**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents (Resident #94) received services in the facility with reasonable accommodations of the resident's needs and preferences related to bariatric equipment (Geri Chair and Shower Bed). The findings include: A review of the facility policy for resident equipment titled Equipment Resident Use dated 08/01/2013 revealed the facility would provide routine equipment for the general use of the resident population. A review of the medical record for Resident #94 revealed the facility admitted the resident to the facility on [DATE] with diagnoses, which included Severe Morbid Obesity and Abnormalities of Gait and Mobility. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed to be cognitively impaired with a Brief Interview for Mental Status (BIMS) score of seven (7) indicating severe cognitive impairment. Observation of Resident #94 conducted on 08/03/2021 at 10:15 AM revealed the resident was resting in a bariatric bed; however, there was no chair in the resident's room. Interview with Resident #94 on 08/04/2021 at 1:08 PM revealed the resident did not currently have a chair in his/her room. According to the resident, he/she previously had a chair he/she was using to set in when out of bed. However, the facility took the resident's chair, and the resident did not know why. Further interview revealed the resident only received bed baths because the facility did not have chair or means to take the resident to the shower. According to Resident #94, the resident could not recall when the he/she last received a shower and only remembered receiving bed baths. Interview with State Registered Nurse Aide (SRNA) #7, on 08/09/2021 at 1:45 PM, revealed Resident #94 use to have a bariatric chair in his/her room which the resident sat in daily; however, the SRNA stated the chair had not been in the resident's room for a month. Per interview, the SRNA was not sure what happened to the chair. Interview with the Station One Unit Manager, on 08/09/2021 at 1:55 PM, revealed the Unit Manager was not sure where Resident #94's chair was and thought the chair was in the resident's room. According to the Unit Manager, the resident was to be bed bathed only because the resident was not safe in a shower chair. According to the Unit Manager, the Administrator had been talking about using a shower bed for the resident but was not sure if the facility was going to purchase one for the resident. Interview with the Rehabilitation Director, on 08/09/2021 at 2:05 PM, revealed the chair that was being used for Resident #94 was borrowed from another facility and had to be returned on 08/03/2021. The Rehabilitation Director stated a request to purchase a chair for the Resident #94 was awaiting approval. Further interview revealed the Resident had been evaluated in February of 2021 for the use of a shower chair and the resident was not safe to use a shower chair due to the resident's condition of a pendulous abdomen and was to be bed bathed only. Interview with the Director of Nursing, on 08/11/2021 at 2:54 PM, revealed the facility had been working on getting Resident #94 a chair. The facility was trying to find something that would work for the resident and had been looking at a shower bed so the resident could take a shower but did not provide any time period for obtaining the shower bed. According to the DON, a resident not being able to take a shower that wanted to could be a dignity issue Interview with the Administrator, on 08/11/2021 at 4:03 PM, revealed the Administrator was not aware the facility had borrowed equipment from anther facility until 08/03/2021. According to the Administrator, she started at the facility in February of 2021 and was not aware of the need for a chair for Resident #94 . The Administrator stated she would have purchased a chair and the equipment needed to use for Resident #94. Further interview revealed the facility should provide the equipment necessary to care for bariatric residents who required care to meet individual needs and to improve the resident's quality of life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility failed to protect the rights of one (1) of twenty two (22) sampled residents (Resident #1). Family Member #1 who was also Resident #1's Power of Attorney (POA) verbally requested a copy of the resident's medical records, on 07/29/2021, and the family member signed the request for the medical record, on 07/29/2021. However, the family member did not receive the medical record until 08/03/2021 (3 business days after the initial request). The findings include: Interview on 08/10/2021 at 2:19 PM, with the Administrator revealed the facility did not have a policy related to providing resident medical record copies but used the form, Request for Inspection/Copy of Protected Health Information. A review of this form revealed areas to be filled out stating who requested the medical record, reason for request, and a date line. Interview with Family Member #1 on 08/03/2021 at 2:34 PM, who was also Resident #1's POA, revealed she had come to the facility and requested copies of the resident's medical record and signed the consent on 07/29/2021. The POA stated she had not yet received a copy of Resident #1's medical record. Record review for Resident #1 revealed the resident was admitted to the facility on [DATE], with diagnoses that included Acute Kidney Failure, Major Depressive Disorder, Pain in Right Shoulder, Polyosteoarthritis, and Alzheimer's Disease. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of three (3), indicating severe cognitive impairment. Further review revealed Family Member #1 was listed as Resident #1's POA. Review of Request for Inspection/Copy of Protected Health Information for Resident #1, revealed the record had been requested, on 07/29/2021. The record request had been signed, on 07/29/2021 by Resident #1's family. The form had not been signed by a facility representative. Interview conducted on 08/10/21 at 2:19 PM with the Administrator revealed she was responsible for ensuring residents or responsible parties received a copy of the medical record when requested. The Administrator stated she would have the resident or responsible party sign a consent and would then send the consent to the Corporate office for authorization to release the medical record. Once it is approved, the Administrator stated she gives the resident or responsible party a copy of the medical record. The Administrator stated Resident #1's responsible party came in and signed a request for the medical record on 07/29/2021. Per the Administrator, she was notified by corporate to release the medical record on 08/03/2021, and she called the responsible party on 08/03/2021, to come and pick up the medical record. The Administrator stated Family Member #1 had picked up the copy of Resident #1's medical record on 08/04/2021. The Administrator stated she had not been aware the facility was required to provide a written copy of the resident's medical record within two (2) days of the written request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the record for Resident #41 revealed the facility admitted the resident on 04/03/2019 with diagnoses that included Arthritis and Anxiety Disorder. Review of the most recent MDS which was a quarterly assessment with a reference date of 06/03/2021 revealed Resident #41 had a BIMS score of fourteen (14) indicating the resident was cognitively intact and interviewable. Further review of the MDS for Resident #41 with a reference date of 06/03/2021 revealed the resident required the physical assistance of one (1) person for bathing. The comprehensive care plan (undated) included the focus area of ADL deficit related to physical functioning that was dated 04/01/2019 and the goal was for the resident to have ADL care needs met daily. The interventions included staff assistance of one (1) with bathing per schedule and as needed. Review of the computer Kiosk where SRNA's document care revealed Resident #41 required the assistance of one person for bathing. The KIOSK revealed the resident would be showered on Sundays and Thursdays, and would receive a bed bath on all other days. Interview with the Resident #41 on 08/05/21 at 10:29 AM during the resident council interviews revealed the resident stated it had been a week or two since he/she had received a shower and maybe longer. Review of the shower records for Resident #41 revealed from 07/21/2021 - 08/10/2021, Resident #41 received only one (1) shower on 07/22/2021, and not twice weekly as directed on the care plan. 4. Review of the record for Resident #59 revealed the facility admitted the resident on 01/21/2021 with diagnoses that included Alzheimer's Disease and Dementia. Review of the significant change MDS with a reference date of 06/22/2021 revealed Resident #59 required physical assistance from one (1) staff person for bathing. Further review of the MDS revealed the resident's BIMS score was three (3) indicating severe cognitive impairment. Further review of the resident's medical record revealed the SRNA care plan indicated that Resident #59 was to receive two (2) showers weekly. Review of the comprehensive care plan (undated) revealed the resident had ADL self-care performance deficit with a goal for the resident to maintain current level of function in ADL status with a target date of 10/05/2021. The interventions included for staff to assist with bathing. Review of the bathing records documented as tasks in the electronic medical record (EMR) revealed Resident #59 was to have a shower twice weekly on Sunday and Thursday with bed baths in between. Further review of the documentation revealed from 07/11/2021 through 08/09/2021, Resident #59 only received four (4) showers (on 07/18/2021, 07/29/2021, 08/02/2021, and 08/05/2021) and did not receive showers twice weekly. 5. Review of the record for Resident #96 revealed the facility admitted the resident on 10/31/2017 with diagnoses that included Coronary Artery Disease and Diabetes Mellitus. Review of the most recent MDS assessment which was a quarterly assessment with a reference date of 07/12/2021 revealed the resident's BIMS score was fifteen (15) indicating that the resident was cognitively intact. Further review of the MDS revealed the resident required the physical assistance of one (1) staff for bathing. Review of the comprehensive care plan (undated) revealed that the focus area of ADL self care performance deficit related to impaired mobility was initiated on 11/14/2017 with the goal for the resident to be clean and odor free per staff assistance and the interventions included one (1) staff was to assist with bathing. Interview with Resident #96 on 08/05/2021 at 10:02 AM revealed the resident stated he/she was supposed to get two (2) showers per week, but it had been two (2) weeks since he/she had received a shower. Review of the bathing records documented as tasks in the electronic medical record (EMR) revealed Resident #96 was to have a shower twice weekly on Tuesday and Friday. Review of the shower records for Resident #96 from 07/21/2021 through 08/10/2021 revealed that only bed baths had been documented for Resident #96 and showers had not been given twice weekly in accordance with the care plan. 6. Review of the record for Resident #101 revealed the facility admitted the resident on 03/05/2021 with diagnoses that included Alzheimer's Disease and Depression. Review of the most recent MDS which was a quarterly assessment with a reference date of 07/15/2021 revealed the BIMS score had not been obtained because the resident was rarely/never understood and the assessment further revealed the resident's cognitive skills for decision making were severely impaired. Further review of the MDS assessment revealed Resident #101 was totally dependent on staff for bathing. Review of the comprehensive care plan (undated) revealed that the resident had a ADL self care performance deficit related to confusion, impaired balance and limited mobility. The care plan interventions stated that the resident required total assistance for bathing. Review of the bathing records documented as tasks in the electronic medical record (EMR) revealed Resident #59 was to have a shower twice weekly on Wednesday and Saturday. Further review of the shower records for resident #101 from 07/11/2021 through 08/09/2021 revealed the resident received four (4) showers (on 07/14/2021, 07/17/2021, 07/21/2021, and 07/28/2021) and bed bath was recorded for all other days during that time period. The resident did not receive showers twice weekly according to the care plan. Interview conducted with the Director of Nursing (DON), on 08/11/2021 at 2:54 PM, revealed residents were to have showers twice a week unless the resident wanted a shower more often or if the resident refused. The DON stated she had not been aware showers were not being done as required. The DON stated the information regarding when a resident was to be showered as well as the assistance and support required was kept in the Kiosk in the computer. The DON stated the potential concern for a resident not getting a shower twice a week was infection control issues, dignity, and depression. The DON stated SRNAs were required to check the Kiosk before providing care. The DON stated she monitored for implementing the care plan by making rounds daily. The DON stated she had not identified any concerns with staff not following the care plan. Interview conducted with the Administrator, on 08/11/2021 at 4:03 PM, revealed she made rounds daily to ensure residents were being provided with the care they required. The Administrator stated she had not identified any concerns with residents not being provided with the care they required as directed in the care plan. The Administrator stated showers were expected to be done twice a week unless the resident refused. Based on observation, interview, record review, and facility policy review, it was determined the facility failed to implement the plan of care for six (6) out of twenty two (22) sampled residents (Residents #1, #41, #59, #69, #96, and #101) related to personal hygiene. Review of the individualized care plans for Residents #1, #41, #59, #69, #96, and #101, revealed the residents were to have a showers twice weekly and bed baths, five (5) days per week, on the days showers were not completed. Review of the bathing documentation, revealed the Resident #1, #41, #59, #69, #96, and #101 were not receiving showers twice weekly. The findings include: Review of the facility's policy titled, Care Plan, Comprehensive, dated 08/01/2013, revealed each care plan was designed and implemented to reflect the resident's wishes regarding care and treatment goals. The policy stated assessments of residents were ongoing and care plans were revised as information about the resident and the resident's condition changed. 1. Review of the closed record review for Resident #1 revealed the resident was admitted to the facility on [DATE], with diagnoses that included Acute Kidney Failure, Major Depressive Disorder, Pain in Right Shoulder, Polyosteoarthritis, and Alzheimer's Disease. The medical record further revealed the resident had been discharged from the facility on 07/27/2021. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of three (3), indicating severe cognitive impairment. The MDS revealed Resident #1 required the extensive assistance of one person for bathing. Review of a State Registered Nursing Assistant (SRNA) care plan undated, revealed staff were to provide assistance with personal care, activities of daily living, and toileting needs. Review of a comprehensive care plan for Resident #1 with an admission date of 07/19/2021, revealed resident would be clean, dry, and odor free. The care plan revealed staff would assist the resident with activities of daily living. Review of a State Registered Nursing Assistant (SRNA) care plan undated, revealed staff were to provide assistance with personal care, activities of daily living, and toileting needs. Review of the computer Kiosk where SRNA's document care on 08/03/2021 at 2:30 PM, revealed Resident #1 required the assistance of one person for bathing. The KIOSK revealed the resident would be showered on Wednesdays and Saturdays, and would receive a bed bath on all other days. Review of bathing documentation for Resident #1, revealed the resident was to receive a shower on 07/21/2021 and 07/24/2021; however, the documentation revealed the resident had received a bed bath instead. Interview conducted with SRNA #11, on 08/10/21 at 11:04 AM, revealed the Kiosk is where the information was kept regarding the care needs of a resident. The SRNA stated she was required to check the Kiosk before providing care to check for changes. The SRNA stated Resident #1 required the assistance of one person for bathing. The SRNA stated she had been responsible for providing a shower for Resident #1 on 07/24/2021, and had no idea why she had given the resident a bed bath instead. The SRNA stated she guessed she had just been too busy because of staff calling in (staff not reporting to work as scheduled). Interview conducted with SRNA #13, on 08/10/2021 at 2:50 PM, revealed the care plan and the Kiosk were where the information was kept regarding the care needs of a resident. The SRNA stated she was required to check the Kiosk before providing care to check for changes. The SRNA stated Resident #1 required the assistance of one person for bathing. The SRNA stated she had been responsible for providing a shower for Resident #1 on 07/21/2021, and had no idea why she had given the resident a bed bath instead. The SRNA stated she guessed she had just been too busy because of staff calling in. The SRNA stated it had probably been hectic that day. 2. Review of the medical record for Resident #69, revealed the facility had admitted the resident on 05/29/2020, with diagnoses which include Myocardial Infarction, Chronic Obstructive Pulmonary Disease, Metabolic Encephalopathy, Dementia, and Syncope. Review of the most current quarterly MDS dated [DATE], revealed the resident had been assessed to have BIMS score of twelve (12) which indicated the resident had moderately impaired cognition. The MDS also revealed Resident #69 had been assessed to require the extensive assistance of one staff for bathing. Review of a SRNA care plan undated, revealed staff were to provide assistance with personal care, activities of daily living, and toileting needs. Review of a comprehensive care plan for Resident #69 with an admission date of 06/26/2020, revealed resident would be clean, dry, and odor free. The care plan revealed staff would assist the resident with activities of daily living. Review of a State Registered Nursing Assistant (SRNA) care plan undated, revealed staff were to provide assistance with personal care, activities of daily living, and toileting needs. Review of the computer Kiosk where SRNA's document care on 08/03/2021 at 2:35 PM, revealed Resident #1 required the assistance of one person for bathing. The KIOSK revealed the resident would be showered on Sundays and Thursdays, and would receive a bed bath on all other days. Review of bathing documentation for Resident #69, revealed the resident scheduled to receive a shower on 07/18/2021, 07/25/2021, 08/01/2021, and 08/08/2021; however, the documentation revealed the resident had received a bed bath on those days instead. Observation of Resident #69 on 08/03/2021 at 2:45 PM, revealed the resident was lying in the bed on his/her back. The resident was observed to be clean and well kempt with no odors observed. Interview conducted with Resident #69 on 08/03/2021 at 2:45 PM, revealed he/she only got a shower once a week. The resident stated he/she was given a bed bath everyday except the shower day. The resident stated he/she would like to have a shower more often. The resident was not aware why he/she had not been given a shower twice a week. Interview conducted with SRNA #12, on 08/10/2021 at 10:52 AM, revealed she had been responsible for completing a shower for Resident #69 on 08/08/2021. The SRNA stated she could not remember if she had given a bed bath or a shower, but stated if she had documented a bed bath that was what she had done. The SRNA stated she should have completed a shower and could have been call-ins that day. The SRNA stated she was required to check the Kiosk before providing care due to things could have changed. Interview conducted with SRNA #13, on 08/10/2021 at 2:50 PM, revealed the care plan and the Kiosk were where the information was kept regarding the care needs of a resident. The SRNA stated she was required to check the Kiosk before providing care to check for changes. The SRNA stated Resident #69 required the assistance of one person for bathing. The SRNA stated she had been responsible for providing a shower for Resident #69 on 07/18/2021, 07/25/2021, and 08/01/2021 and had no idea why she had given the resident a bed bath instead of a shower. The SRNA stated she should have given Resident #69 a shower instead of a bed bath on those days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the record for Resident #41 revealed the facility admitted the resident on 04/03/2019 with diagnoses that included Arthritis and Anxiety Disorder. Review of the most recent MDS which was a quarterly assessment with a reference date of 06/03/2021 revealed Resident #41 had a BIMS score of fourteen (14) indicating the resident was cognitively intact and interviewable. Interview with the Resident #41 on 08/05/21 at 10:29 AM during the resident council interviews revealed the resident stated it had been a week or two since he/she had received a shower and maybe longer. Further interviews at the time of the Resident Council interviews revealed Resident #41 stated that certain staff were assigned each day to give showers, but when there were call ins the staff would be pulled to work other areas and the showers would not be given. Observations of the resident during the interview revealed the resident was clean and well groomed with no odors noted. Further review of the MDS for Resident #41 with a reference date of 06/03/2021 revealed the resident required the physical assistance of one (1) person for bathing. The comprehensive care plan (undated) included the focus area of ADL deficit related to physical functioning that was dated 04/01/2019 and the goal was for the resident to have ADL care needs met daily. The interventions included staff assistance of one (1) with bathing per schedule and as needed. Review of the shower records for Resident #41 revealed from 07/21/2021 - 08/10/2021, Resident #41 received one (1) shower. 4. Review of the record for Resident #59 revealed the facility admitted the resident on 01/21/2021 with diagnoses that included Alzheimer's Disease and Dementia. Review of the significant change MDS with a reference date of 06/22/2021 revealed Resident #59 required physical assistance from one (1) staff person for bathing. Further review of the MDS revealed the resident's BIMS score was three (3) indicating severe cognitive impairment. Further review of the resident's medical record revealed the SRNA care plan indicated that Resident #59 was to receive two (2) showers weekly. Review of the comprehensive care plan (undated) revealed the resident had ADL self-care performance deficit with a goal for the resident to maintain current level of function in ADL status with a target date of 10/05/2021. The interventions included for staff to assist with bathing. Review of the bathing records documented as tasks in the electronic medical record (EMR) revealed from 07/11/2021 through 08/09/2021, Resident #59 only received a shower on 07/18/2021, 07/29/2021, 08/02/2021, and 08/05/2021. Bed baths were documented on all of the other days during that time period. Observation of Resident #59 on 08/03/2021, 08/04/2021, 08/05/2021, 08/06/2021, 08/08/2021, 08/09/2021, and 08/10/2021 revealed the resident was independently ambulatory and appeared clean and well groomed with no odors noted. 5. Review of the record for Resident #96 revealed the facility admitted the resident on 10/31/2017 with diagnoses that included Coronary Artery Disease and Diabetes Mellitus. Review of the most recent MDS assessment which was a quarterly assessment with a reference date of 07/12/2021 revealed the resident's BIMS score was fifteen (15) indicating that the resident was cognitively intact. Further review of the MDS revealed the resident required the physical assistance of one (1) staff for bathing. Review of the comprehensive care plan (undated) revealed that the focus area of ADL self care performance deficit related to impaired mobility was initiated on 11/14/2017 with the goal for the resident to be clean and odor free per staff assistance and the interventions included one (1) staff was to assist with bathing. Interview with Resident #96 on 08/05/2021 at 10:02 AM revealed the resident stated he/she was supposed to get two (2) showers per week, but it had been two (2) weeks since he/she had received a shower. Resident #96 stated that staff were often pulled from the shower room to the floor and there was not enough staff to provide the showers when that happened. Review of the shower records for Resident #96 from 07/21/2021 through 08/10/2021 revealed that only bed baths had been documented for Resident #96 and no showers had been documented as given. 6. Review of the record for Resident #101 revealed the facility admitted the resident on 03/05/2021 with diagnoses that included Alzheimer's Disease and Depression. Review of the most recent MDS which was a quarterly assessment with a reference date of 07/15/2021 revealed the BIMS score had not been obtained because the resident was rarely/never understood and the assessment further revealed the resident's cognitive skills for decision making were severely impaired. Further review of the MDS assessment revealed Resident #101 was totally dependent on staff for bathing. Review of the comprehensive care plan (undated) revealed that the resident had a ADL self care performance deficit related to confusion, impaired balance and limited mobility. The care plan interventions stated that the resident required total assistance for bathing. Review of the shower records for resident #101 from 07/11/2021 through 08/09/2021 revealed the resident received a shower on 07/14/2021, 07/17/2021, 07/21/2021, and 07/28/2021. A bed bath was recorded for all other days during that time period except 07/11/2021, 07/18/2021, 07/22/2021, and 08/06/2021 when not applicable was recorded. Interview with SRNA #14 on 08/11/2021 at 12:51 PM revealed residents get bed baths every day. The SRNA stated that the facility had a shower team that was responsible to give showers each day. She further stated if an aide calls in for the shift, then the aides that were assigned to the resident would then be responsible to give the resident a shower if it is their shower day. SRNA #14 stated when someone calls in that usually leaves them Short handed and the resident may not get a shower, but they always get a bed bath. An interview conducted with the Director of Nursing (DON) on 08/11/2021 at 2:54 PM, revealed residents were to have showers twice a week unless the resident wanted a shower more often or if the resident refused. The DON stated she had not been aware showers were not being done as required. The DON stated the information regarding when a resident was to be showered as well as the assistance and support required was kept in the Kiosk in the computer. The DON stated the potential concern for a resident not getting a shower twice a week was infection control issues, dignity, and depression. The DON stated she had not identified any concerns with staff not showering residents twice weekly. An interview conducted with the Administrator on 08/11/2021 at 4:03 PM, revealed she made rounds daily to ensure residents were being provided with the care they required. The Administrator stated she had not identified any concerns with residents not being provided with the care they required. The Administrator stated showers were expected to be done twice a week unless the resident refused. Based on observation, interview, record review, it was determined the facility failed to ensure six (6) of twenty two (22) sampled residents (Resident #1, #41, #59, #69, #96, and #101) received the necessary care and services to maintain grooming and hygiene. Review of facility bathing documentation, revealed residents were to have received showers twice weekly. However, review of bathing documentation for Residents #1, #41, #59, #69, #96, and #101, revealed the residents were not receiving showers twice weekly. The findings include: Interview conducted with the Corporate Nurse on 08/05/2021 at 11:10 AM, revealed the facility did not have a policy on showers. The Corporate Nurse revealed the expectation was for showers to be completed at least twice weekly unless the resident refused. A bed bath was to be completed on days between showers. The Corporate Nurse stated if the resident wanted a bath more frequently than twice weekly, it would be provided. 1. Review of Resident #1's closed record, revealed the resident was admitted to the facility on [DATE], with diagnoses that included Acute Kidney Failure, Major Depressive Disorder, Pain in Right Shoulder, Polyosteoarthritis, and Alzheimer's Disease. The medical record further revealed the resident had been discharged by the facility on 07/27/2021. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of three (3), indicating severe cognitive impairment. The MDS revealed Resident #1 required the extensive assistance of one person for bathing. Review of a State Registered Nursing Assistant (SRNA) care plan undated, revealed staff were to provide assistance with personal care, activities of daily living, and toileting needs. Review of a comprehensive care plan for Resident #1 with an admission date of 07/19/2021, revealed the resident would be clean, dry, and odor free. The care plan revealed staff would assist the resident with activities of daily living. Review of the computer Kiosk where SRNA's document care on 08/03/2021 at 2:30 PM, revealed Resident #1 required the assistance of one person for bathing. The KIOSK revealed the resident would be showered on Wednesdays and Saturdays, and would receive a bed bath on all other days. Review of Resident #1's bathing documentation, revealed the resident was scheduled to receive a shower on 07/21/2021 and 07/24/2021; however, the documentation revealed the resident had received a bed bath instead. An interview conducted with SRNA #11, on 08/10/2021 at 11:04 AM, revealed the Kiosk is where the information was kept regarding the care needs of a resident. The SRNA stated Resident #1 required the assistance of one person for bathing. The SRNA stated she had been responsible for providing a shower for Resident #1 on 07/24/2021, and had no idea why she had given the resident a bed bath instead. The SRNA stated she guessed she had just been too busy because of staff calling in (staff not reporting to work as scheduled). An interview conducted with SRNA #13, on 08/10/2021 at 2:50 PM, revealed residents were required to be showered twice weekly. The SRNA stated Resident #1 required the assistance of one person for bathing. The SRNA stated she had been responsible for providing a shower for Resident #1 on 07/21/2021, and had no idea why she had given the resident a bed bath instead. The SRNA stated she guessed she had just been too busy because of staff calling in. The SRNA stated it had probably been hectic that day. 2. Review of the medical record for Resident #69, revealed the facility had admitted the resident on 05/29/2020, with diagnoses which include Myocardial Infarction, Chronic Obstructive Pulmonary Disease, Metabolic Encephalopathy, Dementia, and Syncope. Review of the most current quarterly MDS dated [DATE], revealed the resident had been assessed to have BIMS score of twelve (12)which indicated the resident had moderately impaired cognition. The MDS also revealed Resident #69 had been assessed to require the extensive assistance of one staff for bathing. Review of a SRNA care plan undated, revealed staff were to provide assistance with personal care, activities of daily living, and toileting needs. Review of a comprehensive care plan for Resident #69 with an admission date of 06/26/2020, revealed resident would be clean, dry, and odor free. The care plan revealed staff would assist the resident with activities of daily living. Review of the computer Kiosk where SRNA's document care on 08/03/2021 at 2:35 PM, revealed Resident #1 required the assistance of one person for bathing. The KIOSK revealed the resident would be showered on Sundays and Thursdays, and would receive a bed bath on all other days. Review of Resident #69's bathing documentation, revealed the resident was scheduled to receive a shower on 07/18/2021, 07/25/2021, 08/01/2021, and 08/08/2021; however, the documentation revealed the resident had received a bed bath on those days instead. Observation of Resident #69 on 08/03/2021 at 2:45 PM, revealed the resident was lying in the bed on his/her back. The resident was observed to be clean and well kempt with no odors observed. Interview conducted with Resident #69 on 08/03/2021 at 2:45 PM, revealed he/she only got a shower once a week. The resident stated he/she was given a bed bath everyday except the shower day. The resident stated he/she would like to have a shower more often. The resident was not aware why he/she had not been given a shower twice a week. An interview conducted with SRNA #12, on 08/10/21 at 10:52 AM, revealed she had been responsible for completing a shower for Resident #69 on 08/08/2021. The SRNA stated she could not remember if she had given a bed bath or a shower, but stated if she had documented a bed bath that was what she had done. The SRNA stated she should have completed a shower but could have been call-ins that day. An interview conducted with SRNA #13, on 08/10/2021 at 2:50 PM, revealed Resident #69 required the assistance of one person for bathing. The SRNA stated she had been responsible for providing a shower for Resident #69 on 07/18/2021, 07/25/2021, and 08/01/2021 and had no idea why she had given the resident a bed bath instead of a shower. The SRNA stated she should have given Resident #69 a shower instead of a bed bath on those days.

Based on observation, interview and record review it was determined the facility failed to store and serve food in accordance with professional standards for food service safety. Interviews with residents during the survey revealed that food was often served cold and observations of the tray line on 08/03/2021 during the lunch meal revealed food items on the steam table were not held at the appropriate temperatures. Further observations in the kitchen on 08/03/2021 revealed food items in the refrigerator that were not labeled/dated with the date they were opened. Also, observations of food items in the dry storage area were opened, but not labeled/dated with the date they were opened. The findings include: Review of the facility policy titled Dietary Services (undated) revealed the purpose of the policy was to prevent the contamination of food products and therefore prevent foodborne illness. The policy further stated that steam tables must be able to maintain hot foods at temperatures of 140 degrees Fahrenheit (F) and above. Further review of the facility policy revealed the policy did not address the labeling of food items. Interview with the Administrator, on 08/11/21 at 4:02 PM, revealed it was the expectation that food items be labeled with the date they were opened. 1. Observations in the kitchen on 08/03/2021 at 10:20 AM revealed the lunch meal was on the steam table. Interview with the assistant dietary manager on 08/03/2021 at 11:00 AM revealed the food had been on the steam table since approximately 10:00 AM. Continued observations in the kitchen revealed that staff began plating the lunch meal at 10:55 AM; however, food temperatures were not obtained until prompted by the surveyors. Temperatures of the food on the steam table were as follows: pizza, 161 degrees Fahrenheit (F), pureed pizza - 130 degrees F, mashed potatoes - 161 degrees F, green beans - 155 degrees F, salad - 35 degrees F, pureed ham - 123 degrees F, ham - 165 degrees F, pureed green beans - 151 degrees F, chicken noodle soup - 143 degrees F, cream of chicken soup - 160 degrees F, and tomato soup - 161 degrees F. After the tray cart was loaded, the surveyor prompted the dietary manager to review the temperatures of the foods. The dietary manager then stated that the pureed ham and pureed pizza was too cold. Staff retrieved the four (4) trays that had already been plated with pureed pizza, reheated the pureed pizza to 186 degrees F, and replated the meal. Interviews on 08/03/2021 with Resident #13 at 4:13 PM, Resident #68 at 3:19 PM, and Resident #78 at 4:29 PM, revealed the residents stated meals were often served cold. Observation of the lunch meal tray line service on 08/05/2021 at 10:50 AM revealed staff were in the process of plating the lunch meal. During the observations staff removed the carrots and mashed potatoes that were being served and heated them in the microwave. Interview with the assistant dietary manager on 08/05/2021 at 11:15 AM revealed the steam table was not holding the foods at the appropriate temperatures. She stated the dietary staff add water, but the water evaporates quickly. She stated the problem had been reported, but it had not been fixed. She was unaware when it was reported. Interview with the Dietary Manager (DM) on 08/11/2021 at 1:31 PM revealed she had been the dietary manager for four (4) months. The DM stated she was unaware that there were any concerns with food temperatures until 08/03/2021. The DM further stated it was the expectation that hot foods be served hot and cold foods be served cold. Interview with the Administrator on 08/11/2021 at 4:02 PM revealed that she was not aware that there had been any concerns with cold food or with the steam table. She stated that the residents were vocal about the food and did not like the menu, but she was unaware of any concerns related to the temperature of the food. 2. Observations during the initial tour of the kitchen on 08/03/2021 at 10:20 AM revealed the following food items were in the refrigerator and opened and available for use, but were not labeled with the date that they were opened: a container of prepared macaroni salad, a container of prepared chicken salad, and a can of whipped topping. Further observations in the dry storage area of the kitchen during the initial tour revealed the following items were opened and available for use, but not labeled with the date they were opened: a box of powdered sugar, a bottle of canola oil, a package of sugar sprinkles, a bag of potato chips, a jar of peanut butter, and four (4) loaves of bread. Interview with the Dietary Manager on 08/11/2021 at 1:31 PM revealed it was the expectation all food items available for use in the kitchen be dated when they are opened. She stated she does audits weekly to ensure there are no items that have not been dated when opened. The Dietary Manager stated she had not identified any concerns prior to the survey.

Based on interview and record review it was determined the facility failed to review and update the facility assessment when there was a change in facility administration and failed to address the facility's resident population with regards to a resident with bariatric needs. (Refer to F558) The findings included: Review of the Facility Assessment Tool revealed the date of the assessment was 12/07/2020. The assessment did not have the name of the current Administrator or current Director of Nursing (DON) listed as persons who were involved in completing the assessment. Further review of the assessment revealed the section titled Our Resident Profile did not include residents with bariatric needs. Observation of Resident #94 on 08/03/2021 at 10:15 AM and interview with Resident #94 on 08/04/2021 at 1:08 PM revealed the resident did not have a chair in his/her room to allow the resident time out of bed and could only receive bed baths because the facility did not have a shower chair that would accommodate the resident or another means for the resident to shower. Interview with the Rehabilitation Director, on 08/09/2021 at 2:05 PM, revealed Resident #94 required the use of a specialty shower chair due to the resident's condition of a pendulous abdomen. Interview with the DON on 08/11/2021 at 2:58 PM revealed she began as DON of the facility in March of 2021. She stated she had reviewed the Facility Assessment on 07/13/2021 and noted that the administrative staff was not correct. The DON stated she asked at that time if corrections needed to be made to the document. She stated she was told that the Administrator made changes to the document. Further interview with the DON revealed the facility had two (2) residents with bariatric needs and the facility assessment did not address or assess the needs of those residents. Interview with the Administrator on 08/11/2021 at 4:02 PM revealed she had been the administrator of the facility since February 2021. She stated she was aware the Facility Assessment was not current and did not include information about residents with bariatric needs. She stated the updates had not been completed because she thought it was only required annually and therefore would not have been due to be changed until December 2021. The Administrator stated she was unaware the Facility Assessment needed to updated when there were changes at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, it was determined that the facility failed to promote and protect the dignity of one (1) of sixteen (16) sampled residents (Resident #45). Interviews with staff and/or review of the resident's medical record revealed the resident was cognitively impaired, was combative at times, and did not like for his/her feet to be touched. On 12/11/19, State Registered Nurse Aides (SRNAs) #37 and #38 tickled the resident's feet and teased/aggravated the resident. Subsequently, the resident hit his/her arm on the bed rail causing a skin tear and bruising. Interviews revealed on 12/04/19, SRNA #20 was intoxicated and provoked/taunted the resident to hit the SRNA. The findings include: A review of the facility's Dignity policy, dated 08/01/13, revealed each resident would be cared for in a manner that promoted and enhanced quality of life, dignity, respect, and individuality. The policy stated that residents shall be treated with dignity and respect at all times. According to the policy, Treated with dignity meant that the resident would be assisted in maintaining and enhancing his/her self-esteem and self-worth. The policy also stated that staff shall treat cognitively impaired residents with dignity and sensitivity . Review of Resident #45's medical record revealed the resident was readmitted to the facility on [DATE] with diagnoses that included Unspecified Psychosis. According to the resident's quarterly Minimum Data Set (MDS) dated [DATE], the resident's Brief Interview for Mental Status (BIMS) score was three (3), indicating the resident was severely cognitively impaired. Further review revealed Resident #45 had not exhibited any moods/behaviors during the assessment period and required extensive staff assistance for activities of daily living (ADLs). Review of the Comprehensive Care Plan for Resident #45 dated 07/24/17 revealed the facility developed interventions to assist the resident with activities of daily living. Further review of a care plan dated 07/22/17, revealed the facility documented that Resident #45 became combative with staff at times, had a history of making sexually inappropriate comments toward staff, and attempted to invade staff's personal space. Interview with SRNA #38 on 12/18/19 at 4:50 PM, SRNA #41 on 12/18/19 at 5:50 PM, and SRNA #42 on 12/18/19 at 10:45 AM revealed Resident #45 was combative/easily agitated. In addition, according to SRNA #38, the resident did not like anyone to touch his/her feet. An interview with Registered Nurse (RN) #8 on 12/19/19 at 5:30 PM, revealed Resident #45 don't want to be messed with, especially if the resident was sleeping. Review of an Accident/Incident Report dated 12/11/19 at 12:35 PM revealed when staff was undressing Resident #45, the resident became combative and hit his/her left forearm on the bed rail, causing scattered discoloration and a skin tear. According to the report, the injury was discovered and witnessed by SRNA #37, SRNA #38, and SRNA #42. However, review of documentation by the Human Resources (HR) staff person on 12/11/19 revealed that SRNA #42 reported that the bruises on Resident #45's arm were caused from SRNAs aggravating the resident. Interview with SRNA #42 on 12/18/19 at 10:45 AM revealed on 12/11/19, he heard loud laughter coming from Resident #45's room. When he entered the resident's room, he saw SRNAs #37 and #38 tickling Resident #45's feet and teasing the resident. SRNA #42 stated he asked the SRNAs to stop teasing the resident because the resident had become very agitated; however, he stated the SRNAs did not stop. He stated the SRNAs then attempted to undress the resident, and because the resident was already agitated, he/she became combative and hit his/her arm on the bed rail causing bruises and a skin tear on the resident's left forearm. Further review of facility staff interviews revealed on 12/11/19, SRNA #42 also reported to the HR staff member, the Administrator, and the Nurse Consultant that SRNA #20 had worked at the facility and smelled of alcohol while he was caring for residents. Furthermore, SRNA #41 also reported to the Administrator and the Nurse Consultant on 12/12/19 and wrote a witness statement on 12/13/19 that SRNA #20 came back to work from a break, smelling of alcohol, and his actions showed signs of intoxication. Interview with SRNA #41 on 12/18/19 at 5:50 PM revealed on 12/04/19, SRNA #20 smelled strongly of alcohol and appeared intoxicated. According to SRNA #41, SRNA #20 intentionally agitated Resident #34 and provoked the resident to hit him and/or SRNA #41. She stated that SRNA #20 was laughing and thought it was funny to agitate the resident until Resident #45 eventually hit SRNA #20. Observation of Resident #45 on 12/17/19 at 3:50 PM revealed the resident was in bed watching television. Interview with the resident revealed he/she could not remember whether staff had tickled his/her feet.

Based on observation, record review, and review of the facility's policies and procedures, it was determined the facility failed to review and revise the care plan for one (1) of thirty-three (33) sampled residents (Resident #2). The facility failed to review and revise Resident #2's care plan when the resident developed a new pressure sore on 11/11/19. The findings include: Review of the facility policy titled, Comprehensive Care Plans, with a revision date of 11/22/17, revealed the facility would develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the resident's comprehensive assessment. The policy stated plans would incorporate identified problem areas and be reviewed and revised with every comprehensive and quarterly Minimum Data Set (MDS) assessment. A review of the medical record for Resident #2 revealed the facility admitted the resident on 06/05/17, with diagnoses that included Bell's Palsy, Intervertebral Disc Degeneration, Obesity, and Diabetes Mellitus. A review of the most recent quarterly Minimum Data Set (MDS) assessment for Resident #2 dated 08/06/19 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was interviewable. The MDS revealed the facility assessed the resident to require the extensive assistance of two (2) persons with bed mobility and toileting. The MDS also revealed that Resident #2 was at risk for skin breakdown and had one (1) Stage 2 open, unhealed area. A review of Resident #2's physician's orders revealed an order dated 11/11/19 for staff to cleanse the open area to the resident's left posterior thigh with normal saline, apply xeroform gauze (medicated gauze), and cover the area with a border dressing every shift. Review of the orders revealed an order for one (1) pressure ulcer area only. A review of Resident #2's care plan, with a revision date of 11/05/19, revealed staff were required to notify the physician of any red or open areas. The care plan also revealed Resident #2 preferred to sit up for long periods of time and would refuse to change his/her position. The care plan revealed the care plan had not been reviewed or revised with new interventions developed when the new pressure ulcers were identified on 11/11/19. An interview conducted with the MDS Coordinator on 11/16/19 at 2:36 PM, revealed she was responsible for developing, reviewing, and revising residents' comprehensive plans of care. The MDS Coordinator stated she had not been aware Resident #2's care plan should have been updated when the resident developed two (2) new pressure ulcers. An interview conducted with the Director of Nursing (DON) on 11/16/19 at 2:45 PM, revealed she made rounds daily to ensure residents were being provided the care as directed by the comprehensive person-centered plans of care. The DON stated Resident #2's care plan should have been updated when the resident developed two (2) new pressure ulcers. The DON stated she had not identified any concerns with residents' care plans not being reviewed and revised with any changes in the residents' condition.

Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to provide the appropriate treatment and services for pressure sores for one (1) of thirty-three (33) sampled residents (Resident #2). Observation of a wound assessment for Resident #2 on 11/13/19 at 2:48 PM revealed the resident had two (2) open areas on the left posterior upper thigh. However, the ordered treatment was only for one (1) area. In addition, staff failed to provide appropriate handwashing/sanitizing during wound treatment and failed to provide incontinence care when needed during a wound treatment. The findings include: Review of the facility policy titled Wound Protocol, with a revision date of February 2019, revealed residents would receive the appropriate care and treatment for skin issues. Review of the facility's policy titled, Handwashing/Hand Hygiene, with a revision date of April 2010, revealed staff were required to wash/sanitize their hands after removing gloves, after handling used dressings, before handling clean dressings, and before and after any direct resident contact. Review of the medical record for Resident #2 revealed the facility admitted the resident on 06/05/17, with diagnoses that included Intervertebral Disc Degeneration, Bell's Palsy, Obesity, and Diabetes Mellitus. Review of the most recent quarterly Minimum Data Set (MDS) assessment for Resident #2 dated 08/06/19 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was interviewable. The MDS revealed the facility assessed the resident to require the extensive assistance of two (2) persons with bed mobility and toileting. The MDS also revealed that Resident #2 was at risk for skin breakdown and had one (1) Stage 2 open unhealed area. Review of Resident #2's care plan, with a revision date of 11/05/19, revealed staff were required to notify the physician of any red or open areas. The care plan also revealed Resident #2 preferred to sit up for long periods of time and refused to change his/her position. Review of the weekly skin assessment for Resident #2 completed by RN #1 dated 11/11/19, revealed two (2) Stage 2 pressure ulcers had been identified on the resident's left posterior upper thigh. Pressure ulcer #1 measured 0.7 centimeters (cm) long by 0.5 cm wide. Pressure ulcer #2 measured 4.5 cm long by 4.5 cm wide. Review of the physician's orders for Resident #2 revealed an order dated 11/11/19 for staff to cleanse the open area to the resident's left posterior thigh with normal saline, apply xeroform gauze (medicated gauze), and cover the area with a border dressing every shift. Review of the orders revealed an order for one (1) pressure ulcer area only. Observation of a skin assessment for Resident #2 completed by Registered Nurse (RN) #1 on 11/13/19 at 2:48 PM, revealed two (2) open areas to the resident's posterior left upper thigh. The top area measured 1.3 centimeters (cm) long by 1.4 cm wide. The wounds were separated by approximately two (2) cm. Pressure ulcer #2 was observed to be just below area #1 and measured 5.5 cm long by 3.0 cm wide. The facility was staging both wounds at a Stage 2. RN #1 was observed to remove Resident #2's brief and the resident was observed to have had a bowel movement. RN #1 and RN #5 were observed to provide incontinence care prior to beginning wound care. Both RNs were then observed to wash/sanitize their hands and apply gloves prior to beginning wound care. RN #1 was observed to remove the soiled dressing from the resident's left posterior thigh and dispose of it in the trash. The RN then removed her gloves, failed to wash/sanitize her hands, and donned clean gloves. The RN was then observed to clean both pressure ulcers with the same normal saline-soaked 4x4 dressing. RN #1 was then observed to remove her gloves, proceed to the treatment cart, and place Calmoseptine cream into a plastic medicine cup and lotion in another plastic medicine cup, and then put on new gloves without washing/sanitizing her hands. RN #1 was then observed to use a skin prep around both pressure ulcers and asked RN #5 to use a tissue and dry the area between Resident #2's legs. RN #5 was observed to wipe the area between Resident #2's legs with a tissue and it had a small amount of stool on it. RN #1 continued to provide pressure ulcer care for Resident #2 without providing additional incontinence care. RN #1 was then observed to place the same piece of medicated gauze over both wounds and the same border dressing over both areas. Interview with Resident #2 on 11/15/19 at 9:35 AM, revealed the pressure ulcer areas had only been there for a few days. The resident stated staff had provided care for the areas. Interview conducted with RN #1 on 11/16/19 at 2:12 PM, revealed she was required to wash/sanitize her hands when beginning wound care and when going from a dirty to clean area. The RN stated she should have washed/sanitized her hands after cleaning the wounds, after going to the medication cart. The RN stated she should have provided further incontinence care after RN #5 wiped between the resident's legs and stool was found. The RN further stated both wounds should have been cleaned and dressed separately and the orders for wound care should have been written as separate orders for two (2) wounds instead of one (1). The RN stated she had been provided with training from the facility on pressure ulcer care and handwashing. The RN stated she was just nervous. An attempt was made three (3) times on 11/16/19, at 9:15 AM, 1:30 PM, and 2:25 PM to reach RN #5 for interview but was unsuccessful. Interview conducted with the Director of Nursing (DON) on 11/16/19 at 2:30 PM, revealed she made rounds daily to ensure residents are receiving care as they require. The DON stated she had not previously identified any concerns with pressure ulcer care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, it was determined the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete and accurately documented for one (1) of thirty-three (33) sampled residents (Resident #66). Observation during the morning meal service on 11/15/19 at 8:47 AM revealed SRNA #2 failed to accurately document the meal intake for Resident #66. The findings include: Review of the facility policy titled, Charting and Documentation, dated 08/01/13, revealed all services and care provided to a resident will be documented in the medical record in accordance with state law and facility policies. Review of the facility's Guidelines for assisting a resident with eating, not dated, revealed nurse aides are expected to document food intake accurately. Observation of the morning meal service on 11/15/19 revealed SRNA #2 documented 100 percent (100%) food consumption and 240 cc of fluid intake for Resident #66. Observation of the meal tray revealed one (1) half-eaten bowl of oatmeal, one (1) full cup of coffee, and one (1) glass of juice still on the tray. Resident #66 still had two-thirds (2/3) cup of milk at bedside. Review of the medical record revealed the facility admitted Resident #66 on 10/02/19 with diagnoses including Type 2 Diabetes, and Alzheimer's disease. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status score of two (2), which indicated that the resident was cognitively impaired. Further review of the MDS revealed the facility assessed the resident to be totally dependent with eating and requiring assistance of one person. Interview with SRNA #2 on 11/15/19 at 9:23 AM revealed she had been taught to document meal intake as a percentage, with 100% being all food consumed. Fluid intake should be documented in cubic centimeters (cc) to reflect the amount of fluid consumed. SRNA #2 reported that she should have only documented approximately 80% food consumption for Resident #66. SRNA #2 offered no explanation for why she failed to document accurately. Interview with SRNA #3 on 11/15/19 at 2:55 PM revealed she had been taught to document a resident's food intake as a percentage, with 100% indicating that all food on the tray had been consumed. Interview with the Director of Nursing (DON) on 11/16/19 at 3:52 PM revealed the expectation is that staff will document food consumption accurately and according to facility policy. The DON reported no concerns with accurate documentation up to this point.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility policy review it was determined the facility failed to maintain an effective infection control program for one (1) of two (2) sampled residents (Resident #86) on transmission-based precautions out of thirty-three (33) sampled residents. A nurse entered Resident #86's room on 11/16/19 without wearing personal protective equipment as directed by the facility policy. The findings include: Review of the facility policy titled, Droplet Precautions, undated, revealed droplet precautions would be used in addition to standard precautions for residents with infections that can be transmitted by droplets. The resident may be placed in a private room and a mask should be worn when entering the resident's room. Review of the medical record for Resident #86 revealed the resident was readmitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis affecting the right dominant side, Acute and Chronic Respiratory Failure, Heart Failure, and Tracheostomy. Further review of the medical record revealed the resident returned from a hospitalization on 10/24/19 to the facility with a diagnosis of Klebsiella Pneumoniae Extended Spectrum Beta-Lactamases (ESBL) in the sputum. Review of the Minimum Data Set (MDS) quarterly assessment Section C, Cognitive Patterns, dated 10/29/19, revealed Resident #86's cognitive skills for daily decision-making were severely impaired and therefore the resident was not interviewable. Review of Physician orders for Resident #86 dated 10/24/19 revealed the resident was ordered to be placed on droplet precautions. Review of the Comprehensive Plan of Care for Resident #86, dated 05/13/19, had a focus on the resident's cardiac and respiratory status. Further review of the Comprehensive Plan of Care revealed the resident had a new intervention for care dated 10/24/19 for the resident to be placed on droplet precautions related to ESBL. Observation on 11/16/19 at 10:48 AM revealed Registered Nurse (RN) #2 entering and exiting Resident #86's room without putting a mask on. Interview on 11/16/19 at 2:10 PM with RN #2 revealed she went into Resident #86's room to pause his/her enteral feeding pump and did not don a mask before entering. RN #2 further revealed she was nervous and forgot to put on the mask and remembered as she was exiting the room. RN #2 also revealed she had been trained in caring for residents on droplet precautions and instructions were also placed on doors of residents' rooms on transmission-based precautions. Interview with the Director of Nursing (DON) on 11/16/19 at 2:59 PM revealed RN #2 should have donned a mask before entering Resident #86's room. The DON further revealed all staff are trained annually and as needed in the use of personal protective equipment for residents placed on transmission-based precautions. The DON further revealed she had not identified any concerns with staff utilizing personal protective equipment for residents on transmission-based precautions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility policy review, it was determined the facility failed to report an allegation of abuse timely to the Administrator and to state agencies for one (1) of thirty-three (33) sampled residents (Resident #68). A resident abuse allegation was reported to facility staff on 10/22/19 at 5:00 PM; however, the facility failed to ensure the allegation was reported to the Administrator until 10/23/19 at 8:50 AM and to the state agencies until 11:00 AM on 10/23/19. The findings include: Review of the facility policy titled, Reporting Abuse to Facility Management, dated 11/02/17, revealed all alleged violations must be reported immediately, but no later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to the State Survey Agency and Adult Protective Services. Review of the medical record for Resident #68 revealed the resident was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction, Myocardial Infarction, Cognitive Communication Deficit, and Disorientation. Review of the Minimum Data Set (MDS) entry assessment Section C, Cognitive Patterns, dated 10/11/19, revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of six (6), indicating the resident was moderately impaired cognitively and therefore was not interviewable. Observation of Resident #68 on 11/12/19 at 3:27 PM revealed the resident was sitting in his/her room in a wheelchair. The resident was alert but did not respond to questions when asked. The resident had no obvious bruising and did not appear fearful of staff/others. Review of the facility's Resident Abuse Investigation Report Form dated 10/23/19 at 8:50 AM revealed Resident #68's daughter reported an allegation of abuse on 10/22/19 at approximately 5:00 PM. Resident #68's daughter reported to Registered Nurse (RN) #3 on 10/22/19 that the resident had informed her (daughter) that a man entered her room on 10/20/19 during the night and tried to put his hand down her pants. RN #3 did not report the allegation to the Director of Nursing (DON) or Administrator until 10/23/19 at 8:50 AM (greater than 15 hours after initially reported to RN #3). The allegation was therefore not reported to the Administrator, State Survey Agency, or Adult Protective Services within the two (2) hour requirement and was not reported until approximately 11:00 AM on 10/23/19 (16 hours after initially reported). Further review of the investigation revealed the allegation was found to be unsubstantiated by the facility. Interview with Resident #68's daughter on 11/15/19 at 10:19 AM revealed she initially reported the abuse allegation to RN #3 on 10/22/19 at approximately 5:00 PM. Resident #68's daughter further revealed that she felt that her mother got confused due to wearing a brief and having to be changed. The daughter stated that when the nurse aide came into her mother's room and awakened her, it startled her. Resident #68's daughter further stated, I don't feel that mom was touched in any way like that; mom was woken up and it startled and confused her. Interview with RN #3 (who was also a Unit Manager) on 11/14/19 at 3:24 PM revealed Resident #68's daughter informed her of the abuse allegation on 10/22/19 at approximately 5:00 PM and she failed to report the allegation to the Director of Nursing (DON) or Administrator. RN #3 revealed she was busy and it slipped her mind and she did not remember the abuse allegation until the morning of 10/23/19 at approximately 8:50 AM. RN #3 revealed she immediately upon remembering the allegation reported it to the DON. Per RN #3, she was trained in September 2019 regarding reporting and protection when there were allegations of abuse. Review of the training records confirmed RN #3 received training on 09/11/19 related to abuse allegations. Interview with the Director of Nursing (DON) on 11/16/19 at 3:03 PM revealed when RN #3 informed her of the abuse allegation at 8:50 AM on 10/23/19, she and the Administrator immediately assessed the resident for safety and started an investigation. The DON further stated that she ensured that the male that was working on 10/20/19 with Resident #68 was suspended until the investigation was completed. Per the DON, no other males were working in the area where Resident #68 was residing. The DON also revealed reporting agencies were notified and the abuse protocols were enforced. The DON stated RN #3 should have reported the allegation immediately to her or to the Administrator. The DON further revealed staff were trained on abuse and reporting in September 2019, annually, and as needed. The DON stated RN #3 received the abuse training in September 2019. Interview with the Administrator on 11/16/19 at 3:46 PM revealed RN #3 should have reported the abuse allegation for Resident #68 immediately upon being notified by the daughter. The Administrator revealed she immediately followed facility abuse protocols, starting an investigation and reporting to required agencies as soon as she was made aware. The Administrator further revealed staff received training on abuse in September 2019, annually, and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of resident interviews completed by the facility on 10/23/19 revealed Residents #204 and #211 reported allegations of abuse when facility staff asked them if they had been physically harmed. According to the facility's documentation, Resident #211 stated he/she had been knocked down going to a singing. The resident described the person who knocked him/her down as wearing a black dress with a white collar and a gold cross around their neck. Further review revealed Resident #204 replied and told facility staff, Yes, a girl hurt my back. The resident was not able to give details about what happened, but stated the girl who hurt his/her back had long hair. Review of Resident #204's medical record revealed the facility admitted the resident on 10/12/16 with diagnoses that included Moderate Intellectual Disabilities, Cardiomegaly, and Muscle Weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a BIMS score of nine (9), which indicated the resident had moderately impaired cognition. Observation of Resident #204 on 12/19/19 at 2:40 PM revealed the resident was alert and resting in bed. An interview with the resident revealed the girls who came into the resident's room on the night shift were mean to the resident. According to the resident, the nurses made fun of the resident and it made him/her sad. The allegation of abuse was reported to the Administrator at 2:47 PM on 12/19/19. Review of Resident #211's medical record revealed the facility admitted the resident on 06/21/19, with diagnoses that included Myocardial Infarction, Left Bundle Branch Block, and Parkinson's disease. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident had a BIMS score of 12, which indicated the resident had moderately impaired cognition. Observation of Resident #211 on 12/19/19 at 2:45 PM revealed the resident was in a wheelchair in his/her room. An interview with the resident about his/her care and treatment at the facility revealed that a couple of months ago, a nurse hit the resident on the shoulder after a singing activity. The allegation of abuse was reported to the Administrator at 2:47 PM on 12/19/19. Interview with the Social Services Director (SSD) on 12/19/19 at 2:10 PM revealed she had interviewed Resident #211 and Resident #204 on 10/23/19 as part of a plan of correction. The SSD stated she reported the findings of the interviews to the Administrator who led all abuse investigations. The SSD stated she did not remember if the residents' statements were investigated as an allegation of abuse. Interview with the Regional Clinical Operations Consultant on 12/19/19 at 3:50 PM confirmed that the allegations involving Residents #211 and #204 were not fully investigated in accordance with facility policy. The Consultant stated all allegations of resident abuse should be investigated. Interview with the Administrator on 12/19/19 at 4:40 PM revealed the facility had looked into the allegations regarding Resident #211 and Resident #204 some but had not conducted a full investigation (witness statements, interview with other residents, interview with staff on all shifts, etc.) as required by the facility's Abuse Investigation policy. The Administrator stated that Resident #211 had watched a movie called Sister Act (a movie about Nuns) just prior to the allegation and staff thought the resident might have been confused. The Administrator further stated that no one in the facility was dressed as Resident #211 had described on the day of the allegation. In addition, the Administrator stated Resident #204 had just been hospitalized and had some confusion. The Administrator stated the Resident's BIMS score had decreased to less than eight (8) after his/her hospitalization. Interviews were also conducted with the Administrator on 12/18/19 at 2:33 PM and on 12/20/19 at 2:57 PM. The Administrator stated that she interviewed SRNAs #37 and #38 about tickling Resident #45's feet and dropping the resident into a geriatric chair from the mechanical lift. The Administrator stated both SRNAs denied the allegations and after that I didn't think there was any more investigating that needed to be done. The Administrator further stated she thought dropping the resident from the mechanical lift into a geriatric chair was a safety issue and not an allegation of abuse; subsequently, she did not investigate any further regarding the mechanical lift. She further revealed that when SRNA #42 reported on 12/11/19 that SRNA #20 smelled of alcohol while caring for residents at the facility, she conducted interviews with staff who worked with the SRNA on 12/04/19. The Administrator stated she did not feel like there was anything else she needed to do at that point, and did not interview residents or other staff. Interview with the Administrator further revealed she had staff review residents' bowel movement documentation and it did not match up to anything that SRNA #42 had reported. The Administrator stated SRNA #42 reported that SRNAs #37 and #38 had not been providing showers for Resident #7 and Resident #211. However, when nurses assessed the two (2) residents, they were clean. The Administrator further stated that the Director of Nursing had been monitoring residents' intake and output for over a month and she did not see why it had to be investigated. Based on observation, interview, medical record review, and facility policy review, the facility failed to thoroughly investigate allegations of abuse/neglect for five (5) of sixteen (16) sampled residents (Resident #7, Resident #17, Resident #45, Resident #204, and Resident #211) and an unknown number of residents who were allegedly neglected. On 12/03/19, staff reported that Resident #17 did not want staff to remove his/her dentures and State Registered Nurse Aide (SNRA) #29 told Resident #17, If I have to do it you know your [you're] not going to like it. When Resident #17 turned [his/her] head, SRNA #29 shoved her finger into the resident's mouth and jerked [his/her] top denture halfway out of the resident's mouth. The facility initiated an investigation; however, the facility unsubstantiated that abuse occurred based on interviews/assessments of other residents and interviews with staff. The facility failed to consider the resident's statements/reactions to the incident and failed to investigate the comment that the SRNA made to the resident. The facility received allegations of abuse from Resident #211 and Resident #204; however, the facility failed to have evidence of a thorough investigation for either of the abuse allegations. In addition, review of an Incident Report and staff interviews conducted by the facility dated 12/11/19 and 12/12/19 revealed facility staff reported allegations of abuse to the Administrator concerning Resident #45; allegations that staff neglected residents by not providing assistance with showers (including Resident #7 and Resident #211) and falsely documenting that residents had bowel movements and meal intake. Further, staff reported that State Registered Nurse Aide (SRNA) #20 was under the influence of alcohol while caring for residents and intentionally provoked/taunted Resident #45 until the resident was agitated and hit the SRNA. In addition, while under the influence, SRNA #20 allegedly hit Resident #17 on the chin while removing a mechanical lift pad. The facility failed to provide evidence that the allegations were investigated. The findings include: Review of the facility's Abuse Investigations policy, dated 08/01/13, revealed all reports of resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management. The policy stated that should an incident of suspected resident abuse, mistreatment, neglect, or injury of unknown source be reported, the Administrator, or his/her designee, would investigate the alleged incident. According to the policy, The individual conducting the investigation will, at a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident as medically appropriate; f. Consult the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family member, and visitors; i. Interview other residents to whom accused employee provide care or services; and j. Review all events leading up to the alleged incident. 1. Review of a Resident Abuse Investigation Report Form revealed the facility initiated an investigation regarding SRNA #29 putting her fingers in Resident #17's mouth and jerked the resident's top denture halfway out of his/her mouth on 12/03/19 at 6:05 PM. According to the report, the SRNA and resident were joking around when the SRNA asked the resident to remove his/her dentures. The resident rolled his/her eyes and turned his/her head, and then SRNA #29 attempted to remove the resident's dentures. Review of SRNA #42's witness statement revealed on 12/03/19 SRNA #29 asked Resident #17 to take out his/her dentures. According to SRNA #42, Resident #17 responded by rolling his/her eyes and turning his/her head away. SRNA #29 stated to the resident, If I have to do it you know your [you're] not going to like it. Resident #17 turned his/her head again and SRNA #29 shoved her finger in the back of the resident's mouth and jerked his/her top dentures halfway out of the resident's mouth. According to SNRA #42, Resident #17 pulled back and said, Don't do that. SRNA #42 stated he immediately intervened and SRNA #29 left the room. He stated he calmly asked the resident for his/her dentures and the resident started crying and said, What am I supposed to do? Review of SRNA #41's witness statement dated 12/03/19 revealed she was also in Resident #17's room when SRNA #29 asked the resident for his/her dentures. SRNA #41 reported that Resident #17 was playing around and acted like he/she would not give his/her dentures to SRNA #29 and SRNA #29 told the resident, You know you won't like it if I have to do it. According to the statement, SRNA #29 then shoved her fingers in the resident's mouth, and SRNA #42 stepped in and asked the resident's permission to help. The SRNA stated Resident #17 told SRNA #29 not to remove his/her dentures, but proceeded to allow SRNA #42 to remove his/her dentures. Further review of the witness statement revealed SRNA #29 seemed to be frustrated and tried to forcefully grab Resident #17's dentures, when she should have stopped and stepped back. Review of SRNA #29's statement dated 12/03/19 and 12/04/19 revealed when she was trying to remove Resident #17's dentures, the resident did not want to give them to her and tried to bite her fingers. SRNA #29 admitted that she put her fingers in the resident's mouth, and told the resident that she was going to brush and soak the dentures. Interviews were conducted with SRNA #42 on 12/18/19 at 10:45 AM and with SRNA #41 on 12/18/19 at 5:50 PM. SRNA #41 stated she felt SRNA #29 was trying to intimidate Resident #17. According to SRNA #42, SRNA #29 told the resident, You can give me your dentures, or I can take them and we both know you won't like that. SRNA #42 stated Resident #17 said, No, and turned his/her head toward SRNA #42; however, SRNA #29 shoved her fingers into the resident's mouth and tried to pull the dentures out. SRNA #42 revealed the top dentures came halfway out and Resident #17 pulled away. SRNA #42 revealed he intervened and SRNA #29 left the room. He stated he and SRNA #41 just looked at each other because we could not believe what just happened. SRNA #42 revealed Resident #17 started crying and asked, Who could I tell? SRNA #42 revealed he notified the nurse and the nurse came to the resident's room to talk with the resident. Continued review of the facility's investigation revealed although interviews with SRNA #41 and #42 and review of their statements to the facility revealed SRNA #29 made a comment to the resident that the resident would not like it if the SRNA had to remove her dentures, the facility's investigation did not address whether the comment was investigated. Interview with Registered Nurse (RN) #8 on 12/19/19 at 5:30 PM revealed on 12/03/19, SRNA #42 told her that Resident #17 wanted to talk to her. She stated when she went to speak with the resident, the resident told her, That girl got my teeth, and my mouth hurts. RN #8 stated she notified the Director of Nursing (DON) and the resident's Responsible Party (RP) of the incident. Further review of the facility's investigation revealed the Director of Nursing (DON) spoke with Resident #17 on 12/03/19 at 6:25 PM and the resident stated he/she told the girl to quit trying to get [his/her] teeth out that it hurt and the girl stopped. According to the DON's statement, she then asked the resident if the resident thought the girl meant to hurt [the resident] and the resident didn't respond to the question. When the DON asked the resident again, the resident told me to leave [him/her] alone and get out [he/she] just wanted to sleep. Interview with the Director of Nursing (DON) on 12/20/19 at 12:00 PM revealed she was in the facility when the incident occurred with Resident #17 and SRNA #29 on 12/03/19. The DON stated she had the SRNAs to write out their statements, had SRNA #29 leave the facility, and notified the Administrator. The DON stated she also talked to the resident after the incident and the resident told her that he/she did not want to talk about the incident. According to the DON, Resident #17 also told her that he/she was fine, never felt threatened, and stated, Everybody loves me, even though the DON did not document these resident comments in her statement on 12/03/19 at 6:25 PM. According to the facility's investigation completed on 12/06/19, the facility determined that no abuse took place based on interviews with staff, interviews with alert and oriented residents, and skin assessments of non-interviewable residents. There was no documented evidence that the facility considered Resident #17's statements/reactions when determining whether abuse occurred. Further review of the facility's findings revealed the facility was unable to verify abuse occurred stating, When [SRNA #29] saw that [Resident #17] was becoming upset [the SNRA] stepped away from the situation as she has been trained to do. Continued interview with the Director of Nursing (DON) on 12/20/19 at 12:00 PM revealed the facility unsubstantiated that Resident #17 was abused because Resident #17 said nothing happened (even though there was no documentation that the resident made that statement), the resident had no injuries, and the way staff had to remove the resident's dentures was difficult. Interview with the Administrator on 12/20/19 at 2:57 PM revealed the DON took the SRNAs' statements and spoke with them concerning the incident with Resident #17 on 12/03/19. The Administrator stated the Nurse Consultant (and possibly the DON) presented the information as if SRNA #29 was joking around. According to the Administrator, once an investigation was completed she and the DON and Nurse Consultant made the decision whether to substantiate abuse. She stated it was her understanding that Resident #17 was starting to bite the SRNA and the SRNA jerked her hand out of the way. However, the Administrator stated after reading the statements it did not seem like SRNA #29 was joking. Interviews were conducted with the Nurse Consultant and the Regional Director on 12/20/19 at 5:50 PM. According to the Regional Director, the statement that SRNA #29 made to Resident #17 regarding You can give me your dentures, or I can take them out and we both know you won't like that could be seen as a threatening statement. According to the Nurse Consultant, she believed the facility completed a thorough investigation of the statement because they asked the resident if a staff member had been rough. The Regional Director further stated that the Administrator may reach out to the Nurse Consultant regarding an investigation; however, the Administrator made the final decision whether to substantiate or unsubstantiate abuse allegations. 2. Review of Resident #45's medical record revealed the resident was readmitted to the facility on [DATE] with diagnoses that included Unspecified Psychosis, Flaccid Neurogenic Bladder, Pain in the Left Hip, Lack of Coordination, Heart Failure, and Muscle Weakness. Review of Resident #45's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was three (3), indicating the resident was severely cognitively impaired. Further review of the quarterly MDS revealed Resident #45 required extensive assistance from staff for activities of daily living (ADLs). According to the assessment, Resident #45 had not exhibited any moods/behaviors during the assessment period. Review of the Comprehensive Care Plan for Resident #45 dated 07/24/17 revealed the resident required a mechanical lift for all transfers with two (2) staff persons' assistance. Further review of the Care Plan dated 07/22/17 revealed the facility documented that Resident #45 became combative with staff at times, had a history of making sexually inappropriate comments towards staff, and attempted to invade staff's personal space. Observation of Resident #45 on 12/17/19 at 3:50 PM revealed the resident was in bed watching television. The resident stated that he/she did not utilize a mechanical lift and could not remember whether staff had tickled his/her feet. Review of an Accident/Incident Report dated 12/11/19 at 12:35 PM revealed when staff was undressing Resident #45 the resident became combative and hit his/her left forearm on the bed rail, causing scattered discoloration and a skin tear. According to the report, the injury was discovered and witnessed by SRNA #37, SRNA #38, and SRNA #42. However, the only staff statement the facility obtained on 12/11/19 was from SRNA #42. According to SRNA #42's statement, the resident was trying to hit staff and hit his/her left arm a couple of times on the bed rail. Staff documented that the causative factor was resident hit arm on siderails. The DON signed off on 12/11/19 that she had reviewed the Accident/Incident Report and the Administrator signed off on 12/12/19. However, further review revealed a Human Resources (HR) staff person documented on 12/11/19 that SRNA #42 reported that the bruises on Resident #45's arm were caused from SRNAs aggravating the resident. Interview with SRNA #42 on 12/18/19 at 10:45 AM revealed he reported allegations of resident abuse/neglect on 12/11/19. He stated that on 12/11/19, he heard loud laughter coming from Resident #45's room. When he entered the resident's room, he saw SRNAs #37 and #38 tickling Resident #45's feet. SRNA #42 stated he asked the SRNAs to stop teasing the resident because the resident had become very agitated; however, he stated the SRNAs did not stop. He stated the SRNAs then attempted to undress the resident, and the resident already being agitated became combative and hit his/her arm on the bed rail causing bruises and a skin tear on the resident's left forearm. SRNA #42 revealed he wrote a witness statement concerning the incident that occurred on 12/11/19 with Resident #45. In addition, SRNA #42 stated he went to the HR staff member and told the HR staff that SRNAs #37 and #38 were teasing the resident, which caused Resident #45 to become combative. He stated he also reported to the HR staff member that the same two (2) SRNAs were transferring Resident #45 to a geriatric chair via mechanical lift, and used the emergency release button to drop the resident onto the geriatric chair three (3) consecutive times. Further interview with SRNA #42 revealed he also reported to the Administrator and HR staff that staff falsely documented that residents ate, had a bath/shower, and had bowel movements. According to the SRNA, he could only remember the names of two residents that staff had documented that had a bed bath (Resident #7 and Resident #211) when in fact they had not. According to SRNA #42, he reported all this information to the HR staff member and to the Administrator. A review of the Administrator and Nurse Consultant's summary of an interview with SRNA #37 dated 12/12/19, the day after the incident, revealed the SRNA ensured Resident #45 was safe in the mechanical lift. She stated the resident was aggressive when undressing the resident and the only injury that the resident had was when he/she hit the bed rail when swinging his/her fist. Interview with SRNA #37 on 12/18/19 at 6:45 PM revealed Resident #45 received bruises and a skin tear on his/her arm from slinging his/her arms and hit the bed rail. She revealed she was not doing anything to try to agitate the resident. SRNA #37 stated the only time staff would need to use the emergency button release on a mechanical lift was if a resident became combative while in the lift; however, the SRNA did not recall Resident #45 being combative while in a lift. SRNA #37 revealed she did not think they had to lift the resident up again with the mechanical lift after placing him/her in the geriatric chair to reposition the resident, but sometimes they had to because the resident was hard to position in the geriatric chair. A review of the Administrator and Nurse Consultant's summary of an interview with SRNA #38 dated 12/12/19, the day after the incident, revealed the SRNA stated that Resident #45 became combative and sustained three little skin tears from hitting the bed rail. The SRNA denied that the resident was dropped or sat down too quickly in the mechanical lift and denied any teasing or aggravating going on. Interview with SRNA #38 on 12/18/19 at 4:50 PM revealed while she and SRNA #37 were taking Resident #45's clothes off, the resident started slinging his/her arms and the resident's left arm hit the bed rail. She revealed they were not doing anything to agitate the resident, especially not tickling the resident's feet because Resident #45 did not like his/her feet touched. SRNA #38 further stated staff were not allowed to use the emergency release button unless a resident became combative or started having a seizure while in the lift. There was no documented evidence that the facility conducted an investigation of the abuse allegations regarding Resident #45 in accordance with the facility abuse investigation policy (e.g., interview the resident's roommate, family member, and visitors; interview other residents to whom accused employee provide care or services; nor review all events leading up to the alleged incident). 3. Review of staff interviews revealed on 12/11/19, SRNA #42 reported to a Human Resources staff member, the Administrator, and the Nurse Consultant that SRNA #20 had worked at the facility and smelled of alcohol while he was caring for residents. Furthermore, SRNA #41 also reported to the Administrator and the Nurse Consultant on 12/12/19 and wrote a witness statement on 12/13/19 that SRNA #20 came back to work from a break, smelling of alcohol, and his actions showed signs of intoxication. Interview with SRNA #42 on 12/18/19 at 10:45 AM, confirmed that he reported to the Administrative staff on 12/11/19 that he was concerned about SRNA #20 smelling of alcohol while working at the facility on 12/04/19. Interview with SRNA #41 on 12/18/19 at 5:50 PM revealed on 12/04/19, SRNA #20 smelled strongly of alcohol and appeared intoxicated. According to SRNA #41, SRNA #20 intentionally agitated Resident #45 and kept trying to get the resident to hit him, and then tried to get the resident to hit SRNA #41. She stated that SRNA #20 thought it was funny to agitate the resident and Resident #45 eventually hit SRNA #20. In addition, SRNA #41 stated SRNA #20 was very sloppy and careless with residents on 12/04/19. She stated SRNA #20 was operating the mechanical lift while transferring Resident #17, and hit the resident's chin when removing the mechanical lift pad. Review of a typed document signed by the Administrator and the DON revealed they interviewed SRNA #20 by phone on 12/12/19 and the SRNA denied that he had ever had alcohol while at work. Further review of a statement from SRNA #38 dated 12/18/19, the day after the survey was initiated and seven (7) days after the allegation was made, revealed the SRNA documented that she worked with SRNA #20 on 12/04/19 and he was not intoxicated and did not smell like alcohol. There was no documented evidence that the facility investigated the allegations that SRNA #20 mistreated residents while under the influence of alcohol on 12/04/19, in accordance with the facility's abuse investigation policy. 4. Continued review of staff interviews conducted by the facility on 12/11/19, revealed SRNA #42 reported to Human Resources (HR) staff and to the Administrator that staff were guessing when documenting residents' meal intakes and bowel movements (BMs) in the kiosk for residents, and not reporting/documenting accurate information. In addition, when residents did not want a bed bath or shower, staff falsely documented that residents were assisted with bed baths/showers. Interview with SRNA #42 on 12/18/19 at 10:45 AM confirmed that he reported to the DON and the Administrator that staff falsely documented that residents ate, had a bath/shower, and had bowel movements. According to the SRNA, he could only remember the names of two residents that staff had documented that had a bed bath (Resident #7 and Resident #211) when in fact they had not. Observations of Resident #7 on 12/17/19 at 9:35 AM and Resident #211 on 12/17/19 at 9:00 AM revealed both residents were clean and free from body odor. Review of the shower sheets revealed Resident #7 and Resident #211 received their showers and bed baths as scheduled. Review of facility abuse/neglect investigations revealed no documented evidence that the facility conducted an investigation to determine whether staff were neglecting to feed residents, whether residents were eating meals as documented, losing weight, etc.; whether staff neglected to provide bed baths/showers for residents; nor whether residents were actually having bowel movements as documented.

Based on interview, record review, and review of the Administrator's job description, the facility failed to ensure the facility was administered in a manner that enabled the use of its resources effectively and efficiently. The facility was cited at F609 and F610 for failure to report and investigate allegations of resident abuse on 09/06/19. On 11/16/19, the facility was cited for failure to report an allegation of abuse (F609). In addition, during the visit on 12/20/19, the facility was again cited for failure to report and investigate allegations of abuse (F609 and F610) and for failure to review/revise the comprehensive care plan (F657). The Administrator failed to ensure plans of corrections were implemented related to cited deficiencies and failed to ensure ongoing monitoring was completed to ensure corrective actions were effective (refer to F609 and F610). The findings include: Review of the Administrator's Job Description, not dated, revealed the Administrative Functions included Plan, develop, organize, implement, evaluate, and direct all aspects of the facility operations. Ensure that all departments personnel, residents visitors, and government agencies, etc. are able to interpret and follow the department's established policies and procedures. Complete forms, reports, evaluations, studies, etc. related to facility operations. Has principle concerns for the delivery of quality patient care to all residents of the facility. Has responsibility and concern for public relations and patient families and community. Coordinates programs between various departments in the facility. Participates in all facility surveys and in the writing of the plan of corrections to the statement of deficiencies. Serves on the Quality Assurance Committee .Responsibility for staffing, training, supervision, discipline and schedule for departments .Communicate with co-workers at all levels to adequately meet the needs of residents . 1. Review of the facility Plan of Correction (POC) received on 10/11/19 for the statement of deficiencies dated 09/06/19 revealed the facility was cited for failure to report and investigate allegations of resident abuse. The plan of correction stated the DON would evaluate all incident reports (IR) and injuries for the next six months, regardless of cause, to determine if the incident needed to be investigated and whether the abuse protocol needed to be implemented to protect residents, which included ensuring an allegation of abuse was reported to the state agencies. In addition, the POC stated for the next six months the Quality Assurance (QA) Nurse would review all Incident Reports for the week, regardless of type of incident, to evaluate if the appropriate determination was made by the DON regarding investigation, abuse protocol implementation, and reporting for each Incident Report. The plan stated the DON and Quality Assurance Nurse had been trained on reporting alleged violations specific to F609. The facility alleged compliance effective 09/12/19. Review of an Accident/Incident Report dated 12/11/19 at 12:35 PM revealed the facility determined that Resident #45 hit his/her left forearm on the bed rail during a combative episode, causing scattered discoloration and a skin tear. However, review of State Registered Nurse Aide (SRNA) #42's facility interviews revealed that SRNA #42 reported on 12/11/19 that he witnessed the SRNAs aggravating Resident #45, which resulted in the resident's injuries. Further review revealed SRNA #42 also reported that staff were not accurately documenting residents' meal intakes, showers, or bowel movements (BMs). He reported staff would document a resident had a bed bath when they had not. In addition, SRNA #42 reported on 12/11/19 that SRNA #20 had worked at the facility while smelling of alcohol. Further review revealed SRNA #41 provided a statement dated 12/13/19 that SRNA #20 came back from a break smelling of alcohol (a date is not documented) and SRNA #20's actions seemed less careful and his actions showed signs of intoxication. According to an interview with SRNA #42 on 12/18/19 at 10:45 AM, he also reported to the HR staff member and Administrator that SRNAs #37 and #38 tickled Resident #45's feet on 12/11/19 until he/she became agitated and combative, resulting in a skin tear. Further, he stated he reported that the same two (2) SRNAs used the emergency release button on a mechanical lift to drop the resident onto the geriatric chair three (3) times. In addition, an interview with SRNA #41 on 12/18/19 at 5:50 PM revealed she told the Administrator on 12/12/19 that SRNA #20 smelled strongly of alcohol and appeared intoxicated while caring for residents at work on 12/04/19. According to SRNA #41, SRNA #20 intentionally agitated Resident #45 by asking the resident to hit staff. She stated that SRNA #20 thought it was funny to agitate the resident and Resident #45 eventually hit SRNA #20. In addition, SRNA #41 stated SRNA #20 was very sloppy and careless with residents on 12/04/19. She stated SRNA #20 was operating the mechanical lift while transferring Resident #17, and hit the resident's chin when removing the mechanical lift pad. Further review of the Accident/Incident Report revealed the Administrator signed that she reviewed the report on 12/12/19. There was no documented evidence that the facility investigated or reported to state agencies the allegations of abuse/neglect. Interviews conducted with the Administrator on 12/18/19 at 2:33 PM and on 12/20/19 at 2:57 PM confirmed that she did not report any of the allegations of abuse/neglect. The Administrator stated that she interviewed SRNAs #37 and #38 about tickling Resident #45's feet and dropping the resident into a geriatric chair from the mechanical lift. The Administrator stated both SRNAs denied the allegations and after that I didn't think there was any more investigating that needed to be done. The Administrator further stated she thought dropping the resident from the mechanical lift into a geriatric chair was a safety issue and not an allegation of abuse; subsequently, she did not investigate any further regarding the mechanical lift. In addition, even though only one (1) staff member was interviewed about the allegation regarding SRNA #20 on 12/18/19, after the state agency initiated an investigation and seven days after the allegation was reported, the Administrator stated she conducted interviews with staff who worked with the SRNA on 12/04/19. The Administrator stated she did not feel like there was anything else she needed to do at that point, and did not interview residents or other staff. Continued interview with the Administrator revealed she had staff review residents' bowel movement documentation and had a nurse assess Resident #7 and Resident #211 for cleanliness and found no concerns. The Administrator further stated that the Director of Nursing had been monitoring residents' intake and output for over a month and she did not see why it had to be investigated. 2. Review of the facility's Plan of Correction received on 12/09/19 for the survey exit date of 11/16/19 revealed the facility received a deficiency due to failure to report an allegation of abuse timely to the state survey agency. The plan of correction for this tag included interviewing all residents with a Brief Interview for Mental Status (BIMS) score of eight (8) and above and asking if they had been physically harmed. According to the POC, no resident had any concerns with being mistreated/abused, and the facility alleged compliance with the requirements for abuse reporting on 12/09/19. However, review of the facility's interviews revealed Resident #211 stated he/she had been knocked down going to a singing. The resident described the person who knocked him/her down as wearing a black dress with a white collar and a gold cross around their neck. In addition, further review of the facility resident interviews revealed Resident #204 stated, Yes, a girl hurt my back when asked if he/she had been physically harmed. The resident was not able to tell how his/her back was hurt, but stated the girl who hurt his/her back had long hair. Further interview with the Administrator on 12/19/19 at 4:40 PM revealed the allegations from Resident #211 and Resident #204 were reported to her but had not been reported to the State Survey Agency as an allegation of abuse. Per the Administrator, the facility had looked into the allegations some but had not done a full investigation (witness statements, interview with other residents, interview with staff on all shifts, etc.). The Administrator stated she was under the impression the facility could do an internal investigation and then decide whether they needed to report the allegation to state agencies.

Based on interview, record review, and review of the facility policy it was determined the facility failed to have an effective performance improvement program which measured the success and tracked the performance of implemented plans to ensure improvements are sustained in the facility. On 09/06/19, F609 and F610 were cited due to the facility's failure to report and investigate allegations of resident abuse, and on 11/16/19, the facility was cited again for failure to report an allegation of abuse (F609). The State Agency received a Plan of Correction (POC) on 10/11/19 for a survey exit date of 09/06/19. Per the POC, the Director of Nursing (DON) and the Quality Assurance Nurse would evaluate all incident reports for the next six months, regardless of cause, to determine if the incident needed to be investigated and the abuse protocol implemented to protect residents, which included ensuring an allegation of abuse was reported to state agencies. However, interviews with both the DON and Quality Assurance Nurse revealed they reviewed all incident reports, but did not review them to determine if they should be reported/investigated as allegations of abuse. On 12/11/19, Resident #45 sustained an injury and an Incident Report was completed. During interviews with staff regarding the injury, staff reported that Resident #45 was abused. In addition, staff reported other instances of resident abuse/neglect. There was no evidence that staff implemented their Plan of Correction and monitored Incident Reports as alleged. Subsequently, the reports of resident abuse/neglect were not reported to state agencies and were not investigated as required by the facility's policies. The findings include: Review of the facility's Continuous Quality Improvement Policy Statement, not dated, revealed the facility process was comprehensive (involving all departments and key facility practices) and included monitoring, evaluation, and appropriate follow-up actions to continually improve and provide excellence in service. The ultimate objective of Continuous Quality Improvement (CQI) was Quality Service for every resident, every day. Further review revealed, Any CQI quality indicator study which falls outside the acceptable range, may signal the presence of a potential problem, and serves as a 'trigger' for further investigation. The Goal is to minimize risk and to prevent problems from occurring .In addition, to the CQI Indicator Studies, the QI/QM facility reports, information obtained from many other sources assist in identifying potential problems that need to be further reviewed. Sources could be: satisfaction surveys, regulatory surveys, consultant reports, resident council concerns, family complaints, etc .The monitoring is ongoing. Review of the facility's Plan of Correction received as a result of a survey with an exit date 09/06/19 revealed the facility was cited for failure to report and investigate allegations of resident abuse. The plan of correction stated the DON would evaluate all incident reports and injuries for the next six months, regardless of the cause, to determine if the incident needed to be investigated and to ensure the facility's abuse protocol was implemented to protect residents, which included ensuring an allegation of abuse was reported to state agencies. In addition, the facility's plan of correction for the next six months was for the Quality Assurance Nurse to review all incident reports for the week, regardless of the type of incident, to evaluate if the DON made the appropriate determination regarding incident reports (investigating, protecting, and reporting). The plan stated the DON and Quality Assurance Nurse had been trained on reporting alleged violations specific to F609. The facility alleged compliance effective 09/12/19. Further review of Statements of Deficiencies issued to the facility revealed the facility had an annual survey with an exit date of 11/16/19, and deficient practice was identified again related to the facility's failure to report abuse timely to state survey agencies. The facility submitted a POC and alleged compliance with F609 (abuse reporting) effective 12/09/19. Review of an Accident/Incident Report dated 12/11/19 at 12:35 PM revealed Resident #45 hit his/her left forearm on the bed rail, causing scattered discoloration and a skin tear. Further review revealed administrative staff conducted staff interviews with SRNAs #37, #38, and #42 regarding the incident and determined that the resident became combative during care, and hit his/her arm on the bed rail, resulting in bruises and a skin tear to the resident's left forearm. However, review of a typed document that was signed by a Human Resources (HR) staff member dated 12/11/19 revealed SRNA #42 reported that he witnessed the SRNAs aggravating Resident #45, which resulted in the resident's injuries. Continued review of the HR staff's notes revealed SRNA #42 had also reported to the HR staff that staff were not accurately documenting residents' meal intakes, showers, or bowel movements (BMs). He reported staff documented that a resident had a bed bath when they had not. In addition, SRNA #42 reported to the HR staff on 12/11/19 that SRNA #20 had worked at the facility while smelling of alcohol. Review of SRNA #41's statement dated 12/13/19 revealed SRNA #20 came back from a break smelling of alcohol (a date is not documented). SRNA #20's actions seemed less careful and his actions showed signs of intoxication. Further review of the Accident/Incident Report revealed the DON signed that she reviewed the report on 12/11/19. There was no documentation that the Quality Assurance nurse reviewed the report. Interview with the DON on 12/20/19 at 2:15 PM revealed she reviewed Incident Reports during the facility's morning meeting to ensure the resident's physician and family were notified, witness statements were obtained, and to ensure what was reported as happening validated the injury. According to the DON she did not review Incident Reports to ensure abuse/neglect was reported/investigated. Interview with the Quality Assurance (QA) Nurse on 12/20/19 at 5:05 PM revealed staff reviewed Incident Reports during the facility's morning meeting, and then the reports were given to her for review. The QA Nurse stated she reviewed the Incident Reports to ensure they were complete (includes causative factor, actions, interventions, etc.). The QA Nurse stated she did not review Incident Reports to determine if an allegation of abuse should be reported. The QA Nurse stated that after her review she forwarded the reports to the DON and Administrator. Per the QA Nurse, she reviewed the Incident Reports first, not after the DON as stated in the plan of correction. Further interview revealed she was not aware that she was supposed to review Incident Reports to ensure abuse/neglect was reported/investigated.