Based on interview and record review the facility failed to ensure a resident's right to be free from resident to resident physical abuse, for 1 (Resident #77) of 2 (Resident #77 and Resident #20) sampled residents investigated for abuse, in a total sample of 28. Findings: Review of the facility's policy titled Incident Investigation and Reporting with a revision date of 05/2024 revealed in part . 1. Each Resident residing in the facility has the right to be free from any type of abuse including: verbal, sexual, mental, physical abuse, neglect, exploitation, misappropriation of resident property. Abuse: Abuse is the willful infliction of injury. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse: This includes but is not limited to hitting, slapping, pinching, and kicking. Resident #77 Review of Resident #77's medical record revealed an admit date of 07/24/2024, with diagnoses that included in part .Acute Respiratory Failure with Hypoxia, Muscle Weakness, Pain Unspecified, Bipolar Disorder, Puerperal Psychosis, Generalized Anxiety Disorder, Major Depressive Disorder with Psychotic Symptoms and Insomnia. Review of Resident #77's Quarterly MDS with an ARD of 02/12/2025, revealed Resident #77 had a BIMS score of 15, indicating intact cognition. The MDS revealed Resident #77 was dependent for bed mobility, toileting and transfer, and required 2+person physical assist. The MDS revealed Resident #77 used a manual wheelchair for mobility, and had no impairment to upper or lower extremities. Review of Resident #77's Care Plan with a Target Date of 05/09/2025 read in part . 1. Resident has verbal behavioral symptoms directed towards other at times, with interventions that included in part .Approach resident calmly, do not argue with resident. Resident #20 Review of Resident #20's medical record revealed an admit date of 10/27/2016, with diagnoses that included in part .Major Depressive Disorder, Acquired Absence of Right Below Knee and Intermittent Explosive Disorder. Review of Resident #20's Annual MDS with an ARD of 03/20/2025, revealed Resident #20 had a BIMS score of 12, indicating moderately impaired cognition. The MDS revealed Resident #20 was independent with bed mobility, transfer, eating and required limited assistance with toileting. The MDS revealed Resident #20 used a manual wheelchair for mobility, and had no impairment to upper extremities. Review of Resident #20's Care Plan with a Target Date of 06/24/2025, revealed in part . 1. Mood: Resident has potential for Altered Mood related to targeted behaviors of agitation/aggression, with interventions that included in part .observe for changes in mental status, do not argue with resident, Psych evaluation if needed, notify physician of increased behaviors. Review of a Facility Incident Report dated 03/20/2025 at 2:37 p.m., and documented by S1 Administrator, read in part .Resident #77 notified the nurse that she and Resident #20 were in an argument that turned physical. Resident #77 stated that Resident #20 did not hit her, but had tried to. Resident #77 stated she hit Resident #20 on his arm. The residents were on X Hall when the argument began. Staff were passing food trays. The nurse notified Administrator and DON. The nurse assessed for injury and Resident #20 had no redness, no mark, no bruising to his upper right arm, and no complaints of pain. Both resident's RP and physicians were notified. The police were notified and recorded the incident. Interview on 04/15/2025 at 8:30 a.m. with Resident #77, revealed last month 03/2025 (couldn't remember the exact date), she was in her wheelchair passing by Resident #20 in the hallway. Resident #77 stated Resident #20 started talking nonsense to her, and they started arguing. Resident #77 stated Resident #20 started swinging trying to hit her. Resident #77 stated she swung back and hit Resident #20 on his arm. Interview on 04/15/2024 at 8:56 a.m. with S1 Administrator revealed according to surveillance video, on 03/16/2025 at 6:15 p.m., Resident #77 and Resident #20 were going down X hall in their wheelchairs. Resident #77 and Resident #20 started arguing and attempted to hit each other. S1 Administrator confirmed Resident #77 made contact (hit) with Resident #20's right arm. S1 Administrator stated the video was no longer available for viewing. Interview on 04/15/2025 at 3:01 p.m. with S11CNA , revealed he was passing trays on Hall X on 03/16/2025, and witnessed Resident #77 and Resident #20 arguing and swinging at each other; however, S11 CNA stated he did not see Resident #77 hit Resident #20 on the upper right arm. S11 CNA stated Resident #20 and #77 were separated and taken to their rooms with no further incident.

Based on interview and record review, the facility failed to implement a comprehensive person-centered care plan consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #5) resident of 20 sampled residents. The facility failed to ensure Resident #5's care plan reflected accurate and current data by failing to resolved/discontinue a previous hospice care plan. Findings: Review of a facility policy on 04/16/2025 at 2:00 p.m. titled, Care Plan Process revised on 12/2024 revealed the following in part .The care plan must be reviewed and revised periodically, on an ongoing basis to reflect the services provided or arranged, and must be consistent with each resident's written plan of care. The facility shall use the results of the assessments to develop, review, and revise the resident's comprehensive plan of care .Review and revise the current care plan, as needed. Review of Resident #5's medical record revealed a re-admission date of 05/15/2024, with diagnoses that included in part . Alzheimer's Disease, End Stage Renal Disease, Ataxia Following other Non-traumatic Intracranial Hemorrhage, and Pseudobulbar Affect. Review of Resident #5's Annual and State Optional MDS with an ARD of 03/20/2025 revealed a BIMS score of 3, which indicated severe cognitive impairment. Resident #5 required total dependence with two persons for transfers, toilet use, and bed mobility. Resident #5 was not receiving hospice services. Review of Resident #5's current physician orders revealed in part . 08/05/2024 (start date): Admit to the facility for long term care. No active physician orders for hospice services. Review of Resident #5's care plan with an initial date of 09/13/2024 revealed in part . Focus: Resident is on hospice services with a diagnoses of CVA (cerebrovascular accident). Interventions: Staff to provide comfort measures; assess for verbal and nonverbal pain indicators; reposition for comfort as needed; facility nurse to notify hospice promptly of any changes and declines; involve hospice services in care conference; respect and honor the resident's wishes; hospice CNA to assist with ADLs (activities of daily living) as needed: notify Medical Director and hospice if interventions are ineffective; and facility and hospice social worker to visit periodically and offer support. In an interview on 04/15/2025 at 9:34 a.m., S7 LPN revealed that Resident #5 was not currently receiving hospice services. In an interview and record review on 04/16/2025 at 11:31 a.m., S9 MDS LPN revealed she is responsible for updating and revising resident care plans. S9 MDS LPN confirmed Resident #5's current care plan reflected hospice services and Resident #5 was not currently receiving hospice services. S9 MDS LPN confirmed Resident #5's hospice care plan should have been resolved/discontinued to reflect the current plan of care, but was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality by failing to obtain a physician's order for 1 (#6) of 1 resident sampled for respiratory care. The facility failed to ensure a physician's order was obtained for oxygen administration. Findings: Review of the facility's policy on 04/15/2025 titled, Oxygen-Administration, Concentrator, Storage, Assemblage, last reviewed on 01/2024 read in part .Purpose: To provide adequate tissue oxygenation by providing supplemental oxygen. Procedure: 1. Obtain appropriate physician's order. Review of Resident #6's medical record revealed an admission date of 02/18/2025 with a re-entry date of 03/13/2025 with diagnoses that included in part .Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Acute on Chronic Systolic (Congestive) Heart Failure, Sleep Apnea, and Asthma. Review of Resident #6's Admission/Medicare-5 Day MDS with an ARD of 06/19/2025 revealed a BIMS score of 15, indicating intact cognition and requires continuous oxygen therapy. Review of Resident #6's care plan with a review date of 06/17/2025 revealed in part .The resident has Congestive Heart Failure. Intervention: oxygen as ordered. The resident has Coronary Artery Disease. Intervention: oxygen as ordered. The resident has COPD and Asthma. Intervention: oxygen/bi-pap as ordered. The resident has Sleep Apnea. Intervention: oxygen as ordered. In an observation and interview on 04/14/2025 at 10:09 a.m. Resident #6 was observed lying in bed with 3 liters/minute of oxygen being administered via nasal cannula. Resident #6 stated, Sometimes I'm on 2 liters of oxygen or 3 liters of oxygen. In an observation and interview on 04/15/2025 at 10:02 a.m. Resident #6 was observed lying in bed with 3 liters/minute of oxygen being administered via nasal cannula. Resident #6 stated she wears her oxygen continuously. Review of Resident #6's 04/2025 physician orders revealed no order for oxygen administration. Review of Resident #6's 04/2025 EMAR revealed no documentation of oxygen administration. In an interview on 04/15/2025 at 10:32 a.m. S6 LPN stated Resident #6 wears continuous oxygen except during therapy. S6 LPN stated Resident #6 has always worn oxygen. S6 LPN confirmed Resident #6 does not have order for oxygen administration. In an interview on 04/15/2025 at 11:03 a.m. S5 Medical Records LPN confirmed there was no physician's order for oxygen administration for Resident #6 after returning to the facility from the hospital on [DATE]. In an interview on 04/15/2025 at 11:12 a.m. S2 DON confirmed a physician's order for oxygen administration should have been obtained for Resident #6, but had not been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in a secure manner by failing to ensure medications were not left at the bedside for 1 (Resident #10) resident of 20 sampled residents. Findings: Review of a facility policy on [DATE] at 1:35 p.m. titled, Administration of Medications with a revision date of 03/2025 revealed in part .Purpose: To administer medications in accordance with best practice. 4. Medications shall be administered by the person who prepared the dose. 7. Stay with the resident until the resident takes all medications. Topical Medications: 1. Only qualified professionals are allowed to administer medication per state laws. Review of a facility policy on [DATE] at 1:35 p.m. titled, Destruction of Unused, Expired or Discontinued Medications with a revision date of 10/2019 revealed in part .All containers with no labels will be given to the Director of Nursing (DON) for proper disposition. 1. Unused or discontinued non-controlled medications are to be destroyed by the DON (designee) and another licensed nurse. Review of Resident #10's medical record revealed a re-admission date of [DATE], with diagnoses that included in part . Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region, Paraplegia Complete, Peripheral Vascular Disease, Metabolic Encephalopathy, and Orthostatic Hypotension. Review of Resident #10's Quarterly MDS with an ARD of [DATE] revealed a BIMS score of 15, which indicated intact cognition. Resident #10 required extensive assistance with two persons for bed mobility, transfers, and toilet use. Review of Resident #10's current physician orders revealed in part . [DATE] (start date): Nystatin powder 15gm 100000 unit/ 1gram apply topically to skin folds as needed daily for redness every 24 hours. Review of Resident #10's care plan with an initial date of [DATE] and revision date of [DATE] revealed in part . Focus: Resident is at risk for impaired skin integrity related to inability to turn self without staff assist. Interventions: Treatments as ordered. Resident #10 was not care planned for self-administration of medications, powders, creams, ointments, and/or treatments. Further review of the medical record revealed there were no physician's orders to allow Resident #10 to store any medications in the room at the bedside and there were no assessments to determine if Resident #10 was safe to have the medications stored at the bedside to self-administer. Observation on [DATE] at 10:11 a.m., revealed an unattended powdered substance in a small, clear, plastic medication container located on Resident #10's bedside dresser table. In an interview on [DATE] at 10:11 a.m., Resident #10 revealed the powdered substance in the clear, plastic container was Nystatin powder and stated that the staff apply the powder to her skin when her brief is changed. In an observation and interview on [DATE] at 10:20 a.m., S6 LPN accompanied surveyor to Resident #10's bedroom. S6 LPN confirmed that the powdered substance in the clear, plastic container was Nystatin powder and should not be left unattended at the resident's bedside. S6 LPN confirmed the Nystatin powder should have been discarded properly, but was not. In an interview on [DATE] at 9:34 a.m., S7 LPN revealed that Resident #10 had active physician orders for Nystatin powder to be applied to the resident's skin folds as needed daily for redness. S7 LPN confirmed that Nystatin powder should not be left unattended at Resident #10's bedside because she does not self-administer any medications or powders. S7 LPN confirmed that Resident #10's Nystatin powder should had been stored in a locked medication or treatment cart and not stored at the bedside. In an interview on [DATE] at 12:00 p.m., S3 QI Nurse confirmed that Nystatin powder should not be left at a resident's bedside for any reason. In an interview on [DATE] at 1:25 p.m., S2 DON confirmed that Nystatin powder should not have been left unattended at Resident #10's bedside. In an interview on [DATE] at 2:27 p.m., S8 Treatment LPN confirmed that Nystatin powder is stored on the locked treatment cart and should not be stored unattended at the resident's bedside. S8 Treatment LPN confirmed that after application of Nystatin powder, any remaining Nystatin powder should be discarded properly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to transmit a Discharge MDS (Minimum Data Set) Assessment within 14 days of completion for 2 (Resident #34 and Resident #40) of 2 sampled residents with MDS record over 120 days old. Findings: Resident #34 Review of Resident #34's medical records revealed an admission to the facility on [DATE] and a discharged from facility on 11/19/2024. Reviews of Resident #34 MDS transcription report revealed no Discharge MDS was initiated or completed after discharge. Resident #40 Resident #40 was admitted to the facility on [DATE] and was discharged from the facility on 10/28/2024. Review of Resident #40's MDS transcription report revealed no discharge MDS was initiated or completed. Interview on 04/14/2025 at 03:50 p.m. with S4 MDS LPN revealed she is to complete a discharge MDS as soon as the resident discharged from the facility unless the discharge is planned, then she will open for the day they discharged . S4 MDS LPN confirmed that a discharge MDS was not completed for Resident #34 and Resident #40 after discharge but should have been done. Interview on 04/14/2025 at 3:55 p.m. with S2 DON confirmed that no Discharge MDS was completed for Resident #34 and Resident #40 on discharge but should have been.

Based on observation, interview and record review, the facility failed to implement/maintain infection control practices to help prevent and control the spread of an infectious communicable disease. The facility failed to ensure all staff adhered to Enhanced Barrier Precautions for 1 (Resident #3) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) residents reviewed for Quality of Care. Findings: Review of the facility policy titled: Enhanced Barrier Precautions, revealed in part .Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multi-drug resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Wounds generally include chronic wounds, not shorter lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Observation on 05/13/2024 at 9:00 a.m. of the exterior of Resident #3's door revealed an Enhanced Barrier Precautions sign with instructions to wear gloves and a gown for high-contact resident care activities, which included bathing/showering, transferring, dressing, changing linens, providing hygiene, device care or use; central line, urinary catheter, feeding tube, tracheostomy and wound care: any chronic wound taped to the outside of Resident #3's room door. A plastic storage bin was observed to the left of Resident #3's room entrance that contained yellow gowns and biohazard bags. Review of Resident #3's May 2024 Treatment Administration Record revealed in part . Cleanse vascular ulcer to left malleolus with wound cleanser, pat dry. Apply Santyl with 4X4 and cover with ABD pad then wrap with Kerlex and secure with paper tape. Change Q Monday per MD. Order date 03/05/2024. Cleanse arterial ulcer to left lateral foot with wound cleanser, pat dry. Apply Santyl with 4X4 and cover with ABD pad then wrap with Kerlex and secure with paper tape. Change Q Monday per MD. Order date 03/05/2024. Cleanse arterial ulcer to left lateral shin with wound cleanser, pat dry. Apply Santyl with 4X4 and cover with ABD pad then wrap with Kerlex and secure with paper tape. Change Q Monday per MD. Order date 03/28/2024. Observation on 05/13/2024 at 12:25 p.m. revealed S1 LPN performing wound care on Resident #3's left foot. S1 LPN was observed wearing a mask and gloves only while performing wound care. S1 LPN then called for assistance and S2 CNA entered Resident #3's room wearing a mask. S2 CNA donned gloves and proceeded to hold up Resident #3's left leg as instructed by S1 LPN. S1 LPN then proceeded to clean and redress Resident #3's wounds. Interview with S1 LPN after completion of wound care revealed Resident #3 was on Enhanced Barrier Precautions. S1 LPN stated she thought she only needed to wear a gown to perform wound care if the resident had a stage 2 ulcer or worse. S1 LPN confirmed the signage on Resident #3's door stated a gown should be worn when providing wound care to chronic wounds. S1 LPN confirmed she nor S2 CNA wore a gown while providing wound care to Resident #3 and they should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the MDS Assessment accurately reflected a residents' status during the observation period for 1 (Resident #27) of 2 (Resident #13 and Resident #27) residents sampled for positioning and mobility. Findings: Review of Resident #27's clinical record revealed Resident #27 was admitted to the facility on [DATE]. Resident #27 had diagnoses that included Chronic Obstructive Pulmonary Disease, Pressure Ulcer; Stage 2, Pressure Ulcer of Sacral Region; Stage 3, Acquired Absence of Right Leg Above Knee, Muscle Weakness, and Acquired Absence of Left Leg Above Knee. Review of Resident #27's Yearly MDS (Minimum Data Set) Assessment with ARD (Assessment Reference Date) 12/14/2023 indicated Resident #27 had no functional limitation in range of motion (ROM) to the upper extremities. Observation on 03/06/2024 at 11:00 a.m. revealed Resident #27 awake in a geri-chair at his bedside. Interview with Resident #27 at the time of observation revealed he was only able to move his left arm by picking it up with his right arm. Observation revealed Resident #27 lifted his left upper extremity with his right hand and placed it across his body. Resident #27's left upper extremity remained in a flexed position. Interview on 03/06/2024 at 3:32 p.m. with S2 DON confirmed Resident #27 had limited ROM to his left upper extremity as well as a contracture to his left hand. S2 DON confirmed Resident #27 should have been coded on the 12/14/2023 MDS Assessment for upper extremity impairment in ROM on one side and had not been.

Based on observation and interview, the facility failed to ensure that food was properly stored, prepared, distributed and served in accordance with professional standards for food service safety. The facility failed to ensure: 1. Expired/ outdated items were not available for resident consumption 2. Food preparation equipment was clean 3. Cooking and serving utensils were clean and stored under sanitary conditions. The total Facility census was 102 Residents. Findings: Review of the facility's Policy and Procedure titled, Food Storage Labeling read in part . Policy: The facility will ensure the safety and quality of food following good storage and labeling procedures. Procedure: #3. b. Foods stored in storage units will be surveyed routinely to identify and discard foods that have passed its manufacturer use-by date or expiration date. Suggested time frames: Dry Storage - weekly. Review of the facility's Policy and Procedure titled, Cleaning Instructions Deep Fat Fryer read in part . Policy: Equipment shall be maintained in a clean and sanitary condition. On initial tour of the kitchen on 03/04/2024 at 8:40 a.m. accompanied by S5 DM in the dry food storage room revealed the following items on the shelf available for use: 1.One opened plastic bag of croutons ½ full with an expiration date of 01/14/2024. 2.One opened paper 4 lb. bag of sugar ½ full folded partially closed and not labeled or contained. 3.One plastic bag of ice cream dry mix with powder residue noted leaking from a small hole in the bag. Observation on tour of the kitchen on 03/04/2024 at 9:10 a.m. accompanied by S5 DM revealed: 1. Utensils drawer contained one long handled metal spoodle and 2 long handled metal spoons with yellow colored dried gel type residue and loose dark substance particles noted inside the bowl part of the spoons. 2.Large metal deep fat fryer with yellow colored dried gel type residue noted on the outer edges and sides. Multiple loose dark substance particles and dark brown crumbles scattered on the attached metal side work table and noted on the inside wall of the deep fryer and floating on the oil in the deep fryer. Interview on 03/04/2024 at 9:10 a.m. with S5 DM confirmed the above findings. S5 DM revealed she was not aware of the bag of croutons being expired and the dietary staff should have removed the croutons from the dry storage room. S5 DM stated she did not know when the croutons were used and distributed to the residents. S5 DM revealed the ice cream dry mix should have been discarded and was not. S5 DM revealed the deep fat dryer was last used last week and should have been cleaned after use. S5 DM stated that dietary staff worker assigned to clean the deep fat fryer and wash the dishes and were responsible for ensuring that all of the cooking and serving utensils and equipment were cleaned and was not done.

Review of Resident #16's Medical Record revealed an admission date of 03/24/2022 with diagnoses that included Gastrostomy status, Dysphagia following Cerebral Infarction, Ulcerative Chronic Proctitis with Intestinal Obstruction, Hypo-osmolality, Hyponatremia and Hemiplegia following Cerebrovascular Disease affecting right non-dominant side. Review of Resident #16's Quarterly MDS with an ARD of 11/07/2023 revealed a BIMS score of 06, indicative of severe cognitive impairment. Resident #16 required nutritional approaches that included a feeding tube for 51% or more intake by artificial route. Review of Resident #16's Care Plan with a target date of 02/07/2024, revealed a problem of NPO status with need for enteral feeding per PEG tube, secondary to late effect CVA with dysphagia and potential for weight loss. Approaches included in part . Fiber source HN @ 65ml/hour. Observation on 03/04/2024 at 11:13 a.m. of Resident #16 revealed Fiber source HN tube feeding in progress at 65cc/hour per enteral feeding pump. Numerous spots of dried tube feeding drippings were splattered on the face of the enteral feeding pump. Observation on 03/05/2024 at 8:55 a.m. revealed Resident #16's enteral feeding pump had not been cleaned, and numerous spots of dried tube feeding drippings remained splattered on the face of the enteral feeding pump. Interview on 03/05/2024 at 9:58 a.m. with S9 Housekeeper revealed the housekeepers are supposed to clean the tube feeding pumps and poles every day. S9 Housekeeper confirmed the dried residue on the feeding pump was from the drippings of the tube feeding milk in the bag hanging over the pump. Interview on 03/05/2024 at 10:03 a.m. with S3 LPN in Resident #16's room confirmed the above findings, and stated Resident #16's tube enteral feeding pump should have been cleaned every day, and had not been. Based on observations and interviews, the facility failed to maintain a clean, comfortable, and homelike environment. The facility failed to ensure: 1. The front face coverings for air condition/heater units in rooms a, b, c, d, e, and f were properly secured; 2. The walls in rooms, b, c, e, and f did not have peeling sheet rock; 3. The wall mounted molding near the bedside table in room d, did not have a split in the molding with splinters visible. 4. Handrails on Hall A were cleaned and free of debris and dead insects, and chipped paint was repaired; 5. The floor in Room b had been cleaned of dust and dead insects; and 6. Resident #16's enteral feeding pump was free of dried, splattered feeding. Findings: Room a 03/05/2024 at 9:18 a.m. - the front face covering to the wall mounted air condition/heater unit was not secured to the unit. Room b 03/04/2024 at 11:45 a.m. and 03/05/2024 at 8:15 a.m. - a moderate amount of gray dust, and dead black insects were observed on the floor beside, and underneath the air condition/heater unit. The wall mounted air conditioner/heater front face covering was not secured to the unit. There was an opening between the air conditioner/heater unit and the wall, and the surveyor was able to visualize the outside through the opening. The walls near the head of the beds were noted to have peeling sheet rock. Room c 03/52024 at 11:05 a.m. - The front face covering of the wall mounted air condition/heater unit was not secured to the unit. The walls near the head of the beds were noted to have peeling sheet rock. Room d 03/05/2024 at 11:05 a.m. - The front face covering of the wall mounted air condition/heater unit was not secured to the unit. The wall mounted molding near the bedside table was noted to have a split in the molding with splinters visible. Room e 03/05/2024 at 11:05 a.m. - The front face covering of the wall mounted air condition/heater unit was not secured to the unit. The walls near the head of the beds were noted to have peeling sheet rock. Room f 03/05/2024 at 11:05 a.m. - The front face covering of the wall mounted air condition/heater unit was not secured to the unit. The walls near the head of the beds were noted to have peeling sheet rock. Hall A 03/05/2024 at 11:05 a.m. - The handrails were noted to have chipped paint pieces, dead crickets, paper wrapping and dust inside of the rails. Observation on 03/05/2024 at 10:55 of Room b, accompanied by S7 Housekeeping Supervisor, and interview of S7 Housekeeping Supervisor at that time, revealed the floor had been cleaned and mopped earlier that morning. S7 Housekeeping Supervisor confirmed after inspecting the area, that the area beside and underneath the air condition/heater unit was dirty and needed to be cleaned. Observation on 03/05/2024 at 11:30 a.m. of Rooms a and b air condition/heater units, accompanied by S6 Maintenance Supervisor, confirmed the ac units were not properly secured in the frame. S6 Maintenance Supervisor stated in 11/2023 (unable to recall date), all of the units were pulled out for cleaning by an outside contractor, and replaced. S6 Maintenance Supervisor stated he had checked the units, and confirmed that many were loose and had missing screws which needed to be replaced. Observations on 03/05/2024 at 11:45 a.m. and accompanied by S1 Administrator, confirmed the air conditioner/heater units needed to be properly fitted, and the walls was in need of repairs. S1 Administrator stated she was not aware of the units, nor of the repairs needed on the walls in Rooms b, c, e, and f and wall mounted molding in Room d. S1 Administrator after inspecting Hall A handrails, confirmed the inside of the rails needed to be cleaned. S1 Administrator stated it was the responsible of the housekeepers to keep the handrails clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #34 Review of Resident #34's medical record revealed an admit date of 01/29/2024, with diagnoses which included in part .Iron Deficiency Anemia, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Acquired absence of left leg Above Knee and Pain. Review of Resident #34's admission MDS with an ARD 02/02/2024, revealed a BIMS score of 12 (indicating moderately impaired cognition). The MDS was coded as blank for oxygen therapy. Review of Resident #34's care plan revealed no problem/need related to oxygen therapy. Observation on 03/04/2024 at 10:15 a.m. revealed Resident #34 in bed with oxygen via nasal cannula in place. Observation on 03/05/2024 at 9:11 a.m. revealed Resident #34 in bed with oxygen via nasal cannula in place. Review of Resident #34's Physician's Orders dated March 2024 read in part .Oxygen at 2 liters per nasal cannula as needed for Shortness of Breath. Interview and record review on 03/06/2024 at 9:00 a.m. with S6 LPN Assessment Nurse of Resident #34's care plan confirmed she had not been care planned for oxygen with appropriate approaches, and she should have been. Based on interview, observation and record review, the facility failed to develop and implement a comprehensive person-centered care plan for services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #13, Resident #27, and Resident #34) sampled residents in a total sample of 30. The facility failed to ensure a person-centered plan of care was: 1. Implemented for 1 resident (Resident #13) reviewed for impaired mobility. The facility failed to ensure a positioning device was provided to a resident to prevent further complications and contractures. 2. Developed and implemented for 1 resident (Resident #27) that addressed Resident #27's left hand contracture. 3. Developed for 1 resident (Resident #34) who required oxygen therapy. Findings: Resident #13 Review of Resident #13's Medical Record revealed an admission date of 01/15/2016 with diagnoses that included Hemiplegia following Cerebral Infarction affecting Left Dominant Side, Unspecified Sequelae of Non-traumatic Intracerebral Hemorrhage, Bell's Palsy, Osteoarthritis, Spinal Stenosis, Generalized Muscle Weakness, Essential Primary Hypertension and other Idiopathic Peripheral Autonomic Neuropathy. Review of Resident #13's EMAR for 03/2024 revealed a Nursing Instruction order dated 11/24/2021, to Ensure Hand Roll is in place as preventative for skin breakdown. Review of Resident #13's Quarterly MDS with an ARD of 01/18/2024, revealed a BIMS score of 08, which indicated moderate cognitive impairment. The MDS revealed in part .that resident #13 was coded for functional limitation in ROM with impairment on one side to his upper extremities. Review of Resident #13's Care Plan with a target completion date of 04/26/2024, revealed a potential for decreased mobility, with approaches that included in part . Hand roll to left hand. Observation on 03/04/2024 at 1:11 p.m. of Resident #13 revealed his left hand did not have a hand roll in place. Observation on 03/05/2024 at 8:39 a.m. of Resident #13 revealed his left hand was without a hand roll in place. Interview at that time with Resident #13 revealed he couldn't remember the last time he had his hand roll. Observation on 03/05/2024 at 11:40 a.m. of Resident #13, revealed the resident did not have a hand roll to his left hand. Interview on 03/05/2024 at 11:41 a.m. with S8 CNA, Resident #13's CNA, revealed she was not aware that Resident #13 had a hand roll for his left hand. Interview on 03/06/2024 at 12:06 p.m. with S6 LPN Assessment nurse confirmed Resident #13 was care planned for a hand roll to his left hand, and did not have one on and should have. #27 Review of Resident #27's clinical record revealed Resident #27 was admitted to the facility on [DATE]. Resident #27 had diagnoses that included Chronic Obstructive Pulmonary Disease, Pressure Ulcer; Stage 2, Pressure Ulcer of Sacral Region; Stage 3, Acquired Absence of Right Leg Above Knee, Muscle Weakness, and Acquired Absence of Left Leg Above Knee. Review of Resident #27's Yearly MDS with ARD 12/14/2023 revealed Resident #27 was dependent on staff for bathing, toileting, personal hygiene, and upper and lower body dressing. Observation on 03/04/2024 at 9:00 a.m. revealed Resident #27 awake in bed dressed in a hospital gown. A contracture was observed to Resident #27's left hand with no splinting or positioning devices observed in use. Observation on 03/05/2024 at 9:02 a.m. revealed Resident #27 asleep in bed, contracture to left hand with no splinting device present. Observation on 03/06/2024 at 9:34 a.m. revealed Resident #27 asleep in a geri chair at his bedside. Contracture observed Resident #27's to left hand. Review of Resident #27's CPOC with a target date of 03/14/2024 revealed Resident #27's care plan did not indicate Resident #27 had a contracture to the left hand. Interview on 03/06/2024 at 9:45 a.m. with S2 DON confirmed Resident #27 was not care planned for having a contracture to his left hand and should have been. Interview also revealed Resident #27 was not care planned for assistive devices to prevent further progression of the left hand contracture and should have been.

Based on observation, interview and record review the facility failed to ensure that a resident's person-centered plan of care for use of a fall mat beside his bed was followed for 1 (#1) of 3 (#1, #2, and #3) sampled residents. The facility had a total census of 102 residents. Findings: Review of the medical record for Resident #1 revealed an admit date of 09/25/2023 with diagnoses that included in part .Type II Diabetes Mellitus, End Stage Renal Disease, Cerebral Infarction Unspecified, Dependence on Renal Dialysis, Cognitive Communication Deficit, Depression Unspecified, Dysphagia Unspecified, Open-Angle Glaucoma and Chronic Diastolic Heart Failure. Review of Resident #1's Significant Change MDS with an ARD of 12/27/2023 revealed a BIMS score of 9, which indicated mildly impaired cognition. The MDS revealed Resident #1 required substantial/maximal assistance with lying to sitting on bedside. Review of Resident #1's care plan with a target date of 03/01/2024 revealed in part .Resident #1 is at risk for falls related to impaired physical mobility and right sided weakness. Resident fell out of bed on 12/05/2023 with approaches that included fall mat to floor. Interview on 01/22/2024 at 9:40 a.m. with S5 LPN/Medical Records revealed Resident #1 had fallen a few weeks ago out of his bed and sustained a hematoma to the forehead and had went to the emergency room for treatment. Review of nurse's notes dated 12/05/2023 at 7:33 a.m. revealed in part .Resident was sitting on the side of the bed and slid onto the floor. Head to toe assessment performed. Contusion to right side of head. Notified doctor and ambulance service to transport to hospital. Review of nurse's notes dated 12/05/2023 at 2:13 p.m. revealed in part .Resident #1 returned to facility. Noted with hematoma to scalp. Review of a hospital note dated 12/05/2023 revealed in part .Resident #1 was treated for a scalp hematoma due to a fall. Observation on 01/22/2024 at 10:00 a.m. revealed Resident #1 was lying in bed. No fall mats were on the floor beside his bed. Observation and interview with S5 LPN Medical Records on 01/22/2024 at 12:00 p.m. revealed Resident #1 lying in bed, no fall mats were on the floor beside his bed. S5 LPN Medical Records confirmed Resident #1 should have had fall mats on the floor beside his bed and didn't.

Based on observation, record review and interview, the facility failed to ensure services were provided to meet professional standards of practice for 1 (#1) of 3 (Resident #1, Resident #2 and Resident #3) sampled Residents. The facility failed to ensure: 1. Physician's orders were followed for administering Peg-tube feedings for Resident #1; 2. Resident #1's enteral tube feeding container was labeled. Findings: Review of the facility's policy entitled Tube Feedings revealed in part . 1. All tube feedings will be administered in accordance with verified medical necessity, established infection control policies and procedures and physician's orders. 3. Physician's orders for tube feedings will include, tube type, tube size, kind of feeding, caloric value, volume, duration, mechanisms of administration and flushes. Procedures for administering tube feedings are in place and address: (e) Labeling of container. Review of the medical record for Resident #1 revealed an admit date of 09/25/2023 with diagnoses that included in part .Type II Diabetes Mellitus, End Stage Renal Disease, Cerebral Infarction Unspecified, Dependence on Renal Dialysis, Cognitive Communication Deficit, Depression Unspecified, Dysphagia Unspecified, Open-Angle Glaucoma and Chronic Diastolic Heart Failure. Review of Resident #1's Significant Change MDS with an ARD of 12/27/2023 revealed a BIMS score of 9, which indicated mildly impaired cognition. The MDS revealed Resident #1 was dependent for eating. Review of Resident #1's care plan with a target date of 03/01/2024 revealed in part .Resident receiving Nutren 2.0 at 40 ML/HR with approaches that included peg tube formula as ordered. Review of the physician's orders for Resident #1 revealed the following orders: 12/28/2023 order: Nutren 2.0 at 40cc/hour via pump continuously for 20 hours every Monday, Wednesday and Friday to provide 1600 kilocalories, 57 grams of protein, 1153 ML of free water and 1400cc of total fluid volume. Review of the physician's orders for Resident #1 revealed the following orders: 12/28/2023 order: Nutren 2.0 at 40cc/hour via pump continuously for 24 hours every Tuesday, Thursday, Saturday and Sunday to provide 1920 kilocalories, 80 grams of protein, 1264 ML of free water and 1560cc of total fluid volume. Observation on 01/22/2024 at 10:00 a.m. revealed Resident #1 was receiving an enteral peg tube feeding of Nutren 2.0 via pump at a rate of 50cc/hr. The bag of tube feeding formula of (Nutren 2.0) had not been labeled. Observation and interview on 01/22/2024 at 12:00 p.m. accompanied by S5 LPN/Medical Records revealed Resident #1's enteral peg tube feeding of Nutren 2.0 via pump was infusing at a rate of 50cc/hour and the bag of tube feeding formula (Nutren 2.0) had not been labeled. S5 LPN/ Medical Records confirmed Resident #1's tube feeding per peg should have been infusing at 40cc/hour not 50cc/hour and the bag of tube feeding formula (Nutren 2.0), should have been labeled with Resident #1's name, date, time, and infusion rate and it had not been.

Based on observation, interview and record review the facility failed to ensure each resident was treated with respect and dignity for 1 (#2) of 3 sampled residents (Resident #1, Resident #2 and Resident #3). The facility failed to ensure Resident #2 had proper footwear and adequate clothing. Findings: Review of the medical record for Resident #2 revealed an admit date of 07/26/2023, with diagnoses that included in part .End Stage Renal Disease, Anemia in Chronic Kidney Disease, Major Depressive Disorder, Age-related Physical Debility, Type II Diabetes Mellitus, Pain Unspecified and Repeated Falls. Review of Resident #2's Significant Change MDS with an ARD of 12/18/2023 revealed a BIMS score of 15, which indicated intact cognition. The MDS revealed Resident #2 required assistance with upper and lower body dressing. Review of Resident #2's care plan with a target date of 02/02/2024, revealed in part .resident needs assistance with ADL's: Extensive assist x 1 with transfers, dressing and toileting; limited assist with bed mobility and eating, with approaches that included therapy consult as needed, and give verbal cues as needed. Observation and interview on 01/23/2024 at 3:48 p.m. with Resident #2, revealed her sitting in a wheelchair with a blue t-shirt, a pink cotton zip up jacket, and a pair of blue jean capris on. Resident #2 also had on a pair of black fuzzy slippers (with the back out). Resident #2 revealed she came to the facility from the hospital and never got the chance to return home to retrieve any of her clothes/shoes, or other belongings. Resident #2 revealed she went to dialysis 3 days a week outside of the facility. Resident #2 stated she did not have any clothes, shoes or a coat to keep her warm. Observation of Resident #2's closet at that time revealed the following: 1 pair of black jeans, 1 pair of sweatpants, 1 sweatshirt, 1 short sleeved shirt, 1 blouse, 2 muumuu gowns, and 2 coats. Resident #2 stated the 2 coats were given to her by the social worker at the dialysis center, but both coats were too small for her. Observation of Resident #2's room revealed no shoes, other than the pair of black fuzzy slippers she had on her feet. Resident #2 stated the pink cotton zip up jacket she had been wearing was given to her by another resident's granddaughter. Resident #2 stated she told staff at the facility she was cold, and needed some winter clothes and shoes (could not recall the staff she told). Resident #2 stated she did not want anyone feeling sorry for her, but being without clothes and shoes made her feel small and worthless. Telephone interview on 01/23/24 at 4:02 p.m. with the dialysis center [NAME] Clerk revealed Resident #2 came to dialysis 3 x week on Monday, Wednesday and Friday, by the nursing home transportation. The Dialysis [NAME] Clerk stated Resident #2 came to dialysis inadequately dressed for cold winter weather; with capris and slippers on, without a coat. The Dialysis [NAME] Clerk stated the Social Worker at the dialysis center had given Resident #2 two coats. Interview on 01/23/2024 at 4:11 p.m. with S3 SSD revealed Resident #2 was admitted to the nursing home from the hospital, and did not have any personal belongings upon admission. S3 SSD stated Resident #2 was given clothes from the laundry room which had been donated but couldn't remember what clothing she gave. S3 SSD stated she had not done any shopping for Resident #2, and was unaware of Resident #2 not having adequate winter clothing or shoes to wear. Observation and interview on 01/23/2024 at 4:20 p.m. with S3 SSD in attendance revealed Resident #2's closet had the following: 1 pair of black jeans, 1 pair of sweatpants, 1 sweatshirt, 1 short sleeved shirt, 1 blouse, 2 muumuu gowns, and 2 coats. Resident #2 informed S3 SSD that the 2 coats were given to her by the social worker at the dialysis center, but both coats were too small for her. S3 SSD's observation of Resident #2's room revealed no shoes other than the pair of black fuzzy slippers she had on her feet. Resident #2 informed S3 SSD that the pink cotton zip up jacket she had been wearing was given to her by another resident's granddaughter. S3 SSD confirmed the above findings at the time of observation. Interview on 01/24/2024 at 8:30 a.m. with S7 LPN revealed she provided care for Resident #2. S7 LPN stated Resident #2 required assistance with bathing and dressing. S7 LPN stated she had not noticed what Resident #2 had been wearing to dialysis, or if she had shoes on. Interview on 01/24/2024 at 8:35 a.m. with S4 CNA revealed she assisted Resident #2 with bathing and dressing. S4 CNA stated she was aware of Resident #2 not having a coat or shoes. S4 CNA revealed on the days Resident #2 went to dialysis, she left the facility with a blanket around her. S4 CNA stated she never reported Resident #2's lack of clothing or shoes to anyone, because they already knew it. Telephone interview on 01/24/2024 at 9:13 with the Social Worker at the dialysis center revealed she called the nursing home in November 2023, and spoke with S8 Accounts Manager because Resident #2 needed winter clothes and shoes. The Social Worker at the dialysis center stated Resident #2 complained of being cold and she had given her 2 coats, which she later learned were too small for Resident #2. The Social Worker stated the dialysis center would have to give Resident #2 extra blankets when she arrived, and warm her chair because she would be so cold. Social Worker at dialysis stated Resident #2 wore capris with little black slippers in the winter to dialysis. Social Worker at dialysis stated Resident #2 had revealed to her she felt like she was forgotten about in the world. Interview on 01/24/24/2024 at 9:39 a.m. with S6 Transportation/CNA revealed he took Resident #2 to dialysis 3 x a week on Monday, Wednesday and Friday. S6 Transportation/CNA stated Resident #2 always had on socks with slippers (no shoes) and wore a zip up jacket (no coat). S6 transportation/CNA stated Resident #2 complained of being cold. Interview on 01/24/2024 at 9:47 a.m. with S9 Laundry Worker revealed she usually only washed muumuus, towels, socks and underwear for Resident #2. Interview on 01/24/2024 at 10:50 a.m. with S3 SSD confirmed there was no inventory list of Resident #2's belongings in her medical chart. Interview on 01/24/2024 at 11:00 a.m. with S2 DON revealed she was unaware of Resident #2 not having adequate winter clothing or shoes; or leaving the facility inadequately dressed for dialysis. S2 DON confirmed the following: Resident #2 would have had to choose from the selection of clothes she had in her closet, which did not include a coat or shoes; and all staff were responsible for checking residents before they left the facility.

Based on interview and record review, the facility failed to ensure that all staff are aware to report all alleged violations of mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property, for 1 (Resident #6) of 6 (#1, #2, #3, #4, #5, and #6) residents reviewed for abuse. The facility failed to ensure staff reported an incident of resident to resident abuse to facility management. Findings: A review of the facility's Policies and Procedures titled Incident Investigation and Reporting (LA Only) read in part . 3. In the event of any incident involving an allegation or suspicion of mistreatment, exploitation, neglect, abuse, misappropriation or other crime, as well as injuries of unknown origin, elopement, and/or adverse events, each occurrence will be reported immediately to the Administrator of the facility, who will immediately notify the Corporate Compliance Officer and Regional Supervisor. The Administrator will begin an investigation. Review of an incident report dated 09/03/2023 by S1 Administrator revealed she and S2 DON were notified of a physical altercation between Resident #1 and Resident #6. Resident #1 hit Resident #6 in the chest area three times. Resident #1 Review of Resident #1's medical record revealed an admit date of 08/03/2023, with diagnoses which included: Vascular Dementia with other behavioral disorders, Unspecified Dementia, Schizoaffective Disorder Bipolar type, Seizures, and Traumatic Brain Injury. Review of Resident #1's Discharge MDS with an ARD of 09/03/2023 revealed Resident #1 was unable to complete the Brief Interview for Mental Status. Resident #1 was coded as having Physical and Verbal behavioral symptoms directed toward others, Wandering, Rejection of care, and other behavioral symptoms not directed toward others. Resident #1 required limited assistance with bed mobility and transfer; extensive assistance with dressing, toilet use, and personal hygiene; and Supervision with eating. Review of Resident #1's Care Plan (no target/review date) revealed Resident #1 resided on the facility's Secure Unit due to wandering. Review of Progress notes revealed Resident #1 no longer resided at the facility. Resident #6 Review of Resident #6's medical record revealed an admit date of 02/07/2023, with diagnoses which included: Bipolar Disorder, Schizoaffective Disorder, Impulse Disorder Unspecified, Type II Diabetes Mellitus, Anxiety Disorder and Aphasia. Review of Resident #6's Quarterly MDS with an ARD of 08/09/2023 revealed resident had a BIMS score of 12 (indicating moderate cognitive impairment), and was coded as requiring limited assistance of one person for dressing, toilet use, personal hygiene and bathing; bed mobility and transfer- set up help only. Review of Resident #6's Care Plan with a review date of 05/14/2023, revealed resident resided on the secure unit due to Dementia, Bipolar, and Schizophrenia Disorder, with need for a calm environment. Approaches included observe resident for Anxiety/Agitation during crowded activities, high noise level, dining areas. Interview on 09/13/2023 at 8:54 a.m. with S6 CNA revealed she provided care for Resident #1 and Resident #6. S6 CNA stated around breakfast time on 09/02/2023, she witnessed Resident #1 hit Resident #6 in the chest area. S6 CNA stated Resident #1 and Resident #6 were immediately separated and the nurse (S4 LPN) was immediately notified. Observation and interview on 09/13/2023 at 9:00 a.m. with Resident #6 who resided on Hall X, revealed he was ambulatory in his room. Resident #6 stated on 09/02/2023, Resident #1 was attempting to enter a female resident's room across the hall from him. Resident #6 stated he told Resident #1 not to enter the female's room, and that's when Resident #1 hit Resident #6 in the face. Resident #6 stated he had an x-ray of his face done, and he did not see Resident #1 again after the altercation. Interview on 09/13/2023 at 9:12 a.m. with S2 DON revealed she was notified of the physical altercation between Resident #1 and Resident #6 on 09/03/2023 sometime after lunch. S2 DON stated she received a call from S9 LPN on 09/03/2023, and was informed that Resident #1 had hit Resident #6 in the face or chest. S2 DON stated Resident #6 informed S9 LPN on 09/03/2023, that Resident #1 hit him in the face on 09/02/2023. S2 DON stated she instructed S9 LPN to notify the physician and the responsible party of the physical altercation between Resident #1 and Resident #6. S2 DON stated she then notified S1 Administrator of the physical altercation between Resident #1 and Resident #6. S2 DON stated the physician ordered x-rays of Resident #6's face because Resident #6 stated that is where Resident #1 had hit him. Interview on 09/13/2023 at 10:13 a.m. with S1 Administrator revealed she was notified of the physical altercation between Resident #1 and Resident #6 by S2 DON on 09/03/2023 after 1:00 p.m., and then began her investigation and reporting of the incident. S1 Administrator confirmed S4 LPN should have immediately notified her on 09/02/2023 when the physical altercation between Resident #1 and Resident #6 occurred and she did not. Telephone interview on 09/13/2023 at 10:56 a.m. with S4 LPN revealed on the morning of 09/02/2023, S6 CNA notified her of a physical altercation on Hall X between Resident #1 and Resident #6. S4 LPN stated S6 CNA informed her Resident #1 had hit Resident #6. S4 LPN stated she went to Hall X, but the altercation was over, so she assessed Resident #1 and Resident #6 and found no injuries. S4 LPN stated she did not report the physical altercation to her immediate supervisor because she was not the scheduled nurse for Hall X, and she assumed the CNAs would tell the nurse who was scheduled for Hall X. S4 LPN confirmed she should have immediately reported the physical altercation between Resident #1 and Resident #6 to her immediate supervisor, and she did not. Interview with S2 DON on 09/14/2023 at 11:57 a.m. confirmed S4 LPN should have immediately reported the physical altercation between Resident #1 and Resident #6 on 09/02/2023 to her supervisor, and she did not. S2 DON stated all staff is responsible for immediately reporting abuse/suspected abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident's assessment accurately reflected the resident's status for 1 (#2) of 6 (#1, #2, #3, #4, #5, & #6) sampled residents. The facility failed to accurately assess Resident #2 for risk for elopement. Findings: Review of the facility's Elopement/Wandering-General Policy revealed in part . Elopement occurs when a resident who is incapable of adequately protecting themselves leaves the premises without necessary supervision to do so. All residents shall be observed and evaluated for demonstration of elopement risk by using Form NS-874-Admission/readmission Nurse Screening on admission/readmission and Form NS-712-Nurse Data Collection and Screening in the observation period of each MDS. a. After reviewing this key information, the nursing staff will determine if the resident is at risk for wandering/elopement. Review of the facility's smoking policy, revealed it was a general smoking policy for the facility, and did not address supervision of smokers who resided on Hall X. Review of Resident #2's medical record revealed he was admitted to the facility's locked unit on 06/02/2023 with diagnoses that included in part .Unspecified Dementia, Schizophrenia, Neurological Disorder with Lewy Bodies, and Alcohol Dependence. Review of Resident #2's Quarterly MDS with an ARD of 07/26/2023 revealed a BIMS score of 5, which indicated severely impaired cognition. Resident #2 required supervision with bed mobility, transferring, locomotion on the unit, and 1-person physical assist with bathing. Review of Resident #2's comprehensive plan of care with a target date of 12/07/2023, revealed Resident #2 was not identified as a wanderer or elopement risk prior to his elopement on 09/11/2023, despite being placed on Hall X upon admission to the facility, due to his wandering behaviors while living at home. Review of Resident #2's Nurse Data Collection and Screenings dated 06/02/2023, and reassessment screenings dated 07/26/2023 by S10 LPN, each read as follows: 1. Does the resident display cognitive deficits, disorientation, intermittent confusion, or any cognitive impairments that contribute to poor decision-making skills? Answer: Yes 2. Does the resident have a diagnosis that may increase the risk of elopement? Answer: Dementia and Schizophrenia. 3. Does the resident ambulate independently, with or without an assistive device? Answer: Yes 4. Does the resident have a history or currently experiencing any of the following? (Elopement while at home, leaving facility without supervision, leaving the facility without informing staff, verbally expressed desire to go home, wanders aimlessly - moves without purpose, may enter others rooms and explores others belongings, packed belongings to go home or stayed near exit door, recently admitted or readmitted (within 30 days) and not accepting the situation.) Answer: None of the above Has family communicated that the resident has eloped or attempted to elope from home, or shared concerns that the resident may have wandering/elopement tendencies? No Is the resident at risk for elopement? Answer: No Smoking Screen: Current Tobacco use? Answer: No Does resident smoke tobacco? Answer: No Did a complete drug regime review identify potential clinically significant medication issues? Answer: No issues were found during review. Review of Interdisciplinary Notes from an inpatient behavioral health hospital revealed in part .an admit date of 04/27/2023 and discharge date of 05/30/2023. Reason for admission/readmission revealed: Patient is a [AGE] year old with history of Dementia and psychotic disorder who resides at home with his family. Patient presented on a PEC from ER due to combative behavior. Reportedly he fights with family and sometimes he steals from them. He wanders off and almost got hit with a car three times in the last week. He goes out and tries to buy beer. He would get very angry when family tries to stop him from drinking. He stays up all night. He talks to himself. Discharge diagnoses were listed as: Dementia, Lewy body, Severe with Agitation, History of Schizophrenia, and Alcohol Use disorder, mild to moderate. In an interview on 09/13/2023 at 11:53 p.m., S10 LPN confirmed she completed Resident #2's initial assessment when he came into the facility on [DATE] and reassessed the resident on 07/26/2023. S10 LPN stated she didn't think Resident #2 was an elopement risk because he resided on Hall X, and was notified by Resident #2 that he did not smoke cigarettes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a plan of care for a resident who required supervision due to wandering/risk for elopement, and supervision during smoking for 1 (#2) of 6 (#1, #2, #3, #4, #5, and #6) sampled residents. Findings: Review of the facility's Elopement/Wandering-General Policy revealed in part . Elopement occurs when a resident who is incapable of adequately protecting themselves leaves the premises without necessary supervision to do so. All residents shall be observed and evaluated for demonstration of elopement risk by using Form NS-874-Admission/readmission Nurse Screening on admission/readmission and Form NS-712-Nurse Data Collection and Screening in the observation period of each MDS. a. after reviewing this key information, the nursing staff will determine if the resident is at risk for wandering/elopement. Review of the facility's smoking policy, revealed it was a general smoking policy for the facility, and did not address supervision of smokers who resided on Hall X. Review of Interdisciplinary Notes from an inpatient behavioral health hospital revealed in part .an admit date of 04/27/2023 and discharge date of 05/30/2023. Reason for admission/readmission revealed: Patient is a [AGE] year old with history of Dementia and psychotic disorder who resides at home with his family. Patient presented on a PEC from ER due to combative behavior. Reportedly he fights with family and sometimes he steals from them. He wanders off and almost got hit with a car three times in the last week. He goes out and tries to buy beer. He would get very angry when family tries to stop him from drinking. He stays up all night. He talks to himself. Discharge diagnoses were listed as: Dementia, Lewy body, Severe with Agitation, History of Schizophrenia, and Alcohol Use disorder, mild to moderate. Review of Resident #2's medical record revealed he was admitted to the facility's locked unit on 06/02/2023 with diagnoses that included in part .Unspecified Dementia, Schizophrenia, Neurological Disorder with Lewy Bodies, and Alcohol Dependence. Review of Resident #2's Nurse Data Collection and Screenings dated 06/02/2023, and reassessment screenings dated 07/26/2023 by S10 LPN, each read as follows: 1. Does the resident display cognitive deficits, disorientation, intermittent confusion, or any cognitive impairments that contribute to poor decision-making skills? Answer: Yes 2. Does the resident have a diagnosis that may increase the risk of elopement? Answer: Dementia and Schizophrenia. 3. Does the resident ambulate independently, with or without an assistive device? Answer: Yes 4. Does the resident have a history or currently experiencing any of the following? (Elopement while at home, leaving facility without supervision, leaving the facility without informing staff, verbally expressed desire to go home, wanders aimlessly - moves without purpose, may enter others rooms and explores others belongings, packed belongings to go home or stayed near exit door, recently admitted or readmitted (within 30 days) and not accepting the situation.) Answer: None of the above Has family communicated that the resident has eloped or attempted to elope from home, or shared concerns that the resident may have wandering/elopement tendencies? No Is the resident at risk for elopement? Answer: No Smoking Screen: Current Tobacco use? Answer: No Does resident smoke tobacco? Answer: No Did a complete drug regime review identify potential clinically significant medication issues? Answer: No issues were found during review. Review of Resident #2's Quarterly MDS with an ARD of 07/26/2023 revealed a BIMS score of 5, which indicated severely impaired cognition. Resident #2 required supervision with bed mobility, transferring, locomotion on the unit, and 1-person physical assist with bathing. Review of Resident #2's comprehensive plan of care with a target date of 12/07/2023, revealed a plan of care had not been developed that identified Resident #2 as a wanderer, or elopement risk prior to his elopement on 09/11/2023, despite being placed on Hall X upon admission to the facility, due to his wandering behaviors while living at home. In an interview on 09/12/2023 at 4:00 p.m., S1 Administrator stated on 09/11/2023, Resident #2 was brought outside to smoke by S8 CNA. S1 Administrator stated S8 CNA came back into the building leaving Resident #2 outside in the gated area unsupervised. S1 Administrator stated S8 CNA returned later to let Resident #2 back into the building and noticed he was missing. S1 Administrator stated she watched the facility's video surveillance footage which revealed Resident #2 stood on the seat of a bench in the courtyard area, put his foot on top of the fence, hopped over the fence, and exited the facility grounds. S1 Administrator stated the nurse was off of Hall X passing medications on another hall at the time of the elopement. S1 Administrator stated Resident #2 was found in the nearby department store parking lot by S7 CNA, and was walked back to the facility. S1 Administrator stated Resident #2 was assessed and was noted with a superficial wound to the palm of his hand from the wooden fence. S1 Administrator confirmed there should be two CNAs on Hall X at all times. S1 Administrator stated the second CNA scheduled to work Hall X at the time of the elopement, S5 CNA, was running late, but did not notify the ADON or S3 CNA Supervisor of her absence. In an interview on 09/12/2023 at 4:30 p.m., S5 CNA stated when a resident goes out to smoke, staff are to remain with the resident at all times. S5 CNA stated S8 CNA called her at 5:22 p.m. to notify her Resident #2 was missing from the facility while she was working on Hall X alone. Review of Resident #2's plan of care revealed there was no care plan for Resident #2 regarding supervision during smoking. A telephone call to S8 CNA was attempted on 09/12/2023 at 5:17 p.m., and 09/13/2023 at 12:35 p.m. In an interview on 09/13/2023 at 11:53 p.m., S10 LPN confirmed she completed Resident #2's initial assessment when he came into the facility on [DATE] and reassessed the resident on 07/26/2023. S10 LPN stated she didn't think Resident #2 was an elopement risk because he resided on Hall X.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure an allegation of abuse was reported within two hours after the allegation was made for 1 (#1) of 5 sampled residents (#1, #2, #3, #4, #5), and 5 random sampled residents (#R1, #R2, #R3, #R4, #R5) reviewed for abuse. Findings: Review of the facility's Incident Investigation and Reporting policy read in part Purpose: To provide guidance to the facility for investigation and reporting incidents of abuse, neglect, exploitation, misappropriation of property and/or other reportable incidents to LDH, Health Standards Section, local law enforcement, and other as required by state and federal requirements. To ensure reporting reasonable suspicion of crimes against a resident within prescribed timeframes. 1. Abuse, Neglect, Misappropriation of Resident Property and Exploitation are crimes and shall be reported to proper authorities as such. In the event of an incident involving allegation or suspicion of mistreatment, exploitation, neglect, abuse, misappropriation or other crimes, as well as injuries of unknown origin, elopement, and/or adverse events, each occurrence will be reported immediately to the Administrator of the facility, who will immediately notify the Corporate compliance Office and Regional Supervisor. The administrator shall report to the State Survey Agency and local law enforcement entities in which the facility is located, any allegation or reasonable suspicion of a crime against any resident. The administrator shall report not later than 2 hours after forming the suspicion, if the events that cause the suspicion involve abuse or result in serious bodily injury, or not later than 24 hours if the event that cause the suspicion do not involve abuse or result in serious body injury. A review of Resident #1's medical record revealed an admission date of 05/19/2023 with diagnoses that included: Coronary Artery Disease, Hypertension, Heart Failure, Renal Insufficiency, Diabetes Mellitus, Anxiety, Depression, Manic Depression, Bipolar, and Schizophrenia. A review of Resident #1's Quarterly MDS with an ARD of 05/19/2023 revealed a brief interview for mental status (BIMS) score of 15, which indicated Resident #1 was cognitively intact. Resident #1's functional status revealed she required limited one-person physical assistance with dressing, toilet use, personal hygiene and bathing. An interview in 06/21/2023 at 9:08 a.m. with Resident #1 revealed she was brought to the whirlpool for a bath on 05/26/2023. S5 CNA and S8 CNA were present in the whirlpool room at that time. Resident #1 stated that she could not reach to clean her back side, and asked S5 CNA to do it for her. Resident #1 stated S5 CNA stuck her finger in her rectum when she (S5 CNA) reached to clean her. Resident #1 stated she was upset and notified S4 LPN and S6 SSD of the incident after getting out of the whirlpool room. Resident #1 revealed that she was sent to an inpatient psychiatric facility per her request for medication compliance on 05/27/2023, where she notified staff at the inpatient facility of the incident that occurred on 05/26/2023 in the whirlpool while at the nursing facility. A telephone interview on 06/20/2023 at 10:00 a.m. with the Behavioral Hospital's Social Worker revealed that Resident #1 notified him and the charge nurse on 05/27/2023 of allegations of sexual abuse by a nursing facility CNA, when Resident #1 arrived to the inpatient facility. The Behavioral Hospital's Social Worker stated that Resident #1's story was consistent during her hospital stay, and that Resident #1 was discharged back to the SNF on 06/07/2023. A telephone interview on 06/26/2023 at 10:44 a.m. with the Behavioral Hospital's Psych RN revealed Resident #1 notified him and the hospital's Social Worker on admission to the hospital (05/27/2023), of a sexual abuse allegation that occurred at the nursing facility. The Psych RN stated that S10 admission Coordinator for the nursing facility, called the Behavioral hospital on [DATE] to check in on Resident #1, and he notified S10 admission Coordinator of Resident #1's allegation of sexual abuse that occurred at the nursing facility. The Psych RN stated S10 admission Coordinator told him she would contact S1 ADM because she (S10 admission Coordinator) was unaware of the allegation. The Psych RN stated that S1 ADM called him at 10:00 a.m. on 06/01/2023 about the incident, notifying him she was not aware of Resident #1's allegation, and wanted to know what the Behavioral Hospital's policy was regarding the matter. The Psych RN stated he thought the facility was aware because Resident #1 stated she notified the social worker at the nursing facility. A review of the Behavioral Hospital's Psych RN's Multi-Disciplinary Note dated 06/01/2023 read in part .at approximately 8:00 a.m., the Psych RN received a call from S10 admission Coordinator nurse to check on Resident #1. S10 admission Coordinator was informed of Resident #1's current condition, and was told that Resident #1 stated prior to being admitted to the behavioral facility, a nursing facility staff member allegedly stuck a finger in Resident #1's rectum. S10 admission Coordinator revealed she was not aware of the allegation and stated she would speak to S1 ADM. At approximately 10:00 a.m., the Psych RN received a call from S1 ADM who revealed that she was not aware of the incident that took place in the whirlpool with Resident #1, and asked what the Behavioral Hospital's policy was regarding incidents of this nature. An interview on 06/20/2023 at 3:43 p.m. with S10 admission Coordinator revealed she called the Behavioral hospital on [DATE] to get an update on Resident #1. S10 admission Coordinator revealed that hospital staff notified her that they were working on medication adjustments, and asked if she knew anything about an incident involving Resident #1 being touched inappropriately by staff members in the whirlpool. S10 admission Coordinator notified the inpatient staff that she was not aware, and would notify S1 ADM of the allegation. S10 admission Coordinator revealed that she immediately verbally notified S1 ADM of the telephone call she had with the Behavioral hospital, and Resident #1's allegations of sexual abuse. An interview on 06/20/2023 at 2:45 p.m. with S1 ADM revealed that she was unaware of any allegations of sexual abuse for Resident #1 during a whirlpool bath with staff. S1 ADM stated that she has not spoken to the Behavioral Hospital regarding Resident #1, or received a report from the Behavioral Hospital regarding the allegations. An interview on 06/20/2023 at 2:50 p.m. with S2 DON revealed that she was not aware of any allegations of abuse involving Resident #1 and staff during a whirlpool bath, and that no investigation was initiated. An interview on 06/21/2023 at 8:00 a.m. with S5 CNA revealed that on 05/26/2023, Resident #1 was upset and ready to take a bath, and she (S5 CNA) agreed to bring her to the whirlpool even though Resident #1 wasn't her assigned resident for that shift. S5 CNA stated S8 CNA was in the whirlpool room for assistance while S5 CNA gave Resident #1 a whirlpool bath. S5 CNA stated while giving Resident #1 a whirlpool, Resident #1 requested that she clean her backside. S5 CNA stated she notified Resident#1 that once she stood up, she would be able to clean her backside, then Resident #1 got upset and stated that S5 CNA didn't want to help her bathe. S5 CNA revealed that Resident #1 stood up and threw a washcloth at her. S5 CNA stated she tried to calmly talk to Resident #1, but Resident #1 then tried to walk out of the whirlpool room without clothes on. S5 CNA stated she was able to redirect Resident #1 to put her clothes on; however, Resident #1 denied help and left out of the whirlpool room. S5 CNA revealed Resident #1 stopped and told S4 LPN that S5 CNA did not want to help her bath, and was rude to her in the whirlpool. S5 CNA stated that she was never told that Resident #1 accused her of sticking her finger in her rectum at that time, only accusing her of being rude and not wanting to help her bathe. S5 CNA stated she was unaware of the date, but a few days after the incident S9 RN and S7 CNA Supervisor called her and S8 CNA into the office to write a statement about the incident that occurred in the whirlpool room. An interview on 06/20/2023 with S8 CNA revealed that she was in the whirlpool room to provide assistance at the time that S5 CNA was bathing Resident #1. S8 CNA stated that Resident #1 asked S5 CNA to wash her backside, and that S5 CNA stated she would once Resident #1 stood up. S8 CNA stated that Resident #1 then refused care and starting throwing things in the whirlpool room. S8 CNA stated that after Resident #1 was dressed, she saw her speaking to S6 SSD in her office. S8 CNA revealed she is unaware of the date, but S9 RN and S7 CNA Supervisor called her (S8 CNA) into their office, and notified her that the Behavioral Hospital notified the nursing facility that Resident #1 stated that S5 CNA touched her in an inappropriate manner in the whirlpool. S8 CNA stated she was told to write a statement about what occurred in the whirlpool on that day. S8 CNA stated she turned the written statement in to S9 RN. An interview on 06/20/2023 at 12:15 p.m. with S4 LPN revealed Resident #1 came to her upset because she was ready for a bath. S4 LPN revealed she asked S5 CNA to take her to the Whirlpool, and that a short time later Resident #1 came out of the whirlpool upset and stated S5 CNA did not bath her correctly, and stuck her finger in her rectum. S4 LPN stated that she notified another nurse, but could not recall who she notified. S4 LPN stated that she was informed by S5 CNA that she (S5 CNA) reported the incident to S6 SSD. An interview on 06/20/2023 at 10:25 a.m. with S6 SSD revealed Resident #1 did not notify her of an incident that occurred in the whirlpool with a staff member, and denied that any staff member informed her of the incident that occurred with Resident #1 in the whirlpool shower. An interview on 06/20/2023 at 11:33 am with S7 CNA Supervisor revealed she has never been notified by the resident or any staff member of an inappropriate incident that took place in the whirlpool room with Resident #1 and staff. An interview on 06/20/2023 at 2:35 p.m. with S9 RN revealed that on a date the she cannot recall, S8 CNA notified her that Resident #1 complained that staff was being rough with her during a whirlpool shower. S9 RN stated that she had S5 CNA and S8 CNA wrote a statement about the incident that occurred in the whirlpool, and that she then gave the statements to S1 ADM. S9 RN stated she was not aware of any sexual allegation with Resident #1 and staff members. An interview on 06/20/23 4:57 p.m. with S1 ADM revealed she denied ever being notified by S10 admission coordinator about a telephone call from the Behavioral Hospital regarding the abuse allegation for Resident #1, or that she talked to anyone at the Behavioral Hospital regarding the allegation. When asked the explanation of discrepancy, S1 ADM stated that she was floored, and did not understand how she was unaware of the situation. An interview on 06/21/2023 10:38 a.m. with S1 ADM revealed she did not open a SIMS after the incident occurred because she was not notified of the incident until 06/20/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have evidence that a suspicion of abuse was thoroughly investigated and failed to report the results of the investigation to the State Survey Agency within 5 working days of the incident for 1 (#1) of 5 sampled residents (#1, #2, #3, #4, #5), and 5 random sampled residents (#R1, #R2, #R3, #R4, #R5) reviewed for abuse. Findings: Review of the facility's Incident Investigation and Reporting policy read in part Purpose: To provide guidance to the facility for investigation and reporting incidents of abuse, neglect, exploitation, misappropriation of property and/or other reportable incidents to LDH, Health Standards Section, local law enforcement, and other as required by state and federal requirements. To ensure reporting reasonable suspicion of crimes against a resident within prescribed timeframes. 1. The facility will thoroughly investigate all alleged violations under the direct supervision of the administrator. The facility will take necessary steps to prevent occurrence and/or further potential abuse, neglect, exploitation or mistreatment while the investigations in progress. Any employee of the facility involved in incidents of abuse, neglect, misappropriation, and exploitation will be suspended pending investigation until such time as the facility investigation is complete. A review of Resident #1's medical record revealed an admission date of 05/19/2023 with diagnoses that included: Coronary Artery Disease, Hypertension, Heart Failure, Renal Insufficiency, Diabetes Mellitus, Anxiety, Depression, Manic Depression, Bipolar, and Schizophrenia. A review of Resident #1's Quarterly MDS with an ARD of 05/19/2023 revealed a brief interview for mental status (BIMS) score of 15, which indicated Resident #1 was cognitively intact. Resident #1's functional status revealed she required limited one-person physical assistance with dressing, toilet use, personal hygiene and bathing. An interview in 06/21/2023 at 9:08 a.m. with Resident #1 revealed she was brought to the whirlpool for a bath on 05/26/2023. S5 CNA and S8 CNA were present in the whirlpool room at that time. Resident #1 stated that she could not reach to clean her back side, and asked S5 CNA to do it for her. Resident #1 stated S5 CNA stuck her finger in her rectum when she (S5 CNA) reached to clean her. Resident #1 stated she was upset and notified S4 LPN and S6 SSD of the incident after getting out of the whirlpool room. Resident #1 revealed that she was sent to an inpatient psychiatric facility per her request for medication compliance on 05/27/2023, where she notified staff at the inpatient facility of the incident that occurred on 05/26/2023 in the whirlpool while at the nursing facility. A telephone interview on 06/26/2023 at 10:44 a.m. with the Behavioral Hospital's Psych RN revealed Resident #1 notified him and the hospital's Social Worker on admission to the hospital (05/27/2023), of a sexual abuse allegation that occurred at the nursing facility. The Psych RN stated that S10 admission Coordinator for the nursing facility, called the Behavioral hospital on [DATE] to check in on Resident #1, and he notified S10 admission Coordinator of Resident #1's allegation of sexual abuse that occurred at the nursing facility. The Psych RN stated S10 admission Coordinator told him she would contact S1 ADM because she (S10 admission Coordinator) was unaware of the allegation. The Psych RN stated that S1 ADM called him at 10:00 a.m. on 06/01/2023 about the incident, notifying him she was not aware of Resident #1's allegation, and wanted to know what the Behavioral Hospital's policy was regarding the matter. The Psych RN stated he thought the facility was aware because Resident #1 stated she notified the social worker at the nursing facility. A review of the Behavioral Hospital's Psych RN's Multi-Disciplinary Note dated 06/01/2023 read in part .at approximately 8:00 a.m., the Psych RN received a call from S10 admission Coordinator nurse to check on Resident #1. S10 admission Coordinator was informed of Resident #1's current condition, and was told that Resident #1 stated prior to being admitted to the behavioral facility, a nursing facility staff member allegedly stuck a finger in Resident #1's rectum. S10 admission Coordinator revealed she was not aware of the allegation and stated she would speak to S1 ADM. At approximately 10:00 a.m., the Psych RN received a call from S1 ADM who revealed that she was not aware of the incident that took place in the whirlpool with Resident #1, and asked what the Behavioral Hospital's policy was regarding incidents of this nature. An interview on 06/20/2023 at 3:43 p.m. with S10 admission Coordinator revealed she called the Behavioral hospital on [DATE] to get an update on Resident #1. S10 admission Coordinator revealed that hospital staff notified her that they were working on medication adjustments, and asked if she knew anything about an incident involving Resident #1 being touched inappropriately by staff members in the whirlpool. S10 admission Coordinator notified the inpatient staff that she was not aware, and would notify S1 ADM of the allegation. S10 admission Coordinator revealed that she immediately verbally notified S1 ADM of the telephone call she had with the Behavioral hospital, and Resident #1's allegations of sexual abuse. An interview on 06/20/2023 at 2:45 p.m. with S1 ADM revealed that she was unaware of any allegations of sexual abuse for Resident #1 during a whirlpool bath with staff. S1 ADM stated that she has not spoken to the Behavioral Hospital regarding Resident #1, or received a report from the Behavioral Hospital regarding the allegations. An interview on 06/20/2023 at 2:50 p.m. with S2 DON revealed that she was not aware of any allegations of abuse involving Resident #1 and staff during a whirlpool bath. An interview on 06/21/2023 at 8:00 a.m. with S5 CNA revealed that 05/26/2023, Resident #1 was upset and ready to take a bath, and she (S5 CNA) agreed to bring her to the whirlpool even though Resident #1 wasn't her assigned resident for that shift. S5 CNA stated S8 CNA was in the whirlpool room for assistance while S5 CNA gave Resident #1 a whirlpool bath. S5 CNA stated while giving Resident #1 a whirlpool, Resident #1 requested that she clean her backside. S5 CNA stated she notified Resident#1 that once she stood up, she would be able to clean her backside, then Resident #1 got upset and stated that S5 CNA didn't want to help her bathe. S5 CNA revealed that Resident #1 stood up and threw a washcloth at her. S5 CNA stated she tried to calmly talk to Resident #1, but Resident #1 then tried to walk out of the whirlpool room without clothes on. S5 CNA stated she was able to redirect Resident #1 to put her clothes on; however, Resident #1 denied help and left out of the whirlpool room. S5 CNA revealed Resident #1 stopped and told S4 LPN that S5 CNA did not want to help her bath, and was rude to her in the whirlpool. S5 CNA stated that she was never told that Resident #1 accused her of sticking her finger in her rectum at that time, only accusing her of being rude and not wanting to help her bathe. S5 CNA stated she did not remember the date, but a few days after the incident S9 RN and S7 CNA Supervision called her and S8 CNA into the office to write a statement about the incident that occurred in the whirlpool room. An interview on 06/20/2023 with S8 CNA revealed that she was in the whirlpool room to provide assistance at the time that S5 CNA was bathing Resident #1. S8 CNA stated that Resident #1 asked S5 CNA to wash her backside, and that S5 CNA stated she would once Resident #1 stood up. S8 CNA stated that Resident #1 then refused care and starting throwing things in the whirlpool room. S8 CNA stated that after Resident #1 was dressed, she saw her speaking to S6 SSD in her office. S8 CNA revealed she could not remember the date, S9 RN and S7 CNA Supervisor called her into their office, and notified her that the Behavioral Hospital notified the nursing facility that Resident #1 stated that S5 CNA touched her in an inappropriate manner in the whirlpool. S8 CNA stated she was told to write a statement about what occurred in the whirlpool on that day. S8 CNA stated she turned the written statement in to S9 RN. An interview on 06/20/2023 at 12:15 p.m. with S4 LPN revealed Resident #1 came to her upset because was ready for a bath. S4 LPN revealed she asked S5 CNA to take her to the Whirlpool, and that a short time later Resident #1 came out of the whirlpool upset and stated S5 CNA did not bath her correctly, and stuck her finger in her rectum. S4 LPN stated that she notified another nurse, but could not recall who she notified. S4 LPN stated that she was notified by S5 CNA that she (S5 CNA) reported the incident to S6 SSD. An interview on 06/20/2023 at 10:25 a.m. with S6 SSD revealed Resident #1 did not notify her of an incident that occurred in the whirlpool with a staff member, and denied that any staff member informed her of the incident that occurred with Resident #1 in the whirlpool. An interview on 06/20/2023 at 11:33 am with S7 CNA Supervisor revealed she has never been notified by the resident or any staff member of an inappropriate incident that took place in the whirlpool room with Resident #1 and staff. An interview on 06/20/2023 at 2:35 p.m. with S9 RN revealed that on a date that she could not recall, S8 CNA notified her that Resident #1 complained that staff was being rough with her during a whirlpool shower. S9 RN stated that she had S5 CNA and S8 CNA wrote a statement about the incident that occurred in the whirlpool, and that she then gave the statements to S1 ADM. S9 RN stated she was not aware of any sexual allegation with Resident #1 and staff members. An interview on 06/20/23 4:57 p.m. with S1 ADM revealed she denied ever being notified by S10 admission coordinator about a telephone call from the Behavioral Hospital regarding the abuse allegation for Resident #1, or that she talked to anyone at the Behavioral Hospital regarding the allegation. When asked the explanation of discrepancy, S1 ADM stated that she was floored, and did not understand how she was unaware of the situation. An interview on 06/21/2023 at 10:40 a.m. with S2 DON revealed she was unaware of any allegation with Resident #1; therefore, no investigation was initiated prior to 06/20/23 and that she never received any written statements from staff members pertaining to the abuse allegation. An interview on 06/21/2023 10:38 a.m. with S1 ADM revealed she did not receive any written statements from staff pertaining to an abuse allegation for Resident #1, speak to staff at the Behavioral Hospital about Resident #1's allegation and investigate or open a SIMS after the incident occurred because she was not notified of the incident until 06/20/23.

Based on observation, interview, and record review the Facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice for 1 (Resident #4) of 9 (Resident #1, Resident #2, Resident #3, Resident#4, Resident#5, Resident #R1, Resident #R2, Resident #R3, and Resident #R4) sampled Residents. The facility failed to notify the physician of a change in Resident #4's treatment plan. Findings: Review of the Facility's Policy and Procedure titled Change in Resident Medical Status read in part . A Facility must immediately inform the Resident; consult with the Resident's physician; and notify, consistent with his or her authority, the Resident representative (s), when there is- 3. A need to alter treatment significantly; (that is a need to discontinue or change an existing treatment due to adverse consequences, or to commence a new form of treatment). Review of the Facility's Policy and Procedure titled: Refusal of Treatment/Interventions read in part .1. The resident has the right to refuse and/or discontinue treatment including but not limited to medications, treatments, and other interventions. A resident's refusal shall be consistently documented in the resident's record. Refusals of treatment should also be countered by discussion with the resident of the health and safety consequences of the refusal and the availability of any therapeutic alternatives that might exist. Physician and Resident Representative must be notified. Review of Resident #4's medical record revealed an admit date of 05/20/2022 with the following diagnoses in part . Anxiety Disorder, Type 2 Diabetes Mellitus, Hypertension, Pain, Polyosteoarthritis, Unspecified Dementia without Behavioral Disturbance, and Insomnia. Review of the Annual MDS with an ARD of 05/04/2023 revealed Resident #4 had a BIMS score of 15, indicating intact cognition, Resident had score of 0 for behaviors and mood (indicating no symptoms present). Review of Resident #4's 06/2023 Physician Orders read in part . Paxil 10mg po daily. Order Start Date: 06/20/2023 Review of Resident #4's 06/2023 Electronic Medication Administration Record revealed Resident #4 did not receive the scheduled doses of Paxil as ordered, due to Resident #4 refusing the medication on the following dates: 06/27/2023, 06/26/2023, 06/22/2023, and 06/21/2023. Review of Resident #4's 06/2023 Departmental Notes read in part . 06/20/2023 2:25 p.m. Nurse and NP from Behavioral Center did telehealth appointment, and gave new order for Paxil 10mg po every day due to diagnoses of anxiety, decreased cognitive function, and major depressive disorder. Resident Representative notified. 06/22/2023 6:26 p.m. Nurse contacted Resident representative to make her aware the resident is refusing Paxil, and representative stated that's fine. Interview on 06/22/2023 at 8:15 a.m. with Resident #4 revealed she had concerns the facility had her complete a psychiatric evaluation on 06/20/2023, and the NP completing the evaluation prescribed her medication that she did not want to take. Resident #4 stated she had not been informed by the facility, or the NP, that he would prescribe a depression medication. Resident #4 stated she had informed the NP during the tele psych evaluation that she was not anxious or depressed, but stated the facility had reported those things to him. Resident #4 stated the nurses had informed her she could refuse taking the new prescription of Paxil 10mg, so she had refused to take it, and does not understand why nursing staff continues to try and administer the Paxil to her. Interview on 06/22/2023 at 12:30 p.m. with S2 DON revealed Resident #4 had psych evaluation completed on 06/20/2023 because Resident #4 had an increase in anxiety. S2 DON stated Resident #4 had went around the facility to brag that she (Resident #4) called state, and Resident #4 was worried about not getting her medicine on time. Interview on 06/26/2023 at 12:28 p.m. with the Behavioral Center's nurse whom assisted with completing the psych evaluation of Resident #4 on 06/20/2023 revealed the facility called on 06/20/2023 and asked the NP to complete a psych evaluation on Resident #4. The Behavioral Center's nurse stated the facility reported Resident #4 had an increase in anxiety and depression, and was worried about her peers not getting baths and medicines on time. The nurse stated she did not recall Resident #4 verbally stating she was depressed. The nurse stated Resident #4's daughter called and spoke with NP about the prescription for Paxil, and the NP informed Resident #4's daughter that he was okay with Resident #4 not continuing the Paxil. The nurse stated the facility had not contacted the NP to make him aware the Resident was refusing the Paxil. Interview on 06/27/2023 at 11:15 a.m. with Resident #4 revealed she did not want to take Paxil and had refused the doses. Resident #4 stated her daughter had spoken to the NP who prescribed Paxil, and he told her he was okay with her not taking the medication. S12 LPN presented to Resident #4's room at time of interview, and stated Resident #4 had been refusing to take Paxil, so she marked refused on EMAR. S12 LPN stated she should have notified Resident #4's NP of the refusals, but did not. Interview on 06/27/2023 at 11:45 a.m. with S2 DON revealed the facility's policy and procedure when a resident refuses medications is to contact the resident's physician and representative. S2 DON stated staff should have contacted the NP to have Resident #4's Paxil discontinued, but had not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to promptly notify the physician of abnormal Dilantin level lab results received for a resident diagnosed with Seizures for 1 resident (#R1) in a total sample of 9 (#1, #2, #3, #4, #5, #R1, #R2, #R3, #R4) residents Findings: Review of the facility's policy titled Laboratory Services read in part . The attending physician, physician assistant, nurse practitioner, or clinical nurse specialist will be notified of abnormal laboratory results promptly after the facility had been advised of the results. The notification of the physician will be documented in the medical record. Review of #R1's Electronic Medical Record revealed #R1 was admitted to the facility on [DATE], with diagnosis that included in part .Seizures. Review of #R1's 06/2023 Physician Orders revealed orders for Seizure Precautions, and CBC, BMP, and Dilantin level every 3 months (Aug, Nov, Feb, May). Review of #R1's medical record revealed a completed lab result sheet that revealed in part . a Dilantin level was drawn on 05/12/2023, with results dated 05/12/2023. The results revealed a Dilantin level of 3.6 L (Reference Range 10.00-20.00). The lab results sheet was signed by nursing on 05/12/2023, with documentation that it was faxed to the physician. The physician documented on the lab result sheet Repeat Dilantin Level Stat and No K+ Supplement. There was no date or time documented by the physician for the stat Dilantin order. Review of #R1's medical record revealed it did not contain lab results for the stat Dilantin level ordered by the physician. The next Dilantin level lab result was dated 06/20/2023 with a result of 5.2L. Interview on 06/21/2023 at 4:30 p.m. with S2 DON revealed #R1's medical record only contained results for Dilantin level's obtained on 05/12/2023 and 06/20/2023. S2 DON stated she would check to see if any other lab results were located elsewhere, as the results for the Repeat Dilantin Level Stat order from 05/19/2023 should be in #R1's medical record. Interview on 06/22/2023 at 08:50 a.m. with S2 DON revealed she located results for #R1's stat Dilantin level order. S2 DON stated the lab work collected on 05/12/2023 resulted in a low Dilantin level, and staff faxed the lab results to the physician. S2 DON stated the physician came to facility on 05/19/2023 and ordered no K+ supplements. S2 DON stated the physician came to facility on 05/29/2023 and ordered Repeat Dilantin Level Stat. S2 DON stated the physician did not date and time his orders, but should have. S2 DON stated on 05/29/2023, the Dilantin level was redrawn. S2 DON stated the physician came yesterday 06/21/2023 and reviewed the results from 05/29/2023, and ordered to increase #R1's Dilantin medication. Review of #R1's medical record with S2 DON on 06/22/2023 at 8:50 a.m. revealed the medical record contained lab results dated 05/29/2023. The lab results revealed Dilantin level was collected on 05/29/2023 at 2:20 p.m., and an abnormal result was reported to the facility by the lab on 05/29/2023 at 3:19 p.m. for Dilantin result of 5.5 L. Review of #R1's medical record revealed the facility did not contact the physician to inform him of the abnormal result. Review of the 05/29/2023 lab result sheet revealed the lab result sheet had a fax date and time of 06/21/2023 at 4:56 p.m. The lab result sheet had a physician's order dated 06/21/2023 that read, increase Dilantin to 200mg BID. The order was signed off by staff on 06/21/2023. Review of Electronic Medical Record revealed a progress note dated 06/21/2023 at 3:55 p.m. that read in part . new order for Dilantin 200mg bid due to abnormal labs. Telephone interview on 06/22/2023 at 11:45a.m. with #R1's physician revealed he was aware #R1 had routine lab work collected on 5/12/2023, which resulted in a low Dilantin level. The physician stated he ordered a stat Dilantin level on 05/29/2023, and confirmed the facility did not notify him of the abnormal Dilantin level result collected on 05/29/2023 until yesterday 06/21/2023. The physician stated he increased #R1's Dilantin medication on yesterday 06/21/2023. Interview on 06/22/2023 at 12:30p.m. with S2 DON revealed routine labs with abnormal findings, either high or low, are to be reported to the physician. S2 DON confirmed no one from the facility contacted the physician with #R1's abnormal Dilantin results collected on 05/29/2023, but should have prior to 06/21/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to provide care and services that meet professional standards of quality, by failing to administer medications at scheduled ordered times, and failing to monitor and provide oversight to prevent medication errors for 5 (#1, #2, #3, #4, #5) of 5 (#1, #2, #3, #4, #5) sampled residents, and 4 (#R1, #R2, #R3, #R4) of 4 (#R1, #R2, #R3, and #R4) random sampled residents; and failing to notify the physician as ordered for a blood glucose level of 401 to 999 (Resident #5). Findings: Review of the Facility policy titled Administration of Medications read in part . Drugs and biologicals are administered no more than one hour before or no more than one hour after the dosage time on the order. 3. Verify the physician's order, comparing the medication label to the MAR to verify the following: a. right medication b. right dosage c. right route d. right time e. right resident. Resident #2 Record Review revealed Resident #2 was admitted to the facility on [DATE], and had diagnoses that included in part . Diabetes Mellitus with Diabetic Chronic Kidney Disease, Major Depressive Disorder, General Anxiety Disorder, Congestive Heart Failure, and Pain. The medical record revealed Resident #2 was hospitalized from [DATE]-[DATE]. Review of Resident #2's Quarterly MDS with an ARD of 04/13/2023 revealed Resident had a BIMS of 15(cognitively intact). Resident #2 received the following medications: Insulin, Antipsychotic, Antianxiety, Antidepressant, Diuretic and Opioid. Review of Resident #2's 06/2023 EMAR revealed Resident #2 received the following scheduled medications: Ciprofloxacin (an antibiotic) 500mg by mouth twice a day, Buspirone (an anti-anxiety agent) 10mg by mouth three times a day, Escitalopram (an anti-depressant) 20mg by mouth daily, Lantus (Insulin) 20units subcutaneously every night, Amlodipine Besylate (an anti-hypertensive) 5mg by mouth daily, Xanax (an anti-anxiety agent) 0.5mg by mouth twice a day, Entresto (used to treat heart failure) 49mg-51mg tablet by mouth twice a day, Pentoxifylline ER (a vasodilator) 400mg by mouth three times a day, and Carvedilol (an anti-hypertensive) 25mg by mouth twice a day. Review of Resident #2's Order Administration History and EMAR for 06/2023 revealed the following medications were not administered at the ordered scheduled dose times: 1. Ciprofloxacin 500mg scheduled to be given at 9:00 a.m., and 9:00 p.m., was given on the following dates and times: 06/16/2023 - 9:00 a.m. dose given at 12:20 p.m. 06/15/2023 - 9:00 a.m. dose given at 10:13 a.m. 06/14/2023 - 9:00 a.m. dose given at 11:21 a.m. 06/13/2023 - 9:00 a.m. dose given at 10:03 a.m. 06/12/2023 - 9:00 a.m. dose given at 10:58 a.m. 06/10/2023 - 9:00 a.m. dose given at 11:29 a.m. 06/09/2023 - 9:00 p.m. dose given on 06/14/2023 at 2:09 a.m. 06/07/2023 - 9:00 a.m. dose given at 10:28 a.m. 06/07/2023 - 9:00 p.m. dose given on 06/8/2023 at 12:13 a.m. 06/06/2023 - 9:00 p.m. dose given on 06/07/2023 at 12:00 a.m. 2. Buspirone 10mg scheduled to be given at 9:00 a.m., 1:00 p.m., and 9:00p.m., was given on the following dates and times: 06/20/2023 - 9:00 a.m. dose given at 2:21 p.m., and 1:00 p.m. dose given at 3:19 p.m. 06/19/2023 - 9:00 a.m. dose given at 10:24 a.m. 06/18/2023 - 9:00 a.m. dose given at 11:40 a.m., and 1:00 p.m. dose given at 3:43 p.m. 06/17/2023 - 9:00 p.m. dose given at 10:56 p.m. 06/16/2023 - 9:00 a.m. dose given at 12:20 p.m., and 9:00 p.m. dose given on 06/17/2023 at 12:17 a.m. 06/15/2023 - 9:00 a.m. dose given at 10:13 a.m. 06/14/2023 - 9:00 a.m. dose given at 11:21 a.m. 06/13/2023 - 9:00 a.m. dose given at 10:03 a.m., and 1:00 p.m. dose given at 3:09 p.m. 06/12/2023 - 9:00 a.m. dose given at 10:58 a.m. 06/10/2023 - 9:00 a.m. dose given at 11:29 a.m. 06/09/2023 - 9:00 p.m. dose given at 06/14/2023 at 2:09 a.m. 06/07/2023 - 9:00 a.m. dose given at 10:28 a.m., 1:00 p.m. dose given at 4:00 p.m., and 9:00 p.m. dose given at 12:12 a.m. on 06/08/2023. 3. Escitalopram 20mg scheduled to be given at 9:00 a.m. was given on the following dates and times. 06/22/2023 - 9:00 a.m. dose given at 10:07 a.m. 06/20/2023 - 9:00 a.m. dose given at 2:21 p.m. 06/19/2023 - 9:00 a.m. dose given at 10:24 a.m. 06/18/2023 - 9:00 a.m. dose given at 11:40 a.m. 06/16/2023 - 9:00 a.m. dose given at 12:20 p.m. 06/15/2023 - 9:00 a.m. dose given at 10:43 a.m. 06/14/2023 - 9:00 a.m. dose given at 11:21 a.m. 06/13/2023 - 9:00 a.m. dose given at 10:03 a.m. 06/12/2023 - 9:00 a.m. dose given at 10:58 a.m. 06/10/2023 - 9:00 a.m. dose given at 11:29 a.m. 06/07/2023 - 9:00 a.m. dose given at 10:28 a.m. 4. Lantus 20units scheduled to be given at 9:00 p.m., was given on the following dates and times: 06/17/2023 - 9:00 p.m. dose given at 10:56 p.m. 06/16/2023 - 9:00 p.m. dose given at 12:17 a.m. on 06/17/2023. 06/10/2023 - 9:00 p.m. dose given at 9:36 a.m. on 06/12/2023. 06/09/2023 - 9:00 p.m. dose given at 2:09 a.m. on 06/14/2023. 06/07/2023 - 9:00 p.m. dose given at 12:13 a.m. on 06/8/2023. 5. Amlodipine Besylate 5mg scheduled to be given at 9:00 a.m., was given on the following dates and times: 06/22/2023 - 9:00 a.m. dose given at 10:07 a.m. 06/20/2023 - 9:00 a.m. dose given at 2:21 p.m. 06/19/2023 - 9:00 a.m. dose given at 10:24 a.m. 06/18/2023 - 9:00 a.m. dose given at 11:40 a.m. 06/16/2023 - 9:00 a.m. dose given at 12:20 a.m. 06/15/2023 - 9:00 a.m. dose given at 10:13 a.m. 06/14/2023 - 9:00 a.m. dose given at 11:21 a.m. 06/13/2023 - 9:00 a.m. dose given at 10:03 a.m. 06/12/2023 - 9:00 a.m. dose given at 10:58 a.m. 06/10/2023 - 9:00 a.m. dose given at 11:29 a.m. 06/07/2023 - 9:00 a.m. dose given at 10:28 a.m. 6. Xanax 0.5mg scheduled to be given at 8:00 a.m., and 8:00 p.m., was given on the following dates and times: 06/22/2023 - 8:00 a.m. dose given at 10:07 a.m. 06/21/2023 - 8:00 a.m. dose given at 9:57 a.m., and 8:00 p.m. dose given at 9:33 p.m. 06/20/2023 - 8:00 a.m. dose given at 2:21 p.m., and 8:00 p.m. dose given at 9:48 p.m. 06/19/2023 - 8:00 a.m. dose given at 10:24 a.m., and 8:00 p.m. dose given at 9:37 p.m. 06/18/2023 - 8:00 a.m. dose given at 11:40 a.m. 06/17/2023 - 8:00 p.m. dose given at 10:56 p.m. 06/16/2023 - 8:00 p.m. dose given at 12:17 a.m. on 06/17/2023 7. Entresto 49mg-51mg Scheduled to be given at 9:00 a.m., and 9:00 p.m., was given on the following dates and times: 06/22/2023 - 9:00 a.m. dose given at 10:07 a.m. 06/20/2023 - 9:00 a.m. dose given at 2:21 p.m. 06/19/2023 - 9:00 a.m. dose given at 10:24 a.m. 06/18/2023 - 9:00 a.m. dose given at 11:40 a.m. 06/17/2023 - 9:00 p.m. dose given at 10:56 p.m. 06/16/2023 - 9:00 a.m. dose given at 12:20 p.m., and 9:00 p.m. dose given at 12:17 a.m. on 06/17/2023. 06/15/2023 - 9:00 a.m. dose given at 10:13 a.m. 06/14/2023 - 9:00 a.m. dose given at 11:21 a.m. 06/13/2023 - 9:00 a.m. dose given at 10:03 a.m. 06/12/2023 - 9:00 a.m. dose given at 10:58 a.m. 06/10/2023 - 9:00 a.m. dose given at 11:29 a.m. 06/09/2023 - 9:00 p.m. dose given at 2:09 a.m. on 06/14/2023. 06/07/2023 - 9:00 a.m. dose given at 10:28 a.m., and 9:00 p.m. dose given at 12:13 a.m. on 06/08/2023. 8. Pentoxifylline ER 400mg scheduled to be given at 9:00 a.m. 1:00 p.m. and 9:00 p.m., was given on the following dates and times: 06/22/2023 - 9:00 a.m. dose given at 10:07 a.m. 06/20/2023 - 9:00 a.m. dose given at 2:21 p.m., and 1:00 p.m. dose given at 3:19 p.m. 06/19/2023 - 9:00 a.m. dose given at 10:24 a.m. 06/18/2023 - 9:00 a.m. dose given at 11:40 a.m., and 1:00 p.m. dose given at 3:34 p.m. 06/17/2023 - 9:00 p.m. dose given at 10:56 p.m. 06/16/2023 - 9:00 a.m. dose given at 12:20 p.m., and 9:00 p.m. dose given at 12:17 a.m. on 06/17/2023. 06/15/2023 - 9:00 a.m. dose given at 10:13 a.m. 06/14/2023 - 9:00 a.m. dose given at 11:21 a.m. 06/13/2023 - 9:00 a.m. dose given at 10:03 a.m., and 1:00 p.m. dose given at 3:09 p.m. 06/12/2023 - 9:00 a.m. dose given at 10:58 a.m. 06/10/2023 - 9:00 a.m. dose given at 11:29 a.m. 06/09/2023 - 9:00 p.m. dose given at 2:09 a.m. on 06/14/2023 06/07/2023 - 9:00 a.m. dose given at 10:28 a.m., 1:00 p.m. dose given at 4:00 p.m., and 9:00 p.m. dose given at 12:13 a.m. on 06/08/2023. 9. Carvedilol 25mg scheduled to be given at 9:00 a.m., and 5:00 p.m., was given on the following dates and times: 06/22/2023 - 9:00 a.m. dose given at 10:07 a.m. 06/20/2023 - 9:00 a.m. dose given at 2:21 p.m. 06/19/2023 - 9:00 a.m. dose given at 10:24 a.m. 06/18/2023 - 9:00 a.m. dose given at 11:40 a.m. 06/16/2023 - 9:00 a.m. dose given at 12:20 p.m., and 5:00 p.m. dose given at 6:35 p.m. 06/15/2023 - 9:00 a.m. dose given at 10:13 a.m. 06/14/2023 - 9:00 a.m. dose given at 11:21 a.m. 06/13/2023 - 9:00 a.m. dose given at 10:03 a.m. 06/12/2023 - 9:00 a.m. dose given at 10:58 a.m. 06/10/2023 - 9:00 a.m. dose given at 11:29 a.m. 06/08/2023 - 5:00 p.m. dose given at 6:18 p.m. 06/07/2023 - 9:00 a.m. dose given at 4:00 p.m. Interview and record review on 06/27/2023 at 12:15 p.m. with S2 DON revealed the following medications were reviewed for Resident #2: Carvedilol 25mg with scheduled administration times of 9:00 a.m. and 5:00 p.m.; Pentoxifylline ER 400mg with scheduled administration times of 9:00 a.m., 1:00p.m., and 9:00 p.m.; Entresto 49mg-51mg with scheduled administration times of 9:00 a.m. and 9:00 p.m.; Xanax 0.5mg with scheduled administration times of 8:00 a.m. and 8:00 p.m.; Amlodipine Besylate 5mg with scheduled administration time of 9:00 a.m.; Lantus 20units with scheduled administration time of 9:00 p.m.; Escitalopram 20mg with scheduled administration time of 9:00 a.m.; Buspirone 10mg with scheduled administration times of 9:00 a.m., 1:00 p.m., and 9:00 p.m.; and Ciprofloxacin 500mg with scheduled administration times of 9:00 a.m. and 9:00 p.m. S2 DON confirmed Resident #2's medications were not administered, and/or documented at the time the medications were scheduled to be administered according to the Resident's EMAR, but should have been. S2 DON stated that she believed staff administered medications late at times, and other times documented medications as administered at a later time; however, there was no monitoring or oversight by S2 DON or designee to ensure medications were given on time. Resident #4 Review of Resident #4's medical record revealed an admit date of 05/20/2022 with the following diagnoses in part . Anxiety Disorder, Type 2 Diabetes Mellitus, Hypertension, Pain, Polyosteoarthritis, Unspecified Dementia without Behavioral Disturbance, and Insomnia. Review of Resident #4's Annual MDS with an ARD of 05/04/2023 revealed Resident #4 had a BIMS score of 15 (cognitively intact). Resident #4 received insulin 7 out of 7 days, and an opioid 1 out of 7 days. Review of Resident #4's 06/2023 EMAR revealed Resident #4 received the following medications: Trazodone (anti-depressant/sedative) 50mg by mouth every night, Tresiba (insulin)10 units subcutaneously every morning, Amlodipine Besylate (anti-hypertensive) 5mg by mouth every night, and Hydralazine (anti-hypertensive) 50mg by mouth three times daily. Interview on 06/20/2023 at 5:30 p.m. with S4 LPN revealed the following process for administrating medications to residents: review the EMAR, pull medications from cart, push medications from blister pack into medicine cup, and click the medication as administered in the computer at the time medication is placed in medicine cup. S4 LPN stated she had to click administered for each medication, and then press the save and sign button in the computer. S4 LPN confirmed the administration times documented on Order Administration History report was the time medications were administered to Residents. S4 LPN stated she had 1 hour before, and 1 hour after the time on EMAR to administer medicine, and anything after that timeframe would be considered late. Review of Resident #4's Order Administration History and EMAR for 06/2023 revealed the following medications were not administered at the ordered scheduled dose times: 1. Trazodone 50mg scheduled to be given at 8:00 p.m., was given on the following dates and times: 06/21/2023 - 8:00 p.m. dose given at 9:22 p.m. 06/20/2023 - 8:00 p.m. dose given at 9:49 p.m. 06/19/2023 - 8:00 p.m. dose given at 9:38 p.m. 06/17/2023 - 8:00 p.m. dose given at 11:30 p.m. 06/16/2023 - 8:00 p.m. dose given at 12:18 a.m. on 06/17/2023 06/15/2023 - 8:00 p.m. dose given at 9:53 p.m. 06/12/2023 - 8:00 p.m. dose given at 10:00 p.m. 06/11/2023 - 8:00 p.m. dose given at 9:40 p.m. 06/09/2023 - 8:00 p.m. dose not given- no staff 06/08/2023 - 8:00 p.m. dose given at 9:50 p.m. 06/07/2023 - 8:00 p.m. dose given at 10:29 p.m. 06/06/2023 - 8:00 p.m. dose given at 11:41 p.m. 06/05/2023 - 8:00 p.m. dose given at 10:13 p.m. 06/04/2023 - 8:00 p.m. dose given at 1:00 a.m. on 06/05/2023 06/03/2023 - 8:00 p.m. dose given at 11:51 p.m. 06/02/2023 - 8:00 p.m. dose given at 10:06 p.m. 2. Tresiba 10units scheduled to be given at 9:00 a.m., was given on the following dates and times: 06/20/2023 - 9:00 a .m. dose given at 2:36 p.m. 06/18/2023 - 9:00 a.m. dose given at 11:23 a.m. 06/16/2023 - 9:00 a.m. dose given at 12:21 p.m. 06/15/2023 - 9:00 a.m. dose given at 10:09 a.m. 06/13/2023 - 9:00 a.m. dose given at 10:21 a.m. 06/12/2023 - 9:00 a.m. dose given at 11:21 a.m. 06/07/2023 - 9:00 a.m. dose given at 10:16 a.m. 06/03/2023 - 9:00 a.m. dose given at 10:12 a.m. 3. Amlodipine Besylate 5mg scheduled to be given at 8:00 p.m., was given on the following dates and times: 06/22/2023 - 8:00 p.m. dose given at 10:24 p.m. 06/21/2023 - 8:00 p.m. dose given at 9:22 p.m. 06/20/2023 - 8:00 p.m. dose given at 9:49 p.m. 06/19/2023 - 8:00 p.m. dose given at 9:38 p.m. 06/17/2023 - 8:00 p.m. dose given at 11:30 p.m. 06/16/2023 - 8:00 p.m. dose given at 12:18 a.m. on 06/17/2023 06/15/2023 - 8:00 p.m. dose given at 9:53 p.m. 06/12/2023 - 8:00 p.m. dose given at 10:00 p.m. 06/11/2023 - 8:00 p.m. dose given at 9:40 p.m. 06/09/2023 - 8:00 p.m. dose given-Not administered No staff 06/08/2023 - 8:00 p.m. dose given at 9:50 p.m. 06/07/2023 - 8:00 p.m. dose given at 10:29 p.m. 06/06/2023 - 8:00 p.m. dose given at 11:21 p.m. 06/05/2023 - 8:00 p.m. dose given at 10:13 p.m. 06/04/2023 - 8:00 p.m. dose given at 1:00 a.m. on 06/05/2023 06/03/2023 - 8:00 p.m. dose given at 11:51 p.m. 06/02/2023 - 8:00 p.m. dose given at 10:06 p.m. 06/01/2023 - 8:00 p.m. dose given at 9:47 p.m. 4. Hydralazine 50mg scheduled to be given at 6:00 a.m., 1:00 p.m., and 9:00 p.m., was given on the following dates and times: 06/22/2023 - 9:00 p.m. dose given at 10:24 p.m. 06/20/2023 - 1:00 p.m. dose given at 2:36 p.m. 06/17/2023 - 9:00 p.m. dose given at 11:30 p.m. 06/16/2023 - 9:00 p.m. dose given at 12:18 a.m. on 06/17/2023 06/15/2023 - 6:00 a.m. dose given at 8:05 a.m. 06/13/2023 - 1:00 p.m. dose given at 3:46 p.m. 06/12/2023 - 6:00 a.m. dose given at 9:53 a.m. 06/11/2023 - 6:00 a.m. dose given at 9:52 a.m. 06/09/2023 - 9:00 p.m. dose not given- No staff 06/07/2023 - 1:00 p.m. dose given at 3:50 p.m., and 9:00 p.m. dose given at 10:29 p.m. 06/06/2023 - 6:00 a.m. dose given at 7:25 a.m., and 9:00 p.m. dose given at 11:41 a.m. on 06/07/2023 06/05/2023 - 1:00 p.m. dose given at 2:13 p.m., and 9:00 p.m. dose given at 10:13 a.m. on 06/06/2023 06/04/2023 - 9:00 p.m. dose given at 1:00 a.m. on 06/05/2023. 06/03/2023 - 1:00 p.m. dose given at 2:05 p.m., and 9:00 p.m. dose given at 11:51 p.m. 06/02/2023 - 6:00 a.m. dose given at 2:01 a.m. on 06/04/2023, and 9:00 p.m. dose given at 10:06 p.m. 06/01/2023 - 1:00 p.m. dose given at 3:57 p.m. Interview and record review on 06/27/2023 at 11:45 a.m. with S2 DON revealed the following medications were reviewed for Resident #4: Hydralazine 50mg by mouth three times daily with scheduled administration times of 6:00 a.m., 1:00 p.m., and 9:00 p.m.; Amlodipine Besylate 5mg by mouth daily with scheduled administration time of 8:00 p.m.; Tresiba 10 units subq every morning with scheduled administration time of 9:00 a.m.; and Trazodone 50mg by mouth every night with scheduled administration time of 8:00 p.m. S2 DON confirmed Resident #4's medications were not administered, and/or documented at the time the medications were scheduled to be administered according to the Resident's EMAR, but should have been. S2 DON stated that she believed staff administered medications late at times, and other times documented medications as administered at a later time; however, there was no monitoring or oversight by S2 DON or designee to ensure medications were given on time. #R1 Record Review revealed Resident #R1 was admitted to facility on 07/30/2021 with diagnoses that included in part . Chronic Obstructive Pulmonary Disease, Seizures, Hypertension, Major Depressive Disorder and Dementia. Review of #R1's Annual MDS with ARD of 06/01/2023 revealed #R1 had a BIMS of 10 (indicating mild cognitive impairment). Review of #R1's 06/2023 EMAR revealed #R1 received the following scheduled significant medications: Dilantin (an anti-convulsant) 100 mg by mouth three times daily, Norvasc (anti-hypertensive) 10 mg by mouth daily, and Pentoxifylline ER (a vasodilator) 400 mg by mouth three times daily. Review of #R1's Order Administration History and EMAR for 06/2023 revealed the revealed the following medications were not administered at the ordered scheduled dose times: 1. Dilantin 100mg scheduled to be given at 8:00 a.m., 12:00 p.m., and 8:00 p.m., was given on the following dates and times: 06/21/2023 - 8:00 a.m. dose given at 10:27 a.m. 06/20/2023 - 8:00 a.m. dose given at 9:47 a.m., 12:00 p.m. dose given at 3:02 p.m., and 8:00 p.m. dose given at 9:46 p.m. 06/19/2023 - 8:00 a.m. dose given at 10:26 a.m. 06/18/2023 - 8:00 a.m. dose given at 11:25 a.m. 06/17/2023 - 8:00 p.m. dose given at 11:48 p.m. 06/16/2023 - 8:00 p.m. dose given at 12:12 a.m. on 06/17/2023 06/15/2023 - 8:00 a.m. dose given at 10:02 a.m., and 8:00 p.m. dose given at 9:45 p.m. 06/14/2023 - 8:00 a.m. dose given at 9:33 a.m., and 12:00 p.m. dose given at 1:20 p.m. 06/13/2023 - 8:00 a.m. dose given at 10:01 a.m., and 12:00 p.m. dose given at 3:18 p.m. 06/12/2023 - 8:00 a.m. dose given at 10:56 a.m., 12:00 p.m. dose given at 3:36 p.m., and 8:00 p.m. dose given at 9:55 p.m. 06/11/2023 - 8:00 a.m. dose given at 10:13 a.m., and 8:00 p.m. dose given at 10:05 p.m. 06/10/2023 - 8:00 a.m. dose given at 12:00 p.m. 06/09/2023 - 8:00 a.m. dose given at 9:28 a.m., and 8:00 p.m. dose given at 2:05 a.m. on 06/14/2023. 06/08/2023 - 8:00 a.m. dose given at 9:54 a.m. 12:00 p.m. dose given at 1:36p.m, and 8:00 p.m. dose given at 9:53 p.m. 06/07/2023 - 8:00 a.m. dose given at 10:56 a.m. 06/06/2023 - 8:00 a.m. dose given at 9:22 a.m., and 8:00 p.m. dose given at 11:52 p.m. 06/05/2023 - 8:00 p.m. dose given at 9:32 p.m. 06/04/2023 - 8:00 a.m. dose given 10:13 a.m., and 8:00 p.m. dose given at 9:56 p.m. 06/03/2023 - 12:00 p.m. dose given at 2:31 p.m., and 8:00 p.m. dose given at 12:27 a.m. on 06/04/2023. 06/02/2023 - 8:00 a.m. dose given at 9:38 a.m., and 12:00 p.m. dose given at 2:08 p.m. 2. Norvasc 10mg scheduled to be given at 8:00 a.m., was given on the following dates and times: 06/23/2023 - 8:00 a.m. dose given at 10:31 a.m. 06/22/2023 - 8:00 a.m. dose given at 9:32 a.m. 06/21/2023 - 8:00 a.m. dose given at 10:27 a.m. 06/20/2023 - 8:00 a.m. dose given at 9:47 a.m. 06/19/2023 - 8:00 a.m. dose given at 10:26 a.m. 06/18/2023 - 8:00 a.m. dose given at 11:25 a.m. 06/14/2023 - 8:00 a.m. dose given at 9:33 a.m. 06/13/2023 - 8:00 a.m. dose given at 10:01 a.m. 06/12/2023 - 8:00 a.m. dose given at 10:56 a.m. 06/11/2023 - 8:00 a.m. dose given at 10:13 a.m. 06/10/2023 - 8:00 a.m. dose given at 12:00 p.m. 06/09/2023 - 8:00 a.m. dose given at 9:28 a.m. 06/08/2023 - 8:00 a.m. dose given at 9:54 a.m. 06/07/2023 - 8:00 a.m. dose given at 10:56 a.m. 06/06/2023 - 8:00 a.m. dose given at 9:22 a.m. 06/04/2023 - 8:00 a.m. dose given at 10:13 a.m. 06/03/2023 - 8:00 a.m. dose given at 2:31 p.m. 06/02/2023 - 8:00 a.m. dose given at 9:38 a.m. 3. Pentoxifylline ER 400mg scheduled to be given at 9:00 a.m., 1:00 p.m., and 9:00 p.m., was given on the following dates and times: 06/21/2023 - 9:00 a.m. dose given at 10:27 a.m., and 9:00 p.m. dose given at 10:22 p.m. 06/20/2023 - 1:00 p.m. dose given at 3:02 p.m. 06/19/2023 - 9:00 a.m. dose given at 10:26 a.m. 06/18/2023 - 9:00 a.m. dose given at 11:25 a.m., and 1:00 p.m. dose given at 3:47 p.m. 06/17/2023 - 9:00 p.m. dose given at 11:48 p.m. 06/16/2023 - 9:00 a.m. dose given at 12:18 p.m., and 9:00 p.m. dose given at 12:12 a.m. on 06/17/2023. 06/15/2023 - 9:00 a.m. dose given at 10:02 a.m. 06/13/2023 - 9:00 a.m. dose given at 10:01 a.m., and 1:00 p.m. dose given at 3:18 p.m. 06/12/2023 - 9:00 a.m. dose given at 10:56 a.m., and 1:00 p.m. dose given at 3:36 p.m. 06/11/2023 - 9:00 a.m. dose given at 10:13 a.m., and 9:00 p.m. dose given at 10:05 p.m. 06/10/2023 - 9:00 a.m. dose given at 12:00 p.m. 06/09/2023 - 9:00 p.m. dose given at 10:05 p.m. 06/07/2023 - 9:00 a.m. dose given at 10:56 a.m., and 1:00 p.m. dose given at 4:09 p.m. 06/06/2023 - 9:00 p.m. dose given at 11:52 p.m. 06/04/2023 - 9:00 a.m. dose given at 10:13 a.m. 06/03/2023 - 1:00 p.m. dose given at 2:31 p.m., and 9:00 p.m. dose given at 12:27 a.m. on 06/04/2023. 06/02/2023 - 1:00 p.m. dose given at 2:08 p.m. Interview on 06/27/2023 at 12:00 p.m. with S2 DON revealed the following medications were reviewed for Resident #R1: Pentoxifylline ER 400 mg by mouth three times daily with scheduled administration times of 9:00 a.m., 1:00 p.m., and 9:00 p.m.; Norvasc 10 mg by mouth daily with scheduled administration time of 8:00 a.m.; and Dilantin 100 mg by mouth three times daily with scheduled administration times of 8:00 a.m., 12:00 p.m., and 8:00 p.m. S2 DON confirmed Resident #R1's medications were not administered, and/or documented at the time the medications were scheduled to be administered according to the Resident's EMAR, but should have been. S2 DON stated that she believed staff administered medications late at times, and other times documented medications as administered at a later time; however, there was no monitoring or oversight by S2 DON or designee to ensure medications were given on time. Resident #1 A review of Resident #1's medical record revealed a readmission date of 05/12/2023 with diagnoses that included: Coronary Artery Disease, Hypertension, Heart Failure, Renal Insufficiency, Diabetes Mellitus, Anxiety, Depression, Manic Depression, Bipolar, and Schizophrenia. A review of Resident #1's Quarterly MDS with ARD of 05/19/2023 revealed a brief interview for mental status (BIMS) score of 15, which indicated Resident #1 was cognitively intact. Resident #1's functional status revealed she required limited one-person physical assistance with dressing, toilet use, personal hygiene and bathing. Review of Resident #1's Order Administration History for 06/2023 revealed the following medications were not administered at the ordered scheduled dose times: 1. Amitriptyline HCL (an anti-depressant) 25mg tab one tab po 4 times a day at 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m. 06/09/2023 - 8:00 p.m. dose was documented given on 06/12/2023 at 5:00 a.m. 06/12/2023 - 8:00 p.m. dose was documented given at 9:57 p.m. 2. Amlodipine (an anti-hypertensive) 10mg give 1 tab po daily at 8:00 a.m. 06/13/2023 - 8:00 a.m. dose was documented given on 06/14/2023 at 2:14 a.m. 06/14/2023-8:00 a.m. dose was documented given at 10:41 am 3. Atoravastatin (used to lower cholesterol) 20 mg give 1 tab po at bedtime (8:00 p.m.). 06/07/2023 - 8:00 p.m. dose was given on 06/8/2023 at 12:00 a.m. 06/08/2023 - 8:00 p.m. dose was given at 9:55 p.m. 06/09/2023 - 8:00 p.m. dose was given on 06/12/2023 at 5:00 a.m. 06/11/2023 - 8:00 p.m. dose was given at 10:42 p.m. 06/12/2023 - 8:00 p.m. dose was given at 9:57 p.m. 4. Chlorpromazine (an anti-psychotic) 25mg tablet one po QID at 5:00 a.m., 11:00 a.m., 4:00 p.m. and 9:00 p.m. 06/09/2023 - 5:00 a.m. dose was given at 7:07 a.m. 06/13/2023 - 5:00 a.m. dose was documented given on 06/14/2023 at 2:14 a.m. 06/08/2023 - 11:00 a.m. dose was documented given at 1:35 p.m. 06/12/2023 - 4:00 p.m. dose was documented given at 5:53 p.m. 06/07/2023 - 8:00 p.m. dose was documented given on 06/08/2023 at 12:00 a.m. 06/08/2023 - 8:00 p.m. dose was documented given at 9:55 p.m. 06/09/2023 - 8:00 p.m. dose was documented given on 06/12/2023 at 5:00 a.m. 06/11/2023 - 8:00 p.m. dose was documented given at 10:42 p.m. 06/12/2023 - 8:00 p.m. dose was documented given at 9:57 p.m. 5. Hydrocodone Acetaminophen (a narcotic used for pain) 7.5-325 on tab po QID at 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. 06/11/2023 - 12:00 a.m. dose was documented given at 5:11 a.m. 06/12/2023 - 12:00 a.m. dose was documented given at 5:10 a.m. 06/13/2023 - 12:00 a.m. dose was documented given at 3:27 a.m. 06/13/2023 - 6:00 a.m. dose was documented given on 06/14/2023 at 2:14 a.m. 06/13/2023 - 12:00 p.m. dose was documented given at 3:31 p.m. 6. Isosorbide 10 mg give 1 tab po twice daily at 8:00 a.m. and 8:00 p.m. 06/13/2023 - 8:00 a.m. dose was documented given on 6/14/2023 at 2:14 a.m. 06/14/2023 - 8:00 a.m. dose was documented given on 6/14/2023 at 10:41 a.m. 7. Losartan (an anti-hypertensive) 50 mg give 1 tab po daily at 8:00 a.m. 06/13/2023 - 8:00 a.m. dose was documented given on 6/14/2023 at 2:14 a.m. 06/14/2023 - 8:00 a.m. dose was documented given at 10:41 a.m. 8. Metformin (an anti-diabetic) 500mg give one po daily at 8:00 a.m. 06/13/2023 - 8:00 a.m dose was documented given on 6/14/2023 at 2:14 a.m. 9. Potassium CL ER (mineral supplement) 20 MEQ give 1 tab po daily at 8:00 a.m. 06/13/2023 - 8:00 a.m. dose was documented given on 6/14/2023 at 2:14 a.m. 06/14/2023 - 8:00 a.m. dose was documented given at 10:41 a.m. 10. Toprol XL (anti-hypertensive) 100 mg give 1 tab po daily at 8:00 a.m. 06/13/2023 - 8:00 a.m. dose was documented given on 6/14/2023 at 2:14 a.m. 06/14/2023 - 8:00 a.m. dose was documented given at 10:41 a.m. 11. Trileptal (an anti-convulsant) 150 mg give 1 tab po BID at 9:00 a.m. and 9:00 p.m. 06/07/2023 - 9:00 p.m. dose documented given on 6/8/23 at 12:00 a.m. 06/09/2023 - 9:00 p.m. dose documented given on 6/12/2023 at 5:00 a.m. 06/13/2023 - 9:00 a.m. dose was documented given on 6/14/2023 at 2:14 a.m. 06/14/2023 - 9:00 a.m. dose was documented given at 10:41 a.m. An interview on 06/27/2023 at 9:30 a.m. with S2 DON confirmed that the medications Amitriptyline, Amlodipine, Atorvastatin, Chlorpromazine, Hydrocodone, Isosorbide, Losartan, Metformin, Potassium CL, Toprol XL, and Trileptal and the times listed above, were documented as given late, and they should not have been. Resident #3 A review of Resident #3's medical record revealed an admission date of 12/16/2022 with diagnoses that included: Chronic Obstructive Pulmonary Disease, Unspecified Atrial Fibrillation, Acute and Chronic Respiratory Failure with Hypoxia, Essential Hypertension, Anxiety Disorder, Major Depressive Disorder, and Heart Failure. A review of the Quarterly MDS with ARD of 04/04/2023 revealed a brief interview for mental status (BIMS) score of 15, which indicated the Resident #3 was cognitively intact. Resident #3's functional status revealed she required two-person physical assistance with dressing, toilet use, and bed mobility and one-person assist with personal hygiene and bathing. Review of Order Administration History for 06/2023 revealed the following medications were not administered at the ordered scheduled dose times: 1. Cefdinir (an antibiotic) 300mg po q 12 hours at 9:00 a.m. and 9:00 p.m. 06/07/2023 - 8:00 a.m. dose documented given at 11:07 a.m. 06/07/2023 - 9:00 p.m. - dose documented given on 06/8/23 12:26 a.m. 06/09/2023 - 9:00 p.m. - dose documented as given on 06/12/23 at 5:22 a.m. 2. Buspirone HCL (an anti-anxiety agent) 5mg tab give one tab po TID at 9:00 a.m., 1:00 p.m. and 9:00 p.m. 06/02/2023 - 9:00 a.m. dose documented given at 11:36 a.m. 06/03/2023 - 9:00 a.m. dose documented given 10:43 a.m. 06/03/2023 - 1:00 p.m. dose documented given 2:21 p.m. 06/03/2023 - 9:00 p.m. dose documented given on 06/04/2023 at 12:14 a.m. 06/06/2023 - 9:00 p.m. dose documented given on 06/07/2023 at 12:54 a.m. 06/07/2023 - 9:00 a.m. dose documented given at 11:07 a.m. 06/07/2023 - 1:00 p.m. dose documented given 4:12 p.m. 06/08/2023 - 9:00 p.m. dose documented given om 06/09/2023 at 12:26 a.m. 06/09/2023 - 9:00 p.m. dose documented given on 06/12/2023 at 5:22 a.m. 06/12/2023 - 9:00 a.m. dose documented given at 11:04 a.m. 06/13/2023 - 9:00 a.m. dose documented given at 3:28 p.m. 06/16/2023 - 9:00 a.m. dose documented given at 12:13 p.m. 06/17/2023 - 9:00 p.m. dose documented given on 06/18/2023 at 12:26 a.m. 06/18/2023 - 9:00 a.m. dose documented given 11:41 a.m. 06/18/2023 - 1:00 p.m. dose documented give 3:45 p.m. 06/20/2023 - 9:00 a.m. dose documented give at 2:40 p.m. 06/20/2023 - 1:00 p.m. dose documented given at 3:36 p.m. 06/22/2023 - 1:00 p.m. dose documented given at 3:31 p.m. 06/23/2023 - 9:00 p.m. dose documented given at 10:53 p.m. 06/24/2023 - 9:00 a.m. dose documented given at 11:31 a.m. 3. Cymbalta (an anti-depressant) 60mg give 1 cap po at bedtime at 9:00 p.m. 06/03/2023 - 9:00 p.m. dose documented on 06/04/2023 12:14 a.m. 06/06/2023 - dose documented given 06/07/2023 12:54 a.m. 06/07/2023 - dose documented given 06/08/2023 at 12:26 a.m. 06/09/2023 - 9:00 p.m. dose documented give on 06/12/2023 at 5:22 a.m. 06/17/2023 - 9:00 p.m. dose documented given on 6/18/2023 at 12:26 a.m. 4. Metoprolol (anti-hypertensive) 25mg give ½ tab to equal 12.5mg po BID at 9:00 a.m. and 9:00 p.m. 06/01/2023 - 9:00 a.m. dose documented given at 11:39 a.m. 06/02/2023 - 9:00 a.m. dose documented given 11:36 p.m. 06/03/2023 - 9:00 p.m. dose documented given on 06/04/23 at 12:14 a.m. 06/06/2023 - 9:00 p.m. dose documented given on 06/07/23 at 12:54 a.m. 06/07/2023 - 9:00 a.m. dose documented given at 11:07 a.m. 06/07/2023 - 9:00 p.m. dose documented given on 06/08/23 12:26 a.m. 06/09/2023 - 9:00 p.m. dose documented given on 6/14/23 at 2:11 a.m. 06/14/2023 - 9:00 a.m. dose documented given at 10:21 a.m. 06/15/2023 - 9:00 a.m. dose documented given at 10:14 a.m. 06/16/2023 - 9:00 a.m. dose documented given at 12:13 p.m. 06/16/2023 - 9:00 p.m. dose documented given on 06/17/23 at 12:26 a.m. 06/17/2023 - 9:00 p.m. dose documented given at 11:07 p.m. 06/18/2033 - 9:00 a.m. dose documented given at 11:41 a.m. 06/20/2023 - 9:00 a.m. dose documented given at 2:40 p.m. 06/23/2023 - 9:00 p.m. dose documented given at 11:39 pXXX

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to have an effective system in place to provide routine drugs and biologicals to its resident, by not having procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs to meet the needs of 2 (#R2 and #R4) of 4 random sampled residents (#R1, #R2, #R3, and #R4) in a total sample of 9 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, #R1, #R2, #R3, and #R4). Findings: Review of the facility's policy title Administration of Medications revealed in part .Purpose - To administer medications in accordance with best practice. #R2 Review of #R2's EHR revealed he was re-admitted to the facility on [DATE], and re-admitted on [DATE] diagnoses that included: Anemia, COPD, Type 2 DM, Morbid (severe) obesity, and PVD. Review of #R2's Quarterly MDS with ARD of 04/06/2023 revealed #R2 had a BIMS of 14 (cognitively intact). #R2 required two person physical assist with bed mobility, transfers, dressing, eating, personal hygiene, toilet use, and bathing. #R2 received the following medications for 7 or more days: antipsychotic, antianxiety, antidepressant, anticoagulation. Observation of R#2's medication administration on 06/20/2023 at approximately 12:56 p.m. by S3 LPN revealed the resident's 9:00 a.m. medications were being administered at this time. Observation on 06/20/2023 at 12:56 p.m. revealed S3 LPN removed several blister packs from the 3rd drawer of the medication cart. All blister packs were noted to have 9A (9:00 a.m.)in the upper left corner. S3 LPN compared the blister packs to the EMAR, and stated to the surveyor, Oh I don't have his Lasix, and Potassium. I will have to go to the medication room and get the medications. S3 LPN returned at 1:07 p.m. without the Lasix & Potassium blister packets. Review of the #R2's 06/2023 E-MARS revealed Lasix 40 mg po and Potassium CL ER 20 MEQ was documented as not being available. Interview on 06/2023 at 1:18 p.m. with S3 LPN revealed that #R2 had no Lasix and/or Potassium available for administration, and would have to be reordered from the pharmacy. S3 LPN confirmed #R2's Lasix 40 mg po and Potassium CL ER 20 MEQ po were not administered because they were not available. #R4 Review of #R4's EHR revealed she was admitted to the facility on [DATE], with admitting diagnoses that included: Fibromyalgia, Essential (Primary) HTN, Delusion disorder, and Dementia. Review of #R4's Quarterly MDS with an ARD of 06/06/2023 revealed #R4 had a BIMS of 03 (severely cognitively impaired), and required extensive physical assistance with bed mobility, transfer, and ADLs. An interview was conducted on 06/20/2023 at 1:37 p.m. with S3 LPN to verify if any additional resident(s) medication(s) were not available for administration today. S3 LPN stated that #R4's Lisinopril 10 mg po was not available. S3 LPN confirmed that #R4's Lisinopril was ordered daily at 9:00 a.m. and was not available for administration. Review of the E-MAR for #R4 revealed the following: 06/18/2023 at 8:49 a.m. - Lisinopril 10 mg po daily - med unavailable. 06/20/2023 at 9:32 a.m. - Lisinopril 10 mg po daily - documented currently not available. 06/16/2023 at 9:00 a.m. - Metformin 500 mg po bid - documented not available at this time. 06/18/2023 at 9:00 a.m. - Metformin 500 mg po bid - documented not available at this time. Interview on 06/27/2023 at 4:47 p.m. with S2 DON confirmed that medications were not available for medication administration at the scheduled times. S2 DON stated S3 LPN could have called the Pharmacy for renewal. S2 DON stated that refills are to be checked on the night shift; however, it's everyone's responsibility. S2 DON stated that Medications are to be reordered when there is a 10 day supply left. Telephone interview on 06/27/2023 at 5:15 p.m. with a pharmacist at the contracted Pharmacy revealed the pharmacy just implemented a new refill system in order to prevent medications from not being available and/or missed being refilled. The Pharmacist stated on each blister pack, there is a sticker which indicates and alerts the nurses to pull the sticker for refills when there is a 10 day supply left. The Pharmacist stated orders for medications if faxed before 6:30 p.m. will be delivered on the same day. The Pharmacist stated #R2's Lasix 40 mg po was submitted for refill on 06/20/2023, and delivered that afternoon. The Pharmacist stated the following information for #R4's recent refill record: 1. Lisinopril 10 mg po refilled on 05/26/2023 - 14 day supply (until 06/13/2023). Lisinopril was last refilled and delivered to the facility on the evening of 06/21/2023. 2. Metformin 500 mg po refilled on 05/29/2023 -14 day supply (06/13/2023). Metformin was last refilled and delivered to the facility on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that each Resident was treated with respect and dignity and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (#88) out of a total of 45 sampled Residents, by failing to ensure she was free of facial hair. Findings: Review of Resident #88's medical record revealed she was admitted to the facility on [DATE] with diagnoses which included: Chronic Kidney Disease Stage 3, Hypertensive Heart Disease, Alzheimer's Disease Unspecified and Unspecified Dementia. Review of Resident #88's Quarterly MDS with an ARD of 03/09/2023 revealed she had a BIMS score of 4 (indicating severe cognitive impairment). The MDS revealed Resident #88 required one person physical assistance with bed mobility, transfer, dressing, bathing and personal hygiene. Resident #88's MDS coded her as having no behaviors. Review of Resident #88's care plan with a problem onset of 08/18/2020 revealed she required assistance with ADL's and approaches to assist Resident with ADL's while promoting independence. Observation on 03/13/2023 at 9:54 a.m. revealed Resident #88 sitting in the hallway in a wheelchair coloring. Resident #88 noted to be unshaved with long facial, mouth, and chin hair approximately 1 and a half inches long. Observation and interview on 03/14/2023 at 10:56 a.m. revealed Resident #88 sitting in a wheelchair in the dining room. Resident #88 was noted to still be unshaved with long facial, mouth, and chin hair approximately 1 and a half inches long. Interview at the time of the observation with S4 CNA revealed, she made an attempt to shave Resident #88. S4 CNA stated Resident #88 refused to be shaved. S4 CNA confirmed she did not report Resident #88's refusal to be shaved to the Nurse. During the interview with S4 CNA, Resident #88 stated I want to be shaved. Observation and interview on 03/14/2023 at 11:00 a.m. of Resident #88 with S2 DON in attendance revealed Resident #88 sitting in the hallway in a wheelchair. Resident #88 was noted to be unshaved with long facial, mouth, and chin hair approximately 1 and a half inches long. S2 DON confirmed Resident #88's facial hair was long and she was in need of a shave.

Based on observations, interview, and record review, the facility failed to provide services with reasonable accommodation of needs for 1 Resident (#61) out of 45 sampled Residents. The facility failed to ensure the adaptive call light was within reach for Resident #61 to call for assistance when needed. Findings: Review of Resident #61's EHR revealed an admit date of 07/20/2022 with the following diagnoses: Cerebral Infarction, Spastic Hemiplegia affecting right dominant side, Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease with Heart Failure, Other Seizures, and Unspecified Glaucoma. Review of the Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 01/19/2023 revealed Resident #61 was non-interviewble with a BIMS (Brief Interview for Mental Status) of 03 (severely impaired cognition). Resident #61 was coded for being able to sometimes respond adequately to simple direct communication only, comprehends most conversation, and had severely impaired vision. Resident #61 required maximum assistance for transfer and was bed/chair confined. Review of Resident #61's Care Plan revealed a diagnosis of Hemiplegia with potential for self-care deficits, history of Cerebral Vascular Accident with a goal to have Resident #61's needs met. Approaches included to encourage Resident to use assistive device. Resident #61 had a problem of highly impaired vision with potential for falls related to diagnosis of Glaucoma with a goal of Resident #61 will be free of injury and complications related to impaired vision. An approach included was to encourage Resident #61 to use assistive device. On 03/13/2023 at 2:38 p.m., an observation was made of Resident #61 in a geri-chair in his room with an adaptive call light wrapped around the left side rail of the bed hanging on the floor. The adaptive call light was out of Resident #61's reach. On 03/15/2023 at 10:10 a.m., an observation was made of Resident #61 in bed with his adaptive call light draped over the head of the bed out of Resident #61's reach. On 03/15/2023 at 10:20 a.m., an interview was conducted with S2 DON. Observation at the time of interview revealed Resident #61 in bed with his adaptive call light positioned over the top of the headboard of his bed. S2 DON confirmed Resident #61's adaptive call light was not within his reach for assistance, but should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the Resident's right to formulate an advanced directive was properly reflected in the Resident's medical record for 1 (#47) of 2 (#48, #87) Residents reviewed for advance directives. The total sample size was 45. The facility failed to ensure all medical records regarding code status consistently reflected the Resident's wishes to be a DNR (Do Not Resuscitate). Findings: Review of Resident #47's electronic medical record revealed an admit date of [DATE] with admitting diagnosis of Heart Failure. Other diagnoses included: Dysphagia, Major Depressive Disorder, Chronic Kidney Disease, Unspecified Convulsions, Anxiety Disorder, and Dementia. Review of Resident #47's Quarterly MDS with an ARD date of [DATE] revealed in part . Resident #47 was non-interviewable with a BIMS of 99. Resident #47 required total assistance for eating and transfers. Resident #47 required extensive assistance for bed mobility, personal hygiene, bathing, toileting, and dressing. Review of Resident #47's [DATE] physician's orders revealed an order dated [DATE], listing the code status as Full Code, and an order dated [DATE] to admit Resident to hospice care. Review of the LaPOST (Louisiana Physician Order for Scope of Treatment) for Resident #47 revealed Resident #47's code status was listed as DNR (Do Not Resuscitate) and was signed by Resident #47's daughter on [DATE] and by Resident #47's physician on [DATE]. Further review of the paper chart revealed a form titled Resident/Family Consent for Cardiopulmonary Resuscitation which read in part . Cardiopulmonary Resuscitation (CPR) SHOULD NOT be done on this Resident and was signed and dated by Resident #47's daughter on [DATE], and signed by Resident #47's physician on [DATE]. Interview on [DATE] at 9:59 a.m. with S8 LPN revealed she was providing care and services to Resident #47. S8 LPN revealed Resident #47 was a full code. S8 LPN confirmed this information after reviewing Resident #47's physician's orders. S8 LPN confirmed information of Residents' Code Status are obtain from the Medical Record (physician orders and code sticker in the chart). Interview on [DATE] at 10:55 a.m. with S7 Hospice RN revealed Resident #47 was admitted to Hospice on [DATE], and on [DATE] Resident #47's Code Status was changed from Full Code to DNR (Do Not Resuscitate). Interview on [DATE] at 4:25 p.m. with S2 DON revealed there was conflicting Code Status information within Resident #47's medical records, and it should not have been.

Based on observation, record review, and interview, the facility failed to ensure a resident with an injury of unknown origin was reported to the State Agency not later than 24 hours in accordance with state law, for a resident who sustained a fracture of the right distal fifth metacarpal shaft, for 1 (#69) of 45 sampled residents. Findings: Review of the facility's policy titled Incident Investigation and Reporting (LA Only) read in part . Purpose: To provide guidance to the facility for investigation and reporting incidents of abuse, neglect, exploitation, misappropriation of property and/or other reportable incidents to LDH, Health Standards Section, local law enforcement, and others as required by state and federal requirements. Review of Resident #69's medical record revealed an admit date of 02/24/2022 with diagnoses that included in part . Repeated Falls, Disorientation Unspecified, Hallucinations Unspecified, Restlessness and Agitation, Unspecified Dementia-Unspecified severity with behavioral disturbance, Pain Unspecified, and Fracture to Right Fifth Metacarpal Shaft. Review of Resident #69's Quarterly MDS with an ARD of 02/16/2023 revealed a BIMS score of 2 (indicating severe cognitive impairment). Resident #69 required extensive assistance of 2 persons for bed mobility, transfer, bathing and toilet use; and 1 person extensive assistance with dressing, personal hygiene and locomotion on and off unit. Resident #69 had no range of motion impairment to upper extremities, and impairment on one side of lower extremity. Review of Resident #69's care plan with onset of 03/07/2022 revealed a problem of physical behavioral symptoms directed towards others related to diagnosis of Alzheimer's disease. Dementia with behavioral disturbance and hallucinations. Resident #69 does have episodes of confusion where she becomes combative physically grabbing at staff clothes attempting to hit them with approaches to include: Talk with Resident in a calm voice when behavior is disruptive, approach Resident calmly, administer medications as ordered, provide comfort/reassurance, reposition as needed. Observation and Interview on 03/13/2023 at 9:50 a.m. revealed Resident #69 lying in bed with her eyes closed. Resident #69 stated she was not hurting and just wanted to sleep. S9 CNA stated at that time that Resident #69 hurt her right pinky finger in February 2023, but it was well now. Review of nurses' progress notes dated 02/17/2023 on the 7:00 a.m. to 3:00 p.m. shift read in part .Resident has swelling noted to right wrist, minimal redness noted. Pain to touch and with movement. New orders obtain x-ray. Orders carried out. Review of Resident #69's X-ray report dated 02/17/2023 read in part . Procedure-Right wrist. Findings: There is a fracture identified in the distal fifth metacarpal shaft with fairly blunted margins suggestive of potential subacute injury. Impressions: Fracture of the distal fifth metacarpal shaft of indeterminate age. Interview on 03/13/2023 at 12:27 p.m. with Resident #69's daughter revealed she accompanied Resident #69 to her Orthopedic appointment on 02/23/2023. Resident #69's daughter revealed the Orthopedist stated the fracture to Resident #69's right fifth metacarpal shaft was about six weeks old. Review of the Orthopedic Physician Progress Notes dated 02/23/2023 read in part .fracture-healing 5th metacarpal shaft and right wrist with ganglion cyst. Fracture healing. Ok for normal use of hand. Interview on 03/15/2023 at 9:49 a.m. with S1 Administrator revealed an investigation report on Resident #69 was opened on 03/07/2023 due to a fracture of unknown origin that was discovered on 02/17/2023. S1 Administrator stated that Resident #69 had severe Dementia and was unable to state what happened. S1 Administrator stated the fracture to Resident #69's right fifth metacarpal shaft happened over 6 weeks ago, and she thought she didn't need to do a report because it was an old fracture. S1 Administrator stated on 03/07/2023 she revisited the incident. S1 Administrator confirmed a report should have been opened on 02/17/2023 when x-ray results revealed Resident #69 had a fracture to her distal fifth metacarpal shaft, and it was of unknown origin.

Based on interview and record review, the facility failed to ensure that the individual designated as the Infection Preventionist, completed specialized training in infection prevention and control. Findings: Review of the facility's Infection Control Records revealed there was no documented evidence that S2 DON, who was the facility's designated Infection Preventionist, had completed specialized training in infection prevention and control. In an interview on 03/14/2023 at 4:01p.m., S2 DON confirmed she had no specialized training in infection prevention and control. S2 DON stated S3 LPN/MDS Nurse had completed specialized training in infection prevention and control, was hired as a staff nurse and had never been assigned and/or performed the duties as the facility's Infection Preventionist Nurse.

Based on interview, record review, and policy review, the facility failed to ensure Residents' representatives and families were notified by 5:00 p.m. the next calendar day when a confirmed COVID-19 infection had been identified in the facility. Findings: 483.80 (g) COVID-19 reporting. The facility must inform Residents, their representatives, and families of those residing in facilities by 5:00 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, three or more Residents or staff with new-onset of respiratory symptoms. Interview on 03/13/2023 at 8:45 a.m. with S2 DON revealed a facility staff member tested positive for COVID-19 on 03/11/2022 while on duty at the facility. Interview on 03/15/2023 at 2:05 p.m. with S1 Administrator revealed Residents' families or representatives are notified by blast emails (from an outside source) of any new positive COVID-19 cases in the facility. S1 Administrator stated if a responsible party or representative does not have an email address the social worker would contact them by phone. Review of an email dated 03/14/2023 from the facility's communication partner (company who sends out emails for the facility), revealed a confirmation for notifications was sent to responsible parties or representatives on active case (s) of the novel coronavirus COVID-19 of Residents and or staff identified on 03/14/2023 at 9:10 a.m. Interview on 03/13/2023 at 2:13 p.m. with S6 SSD revealed she was responsible for notifying the Residents representatives and families of new COVID-19 infections in the facility if they do not have an email address. S6 SSD stated she called Residents' representatives and families Monday 03/13/2023, but did not document these phone calls. Interview on 03/15/2023 at 3:46 p.m. with S1 Administrator revealed she did not notify Residents' representatives or families of the confirmed COVID-19 infection identified in the facility on 03/11/2023 until 03/13/2023. S1 Administrator confirmed she was out of compliance with notifying Residents' representatives or families by 5:00 p.m. the next calendar day.

Based on observation, interview, and record review the facility failed to provide care to 2 (Resident #1 and Resident #3) of 5 sampled Residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) in accordance with professional standards of practice. The facility failed to ensure Resident #3 received medications as ordered by the physician and failed to notify the physician of a change in Resident #1's treatment plan. Findings: Review of the Facility's Policy and Procedure titled Change in Resident Medical Status read in part . A Facility must immediately inform the Resident; consult with the Resident's physician; and notify, consistent with his or her authority, the Resident representative (s), when there is- 3. A need to alter treatment significantly; (that is a need to discontinue or change an existing treatment due to adverse consequences, or to commence a new form of treatment). Resident #3 Review of Resident #3's medical record revealed an admit date of 11/21/2022 with the following diagnoses in part: Type 2 Diabetes Mellitus, Hyperlipidemia, Major Depressive Disorder, and Pain- Unspecified. Review of the Care Plan with a target date of *******for Resident #3 revealed a problem of actual skin impairment with a potential for further skin impairment: 02/09/2023 Right fifth digit wound with approaches to administer antibiotics as ordered. Review of the Quarterly MDS with an ARD of 12/08/2022 revealed Resident #3 had a BIMS score of 12 (indicating moderately impaired cognitive function). Review of the MDS revealed Resident #3 required extensive assistance of two persons for bed mobility, transfers and toileting and one person physical assistance for dressing, personal hygiene and eating. Review of Resident #3's February 2023 Physician Orders read in part . Bactrim DS Tablet, one tablet two times a day x14 days for wound infection. Order date: 02/09/2023, Stop Date: 02/24/2023 Review of Resident #3's February 2023 Electronic Administration Record revealed Resident #3 did not receive scheduled doses of Bactrim DS (an antibiotic) as ordered on the following dates: 02/09/2023 7:00 p.m. dose, 02/10/2023 7:00 p.m. dose, 02/11/2023 7:00 p.m. dose, and 07/12/2023 7:00 a.m. dose. Review of Resident #3's February 2023 Departmental Notes read in part . 02/13/2023 2:15 p.m. This nurse contacted pharmacy. Bactrim DS to be delivered this evening. One taken from emergency kit and a fax sent to pharmacy. Interview on 02/22/2023 at 4:30 p.m. with S2 RN revealed she provided care to Resident #3 on 02/09/2023, and 02/10/2023 7:00 p.m. shift. S2 RN stated she did not administer the prescribed Bactrim DS (an antibiotic) on these dates because the medication was not available at facility. S2 RN stated she did not contact the Resident's physician to notify him the medication was not given as ordered. S2 RN stated she was unaware the facility had medication available in the emergency kit until several shifts later when a co-worker educated her on this. Interview on 02/22/2023 at 4:15 p.m. with S1 DON revealed Resident #3 had missed doses of Bactrim DS on 02/09/2023 7:00 p.m. dose, 02/10/2023 7:00 p.m. dose, 02/11/2023 7:00 p.m. dose, and 07/12/2023 7:00 a.m. dose. S1 DON confirmed the missed doses recorded on the Electronic Administration Record. S1 DON confirmed the physician should have been contacted by nursing staff regarding medication not being given as ordered, but was not. Resident #1 Review of Resident #1's medical record revealed an admit date of 08/09/2022 with diagnoses which included: Chronic Kidney Disease Stage 5, Bloodstream infection due to Central Venous Catheter, Muscle Weakness, Acute Respiratory Failure, Legal Blindness, Type 2 Diabetes Mellitus, Pain Unspecified, Metabolic Encephalopathy, Anemia, Major Depressive Disorder, recurrent severe with psych symptoms and Urinary Tract Infection, site not specified. Review of the Quarterly MDS with an ARD of 11/29/2022 revealed Resident #1 had a BIMS score of 14 (indicating intact cognition). Review of the MDS revealed Resident #1 required limited assistance of one person for bed mobility, toilet use, transfer, personal hygiene, and bathing; supervision with eating. Review of the Care Plan with a target date of 12/08/2022 for Resident #1 revealed a potential for altered fluid volume related to hemodialysis with risk for Orthostatic Hypotension-Dialysis 3 x week on Monday, Wednesday and Friday at Dialysis Center with interventions to administer medications as ordered and notify medical doctor of any complications. Review of nurse notes dated 01/17/2023 read in part: Resident is lying in bed at this time. Resident is weak for dialysis this afternoon. Staff notified ambulance to transport Resident to dialysis due to weakness. Dialysis center notified of Resident's condition asked staff to obtain vitals and to have Resident at dialysis center no later than 1:30 p.m. Ambulance running two hours behind, not able to get Resident to center before 1:30 p.m. this nurse (S3 LPN Agency Nurse) reported to S1 DON . S1 DON spoke with dialysis center. Dialysis Center recommended to get Resident to dialysis first thing in the AM tomorrow 01/18/2023. Telephone interview on 02/22/2023 at 3:25 p.m. with S3 LPN revealed she was Resident #1's nurse on 01/17/2023 day shift. S3 LPN stated Resident #1 was too weak to ride the facility's van to the dialysis center, so the ward clerk called for an ambulance. S3 LPN stated the ambulance service was unable to transport Resident #1 timely so she notified S1 DON. S3 LPN stated S1 DON spoke with the dialysis center and Resident #1's dialysis was rescheduled for the next morning (01/18/2023). S3 LPN confirmed she did not notify the physician of Resident #1's hemodialysis being canceled and rescheduled until the following morning (01/18/2023). Interview on 02/22/2023 at 3:47 p.m. with S1 DON revealed on 01/17/2023 the ambulance service was backed up and could not transport Resident #1 to the dialysis center at her scheduled time. S1 DON called the dialysis center and spoke with staff to update them of the transportation issue with the ambulance service. Staff at the dialysis center recommended to reschedule Resident #1's hemodialysis for the following morning (01/18/2023). S1 DON confirmed the physician was not notified of Resident #1's hemodialysis being canceled on 01/17/2023 and rescheduled for 01/18/2023 and he should have been.