affect the medication efficacy. She further stated she would replace any medications stored out of temperature range. Interview with Pharmacist #2, on 02/1720/23 at 12:57 PM, revealed the facility should store insulin pens in the refrigerator until removed for use. Further interview revealed insulin pens could not be stored at temperatures greater than 86 degrees longer than 14 days and should not be stored below freezing, 32 degrees F. Further interview revealed for tuberculin testing vials if they were stored at less than 35 °F, then they could potentially not be active after it thaws. Continued interview revealed insulin should ideally be stored in the middle of the refrigerator, but she was not aware of an official recommendation. She stated the pharmacy did dispense some flu vaccine in the A/B wings of the facility and that excursions would be even just a few hours, but the medication should not be stored below 35° F. Continued interview revealed that specifically flu vaccines should be stored between 36° F and 46 °F. Interview with LPN #3, on 02/20/2023 at 3:23 PM, revealed she was not sure what the range medications were supposed to be stored. She stated the effectiveness of the medications could be affected by the wrong temperature. Interview, on 02/20/2023 at 4:59 PM, with the Interim Director of Nursing (IDON) revealed she knew the appropriate temperature range for medication storage refrigerators was 36 - 46 degrees F. She stated there was no specific clarity in how staff would know what the correct temperature range was or what to do if finding the refrigerator was out of range. 2. Observation of the D Hall treatment cart, on 02/21/2023 at 2:42 PM revealed it was located in the hall below the sign, D HALL 135-148 and was unlocked. Observation of the D Hall treatment cart, on 02/21/2023 at 2:49 PM, revealed an Activities staff member placed a sign on the unlocked treatment cart that read Resident Council in Progress. She subsequently took the sign off the cart and placed it on a nearby medication cart. At that time, observation revealed no nurses were supervising the unlocked treatment cart. Observation of Resident #103, on 02/21/2023 at 2:55 PM, revealed he/she pushed the treatment cart aside to enter the activities room and attended the upcoming Resident Council meeting. The treatment cart remained unlocked, and at this point, the cart had been unlocked and unattended by staff for thirteen (13) minutes. Observation of the treatment cart, on 02/21/2023 at 3:16 PM, revealed it was locked and RN #2 was now at the nearby nurses station. Observation of the treatment cart contents and subsequent interview with Registered Nurse (RN) #2, on 02/21/2023 at 3:16 PM, revealed it contained the following: silver sulfadiazine cream; povidone-iodine antiseptic spray; hydrogel silver antimicrobial wound gel with the cap removed; nystatin/triamcinolone/acetonide ointment; six (6) zinc oxide formula packets; anti-fungal cream and antifungal powder; petroleum jelly; collagen wound dressing with silver alginate wound dressing; collagenase ointment; wound cleanser spray; and a brown substance on the bottom of the treatment cart drawer. Interview with RN #2 revealed the treatment cart should remain locked for safety purposes and only licensed personnel should be able to access the cart and its contents. Interview, with RN #6, on 02/21/2023 at 5:36 PM, revealed she asked RN #2 to unlock the treatment cart so she could get some supplies, but she could not remember if she re-locked it. RN #6 stated the treatment cart should be locked and if it was not locked residents could get something out of the unlocked treatment cart and ingest it. Observation, on 03/04/2023 at 4:56 PM, revealed the medication cart on the [NAME] Unit was unlocked. The unlocked medication cart was located in a resident common area between the Physical Therapy Gym door and the Nurses' Station. At that time, observation also revealed no nurses were supervising the unlocked medication cart. Interview, with RN #11 on 03/04/2023 at 4:57 PM, who was assigned to the medication cart, revealed she did not lock the cart. She stated the cart should be locked, and if it was not locked residents could get into the cart. Interview, with the Interim Director of Nursing (IDON), on 03/16/2023 at 4:00 PM revealed she expected medication and treatment carts to be locked when not in use. The IDON stated anything could happen if a medication or treatment cart was left unlocked, such as a resident could grab something that was not theirs. Interview, with the Executive Director, on 03/16/2023 at 11:34 AM revealed her expectation was that nurses would keep medications securely stored. Further interview revealed she expected medication carts to remain locked when unattended because this could be a safety risk to the residents. Continued interview revealed she expected to be notified if the medication storage refrigerator temperatures were out of range so she could develop a solution. She also stated she expected staff would remove items from a refrigerator with a temperature that was unsuited for medication storage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Interview with Dietary Manager, on 02/20/2023 at 1:42 PM, revealed she required the staff to wear masks in the kitchen area to prevent the spread of COVID. Observations on 02/19/2023 at 2:27 PM, of Dietary Aides #1, #4, and [NAME] #3, revealed the staff were not wearing N95 masks. Observation in the kitchen, on 02/20/2023 at 9:47 AM of [NAME] #3 and Diet aide #1, revealed they were not wearing mask. Interview with [NAME] #2, on 02/20/2023 at 1:03 PM, stated it was hot around the ovens and he would just raise his mask to cool off. Interview with Dietary Aide #1, on 02/20/2023 at 1:26 PM, revealed it was hard to breathe through the mask. The aide stated the Dietary manager required staff to wear the mask, because it protected residents/staff against COVID infections. Interview with [NAME] #3, on 02/20/2023 at 1:30 PM, revealed staff were required to wear a mask in the kitchen, and wearing a mask decreased the transfer of COVID to residents with underlying health issues. Interview with Diet Aide #2, on 02/20/2023 at 1:34 PM, and Diet Aide #4, on 02/20/2023 at 1:39 PM, revealed they both were to keep mask on, and they wore the mask to prevent COVID spread to the residents. Interview with Dietary Manager (DM,) on 02/20/2023 at 1:42 PM, revealed staff were to keep a mask on in the patient care areas, to prevent the spread of COVID, to staff and residents. DM further stated she also required the staff to wear masks in the kitchen area, to prevent the spread of COVID. Interview with Interim Director of Nursing (DON) Infection Control, on 02/22/2023 at 2:05 PM, revealed staff wore N95 masks in the patient care areas. She stated the facility followed the CDC guidelines concerning the of masks in resident areas. She stated she supported the DM, concerning staff wearing masks in the kitchen. Interview with Executive Director (ED) on 02/26/2023 at 2:24 PM, revealed she supported the Dietary manager in regards to requirement for staff to wear their masks in the kitchen. She stated wearing masks prevented the spread of COVID. Based on observation, interview, and review of facility's policy it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control communicable diseases and to implement interventions per the Centers for Medicare and Medicaid (CMS) and the Centers for Disease Control and Prevention (CDC). Observations revealed Personal Protective Equipment (PPE) was not worn for sorting dirty laundry, and staff allowing clean linens to touch front of garment while folding clean linens. In addition, food particles observed in floor and on tabletops in west dining room. Further observations revealed all required PPE was not worn while providing direct resident care to resident in enhanced barrier precautions. Continued observations included staff placing dish on resident's food tray, after picking it up off the floor and staff not wearing N95 masks in the kitchen, per department practice. Also staff observed hand feeding residents cookies, from a cookie bag, without sanitzing hands in between residents. Findings include: 1. Review of the facility's policy titled Policies and Practices - Infection Control revised 10/2018, revealed the facility's infection control policies and practices were intended to facilitate and maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Significant objectives of the facility infection control policy included (1) Maintaining a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public; (2) Establish guidelines for implementing Isolation Precautions, including Standard and Transmission-Based Precautions; and (3) Establish guidelines for the availability and accessibility of supplies and equipment necessary for Standard and Transmission-Based Precautions. Review of the facility's Environmental Services Operations Manual policy titled Healthcare Services, Inc. and its Subsidiaries Infection Control Policy with revision date of 09/05/2017, revealed purpose of the policy was to orient environmental services employees to the basic principals of infection control and to describe how those principles would affect his or her work routines and the employee would recieve one on one training. Further review of environmental policy revealed the staff were to use proper personal protective equipment (PPE) as a barrier to exposure to any body fluids whether known to be infected or not. Added review of policy revealed to prevent the spread of infection employees were to implement hand hygeine practices consistent with accepted standards of practice to reduce the spread of infections and prevent cross contamination. and to properly store, handle, process and transport (cover) linens/food to minimize possible contamination. Further review revealed hand hygeine continued to be primary means of preventing the ransmission of infection and should be practiced including after handling soiled or used linens. Policy review revealed environmental services employees must follow all isolation procedures for laundry and linen procedure must be designed to pervent cross contamination. Continued review of the healthcare services group (HCSG) policy revealed routes of disease transmission to employees or residents included contact with clothing, uniforms which may have become contaminated. Added review of HCSG policy revealed in addition to cleaning isolations rooms or wings, focus should also be on disinfecting high touch areas to prevent the spread of the virus including table tops, counters and other horizontal surfaces in the common area. Review of the facility's policy titled coronavirus Disease (COVID-19) Source Control revealed policy statement to have source control measures utilized as part of the infection prevention and control measures during the Covid- 19 pandemic. Implementations reviewed revealed the usage of well fitting face masks. Continued review revealed if during the care of a resident for which a NIOSH-approved respirator was indicated for PPE they would be removed, discarded after resident care encounter. Review of CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (Covid-19) Pandemic updated 09/23/2022, revealed health care workers who enter the room of a patient with suspected or confimed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH- approved particulate respirator with N-95 filters or higher, gown, gloves, and eye protection. Further review or CDC guidance document revealed in general, asymtomatic patients do not require empiric use of Transmission-Based Precautions while being evaluated for SARS-CoV-2 following close contact with someone with SARS-CoV-2 infection however; these reidents should still wear source control. Review of facility's policy titled Coronavirus Disease (COVID-19)-Indentification and Management of Ill Residents dated 09/2022, revealed a resident with suspected or confirmed SARS-CoV-2 infection was placed in Transmission Based Precautions with the door closed. Added interview of policy revealed if keeping door closed poses resident safety risks the door needs to remain open Review of the facility's policy titled Handwashing/Hand Hygiene revealed the facility considers hand hygiene the primary means to prevent the spread of infections. Added review of facility policy revealed implemenations includes all personnel shall be trained and regularly inserviced and personnel shall follow the handwashing/hand hygiene procedures. Review of the policy continued and revealed staff were to wash hands with soap and water or use an alcohol-based hand rub containing at least sixty-two (62) percent for situations including before and after direct contact with residents and before and after assisting a resident with meals. Observation on 02/14/2023 at 10:20 AM, revealed no hand soap on men's memory care unit in shared rest room. Observation continued and revealed folding area with cart containing clean folded linens, with covering for transport. Observation revealed Environmental staff #26 was folding a flat clean sheet, allowing it to touch front of her clothing and no hand hygiene was practiced prior to folding linen. Observation on 02/23/2023 at 1:45 PM, revealed one staff member, CNA #17, in room [ROOM NUMBER], with gloves and mask donned, but no gown donned, providing direct resident care. Continued observation revealed signage for Enhanced Barrier Precaution indicating PPE to be worn when providing direct resident care, including gown. Observation on 03/04/23 at 8:30 AM, and 03/05/2023 at 8:30 AM, revealed the dining room for [NAME] Hall had food crumbs in floor and sticky in spots,and food crumbs tabletops. The floor was wiped with a damp antibacterial wipe and it contained brown/black substance after wiping floor. Continued observations revealed there was no cleaning of dining room on 03/04/2023 and 03/05/2023. Observation on 03/06/2023 at 7:25 PM, revealed Certified Nursing Assistant (CNA) #30 fed small cookies to residents directly from her hand to each of the resident's mouths, while they were sitting in common area on memory care unit. Continued observation revealed she used her bare hands to reach into the bag/s to retrieve cookies, without performing hand hygiene between residents. Observation on 03/07/2023 at 8:20 AM, revealed Certified Nurse Aide (CNA) #25, dropped a bowl of hot cereal in floor, then picked up the bowl, with lid intact and placed it on a resident's tray as resident was still eating. Observation continued and revealed no hand hygiene practiced after retrieving bowl from floor, and at this point CNA #25 left the unit to get another mask. Observation of memory care unit, on 03/07/2023 at 1:12 PM, revealed dirty and clean dishes were together on the meal cart. Observation on 03/07/2023 at 1:24 PM, revealed residents were being seated where other residents had prviously eaten without area being wiped down. Resident #73's tray was sat in a dirty spot and the resident [NAME] napkin and started cleaning the chair and floor. Observation continued and revealed another resident came into eat and was seated at uncleaned spot at table. Interview with Environmental staff #26, on 02/23/2023 at 1:15 PM, revealed the only Personal Protective Equipment (PPE) staff wore, when sorting dirty laundry were gloves and mask, no gown or face shield was worn. She continued to state once laundry finished the wash cycle, it was then placed in a cart and taken through door to the clean drying area. Interview with Certified Nursing Assistant (CNA) #17, on 02/23/2023 at 1:45 PM, revealed she was agency and did not know about the Enhanced Precautions needed for resident in 113. She stated she had not gotten report from nurse that morning and the night shift nurse aides had already gone, when she arrived to work. She continued and revealed she had looked at [NAME] but still did not know about enhanced precautions for room [ROOM NUMBER]. Interview on 03/06/2023 at 7:25 PM, with CNA #30, revealed she knew better than to touch food and place in resident's mouths without gloves and should have washed her hands. Added interview revealed she should have not given residents cookies from the same bag. Continued interview revealed she has had training on hand hygiene and knew practice stops spreading of germs. Interview with Certified Nurse Aide #25, on 03/07/2023 at 8:20 AM, revealed she could not really remember if facility had provided infection control training or not and could not verbalize the reason the bowl should not have been placed on resident tray after falling to floor. She added she thought practice was appropriate to place on tray since lid remained intact. Interview with Interim Director of Nursing, on 02/22/2023 at 2:15 PM, revealed staff should treat all laundry as if infected. She also stated she completed hand washing audits but had not recorded results. She stated the facility followed the Centers for Disease Control and Prevention (CDC) guidance for usage of N-95 masks when there was active Covid in the building.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area from each resident's bedside and toilet and bathing facilities. Observations revealed call lights were non-functional upon entrance to the facility on [DATE] through 02/23/2023. Interview and review of documentation revealed the call light system had been non-functional since 02/09/2023. The findings include: On 02/14/2023 at 11:15 AM, a request was made to the Executive Director and the Interim DON for the facility's Policy regarding its call light system. No policy was produced during the survey. Observations, on 02/14/2023 at 9:00 AM revealed the facility's call light system for the East Wing was not functioning. Interview, with Certified Nurse Aide (CNA) #1 on 02/14/2023 at 11:45 AM revealed the call lights had been out for a couple of days and the residents had bells they used to call staff. The CNA stated the bells were not working very well. CNA #1 stated some of the bells worked and some did not but only on the East Wing. Further interview revealed she did not know why. She stated maintenance and leadership were aware. CNA #1 stated no additional staff had been brought in to assist with the challenge of the broken call light system. Interview, with Resident #27 on 02/17/2023 at 9:20 AM revealed the call lights had not worked in about a week. Further interview revealed although the residents were given a hand bell or a whistle to use when they needed something Resident #27 stated some residents just yelled. Interview, with Resident #34 on 02/14/2023 at 12:10 PM revealed he/she thought the call light system went down a couple of days ago. Interview revealed Resident #34 had a cow bell he/she was supposed to use instead of a call light. Resident #34 stated sometimes the staff could not hear the cow bell, especially when the door to his/her room was closed. Further interview revealed he/she would wait until he/she heard someone in the hall and then would yell and ring the cow bell until someone came in to assist him/her. Interview, on 02/15/2023 at 2:36 PM, with Family Member (FM) #1, revealed Resident #114 had called on a Saturday night at about 11:45 PM and stated his/her roommate, Resident #96, had fallen. FM #1 revealed Resident #96 could be heard yelling in pain. Per the interview, the facility had given the residents a teeny tiny bell to ring. Continued interview revealed the call light response time was extremely slow. FM #1 further revealed Resident #114 called another night to ask FM #1 to call the facility and ask them to come change Resident #114 since he/she had been ringing the bell for one (1) hour and five (5) minutes. Interview, with Maintenance Director #1, on 02/14/2023 at 2:52 PM, revealed the call lights were not functioning throughout the entire facility. He stated the entire system needed to be rewired. Continued interview revealed parts had been ordered, and when they were received the repair service team would be back to finish the repairs. Observation on 02/20/2023 at 2:25 PM revealed the call lights were not functioning properly throughout the entire facility. Interview, with the Interim Director of Nursing (IDON) on 02/16/2023 at 8:47 AM revealed the call lights had been out for about a week and a repair service was called as soon as the problem was discovered. Further interview revealed the technicians came to the facility to assess the situation and determined what parts needed to be ordered to repair the broken call light system. The IDON stated the hand bells and whistles the residents had been provided were not a perfect fix but, that was the best they could do at the time. Interview, with the Executive Director (ED) on 03/01/2023 at 3:15 PM revealed the call light system was found not to be working properly on 02/09/2023 and was finally repaired on 02/23/2023. The ED stated residents were provided with bells and whistles they used while the call light system was not functioning. Continued interview revealed the ED expected the facility to have a functioning call light system at all times for residents' health and safety. Record review revealed an Invoice, dated 02/13/2023 revealed on that date the facility was billed for services and materials to install, program, and test a new call light system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the facility's policy, review of 906 [NAME] (Kentucky Administrative Regulations) 1:190, Section 1(4), a disqualifying offense, and review of the Kentucky Revised Statues (KRS) 209.032, it was determined the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, exploitation, and misappropriation related to screening of new employees for thirty (30) of thirty-one (31) personnel files reviewed. Additionally, the facility failed to ensure it did not employ individuals who had been found guilty by a court of law for abuse, neglect, misappropriate of property, exploitation, or mistreatment in accordance with the facility's policy and the list of Kentucky Disqualifying Offenses, for four (4) of thirty-one (31) personnel files reviewed. (Director of Maintenance (DM) #1, Activities Assistant (AA) #4, Certified Nursing Assistant (CNA) #71, and CNA #70). The findings include: Review of the facility's policy, Background Screening, dated 06/14/2019, revealed the company would complete background investigations for all candidates for employment and would not employee a person who was convicted of any offense listed on the State specific disqualifying offenses list. However, review of the policy further revealed a reported criminal offense would not necessarily disqualify a candidate from employment. Review of the Kentucky National Background Check Disqualifying Offenses List revealed, Pursuant to 906 [NAME] 1:190, Section 1(4), a disqualifying offense is: a. Identification on the Kentucky Nurse Aide Abuse Registry, Kentucky Child Abuse and Neglect Central Registry, Kentucky Caregiver Misconduct Registry, Federal List of Excluded Individuals and Entities (LEIE), or any available abuse registry, including abuse and neglect registries of another state; b. A crime described in 42 USC 1320a-7; c. A substantiated finding of neglect, abuse, or misappropriation of property by a state or federal agency pursuant to an investigation conducted in accordance with 42 USC 1395i-3 or 1396r; d. Registration as a sex offender under federal law or under the law of any state; e. An offense under a criminal statute of the United States or of another state similar to an offense listed in the document; f. A conviction of, or plea of guilty, an [NAME] plea, or a plea of nolo contendere to: A misdemeanor offense related to: 1. Abuse, neglect, or exploitation of an adult as defined by KRS 209.020(4); 2. Abuse, neglect, or exploitation of a child; 3. A sexual offense; 4. Assault (including domestic violence) occurring less than seven (7) years from the date of the criminal background check; 5. Stalking occurring less than seven 97) years from the date of the criminal background check; 6. Theft occurring less than seven (7) years fro the date of the criminal background check; 7. Fraud occurring less than seven (7) years from the date of the criminal background check; 8. Unlawfully possessing or trafficking in a legend drug or controlled substance occurring less than seven (7) years from the date of the criminal background check; or 9. KRS 525.130, Cruelty to animal in the second degree-Exemptions-Offenses involving equines; 10. Any other misdemeanor offense relating to abuse, neglect, or exploitation that is not listed in this subsection and occurred less than seven (7) years from the date of the criminal background check. Review of KRS 209.032, revealed Long Term Care facilities shall query the Cabinet' for substantiated findings of abuse, neglect or exploitation against an individual who was a perspective employee. Review of the employee file for Activities Assistant (AA) #4, revealed she was hired on 10/04/2022. However, the facility did not complete the background check until 10/06/2022. Review of AA #4's background check revealed she had been found guilty of theft by unlawful taking and fraudulent use of credit cards on 08/14/2014 and theft on 02/19/2015, three (3) felony convictions. Review of Certified Nursing Assistant (CNA) #71's employee file revealed he was hired on 12/15/2022, and the background check remained in Client Review Required status as of 03/31/2023, without evidence of further review. Review of the background check revealed he had controlled substance and possession of Marijuana convictions, listed on the Disqualifying Offense List referenced on the facility's policy. Review of the Employee File for CNA #70 revealed he was hired on 10/19/2022 and the facility failed to complete a background check for this applicant until 03/31/2023. This background check determined he was found guilty of possession of marijuana, an offense listed on the Disqualifying Offence List. Review of the Employee File for Director of Maintenance (DM) #1 revealed he was hired on 12/09/2021. The background check identified him to have a guilty charge of Assault 4th Degree, Domestic Violence with minor injury on 06/19/2020. Interview with the Executive Director (ED) 03/30/2023 at 9:00 AM, revealed the facility forwarded all applications to Corporate Human Resources (HR) for background review. She stated she only hired an employee after final approval was given from Corporate HR. Review of the personnel files revealed thirty (30) out of thirty-one (31) employees lacked documented evidence the facility checked the Caregiver Misconduct Registry. Review of the facility's personnel files also revealed nine (9) out of thirty-one (31) staff were hired and started work prior to a completed background check and two (2) of the thirty-one (31) had no evidence of a background check. Additionally, seventeen (17) of the thirty-one (31) files reviewed revealed background checks noted, Client Review Required. When the checks were noted Client Review Required, this indicated that staff at the Corporate level would investigate further before giving the approval to hire. However, there was no evidence the facility completed further review. Interview with the Executive Director (ED), on 03/30/2023 at 9:00 AM, revealed the facility forwarded all applications to Corporate Human Resources (HR) for background review and she only hired an employee after final approval was given from Corporate HR. Continued interview with the ED on 03/31/2023 at 7:00 PM, revealed she was confident when the approval for employment came from the Corporate Office, that all of the required background checks had cleared the employ for hire. Interview with the [NAME] President (VP) of Human Resources (HR), on 03/31/2023 at 7:00 PM, revealed the applications were sent to Corporate HR to complete the background checks using a third-party vendor. She stated if the report from the vendor indicated Client Review Required, then the HR Generalist at the Corporate level would investigate further before giving the approval to hire. She stated during their audit they initiated on 02/17/2023, they found several that should not have been approved. The VP stated the HR Generalist was no longer with the company. She stated the third-party vendor reports were slow to be returned and were difficult to read and interpret, so they contracted with a different third-party vendor for the background checks on 01/12/2023. Further interview revealed she was not aware of the requirement per KRS 209.032, for the Caregiver Misconduct Registry checks. She stated the HR Generalist was trained on the disqualifying offences, that would prevent a candidate from being hired. Interview with the Chief Operating Officer (COO), on 03/30/2023, at 1:00 PM, revealed she was not aware DM #2 had a criminal background until 02/17/2023, when she was talking with a potential Corporate Level employee that indicated to her that DM #1 had a criminal background with previous assault convictions. She stated she informed the [NAME] President (VP) of Human Resources (HR) of that information, which triggered an initial audit of all employee background checks. She stated they suspended DM #1 on 02/17/2023 pending further investigation.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to store and handle food properly. Observations, on 02/15/2023 and 02/16/2023 revealed thickened liquids stored in the [NAME] Unit refrigerators with no open date, and the expiration date was within seven (7) days. Observations, on 02/16/2023, of the nourishment refrigerator on the East Unit revealed a resident's food not identified by a resident's name and not dated. Observation, on 03/04/2023, revealed an incomplete temperature log for the [NAME] nourishment refrigerator. Observation, of the kitchen on 03/06/2023, revealed staff rolling silverware and touching the utensil ends of the spoons, forks, and knives. The findings include: Review of the facility's form titled, Cold Food Storage, not dated, revealed refrigerated storage potentially hazardous foods/time temperature control for safety (PHF/TCS) foods must be maintained at or below 41 degrees Fahrenheit (F), unless otherwise specified by law. All opened containers should have an opened date to assure correct rotation. Review of the facility's policy titled, Foods Brought by Family/Visitors, dated 10/2017, revealed food brought by family/visitors that was left with the resident to consume later, must be labeled and stored in a manner that it was clearly distinguishable from facility prepared food. Containers will be labeled with the resident's name, the item and the use by date. Review of the thickened tea and water manufacturer's instructions, not dated, revealed the unopened products were shelf stable for 210 days at storage temperatures of 60 to 90 degrees Fahrenheit (F) until opened. Continued review revealed the product could only be used up to seven (7) days after opening. The State Survey Agency (SSA) requested, from the Executive Director, on 03/15/2023 at 3:30 PM, 03/16/2023 at 9:54 PM, and 03/16/2023 at 9:45 AM, the policies for taking temperatures of the refrigeration, which would include the nourishment refrigerators. However, the policies were not provided by the facility. Observation, on 02/15/2023 at 10:49 AM, of the nourishment refrigerator on the [NAME] Unit, revealed thickened liquid dated 12/13/2022. The directions stated after opening, the thickener may be kept up to seven (7) days under refrigeration. However, the container was opened with no open date. Continued observation, on 02/15/2023 at 10:45 AM, revealed popsicles with no name or date. The popsicles were unboxed lying on the freezer shelf. Interview, with Registered Nurse (RN) #2, on 02/21/2023 at 4:14 PM, revealed the thickened liquids should be dated when opened and the expiration date should be on the bottle. Observation, on 02/16/2023 at 2:15 PM, of the East Unit nourishment refrigerator revealed a white plastic grocery bag with a resident's food brought in by family. The bag had no name and no date. Observation, on 02/19/2023 at 3:00 PM, revealed the [NAME] Unit nourishment refrigerator had brown covered bowls with mixed fruit, and soup with no date or name. There was a meat sandwich on a bun, wrapped with no name or date. Continued observation revealed an opened chocolate milk, 1/2 full on the refrigerator shelf, with no name or open date and two (2) clear glasses of orange drink with no name or date. Observation, on 02/19/2023 at 3:15 PM, of the nourishment refrigerator on the East Unit, revealed a plastic white grocery bag with food for a resident, brought in by the family, that was not dated. Observation, on 03/04/2023 at 11:15 AM, of the [NAME] Unit nourishment refrigerator revealed the temperature log was not completed: 03/02/2023 on the evening shift; no temperatures recorded for 03/03/2023 on both shifts; and, on 03/04/2023 for day shift. Interview, with Licensed Practical Nurse (LPN) #2, on 03/14/2023 at 9:55 PM, revealed the nurse for day or night shift, or the Unit Manager was responsible for ensuring the nourishment refrigerator temperatures were taken daily and within the proper range. She stated if the temperatures were not checked the food could go bad. Observation, on 03/07/2023 at 7:24 PM, revealed Dietary Staff rolled silverware in the napkins. The staff were observed touching the eating end of the utensils with their bare hands. They were not wearing a mask or gloves. Interview, with [NAME] #4, on 03/10/2023 at 3:12 PM, revealed she had poor control of her hands and she did not realize she had touched the eating ends of the silverware. Interview, with the Food Services Manager, on 02/17/2023 at 8:47 AM, on 02/20/2023 at 8:58 AM, and on 03/08/2023 at 11:12 AM, revealed the nourishment refrigerators were cleaned by dietary and the food should be rotated. She stated food not labeled and dated should be thrown out. The Food Services Manager stated the thickened liquids were dated with the received date and were shelf stable until opened,. She stated they should be dated when opened and thrown out according to the manufacture's recommendations. Continued interview revealed the staff should date the food item when opened. The Food Services Manager stated thickened liquids should only be used for seven (7) days once opened. She stated staff should roll the knives, forks, and spoons into the napkin using the handles and not the end used for eating. She stated should wear gloves while performing this task. Interview, with the Interim Director of Nursing (DON), on 02/23/2023 at 8:10 AM and on 03/15/2023 at 1:54 PM, revealed the thickened liquids should be dated when opened and the directions were on the box. Continued interview revealed that if staff left the box opened on the shelf that could cause the bacteria count to go up even in the refrigerator. She further stated she believed Dietary took the temperatures for the nourishment refrigerators. The IDON clarified that Dietary was responsible; however, if they missed the refrigerator checks then nursing should fill the information in, on the temperature log. Interview with Executive Director (ED), on 02/26/2023 at 2:24 PM and 03/15/2023 at 3:30 PM, revealed food items in the refrigerator should be labeled and dated for residents' foods and thickened liquids. The ED stated all foods should be dated after opening to prevent bacteria growth. She stated it was important to record temperatures to protect the stored food product and ensure the residents did not receive food items that could be out dated or unsafe.

Based on interview, review of the facility's policies, review of the Executive Director's Job Description, and review of the Plans of Correction (PoC ) submitted for the On-site Revisit/Abbreviated Survey with exit date 04/04/2023, it was determined the facility failed to ensure it was administered in a manner that enabled it to use its' resources effectively and efficiently to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The State Survey Agency (SSA) identified continued non-compliance in the areas of 42 CFR 483.10 Resident Rights (F550, F578); 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600); 42 CFR 483.20 Resident Assessments (F635, F641); 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656, F657); 42 CFR 483.24 Quality of Life (F679); 42 CFR 483.25 Quality of Care (F689); 42 CFR 483.35 Nursing Services (F725); 42 CFR 483.45 Pharmacy Services (F755, F761); and 42 CFR 483.70 Administration (F837). Additionally, the facility failed to maintain substantial compliance in the areas of 42 CFR 483.10 Resident Rights (F584); 42 CFR 483.24 Quality of Life (F680); 42 CFR 483.25 Quality of Care (F685, F695); 42 CFR 483.70 Administration (F835, F849); and 42 CFR 483.75 Quality Assurance and Performance Improvement (F867). Review of the facility's Plan of Correction (PoC) revealed its' Administration failed to have an effective process in place to address systemic failures through the Quality Assurance Performance Improvement (QAPI) process. As a result, the facility failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. The facility was recited at the highest scope and severity (S/S) of a K, for the 06/02/2023, second (2nd) revisit. (Refer to F578, F656, F657, F689, F835, and F867) The findings include: Review of the facility's, Job Title: Executive Director, undated, revealed the Executive Director (ED) was to direct the administration of the health care facility within the authority of the facility's management company. Per the review, the ED directed and performed Quality Assessment and Assurance functions including but not limited to regulatory compliance rounds to monitor the facility's performance and to continuously improve quality. Further review revealed the ED was responsible for the implementation of programs to gather and analyze data for trends and institute actions to resolve problems promptly, and report and make recommendations to the appropriate committee. Review of the facility's acceptable Plans of Correction (PoC), for the Standard Recertification/Abbreviated/Extended Survey concluded on 03/16/2023 and the On-site Revisit/Abbreviated Survey concluded on 04/04/2023, revealed the Executive Director failed to ensure the facility achieved substantial compliance. The facility remains out of compliance with repeat deficiencies following the second (2nd) revisit, concluded on 06/06/2023. 1. Review of Resident #2's, Resident #23's and Resident #89's medical records and the Plan of Correction for the survey, revealed the residents had a Do Not Resuscitate (DNR) order. However, there was no evidence that the Emergency Medical Service (EMS) DNR forms had been completed for the residents. The facility's failure to ensure the EMS DNR forms were completed for Resident #2, Resident #23, and Resident #89 has caused or is likely to cause serious harm or serious injury to residents. (Refer to F578) 2. Based on observation, interview, record review and the Plan of Correction for the survey, along with the facility's policy it was determined the facility failed to develop and implement care plans with individualized person-centered interventions to prevent falls for five (5) of thirty-three (33) sampled residents (Residents #20, #35, #97, #146, and #821) who were identified with multiple falls with injuries. (Refer to F656) 3. Based on observation, interview, record review, and facility policy review, it was determined the facility failed to have an effective system in place to ensure care plans were revised to provide proper care and supervision to residents to prevent falls/accidents for two (2) of thirty-three (33) sampled residents (Residents #146 and #821). (Refer to F657) 4. Based on observation, interview, record review, review of the facility policy and Plan of Correction, the facility failed to have an effective system to ensure adequate supervision and monitoring to prevent falls/accidents. The facility failed to identify risks and hazards; failed to establish root cause analyses of previous falls; and failed to implement and evaluate interventions to prevent further falls for six (6) of thirty-three (33) sampled residents (Residents #20, #35, #90, #97, #146 and #821). (Refer to F689) In an interview with the Minimum Data Set (MDS) Coordinator #1 on 06/02/2023 at 3:12 PM, she stated she reviewed care plans with every major assessment quarterly, annually and with a significant change. She stated she made changes as appropriate to update the care plans to the most appropriate interventions based on records found in the residents Electronic Medical Record (EMR) and through observations of the resident. She stated she was responsible for all MDS's now but some things were done by a remote team. In an interview with the Director of Nursing (DON), on 06/02/2023 at 11:46 AM, she stated the facility had not identified any trends as they related to falls. She said they did identify that the D Hall seemed to have more falls, but they could not determine a certain time, shift or staff member involved. When asked who trained her on how to do a root cause analysis (RCA), she said it was the previous [NAME] President of Clinical Operations (VPOC). In an interview with the Executive Director (ED) on 06/02/2023 at 1:20 PM she stated she was a member of the Quality Assurance Performance Improvement (QAPI) Committee and meetings were held weekly now and usually daily as the needs arose with survey, but normally they were held monthly. She stated in attendance generally were the Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Managers (UM), and all department heads naming a few such as Housekeeping, Business office and Human Resources. She added the discussions addressed old business first then new business, employee turnover, retention, orientation, marketing, point click care, infection control, and Relias training. She added mainly they discussed the survey findings and citations and the facility was working through the cited deficiencies. She stated other topics discussed in QAPI, were training of new employees, re-admissions and discharges of residents. In continued interview with the ED on 06/02/2023 at 1:20 PM she said the Medical Director would be providing In-Services for the staff on falls. Per the interview, the ED stated the care plans should have been developed initially when the residents were admitted , and revised with any change of condition and quarterly. In an interview with the Chief Operations Officer (COO) on 06/02/2023 at 3:41 PM, she stated the facility utilized audit tools and she was just made aware of the findings and the Care Plan Team would be in the facility to work on the concerns the State Survey Agency (SSA) identified on 06/03/2023, to review the care plans and Minimum Data Set (MDS), to ensure they were correct. The COO also stated the team created the audit tools based on the POC to work toward compliance. She said additional rounds were conducted with a new rounding tool, twenty-four (24) hours around the clock. Further, she stated she felt the facility was moving in the right direction and things were getting better. However, review of the PoC for surveys with exit date of 03/16/2023 and 04/04/2023, revealed the facility was recited at the Immediate Jeopardy (IJ) level.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of the facility's policy, and review of the facility's personnel records, it was determined the facility's Governing Body failed to ensure their Human Resources (HR) timely obtained background information, to include the requirements of 906 Kentucky Administrative Regulations ([NAME]) 1:190, Section 1(4), a disqualifying offense, and Kentucky Revised Statues (KRS) 209.032, prior to hiring for potential employees, and failed to establish and implement adequate policies related to employee screening to ensure safe management and operation of the facility as related to employing staff with adverse actions. (Refer to F606) The findings include: Review of the facility's policy Background Screening, dated 06/14/2019, revealed the company would conduct background investigations on all candidates for employment prior to making an employment offer and may use a third party to conduct these background checks. Further review revealed the company would not employ a person who was convicted of any offense listed on the State-specific disqualifying offenses list. However, review of the policy further revealed a reported criminal offense would not necessarily disqualify a candidate from employment. The nature and seriousness of the offense, the surrounding circumstances, rehabilitation, and the relevance of the offense to the specific position(s). The Company would follow company procedures for making decisions regarding potential adverse actions. Review of KRS 209.032 revealed a vulnerable adult services provider, which included long-term care facilities as defined by KRS 216.510, shall query the cabinet as to whether a validated substantiated finding of adult abuse, neglect, or exploitation has been entered against an individual who was a prospective employee of the provider. Review of the facility's Personnel Files revealed thirty (30) of thirty-one (31) employee files reviewed revealed a lack of documentation to support the facility completed thorough background checks prior to employment, to include Kentucky's Caregiver Misconduct Registry. Further review revealed the facility hired four (4) employees who had documented evidence of convictions that would be considered disqualifying offenses. Continued review revealed there were seventeen (17) employees who were noted to have Client Review Required located within their employee files, which, per interview, indicated the employee needed further review by Corporate HR before hiring would be approved. Interview with the Executive Director (ED), on 03/30/2023 at 9:00 AM, revealed the facility sent all applications to Corporate HR to complete, what she thought, was all federal and state required information and background checks, to ensure the candidates for employment were cleared for all required federal and state background checks. She stated Corporate HR would inform the facility's HR and or the ED within a few days of the decision of whether the facility could hire the potential employee. Interview with the [NAME] President (VP) of HR, on 03/30/2023 at 1:30 PM, revealed the process for hiring was for the facility HR to forward the application to Corporate HR to review and complete the third-party background check. She said she was not aware of the required check with the Kentucky Cabinet as per KRS 209.032 (the Caregiver Misconduct Registry). She stated the review of the third-party background check results was conducted by Corporate HR and if there were any questionable offenses, they would make the final decision if the applicant would be cleared for hire. She further revealed any candidate that came back from the third party with Client Review Required, or that was not 100% cleared for employment, would be reviewed by the Corporate Director of HR. Continued interview with the VP of HR, on 03/31/2023 at 7:00 PM revealed the Corporate HR Director would review the offenses, consider the timeframe and the offense, then would make the decision on whether to hire the employee. She stated she was not aware of all federal and state-required background checks. Further interview revealed the third-party reports were difficult to read, in order to determine if the applicant had a disqualifying offense, and she thought they were all inclusive of the requirements to be compliant with federal and state laws. Interview with the Chief Operating Officer (COO), on 03/30/2023 at 1:45 PM, revealed she became aware that an employee of the facility, may have convictions that would be a disqualifying offense on 02/17/2023. Further interview revealed she reached out to Corporate HR and found out the background check completed on 12/06/2021, for the Maintenance Director, at that time, contained prior convictions listed as a disqualifying offense, which prompted a sweep of all current employee files. The COO revealed she was not aware the pre-employment checks did not include the required Caregiver Misconduct Registry as per KRS 209.032.

Based on interview, record review, review of the facility's policy, and review of the Plans of Correction (PoC) submitted for the 04/04/2023 survey, it was determined the facility failed to have an effective process in place to address systemic failures through the Quality Assurance Performance Improvement (QAPI) process. As a result, the facility failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. The facility failed to effectively track adverse resident events, analyze their causes, and implement preventive action. The facility failed to ensure there was an effective system in place to regularly review and analyze audit data, including data collected under the QAPI program, and act on available data to make improvements and maintain substantial compliance. 1. Review of the facility's Form CMS-672 Resident Census and Conditions of Residents, identified forty-four (44) residents were assessed to be at risk for falls. The facility reported residents had over thirty (30) falls between 04/16/2023 and 05/26/2023. However, there was no evidence the facility was discussed the falls, reviewed previous falls, analyzed the time of day and staff patterns for each fall in order to determine the root cause of the falls and to implement person centered intervention to prevent further falls. 2. Review of the facility's audit tool for residents' Care Plans showed multiple times the care plans were inaccurate. 3. Review of the facility's audit tool for Accurate Coding revealed three (3) residents, who had inaccurate coding on the Minimum Data Set (MDS) assessments, and the care plans that did not match the coding/assessments. 4. Review of the facility's Controlled Substances Log Book Shift Count revealed multiple times two (2) Licensed Nurses' signatures were not present. This was not reflected on the audit tool. 5. Review of the audit tool for Drugs and Biologicals revealed it had not been completed for seven (7) days. Further, observation revealed unlocked medication carts; inconsistent temperatures taken by two (2) different thermometers; and insulin stored at an inappropriate temperature. 6. Review of the audit tool for 04/17/2023, 04/18/2023, and 04/19/2023 revealed they were incomplete. The findings include: Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Program-Governing and Leadership, last revised March 2020, revealed the Administrator (Executive Director) was a member and was ultimately responsible for the QAPI Program and for interpreting its results and findings to the Governing Body. The QAPI Coordinator coordinated the activities of the QAPI Committee. The policy stated the responsibilities of the QAPI Committee were to collect and analyze data, identify, evaluate, monitor, and improve the facility's systems and processes of care and services, identify and help to resolve negative outcomes and quality of care problems identified during QAPI. The committee would also determine the root cause analysis to help identify problems pointed to underlying systemic problems, help departments, consultants, and ancillary services implement a system to correct potential/actual issues of quality of care. The policy also revealed the committee was to establish benchmarks and goals to measure performance improvement projects to achieve specific goals. It also was to communicate all phases of the QAPI process to the Administrator (Executive Director) and Governing Body through sharing meeting minutes, committee activities, and results of QAPI activities. Continued review of the QAPI policy revealed the committee had full authority to oversee the implementation of the QAPI program, to establish performance and outcome indicators for quality of care and services delivered in the facility, choosing, and implementing the tools that best captured and measured the data about chosen indicators, appropriately interpreting data within the context of standards of care, benchmarks, targets and the strengths and challenges of the facility. Per the policy, the committee was responsible to communicate the information gathered and their interpretation to the Owner/Governing Body. The policy also revealed the QAPI Committee was made up of the Administrator/Executive Director or designee, the Director of Nursing (DON), the Medical Director (MD), and the Infection Preventionist. Additionally, the Administrator/Executive Director could request a representative from each department: pharmacy, social services, activities, environmental services, human services, and medical records. Per the policy, the committee must meet at least quarterly and should be reminded of the meeting day, time, and location via e-mail at least two (2) days prior to the meeting. The policy stated special meetings could be called prior to the next scheduled meeting by the Administrator/Executive Director as needed. Review of the facility's 04/17/2023 audit tool the facility created revealed it covered each tag, F550, F656, F689, F725, F726, F761, F880 and F919. Staff members were to randomly pick ten (10) residents to audit daily. They were to audit to ensure urinary catheters were covered with a dignity bag, the Kardex (an abbreviated care plan for aides) was followed by aides as the plan of care, residents were turned and repositioned, to check water temperatures, to ensure call lights were answered timely, residents' supervision needs were being met, gait belts were used during transfer, unused medication was discarded from the medication carts, and the unit medication carts were locked. Additionally, the same ten (10) residents were to be observed as staff interacted with them to ensure proper Personal Protection Equipment (PPE) was used, hand hygiene between meals, gloves were used by staff when touching food, clean trays and dirty trays were kept separate, the dining room was clean, items on the floor were disposed of, hand hygiene between carts, call lights were functional, and the toilets worked. 1. Review of the facility's Plan of Correction (PoC), with an alleged compliance date of 04/16/2023, revealed the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Staff Development Coordinator (SDC) conducted education to all Licensed Nurses (LN), starting 03/08/2023 and ongoing related to ensuring the facility provided an environment free from accident hazards and provided supervision and assistive devices to prevent accidents including falls based on the root cause of the falls. Further review revealed management staff including the Executive Director, DON, ADON, and SDC would make visual observation rounds daily to determine resident needs were met to prevent accidents including falls, and these audits would be submitted to the Quality Assurance Performance Improvement (QAPI) Committee weekly. Review of the weekly QAPI meeting documentation presented by the facility revealed a flow sheet outlining each non-compliance tag. Review of the information related to F689 (falls) revealed the QAPI was identifying the number of falls for each week; however, there was no documented evidence the facility was discussing the falls, looking at previous falls, analyzing the time of day and staff patterns for each fall in order to determine the root cause of the falls and to implement person centered intervention to prevent further falls. Review of the facility's Quality Assurance and Performance Improvement (QAPI) meeting minutes for 04/21/2023 for F689 revealed there were six (6) falls for the prior week. It was noted a Root Cause Analysis (RCA) was done for each fall and appropriate interventions were in place for all residents. However, this statement written in the minutes could not be verified because there was no other documented evidence, and the facility was not able to provide any details in interviews that this occurred. Review of the signature sheet revealed the Executive Director (ED) was present as well as the Staff Development Coordinator (SDC), the Director of Rehabilitation (DOR), Environment Services Supervisor (ESS), Admissions Coordinator (AC), the Director of Maintenance, the Business Office Manager (BOM), the [NAME] President of Maintenance (VPM), the Medical Director (MD), a nurse aide, and a licensed nurse. Review of the facility's QAPI meeting minutes for 04/28/2023 for F689 revealed it was documented there were five (5) falls for the previous week, an RCA was done for each fall, and appropriate interventions were in place for all residents. However, this statement written in the minutes could not be verified because there was no other documented evidence, and the facility was not able to provide any details in interviews that this occurred. Review of the signature sheet revealed present at the meeting was the Director of Nursing (DON), a Registered Nurse (RN), the Assistant Director of Nursing (ADON), the Social Service Director (SSD) and the [NAME] President of Clinical Education (VPCE). Review of the facility's QAPI meeting minutes for 05/05/2023 for F689 revealed it was documented the facility had thirteen (13) falls during the previous week. The minutes also documented an RCA was done for each fall, and all residents involved had appropriate interventions in place. However, this statement written in the minutes could not be verified because there was no other documented evidence, and the facility was not able to provide any details in interviews that this occurred. Review of the signature sheet revealed present for this meeting was the ED, DON, ADON, DOR, Medical Records, the Dietary Manager (DM), SSD, BOM, Minimum Data Set (MDS) Coordinator and the MD, as well as a licensed floor nurse. Review of the facility's QAPI meeting minutes for 05/12/2023 for F689 revealed it was documented the facility had seven (7) falls during the previous week, an RCA was done for each fall, and each resident had the appropriate interventions in place. However, this statement written in the minutes could not be verified because there was no other documented evidence, and the facility was not able to provide any details in interviews that this occurred. Review of the signature sheet revealed present at the meeting was the ED, DON, DOR, a Unit Manager (UM) illegible name, Environment Services Supervisor, MDS Coordinators #1 and #2, DM, and a floor CNA #18. Review of the facility's QAPI meeting minutes for 05/19/2023 for F689 revealed it was documented the facility had six (6) falls the previous week, an RCA was completed on each fall, and each resident had appropriate interventions. However, this statement written in the minutes could not be verified because there was no other documented evidence, and the facility was not able to provide any details in interviews that this occurred. Review of the signature sheet revealed present at the meeting were the ED, DM, ADON, SSD, Medical Records, and two (2) illegible names. In an interview with the Director of Nursing (DON), on 05/25/2023 at 11:55 AM, the DON stated when a fall occurred, the nurse on duty was to contact her and start the fall event in the Electronic Medical Record (EMR). She said then she came up with the root cause of the fall and made sure an intervention was implemented. She said she had received training on determining the root cause for falls but could not remember what the training was called or when she received it. She said she usually used the information provided by the reporting nurse to determine the root cause. The DON also stated the falls were discussed in the Interdisciplinary Team (IDT) meetings that included the ED, ADON, Unit Managers, Department Heads and the MD. She was unable to provide documented evidence the IDT was analyzing the falls to review staffing patterns, time of day, previous falls, or what level of monitoring/supervision was being provided at the times of the falls. She said she realized the IDT needed to do more analysis of the falls and document this. In another interview with the DON, on 05/25/2023 at 12:55 PM, she stated she did not have knowledge of Resident #90 falling in the early morning hours today. She added either she, the Assistant Director of Nursing (ADON), or the Executive Director (ED) should be notified immediately when a fall occurred, and care plan interventions should be placed immediately as well. The ED was also in the room and stated she had not been informed of Resident #90's fall. The ED stated this notification was not in the facility's policy, but they preferred to be notified. At this point, the DON contacted the ADON, and she came to the ED's office. When the ADON was asked if she had been notified of the fall, she stated she had not. All three (3) stated that perhaps one (1) of the unit managers had been notified. When asked if the process had been followed, the DON said probably not, and the nurse should have notified one (1) of them. In an interview with the ED, on 05/25/2023 at 12:15 PM, she stated the DON received a report of every fall. She stated the DON reviewed what the nurse on duty at the time documented and determined the root cause of the fall. She stated the IDT discussed the falls in their meeting each morning. She further stated she was not sure if the DON had received any training on determining the root cause of falls. The ED stated there was no set format to follow when discussing the falls. She stated they used to have a falls meeting specifically to talk about and analyze the falls, using the environment, time of day, pattern of falls, and the use of assistive devices to come up with the root cause of the falls. That way, she stated, appropriate interventions could be implemented. She said she could not put all residents with repeat falls on one-to-one (1:1) observation; the facility just did not have enough staff for that to be done. When the ED was asked how many residents the facility had that had been assessed to be a fall risk, she said she was not sure, but she thought the falls had decreased. In an interview with the DON, on 06/02/2023 at 11:46 AM, she stated the facility had not identified any trends as they related to falls. She said they did identify that the D Hall seemed to have more falls, but they could not determine a certain time, shift or staff member involved. When asked who trained her on how to do a root cause analysis (RCA), she said it was the previous [NAME] President of Clinical Operations (VPOC). In an interview with the ED, on 05/19/2023 at 3:43 PM, she stated the DON was responsible to complete an RCA of a fall. She stated once the DON had identified a root cause, it was then discussed in the clinical meetings. She said the team would give input and determine if they all agreed with the DON's analysis of the incident. The ED also stated interventions were discussed daily in the clinical meetings and with each fall that occurred. She stated the team looked over the interventions and determined if they had been effective. She stated if not, the IDT would identify a new intervention. The ED stated the facility had not determined a trend related to their falls, but if she had to pick an area, it was related to the residents' behaviors. The VPCO stated, in an interview on 06/02/2023 at 3:12 PM, facility staff was looking into a new program that would help detect a resident's movement before a fall. She stated the increased rounding, including by management staff, being done throughout shifts helped decrease the amount of falls they have had. She reported resident falls were down eighty percent (80%). 2. Review of the audit tool created to check on care plans and to make observations of staff providing care for residents, any corrective action, and the signature of the auditor, dated 04/19/2023, revealed one (1) resident was still care planned for a wheelchair and a walker that the resident no longer used. However, these assistive devices remained on the care plan. Another resident was care planned for a cushion on his/her wheelchair, but the resident did not have a cushion, which was not needed, and it still remained on the care plan. An additional resident, who did not use a cane, had been care planned to use a cane. Review of the audit tool for 04/20/2023, revealed a resident was care planned for a walker but did not use a walker. Another resident's care plan reflected the resident had one-half (½) side rails, when in fact it was one-quarter (¼) side rails. Also this resident was care planned for two (2) staff for care, which was noted as inaccurate, and it was deleted from the care plan. Additionally, the two (2) residents, who previously requested the side rails to be removed revealed they were still present. Review of the QAPI Review-Entire Survey document and meeting minutes for 04/21/2023, revealed for F656 the team discussed a wandering resident who was placed on one-to-one (1:1) supervision, and six (6) falls in which the root cause was identified, and the care plans were noted to be revised. However, there was nothing documented on any audits to show the items were addressed. For F657, it was noted they found no concerns. The signature sheet for this meeting showed the ED was present as well as the SSD, licensed floor nurse, the DOR, Admissions, Activities Assistant, the DON, the MD, the BOM, and the [NAME] President of Maintenance (VPM). Review of the QAPI Review-Entire Survey document and meeting minutes for 04/28/2023, revealed no concerns were identified for F656 and F657. However, review of the audits for 04/21/2023, revealed one (1) resident who required a perimeter mattress be added to his/her care plan; one (1) resident was noted to still not have side rails to his/her bed, and one (1) resident was noted to have a walker and bedpan on the care plan, which the resident no longer used. Review of the 04/24/2023 audit revealed a resident still had a urinal care planned but no longer used it; another was care planned for the use of a jumpsuit and binders, which the resident refused to use. Review of the 04/26/2023 audits revealed two (2) residents had perimeter mattresses but were not care planned for them. Review of the QAPI Review-Entire Survey document and meeting minutes for 05/05/2023, revealed F656 had two (2) residents that were readmitted from the hospital, with wander guards in place for both and all orders in place. The document noted F657 had no concerns noted. However, review of the 05/03/2023 audit tool, revealed one (1) resident was found to have non-skid strips next to the bed, but it was not noted on the care plan as an intervention. Another resident was found to be with the bed against the wall, but it was not noted on the care plan as an intervention; it was later added to the care plan. Review of the signature sheet for 05/05/2023, revealed the ED was present as well as the DON, the ADON, a licensed floor nurse, Medical Records, SSD, DM, BOM, an illegible name, and the MD. Review of the QAPI Review-Entire Survey document and meeting minutes for 05/12/2023, revealed no concerns were found with F656 or F657. However, on the 05/06/2023 audit tool, three (3) residents were noted to have perimeter mattresses, none of which were care planned. The audit tool noted they were added as an intervention. Review of the 05/07/2023 audit tool, revealed a resident was care planned with a rollator but no longer had one, and it was resolved on the care plan. Another resident was noted not to be walking, and the care plan had not been revised to reflect the March 2023 MDS. Another resident was identified with a perimeter mattress which had not been care planned before a staff member informed management of the finding. Review of the 05/10/2023 audit tool revealed Resident #821 did not have anti-tippers on his/her wheelchair; however he/she had an anti-rollback device, and it was not care planned. Review of the signature sheet for 05/12/2023, revealed the ED was present as well as the DOR, Minimum Data Set Coordinator (MDSC) #1, a licensed floor nurse, DON, MDSC #2, Housekeeping, Receptionist #1, Activity Assistant #5, and two (2) illegible signatures. Review of the QAPI Review-Entire Survey document and minutes for 05/19/2023, revealed F656 had a note which revealed some wandering residents had been identified, and their care plans had interventions implemented. F657 had a note which revealed some behaviors were identified, and the care plans were revised. However, review of the audit tools for F656 and F657 on 05/14/2023 revealed a resident was identified with a perimeter mattress, and it had not been care planned; later, the care plan was revised. Review of the audit tool dated 05/15/2023, revealed a resident who was care planned for dycem in the chair, but the dycem was under the chair instead of in the chair. 3. Review of the facility's PoC for F641, revealed all residents' MDS Assessments, care plans, and Kardex would be audited by 04/04/2023 by the MDS nurse to ensure accuracy of MDS coding, the care plan in place, and the Kardex to reflect use of devices. Further review revealed any MDS with coding errors had been modified to reflect accurate coding in Section G0600 Mobility Devices and care plans, and the Kardex accurately reflected the use of any mobility device, including wheelchairs. Continued review revealed the Director of Clinical Reimbursement, MDS nurse, and/or a licensed nurse would conduct a weekly audit of up to ten (10) completed MDS's to ensure any resident with a mobility device was appropriately coded on the MDS in Section G0600, and the care plan/Kardexes were up to date. This audit would continue for four (4) weeks, and if no issues were identified, the audit would decrease to monthly by the fifteenth (15th) of each month for the next six (6) months. Per the PoC, if no issues were identified after six (6) months of monthly audits, the audits would end. If issues were identified, audits would remain weekly until four (4) weeks were completed without errors. The results of the initial, weekly, and monthly audits would be reviewed by the MDS Coordinator, Director of Clinical Reimbursement, [NAME] President of Clinical Reimbursement, and Facility Executive Director (ED), and the findings and Performance Improvement Plan would be presented in the facility QAPI plan monthly until the audits were no longer required. Review of the facility's initial audit revealed multiple modifications were needed to the Care Plan and Kardex. The facility alleged compliance on 04/16/2023 with their audits. Review of the audits revealed all weekly audits were conducted by the [NAME] President of Clinical Reimbursement. A. Review of the Quarterly MDS Assessment, dated 02/10/2023, for Resident #146 revealed it was coded for a walker and wheelchair. Review of the 04/16/2023 audit for Resident #146 revealed the resident used a walker and a wheelchair during the look back period for the MDS, and the care plan and Kardex were correct. Review of the 05/07/2023 audit for Resident #146 revealed the resident used a wheelchair and walker during the MDS look back period, and the walker was not on the care plan or Kardex. Further review revealed the audit stated the walker was added to the care plan and Kardex. Review of the Quarterly MDS Assessment, dated 05/08/2023, for Resident #146 revealed it was coded for a walker and wheelchair. Review of the 05/21/2023 audit for Resident #146 revealed the resident used a walker and wheelchair during the MDS look back period and they were both on the care plan and Kardex. However, in review of Resident #146's care plan, there was no evidence it included an intervention for a walker. Further, review of Resident #146's Kardex revealed there was no evidence of a walker documented on the Kardex. B. Review of the 04/30/2023 audit for Resident #821 revealed the resident used a walker (with rehab only) and a wheelchair during the MDS look back period, and this was accurately reflected on the Care Plan and Kardex. Review of the resident's Quarterly MDS Assessment, dated 04/08/2023, and Quarterly MDS Assessment, dated 04/24/2023, revealed they were coded for a walker and wheelchair. Review of the Care Plan for Resident #821 revealed interventions for a wheelchair. However, there was no evidence of an intervention for a walker. Review of the resident's Kardex revealed the wheelchair was listed under devices, but there was no documentation the resident required a walker. Observation on 06/02/2023 at 4:10 PM, revealed Certified Nursing Assistant (CNA) #6 sitting with Resident #821 one-to-one (1:1) with a walker in the resident's room. CNA #6 stated she requested it to help the resident ambulate as he/she loves to walk. C. Review of the 05/14/2023 audit for Resident #48 revealed the resident used a walker and a wheelchair during the MDS look back period, and this was reflected accurately on the Care Plan and Kardex. Review of the resident's Quarterly MDS Assessment, dated 04/07/2023, and Quarterly MDS Assessment, dated 05/11/2023, revealed they were coded for a walker and wheelchair. Review of Resident #48's care plan revealed an intervention for a walker. However, there was no evidence of wheelchair use documented. Review of Resident #48's Kardex revealed use of a walker. However, there was no intervention documented for a wheelchair. Observation of Resident #48, on 06/02/2023 at 1:38 PM, revealed the resident was sitting on a couch in the unit's common area and did not have a wheelchair present. Upon interview, on 06/02/2023 at 1:38 PM, CNA #88 stated Resident #48 did not use a wheelchair. Upon interview, on 06/02/2023 at 3:12 PM, MDS #1 stated she was responsible for making sure MDS assessments were completed, and she reviewed residents' care plans as she completed quarterly and annual MDS assessments. She stated she made changes appropriately so the residents' care plans and MDS assessments were aligned. She further stated Resident #48's 05/11/2023 Quarterly MDS Assessment was completed by another nurse off site by reviewing the resident's medical record. She also stated she did not participate with the audit process, and the audits were completed by the [NAME] President of Clinical Reimbursement solely. During interview with the Director of Nursing (DON), on 05/30/2023 at 11:45 AM, she stated all audits for F641 were completed by the [NAME] President of Clinical Reimbursement remotely, and the DON did not participate in any way with completing or reviewing the audits. The State Survey Agency (SSA) Surveyor left voice messages per telephone to the [NAME] President of Clinical Reimbursement, on 06/02/2023 at 1:32 PM and 3:38 PM, with no call back. During interview with the ED, on 06/01/2023 at 3:46 PM, she stated she did not participate in the audit process for F641. 4. Review of the facility's PoC for F755, with an alleged compliance date of 04/16/2023, revealed the facility had conducted education for all Licensed Nurses (LN) and Certified Medication Technicians (CMT) to include agency staff on documenting that the on-coming nurse and the off-going nurse both signed that the count verification had been completed at the end of each shift by 04/15/2023. Review of the PoC further revealed starting on 04/14/2023, the Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC) or the Unit managers (UM), would visually audit three (3) narcotic blue books to ensure on-coming and off-going nurses signed the count verification daily. The audit information would be reported to the Quality Assurance Performance Improvement (QAPI) committee weekly. Review of the facility's Controlled Substances Log Book Shift Count for the six (6) of six (6) medication carts, revealed omissions of the required two (2) signatures of either coming on duty or going off duty licensed nurses on fifty-four (54) occasions between 04/16/2023 and 05/30/2023. Review of the facility's document titled Survey Education for 755 test, revealed question number four (4) was: two (2) licensed nurses count the narcotic medications at the beginning of each shift with the correct answer as true. Further review of the test revealed twenty-eight (28) tests had a one-hundred percent (100%) passing grade. During an interview with the Staff Development Coordinator (SDC), on 05/22/2023 at 10:00 AM, she stated she was in charge of educating Agency staff prior to working related to all the plans of correction issues. She stated today' the facility had a call-in at 6:30 AM, and RN #30 was needed on the floor at 7:00 AM; so she had not yet educated RN #30 on counting the narcotics with two (2) nurse signatures that the count was correct. During another interview with the SDC, on 06/01/2023 at 10:30 AM, she stated she had provided training for the narcotic count to occur at the end of shift and knew of no staff pre-signing narcotic books. She stated the UMs were completing the audits and reporting to her and that she had not observed change of shift narcotic counts during the audits starting on 04/15/2023. In an interview with Licensed Practical Nurse (LPN) #3/UM, on 05/23/2023 at 2:10 PM, she stated she had training on signing the narcotic book between shifts. In another interview with LPN #3/UM, on 06/02/2023 at 11:20 AM, she stated she was never made aware of nurses pre-signing narcotic books. She added she had not observed shift change narcotic counts and if pre-signing was occurring, there could be discrepancies in the count. She stated she had reported to the ADON and the DON that she was finding missing signatures when she was auditing the Controlled Substances Log Book Shift Count. During an interview with the DON, on 05/25/2023 at 3:00 PM, she stated the facility's process for controlling narcotics was to have the narcotics counted at each shift change by the on-coming nurse and the off-going nurse. She stated this education was provided to all staff as part of the PoC. The DON stated there was someone assigned to audit this process, who turned the audits into her, and she had noted no problems. She stated she had not completed any observations of this medication count process as part of Quality Assurance (QA). The DON further stated she was surprised to find out there were so many missing signatures from the Blue Books. 5. Review of the facility's PoC for F761, with an alleged compliance date of 04/16/2023, revealed all Licensed Nurses (LN), including Agency Staff were educated by the DON, ADON, or the SDC by 04/06/2023 on the proper storage of drugs and biologicals. This education included drugs and biologicals should be stored in locked compartments and under proper temperature and that discontinued or outdated medications would be promptly returned to the pharmacy or destroyed. Further review revealed beginning 04/10/2023 the DON, ADON, SDC or UM would round the facility to ensure proper storage of medications daily and report the daily audits to the Quality Assurance Performance Improvement (QAPI) Committee, which met weekly. Observation on 05/22/2023, revealed the medication refrigerator on the B/C Hall contained two (2) thermometers, one (1) read forty-two (42) degrees Fahrenheit (F), and the other read twenty-eight (28) degrees F. Continued observation of the refrigerator revealed it contained medications, including insulin, for Residents #103, #22 and #95. Continued observation revealed discontinued medications for Residents #95 and #400 were stored in the refrigerator. Additionally, observation revealed the facility's audit tool, posted on the front of the medication refrigerator, indicated the refrigerator had not been audited for proper storage and temperature, since 05/15/2023. Further, the facility failed to ensure all drugs and biologicals were stored in locked compartments in accordance with State and Federal laws. Observations revealed the facility failed to ensure two (2) of the six (6) medication carts were locked when unattended. Observations on 05/22/2023, revealed the medication cart on B Hall was unlocked and unattended, and observation on 06/02/2023, revealed the medication cart on D Hall was unlocked and unattended. Both medication carts contained drugs [TRUNCATED]