Based on interview and record review, the facility failed to provide showers to residents who required assistance with their activities of daily living (ADLs), for 2 of 13 residents sampled for ADL care (Resident (R)96 and R100).The findings include:1. Review of the Resident Face Sheet for R96 revealed the facility admitted the resident on 08/09/2024, with a diagnosis of end stage renal disease. Further review revealed the facility discharged R96 on 09/15/2024. Review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 08/15/2024, revealed the facility assessed R96 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. Further review revealed the facility assessed R96 to require substantial/maximal assistance with showering/bathing.Review of R96's Care Plan initiated 08/12/2024, the facility developed a Profile Care Guide for R96, to communicate the resident's care needs. Continued review revealed the interventions included staff to provide R96 a shower on Tuesdays and Fridays during the second shift.Review of the facility's shower/bath history report for R96, for the timeframe of 08/09/2024 through 08/31/2024, revealed no documented evidence the resident received a shower, bath, or bed bath from 08/15/2024 through 08/22/2024, a total of eight days. Continued review of the facility's shower/bath history report for R96, for the timeframe from 09/01/2024 through 09/13/2024, revealed staff documented the resident did not receive a shower, bath, or bed bath from 09/07/2024 through 09/12/2024, a total of six days.During interview on 07/18/2025 at 10:43 AM, Certified Resident Care Associate (CRCA) 5 stated she did not recall R96. She reported residents had scheduled showers based on their room numbers, and showers were provided twice a week.2. Review of the Resident Face Sheet for R100 revealed the facility admitted the resident on 04/22/2025, with a diagnosis of displaced intertrochanteric left femur fracture. Further review revealed the facility discharged R100 on 05/14/2025.Review of the admission MDS Assessment, with an ARD of 04/28/2025, revealed the facility assessed R100 to have a BIMS score of 12, which indicated moderate cognitive impairment. Further review revealed the facility assessed R100 to require substantial/maximal assistance with showering/bathing.Review of R100's Care Plan revealed a problem statement initiated 04/23/2025, which indicated the resident required staff assistance to complete safe-care and mobility functional tasks completely and safety. Further review revealed no documented evidence of how often R100 was to be provided showers/baths or when the showers/baths were to be performed.Review of R100's Resident Progress Notes dated 05/04/2025 at 10:34 PM, revealed a family member of the resident inquired about when the last time the resident was given a shower.Review of the facility's shower/bath history report for R100, for the timeframe of 04/22/2025 through 05/14/2025 , revealed no documented evidence the resident was provided a shower, bath, or bed bath from 04/23/2025 through 04/27/2025, a total of five days; or from 05/06/2025 through 05/12/2025, a total of seven days.During interview on 07/19/2025 at 10:05 AM, the Director of Health Services (DHS) Float, the facility's former DHS, stated resident showers were scheduled to be given twice a week unless the resident wanted to have a shower more frequently. The DHS Float said a bed bath was offered as an alternative to a shower. The DHS Float stated bathing documentation was documented in the resident's electronic health record. The DHS Float further stated if a resident went six or eight days with no bathing activity, she expected a refusal to be documented. The DHS Float additionally said going six to eight days without a shower did not meet the facility's expectations.During interview on 07/19/2025 at 11:19 AM, the Executive Director (ED) stated a resident going six to eight days without bathing would not meet the facility's expectations. The ED further stated however, there could be extenuating circumstances, like being sent out to a hospital or refusals as to why there would be no documentation of bathing.Based on interview and record review, the facility failed to provide showers to residents who required assistance with their activities of daily living (ADLs), which affected 2 (Resident #96 and Resident #100) of 13 residents reviewed for ADL care. Findings included: 1. A “Resident Face Sheet” revealed the facility admitted Resident #96 on 08/09/2024. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of end stage renal disease. The Resident Face Sheet indicated the facility discharged the resident on 09/15/2024. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/15/2024, revealed Resident #96 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident required substantial/maximal assistance with showering/bathing. Resident #96's “Care Plan” initiated 08/12/2024, indicated the resident had a “Profile Care Guide” to communicate resident care needs. Interventions directed staff to provide the resident a shower on Tuesdays and Fridays during the second shift (initiated 08/12/2024). Resident #96’s shower/bath history report, for the timeframe from 08/09/2024 through 08/31/2024, revealed no documented evidence the resident received a shower, bath, or bed bath from 08/15/2024 through 08/22/2024, a total of eight days. Resident #96’s shower/bath history report, for the timeframe from 09/01/2024 through 09/13/2024, revealed staff documented the resident did not receive a shower, bath, or bed bath from 09/07/2024 through 09/12/2024, a total of six days. During an interview on 07/18/2025 at 10:43 AM, Certified Resident Care Associate #5 stated she did not recall Resident #96, residents had scheduled showers based on their room numbers, and showers were provided twice a week. 2. A “Resident Face Sheet” indicated the facility admitted Resident #100 on 04/22/2025. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of displaced intertrochanteric left femur fracture. The Resident Face Sheet indicated the facility discharged the resident on 05/14/2025. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/28/2025, revealed Resident #100 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required substantial/maximal assistance with showering/bathing. Resident #100’s “Care Plan” included a problem statement initiated 04/23/2025, that indicated the resident required staff assistance to complete safe-care and mobility functional tasks completely and safety. The Care Plan revealed it did not include how often or when the resident was to be provided with showers/baths. Resident #100’s “Resident Progress Notes” dated 05/04/2025 at 10:34 PM, that indicated a family member of the resident inquired about when the last time the resident was given a shower. Resident #100’s shower/bath history report, for the timeframe from 04/22/2025 through 05/14/2025 , revealed no documented evidence the resident was provided a shower, bath, or bed bath from 04/23/2025 through 04/27/2025, a total of five days; or from 05/06/2025 through 05/12/2025, a total of seven days. During an interview on 07/19/2025 at 10:05 AM, the Director of Health Services (DHS) Float, the facility’s former DHS, stated resident showers were scheduled to be given twice a week unless the resident wanted to have a shower more frequently. The DHS Float stated a bed bath was offered as an alternative to a shower. The DHS Float stated that bathing documentation was documented in the resident’s electronic health record. According to the DHS Float, if a resident went six or eight days with no bathing activity, she expected a refusal to be documented. The DHS Float stated that generally going six to eight days without a shower did not meet expectations. During an interview on 07/19/2025 at 11:19 AM, the Executive Director stated that a resident going six to eight days without bathing would not meet expectations, but there could be extenuating circumstances, like being sent out to a hospital or refusals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, facility policy review, and review of the insulin pen instruction manual, the facility failed to ensure a medication error rate was not 5 percent (%) or greater for 1 of 4 residents observed during the medication administration task, (Resident (R)89).The findings include:Review of the facility policy titled, Medication Administration- General Guidelines, revised 11/2018, revealed medication were to be administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Further review of the policy revealed under the Procedures was included the FIVE RIGHTS- Right resident, right drug, right dose, right route and right time were applied for each medication being administered.Review of the Instructions for Use Lantus Solostar instruction manual, revised 12/01/2021, revealed under, Step 3: Perform a safety test, which noted to always perform the safety test before each injection. Per review, doing that ensured you get an accurate dose by, including ensuring the pen and needle work properly, and removing air bubbles. Per review of the manual revealed to select a dose of 2 units by turning the dosage selector clockwise, and take off the outer needle cap and keep it to remove the used needle after injection. Continued review revealed to take off the inner cap and discard it, hold the pen with the needle pointing upwards, tap the insulin reservoir so that any air bubbles rise up towards the needle, and press the injection button all the way in. Check if insulin comes out of the needle tip. The instructions indicated, You must perform safety tests before you use the pen until you see insulin coming out of the needle tip. If you see insulin coming out of the needle tip, the pen was ready to use. Further review revealed if insulin was not seen coming out before taking a dose, you could get an underdose or no insulin at all. This could cause high blood sugar.Review of the Instructions for Use Humalog [NAME] KwikPen insulin lispro (100 units/mL [milliliter], 3mL pen) instruction manual, revised 03/31/2020, revealed, priming the pen was to be done before each injection. Per review, priming the pen meant removing air from the needle and cartridge that might collect during normal use. Per review, it was important to prime the pen so that it would work correctly, and if you do not prime the pen before each injection, you may get too much or too little insulin. Continued review of the manual revealed, Step 5: To prime your Pen, turn the Dose Knob to select 2 units. Step 6: Hold your Pen with the Needle pointing up. Tap the Cartridge holder gently to collect air bubbles at the top. Step 7: Continue holding your Pen with the Needle pointing up. Further review revealed to push the Dose Knob in until it stopped, and ‘0' was seen in the Dose Window, the hold the Dose Knob in and count to 5 slowly. Additionally review revealed You should see insulin at the tip of the needle.Review of the Resident Face Sheet for F89 revealed the facility admitted the resident on 06/26/2024, with a diagnosis of type 2 diabetes mellitus with hyperglycemia (high blood sugar).Review of the Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 04/21/2025, revealed the facility assessed R89 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. Further review of the MDS Assessment revealed the facility assessed R89 to receive insulin injections each day during the seven-day assessment period.Review of R89's Care Plan revealed the facility developed a problem statement initiated 06/27/2024, that indicated the resident was at risk for hypoglycemia (low blood sugar)/hyperglycemia related to diabetes mellitus. Further review revealed the interventions included staff to administer the resident's medications as ordered (initiated 06/27/2024).Review of R89's Physician Order Report, for the timeframe of 06/19/2025 through 07/19/2025, revealed an active order dated 01/242025, for Humalog [NAME] KwikPen U-100 insulin pen, with instructions to inject 3 units subcutaneously before meals,. Further review of the Physician Order Report revealed an order dated 01/24/2025, for Lantus Solostar U-100 insulin pen, with instructions to inject 25 units subcutaneously once a day.Observation, during medication administration, on 07/17/2025 at 5:51 AM, Registered Nurse (RN) 1 prepared R89's medications, to include Humalog [NAME] KwikPen insulin pen and a Lantus Solostar insulin pen. Per observation, RN 1 selected a dose of 3 units on the Humalog [NAME] KwikPen insulin pen and administered the medication to the resident. Continued observation revealed RN 1 selected a dose of 25 units on the Lantus Solostar insulin pen and administered the medication to the resident. Further observation revealed RN 1 did not complete the safety test for the Lantus Solostar insulin pen as specified by the manufacturer and also did not prime the needle for the Humalog [NAME] KwikPen as specified by the manufacturer prior to administering the medications. (The two medication errors out of the 26 opportunities, resulted in a 7.69% medication error for R89).During interview on 07/17/2025 at 7:01 AM, RN 1 stated she had not primed the insulin pens as required. During interview on 07/18/2025 at 7:04 AM, the Staff Development (SD) RN stated the process for insulin pen administration was to look at the physician's order for number of units, apply the needle to the insulin pen, dial the pen to two units to prime the needle and then dial to the units ordered. The SD RN reported the insulin pens should be primed to ensure there was no air in the needle. The SD RN further stated it would not be the correct process to dial the dose ordered and administer the insulin because it would not be the correct dose being administered without priming the pen. In addition, the SD RN said she expected the pen to be primed and then the ordered dose to be dialed on the pen.During interview on 07/18/2025 at 7:12 AM, the Director of Health Services (DHS) stated she expected insulin pens to be primed and administered as per the manufacturer's guidelines. The DHS said that included priming the pen, typically with two units. The DHS further stated it was important to prime the insulin to remove air and make sure the pen was working properly before administering the insulin. During interview on 07/18/2025 at 2:59 PM, the Executive Director (ED) stated he expected the facility's medication error rate to be less than 5%. The ED further stated he deferred questions related to insulin pens to the DHS.The findings include:Review of the facility policy titled, Medication Administration- General Guidelines, revised 11/2018, revealed medication were to be administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Further review of the policy revealed under the Procedures was included the FIVE RIGHTS- Right resident, right drug, right dose, right route and right time were applied for each medication being administered.Review of the Instructions for Use Lantus Solostar instruction manual, revised 12/01/2021, revealed under, Step 3: Perform a safety test, which noted to always perform the safety test before each injection. Per review, doing that ensured you get an accurate dose by, including ensuring the pen and needle work properly, and removing air bubbles. Per review of the manual revealed to select a dose of 2 units by turning the dosage selector clockwise, and take off the outer needle cap and keep it to remove the used needle after injection. Continued review revealed to take off the inner cap and discard it, hold the pen with the needle pointing upwards, tap the insulin reservoir so that any air bubbles rise up towards the needle, and press the injection button all the way in. Check if insulin comes out of the needle tip. The instructions indicated, You must perform safety tests before you use the pen until you see insulin coming out of the needle tip. If you see insulin coming out of the needle tip, the pen was ready to use. Further review revealed if insulin was not seen coming out before taking a dose, you could get an underdose or no insulin at all. This could cause high blood sugar.Review of the Instructions for Use Humalog [NAME] KwikPen insulin lispro (100 units/mL [milliliter], 3mL pen) instruction manual, revised 03/31/2020, revealed, priming the pen was to be done before each injection. Per review, priming the pen meant removing air from the needle and cartridge that might collect during normal use. Per review, it was important to prime the pen so that it would work correctly, and if you do not prime the pen before each injection, you may get too much or too little insulin. Continued review of the manual revealed, Step 5: To prime your Pen, turn the Dose Knob to select 2 units. Step 6: Hold your Pen with the Needle pointing up. Tap the Cartridge holder gently to collect air bubbles at the top. Step 7: Continue holding your Pen with the Needle pointing up. Further review revealed to push the Dose Knob in until it stopped, and ‘0' was seen in the Dose Window, the hold the Dose Knob in and count to 5 slowly. Additionally review revealed You should see insulin at the tip of the needle.Review of the Resident Face Sheet for F89 revealed the facility admitted the resident on 06/26/2024, with a diagnosis of type 2 diabetes mellitus with hyperglycemia (high blood sugar).Review of the Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 04/21/2025, revealed the facility assessed R89 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. Further review of the MDS Assessment revealed the facility assessed R89 to receive insulin injections each day during the seven-day assessment period.Review of R89's Care Plan revealed the facility developed a problem statement initiated 06/27/2024, that indicated the resident was at risk for hypoglycemia (low blood sugar)/hyperglycemia related to diabetes mellitus. Further review revealed the interventions included staff to administer the resident's medications as ordered (initiated 06/27/2024).Review of R89's Physician Order Report, for the timeframe of 06/19/2025 through 07/19/2025, revealed an active order dated 01/242025, for Humalog [NAME] KwikPen U-100 insulin pen, with instructions to inject 3 units subcutaneously before meals,. Further review of the Physician Order Report revealed an order dated 01/24/2025, for Lantus Solostar U-100 insulin pen, with instructions to inject 25 units subcutaneously once a day.Observation, during medication administration, on 07/17/2025 at 5:51 AM, Registered Nurse (RN) 1 prepared R89's medications, to include Humalog [NAME] KwikPen insulin pen and a Lantus Solostar insulin pen. Per observation, RN 1 selected a dose of 3 units on the Humalog [NAME] KwikPen insulin pen and administered the medication to the resident. Continued observation revealed RN 1 selected a dose of 25 units on the Lantus Solostar insulin pen and administered the medication to the resident. Further observation revealed RN 1 did not complete the safety test for the Lantus Solostar insulin pen as specified by the manufacturer and also did not prime the needle for the Humalog [NAME] KwikPen as specified by the manufacturer prior to administering the medications. (The two medication errors out of the 26 opportunities, resulted in a 7.69% medication error for R89).During interview on 07/17/2025 at 7:01 AM, RN 1 stated she had not primed the insulin pens as required. During interview on 07/18/2025 at 7:04 AM, the Staff Development (SD) RN stated the process for insulin pen administration was to look at the physician's order for number of units, apply the needle to the insulin pen, dial the pen to two units to prime the needle and then dial to the units ordered. The SD RN reported the insulin pens should be primed to ensure there was no air in the needle. The SD RN further stated it would not be the correct process to dial the dose ordered and administer the insulin because it would not be the correct dose being administered without priming the pen. In addition, the SD RN said she expected the pen to be primed and then the ordered dose to be dialed on the pen.During interview on 07/18/2025 at 7:12 AM, the Director of Health Services (DHS) stated she expected insulin pens to be primed and administered as per the manufacturer's guidelines. The DHS said that included priming the pen, typically with two units. The DHS further stated it was important to prime the insulin to remove air and make sure the pen was working properly before administering the insulin. During interview on 07/18/2025 at 2:59 PM, the Executive Director (ED) stated he expected the facility's medication error rate to be less than 5%. The ED further stated he deferred questions related to insulin pens to the DHS.

Based on observations, interviews, record reviews, and review of the facility policy, it was determined the facility failed to assess two(2) (Resident #15 and Resident #19) of eighteen (18) sampled residents for the resident's ability to self-administer their medications. Findings include: A review of the facility policy titled, Medication Administration-General Guidelines, revised in November 2018, revealed 13. Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. 1. A review of Resident #15's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/26/2023, revealed the facility readmitted Resident #15 on 11/13/2021. The MDS revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS indicated Resident #15 had active diagnoses to include stroke, hypertension, and hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage. A review of Resident #15's Care Plan, edited on 11/09/2023, revealed the resident was at risk for pain related to chronic pain. Interventions directed staff to administer medications as ordered and notify the physician of any side effects observed or lack of effectiveness. A review of Resident #15's physician orders revealed an order dated 01/18/2023, for Biofreeze (a topical pain reliever) to apply a small amount topically to areas of muscle soreness twice a day as needed. There was no indication the resident was to keep the medication at the bedside or had the ability to self-administer the medication. On 01/08/24 at 10:38 AM, the surveyor observed two (2) tubes of Biofreeze at the bedside of Resident #15. Resident #15 stated staff allowed the medication to be kept at their bedside. On 01/09/2024 at 4:00 PM and 01/10/2024 at 10:49 AM, the surveyor observed 2 tubes of Biofreeze on the over-the-bed table in Resident #15's room. During an interview on 01/10/2024 at 11:36 AM, Licensed Practical Nurse (LPN) #21 stated she had not been advised of any residents on the unit that self-administered medications. LPN #21 stated before a resident self-administered medication an assessment had to be completed to verify the resident knew what the medication was for, how to administer the medication, when to administer the medication, and how to administer the medication. LPN #21 stated residents were not allowed to keep any medications at bedside without a physician's order. LPN #21 added this would include cough medication, Biofreeze, antifungal powders and creams. LPN #21 reviewed the physician orders for Resident #15 and stated the resident had an order for Biofreeze twice a day. Per LPN #21, if the resident had a physician's order to self-administer the Biofreeze, the physician's order would include the resident may keep the medication at bedside. LPN #21 confirmed the resident did not have a physician's order to keep the Biofreeze medication at their bedside. LPN #21 observed the medication in Resident #15's room and explained to the resident that she needed to remove the Biofreeze until a physician's order for self-administration could be obtained. During an interview on 01/11/2024 at 10:20 AM, the Director of Health Services (DHS) stated Resident #15 had not been assessed for their ability to self-administration their medication. The DHS stated Resident #15 should not have had the 2 tubes of Biofreeze at bedside. During an interview on 01/11/2024 at 12:49 PM, the Executive Director stated he expected a resident assessment for self-administration competency and a system to provide safe storage of medications prior to self-administration. 2. A review of Resident #19's Resident Face Sheet, revealed the facility had admitted the resident on 04/28/2021 with diagnoses that included acute kidney failure, hypertensive heart disease and chronic kidney disease with heart failure, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. A review of Resident #19's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/2023, revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A review of Resident #19's Care Plan, edited on 12/28/2023, revealed the resident had potential for complications, functional and cognitive status decline related to respiratory disease. Interventions directed staff to administer medications as ordered. A review of Resident #19's Order History, for the time frame 12/01/2023 to 01/09/2024, did not reveal an order for the resident to be administered Delsym, a cough suppressant medication. On 01/08/2024 at 12:06 PM, the surveyor observed a bottle of Delsym at the bedside of Resident #19. Resident #19 stated their renal doctor prescribed the medication for them and the facility nurses administered the medication to the resident on 01/07/2024. On 01/09/2024 at 4:05 PM, while seated in a wheelchair in their room, Resident #19 pointed to the bottle of Delsym on their bed. Resident #19 picked up the bottle and stated they took the medication every 12 hours as directed on the label. During an interview on 01/10/2024 at 11:36 AM, Licensed Practical Nurse (LPN) #21 stated she had not been advised of any residents on the unit that self-administered medications. LPN #21 stated before a resident self-administered medication an assessment had to be completed to verify the resident knew what the medication was for, how to administer the medication, when to administer the medication, and how to administer the medication. LPN #21 stated residents were not allowed to keep any medications at bedside without a physician's order. LPN #21 added this would include cough medication, Biofreeze, antifungal powders and creams. LPN #21 reviewed the physician orders for Resident #19 and stated the resident did not have an order for Delsym. LPN #21 stated the medication should not be at the bedside of the resident. LPN #21 observed the medication in Resident #19's room and explained to the resident that she needed to remove the Delsym until a physician's order for self-administration could be obtained. During an interview on 01/11/2024 at 10:20 AM, the Director of Health Services (DHS) stated Resident #19 had not been assessed for their ability to self-administration their medication. The DHS stated Resident #19 should not have had the Delsym medication at their bedside. During an interview on 01/11/2024 at 12:49 PM, the Executive Director stated he expected a resident assessment for self-administration competency and a system to provide safe storage of medications prior to self-administration.

Based on interview, record reviews, document review, and facility policy review, it was determined the facility failed to have evidence to indicate an allegation of abuse which involved two residents, Resident #39 and Resident #179, of five (5) sampled residents reviewed for abuse prohibition, was thoroughly investigated. Findings include: A review of the facility policy titled, Abuse, Neglect and Exploitation Procedural Guidelines, revised on 08/29/2019, revealed f. Investigation i. The Executive Director is accountable for investigating and reporting. ii. Exercising caution in handling evidence that could be used in a criminal investigation iii. Investigating different types of allegation violations iv. Identifying and interviewing all involved person, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations v. Focusing the investigation of determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause. vi. Providing complete & thorough documentation of the investigation. A review of Resident #39's Resident Face Sheet revealed the facility admitted the resident on 08/24/2020, with diagnoses to include dementia with behavioral disturbance and anxiety disorder. A review of Resident #39's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/28/2021, revealed the resident had a Brief Interview for Mental Status (BIMS) score of zero (0), which indicated the resident had severe cognitive impairment. A review of Resident #39's care plan, with a start date of 08/30/2020, revealed the resident demonstrated significant severe cognitive deficits. A review of Resident #179's Resident Face Sheet, revealed the facility admitted the resident on 07/17/2021, with diagnoses to include vascular dementia with behavioral disturbance and anxiety. A review of Resident #179's admission MDS, with an ARD of 07/23/2021, revealed the resident had severely impaired cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS). A review of Resident #179's care plan, with a problem start date of 07/19/2021, revealed the resident demonstrated significant severe cognitive deficits. A review of an Event Report, revealed on 08/01/2021 at 11:38 AM, Resident #179 became aggressive and smacked Resident #39 on their shoulders several times. The report revealed Resident #179 started to push Resident #39 in their wheelchair and asked the resident to turn their hat around and for the resident to move. When Resident #39 did not, Resident #179 became agitated and began to hit Resident #39 on the shoulder several times. A review of the facility's investigation file revealed no evidence to indicate all involved persons, to include the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation were interviewed during the investigation. During an interview on 01/11/2024 at 12:27 PM, the Executive Director (ED) stated when there was an altercation between two (2) residents, the facility conducted an investigation which included interviewing the resident, if possible, conducting skin and pain assessments, interviewing staff, and looking into any potential patterns. The ED stated it was important do so to protect the residents to ensure no abusive situations occurred. The ED acknowledged he could not find the facility's investigation into the incident that involved Resident #39 and Resident #179.

Based on record review, interviews, and facility policy review, it was determined the facility failed to follow physician's orders for one (1) of six (6) sampled residents, whose medications were reviewed, Resident #126. Findings include: A review of a facility policy titled, Medication Administration-General Guidelines, revised in November 2018, revealed If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g. [exempli gratia, for example], other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication may be removed from the emergency drug supply. The policy further revealed, Medications are administered in accordance with written orders of the prescriber. A review of Resident #126's Resident Face Sheet revealed the facility admitted the resident on 10/05/2023 with diagnoses which included metabolic encephalopathy, infection and inflammatory reaction due to internal right knee prosthesis, rheumatoid arthritis, anemia, uncomplicated, unspecified asthma, personal history of thrombosis and embolism, personal history of other malignant neoplasm of the skin, and personal history of methicillin resistant staphylococcus aureus (MRSA) infection. The Resident Face Sheet revealed the facility discharged the resident on 10/09/2023. A review of a hospital Discharge Summary, dated 10/05/2023, indicated Resident #126 was to be treated with daptomycin (an antibiotic) per intravenous (IV) access for 6 weeks. The Discharge Summary also indicated Resident #126 was to receive apixaban (an anticoagulant medication), cyanocobalamin (vitamin B12 supplement), duloxetine (an antidepressant medication), esomeprazole (a medication used to treat gastrointestinal distress), flecainide (a heart medication), gabapentin (a medication used to treat neuropathic pain), and folic acid. A review of Resident #126's Medication Administration History, for 10/01/2023 through 10/09/2023, revealed staff documented that Resident #126 did not receive the cyanocobalamin on 10/06/2023 and 10/08/2023 during the day shift, daptomycin on 10/06/2023, duloxetine on 10/09/2023, apixaban on 10/06/2023 during the day shift, flecainide on 10/06/2023 during the day shift, gabapentin on 10/06/2023, 10/07/2023, and 10/08/2023, esomeprazole magnesium on 10/06/2023, and folic acid on 10/08/2023. The Medication Administration History revealed staff documented the reason for the missed medications were due to the medications not being available. The Medication Administrator History revealed entries of the missed medications were created by staff, to include Licensed Practical Nurse (LPN) #14 and LPN #18. A review of Resident #126's Resident Progress Notes, dated 10/05/2023 through 10/09/2023, revealed no evidence to indicate the pharmacy and/or physician had been notified of missed medication or medications not being received. In an interview on 01/10/2024 at 12:03 PM, LPN #14 stated admission orders were obtained from the hospital discharge summary and confirmed with the attending physician. She stated the attending physician made any needed changes to the medications. LPN #14 stated the pharmacy was typically able to get medications to the facility overnight. She stated if it was past admission and the medications had not arrived, she alerted her supervisor, called the pharmacy, and documented her actions to get the medications. LPN #14 reviewed Resident #126's medication administration record (MAR) and stated the pharmacy should have been called and the medications sent immediately to the facility. The LPN stated she was not sure there was a backup pharmacy and added she had always been able to get medications from the facility pharmacy. She stated there should be nurse's notes that explained what was done to get the medications. She stated the danger of not getting the IV antibiotics would be worsening of the infection and having to start the antibiotic cycle over again. LPN #14 stated she remembered the resident's name because she had worked on the resident's unit but was unable to remember specifics about the resident. LPN #14 stated not receiving the resident's medications was an issue and stated she would not have been able to follow the physician's orders without the medications. In a telephone interview on 01/10/2024 at 3:38 PM, Registered Nurse (RN) #15 stated she worked the 6:00 PM to 6:00 AM shift and when a resident was admitted on that shift, she usually called the pharmacy with the medication list and the medications were delivered within four hours. RN #15 stated the facility also had a first dose machine where medications could be taken. RN #15 added if a resident's medications were not delivered, she called the pharmacy and the physician to notify them the medications were not available and document the notification in the nurse's notes. The RN stated if Resident #126 had not received the ordered antibiotics for several days, it would slow down the healing process and could harm the resident. In a telephone interview on 01/11/2024 at 6:30 AM, RN #9 stated admission orders were taken from the hospital discharge summary. He stated when a resident was admitted on his shift, which was between 6:00 PM and 6:00AM, he ordered the medications immediately from the pharmacy and the medications usually arrived within 4 hours. RN #9 stated the facility had an emergency kit with some medications and he could also borrow medications from a sister facility's emergency kit if needed. He stated a resident should not go two to three days without ordered medications, especially antibiotics, since going without the antibiotic could cause the resident to have sepsis. RN #9 stated he would notify the pharmacy and the physician about missing medications and would document those conversations in the resident's progress notes. The RN stated he was unable to remember the resident and had no idea why the medications were not received and why there were no attempts documented to call the physician or the pharmacy. In an interview on 01/11/2024 at 2:14 PM, LPN #18 stated she vaguely remembered Resident #126. LPN #18 stated if the IV antibiotic for Resident #126 was not available she would have called the pharmacy and the physician and checked the first dose machine. The nurse stated she would have documented the conversations in the progress notes. LPN #18 stated if there were no notes in Resident #126's chart regarding notification of missed medications, then she probably had forgotten to call. In an interview on 01/11/2024 at 10:40 AM, the Director of Health Services (DHS) stated admission orders were received from the hospital on the discharge summary, history and physical, and then verified with the attending physician. The DHS stated if the attending physician ordered additional medications or made changes, they were entered into the electronic medical record (EMR) and stated that a written progress note was not required. She stated that when the orders were entered into the EMR, the pharmacy was able to review the orders and the medications were sent to the facility the same night, or the following day if the order was not received by the pharmacy by 3:00 PM. The DHS stated if a medication was needed on the day of admission, the nurse utilized the first dose machine but if the medication was not in the first dose machine, she expected staff to notify the physician and the pharmacy to have the medication sent immediately and was usually received within 4 hours. The DHS added if medications were not received within 24 hours, the physician was expected to be notified for further instructions and the pharmacy should be contacted to see if the medications were on the way to the facility. The DHS stated negative consequences of not receiving an ordered antibiotic would depend on the individual resident's risk factors. The DHS reviewed Resident #126's MAR and stated the nurses should have documented the provider was notified on 10/06/2023 when the medications were not available. In an interview on 01/11/2024 at 1:47 PM, the Executive Director (ED) stated he expected medications to arrive within 24 to 48 hours and for staff to remove medications out of the first dose kit if available. The ED stated he expected nurses to follow the physician orders and notify the physician if they were unable to follow the orders. In a telephone interview on 01/11/2024 at 4:02 PM, Resident #126's primary care physician (PCP) stated if medications were delayed, he expected to be notified. The PCP stated he was unsure if he had been notified or not since he did not have the chart for review. He stated the negative outcome for missed medications would be a delay in healing.

Based on interviews, record reviews, document reviews, and facility policy review, it was determined the facility failed to ensure three (3) (Residents #39, #177, and #178) of five (5) sampled residents reviewed for abuse, were from abuse. On 08/01/2021, Resident #179 physically abused Resident #39 when the resident did not respond to Resident #179's command. On 05/09/2023, Resident #176 pulled Resident #177 from their bed. On 09/04/2022, a staff member took an unauthorized photo of Resident #178 and showed the picture to other staff. Findings include: A review of the facility policy titled, Abuse, Neglect and Exploitation Procedural Guidelines, revised on 08/29/2019, revealed, 3. Definitions: ABUSE is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. 1. A review of Resident #39's Resident Face Sheet revealed the facility admitted the resident on 08/24/2020, with diagnoses to include dementia with behavioral disturbance and anxiety disorder. A review of Resident #39's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/28/2021, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. A review of Resident #39's care plan, with a start date of 08/30/2020, revealed the resident demonstrated significant severe cognitive deficits. A review of Resident #179's Resident Face Sheet, revealed the facility admitted the resident on 07/17/2021, with diagnoses to include vascular dementia with behavioral disturbance and anxiety. A review of Resident #179's admission MDS, with an ARD of 07/23/2021, revealed the resident had severely impaired cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS). A review of Resident #179's care plan, with a problem start date of 07/19/2021, revealed the resident demonstrated significant severe cognitive deficits. A review of an Event Report, revealed on 08/01/2021 at 11:38 AM, another resident (Resident #179) became aggressive and smacked Resident #39 on their shoulders several times. The report revealed the resident was sitting in a wheelchair propelling around the unit. Resident #179 started to push Resident #39 in the wheelchair and asked the resident to turn his/her hat around and asked the resident to move. When Resident #39 did not, Resident #179 became agitated and began to hit Resident #39 on the shoulder several times. A review of the facility's final report, dated 08/05/2021, revealed staff separated the residents and completed a skin assessment on Resident #39 and noted no injury. The report revealed Social Services Director (SSD) #7 attempted to interview both residents on 08/04/2021 and neither could remember the incident. Staff assigned to the unit reported no history between the residents. The report indicated both residents had been in the common area at the same time with no further incidents. The facility made a referral to a behavioral hospital for Resident #179, and the resident was accepted for treatment on 08/05/2021. The facility determined the contact between the residents was incidental because staff responded quickly to protect both residents, there were no injuries, and there was a lack of apparent intent by either resident to harm the other. During an interview on 01/10/2024 at 3:22 PM, activities associate (AA) stated she witnessed the incident between Resident #39 and Resident #179. Per the AA, Resident #39 liked to self-propel in a wheelchair and did not like to pick up their feet. The AA stated she witnessed Resident #179 push Resident #39's wheelchair and Resident #179 smacked Resident #39 on the chest. The AA stated the smack was not a hard hit and Resident #39 had no injury and laughed about the incident. The AA stated she took Resident #39 to the nurse's station following the incident. During an interview on 01/09/2024 at 11:57 AM, Certified Resident Medication Assistant (CRMA) #2 stated she thought Resident #179 became upset or was trying to move Resident #39 out of the way. CRMA #2 could not remember which resident was hit. During an interview on 01/10/2024 at 11:20 AM, SSD #7 stated she did not remember the details of the incident between Resident #179 and Resident #39 but her role in alleged abuse investigations included checking on the residents to ensure there were no residual effects from the altercation. SSD #7 further stated neither resident had a history of behaviors towards others. During an interview on 01/11/2024 at 10:01 AM, the Director of Health Service (DHS) stated the incident between Resident #179 and Resident #39 occurred before she was the DHS. She stated Resident #39 had no behaviors and self-propelled in their wheelchair around the unit. During an interview on 01/11/2024 at 12:27 PM, the Executive Director (ED) stated he did not remember the incident on 08/01/2021 but read the reportable. He stated he did not remember Resident #179. He stated Resident #39 was always happy and smiling. The ED stated he did not think the resident provoked anything and there was no reason to believe that Resident #39 was at risk. He stated he thought it was just two residents with cognitive decline. 2. A review of Resident #176's Resident Face Sheet revealed the facility admitted the resident on 12/29/2022 with diagnoses that included which included pelvic and sacral fracture, age-related osteoporosis, anxiety, and heart disease. A review of Resident #176's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/06/2023, revealed Resident #176 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. A review of Resident #176's care plan, with a problem start date of 01/04/2023 and revised 10/10/2023, revealed the resident demonstrated significant severe cognitive deficits. A review of Resident #177's Resident Face Sheet revealed the facility admitted the resident on 12/13/2022, with diagnoses to include Alzheimer's disease and dementia with other behavioral disturbance. A review of Resident #177's quarterly MDS, with an ARD of 02/21/2023, revealed Resident #177 had a BIMS score of 4, which indicated the resident had severe cognitive impairment. A review of Resident #177's care plan, with a problem start date of 12/17/2022 and revised 08/21/2023, revealed the resident demonstrated significant severe cognitive deficits. A review of the facility's final report, dated 05/19/2023, revealed Resident #176 alleged Resident #177 pulled them out of bed. Resident #177 seemed confused about which room was theirs and thought Resident #176 was in their bed. Staff separated the residents, assessed them for injuries, and obtained an x-ray for Resident #176, which was negative for fractures. Staff identified a possible contributing factor to Resident #177's confusion could have been their missing shadow box outside their room because it was being updated at the time with new personal items and pictures to aid in room identification. Staff placed Resident #177 on 1:1 supervision but the resident's physician evaluated the resident and determined they were not a threat and released them from one-to-one care. The investigation could not conclude that abuse occurred due to the residents' cognitive function and the lack of witness. During an interview on 01/09/2024 at 2:30 PM, Certified Resident Medication Assistant (CRMA) #4 stated as she sat at the nurse's station, she heard Resident #177 yell. CRMA stated she responded and met Resident #177 in the doorway of Resident #176's room and Resident #176 was on the floor of their room. Per CRMA #4, one staff member took Resident #177 to their room, and she waited on the nurse to assess Resident #176 for any injury. Per CRMA #4, there was no history of behaviors between these two residents. During an interview on 01/09/2024 at 3:36 PM, Registered Nurse (RN) #5 stated Resident #177 had sustained significant cognitive decline and had no history of any similar behaviors towards others. During an interview on 01/10/2024 at 10:58 AM, Licensed Practical Nurse (LPN) #6 said she was the nurse on the other side of the hall when the incident between Resident #177 and Resident #176 occurred. LPN #6 stated staff obtained vital signs and there were no apparent injuries. She stated both residents had advanced dementia with no history of incidents involving other residents. During an interview on 01/10/2024 at 11:20 AM, Social Services Director (SSD) #7 stated neither Resident #177 nor Resident #176 had a history of behaviors towards others. During an interview on 01/10/2024 at 3:22 PM, the activities associate (AA) stated both Resident #177 and Resident #176 had no history of verbal or physical behaviors towards others. During an interview on 01/11/2024 at 10:01 AM, the Director of Health Services (DHS) stated when staff found Resident #176 on the floor, the situation first presented as a fall. However, when Resident #176 stated that Resident #177 pulled them out of bed, staff were able to piece together what happened. Per the DHS, staff reported to her that Resident #177 was in the doorway of Resident #176's room thinking someone else was in their bed. Staff redirected Resident #177 to their room and then found Resident #176 on the floor. The DHS stated staff initially placed Resident #177 on one-on-one supervision following the incident. According to the DHS, neither resident had a history of altercations with other residents. During an interview on 01/11/2024 at 12:27 PM, the Executive Director (ED) stated he monitored interactions between residents to prevent any alleged incidents of abuse or neglect and followed up on what was reported. Per the ED, when there was an altercation between two (2) residents, he expected staff to protect the residents. Once an incident occurred, the facility investigated. They interviewed the residents, if possible, completed skin and pain assessments, interviewed staff, and investigated any potential patterns. The ED stated it was important to do so to protect the residents to ensure no abusive situations occurred. The ED stated he believed someone brought staffs' attention to the room and staff found Resident #176 on the floor. The ED did not think anyone saw what happened. He believed the facility placed Resident #177 on one-on-one supervision and attended to Resident #176 to make sure there were no injuries. The ED stated there was a question whether Resident #177 was confused on the location of their room. The ED stated to prevent this from occurring again, the facility acquired an extra shadow box for personal effects in the event one needed to be taken down. 3. A review of the facility policy titled, Cell Phones, Cameras & Electronic Devices, updated June 2023, revealed This policy is designed to maintain excellent customer service, comply with healthcare regulations, and protect residents' rights to privacy and confidentiality. It is of utmost importance to avoid taking or using photographs or making recordings that might be demeaning, humiliating or could potentially cause emotional or mental abuse to a resident. A review of Resident #178's Resident Face Sheet revealed the facility most recently admitted the resident on 03/09/2017, with diagnoses to include unspecified dementia, anxiety, psychosis, and major depressive disorder. A review of Resident #178's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/19/2023, revealed the resident had Brief Interview for Mental Status (BIMS) score was 0, which indicated the resident had severe cognitive impairment. A review of Resident #178's care plan, with a problem start date of 03/09/2017, revealed the resident had impaired cognition with associated short term memory impairment and was at risk for confusion, disorientation, altered mood, and impaired or reduced safety awareness related to dementia. A review of the facility's Long Term Care Facility - Self- Reported Incident Form, dated 09/04/2022, revealed Housekeeper #24 allegedly took an unauthorized photo of Resident #178 on her personal cell phone. Per the form, the resident could allegedly be identified in the photo and the resident had no knowledge of the photo being taken. During an interview on 01/10/2024 at 2:04 PM, Housekeeper #24 stated she took a picture of the resident to show the Executive Director (ED) because she asked staff to help the resident and staff would not help. Housekeeper #24 stated the resident had feces on their face, hands, and on the bed. She stated the facility told her to erase the picture from the phone, then her employment was terminated. Housekeeper #24 initially stated she only showed the picture to the environmental service director (ESD) and the ED, but then stated she also showed the picture to her mother and a staff member in the kitchen. During an interview on 01/10/2024 at 3:48 PM, the ESD stated Housekeeper #24 sent her a text message about a resident who had been playing in their feces. Per ESD, approximately five (5) minutes later, she went to the resident's room to check on them and staff already had the resident in the shower. The ESD stated she told Housekeeper #24 that staff took care of the resident. The ESD stated later the ED notified her that Housekeeper #24 had taken a picture of the resident with her phone. According to the ESD, the ED asked her to contact the employee to remove the picture from their cell phone. However, the ESD stated Housekeeper #24 had already shown the picture to Dietary Aide (DA) #25. According to the ESD, Housekeeper #24 admitted to also showing the picture to her mother. During an interview on 01/11/2024 at 10:02 AM, the Director of Health Services (DHS) stated staff were told to keep their cell phones out of resident care areas. The DHS stated taking pictures of a resident in an embarrassing situation was inappropriate behavior and potential abuse. The DHS stated if staff showed the pictures to a family member it was considered abuse even if the resident was not aware of the picture being taken. During an interview on 01/11/2024 at 12:48 PM, the ED stated when he met with the ESD, the Housekeeper #24 said she took the picture so she could show him that Resident #178 had not been cared for. The ED stated Housekeeper #24 was suspended and then her employment was terminated.