**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 (Resident #47) of 24 sampled residents. The facility failed to ensure all medical records regarding code status consistently reflected Resident #47'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 diagnoses of Cellulitis of Right Lower Limb, Unspecified Neuralgia and Neuritis, Severe Sepsis with Septic Shock, Adult Failure to Thrive, Anemia, Moderate Protein Calorie Malnutrition, Hyperlipidemia, Depression, and Essential Primary Nutrition. Review of Resident #47's admission MDS with an ARD date of [DATE] revealed in part . Resident #47 had a BIMS score of 9, which indicated moderate cognitive impairment. On [DATE] at 11:02 a.m. review of Resident #47's [DATE] physician orders revealed an order dated [DATE], listing the code status as Full Code and an order dated [DATE], listing code status as DNR (Do Not Resuscitate). On [DATE] at 11:30 a.m. review of Resident #47's care plan revealed Resident #47 was a Full Code with interventions that included: if respiratory/cardiac arrest occurs perform Cardiopulmonary Resuscitation (CPR), continue CPR until resident responds or Emergency Medical Services (EMS) arrives and assumes code responsibilities, review code status with resident/family with each review to ensure wishes have not changed and wishes are respected. On [DATE] at 10:56 a.m. review of Resident #47's 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 on [DATE], and signed by Resident #47's physician on [DATE]. On [DATE] at 12:08 p.m. interview with Resident #47 revealed she signed a DNR form with facility upon admission. Resident #47 confirmed her code status was DNR. Interview [DATE] at 12:15 p.m. with S3ADON and S10RNConsultant revealed there was conflicting Code Status information within Resident #47's medical records, and it should not have been.

Based on interview and record review, the facility failed to ensure the NOMNC Form CMS-10123 (Notice of Medicare Non-Coverage) was provided to the resident and/or the resident's representative prior to discharge from Medicare Part A services for 2 (Resident #115 and Resident #116) of 2 sampled residents for Advanced Beneficiary Notice (ABN). Findings: Review of the SNF Beneficiary Notification Review forms completed by the facility revealed the following: Resident #115- Medicare Part A Skilled Services Episode start date 12/20/2024; last covered day 01/06/2025. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. No evidence of NOMNC Form CMS 10123 being issued. Resident #116- Medicare Part A Skilled Services Episode start date 01/17/2025; last covered day 02/03/2025. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. No evidence of NOMNC Form CMS 10123 being issued. Interview on 06/18/2025 at 12:30 p.m. with S12 HR/BOM stated that Resident #115 and Resident #116 did not receive the NOMNC Form CMS 10123 prior to discharge from Medicare Part A services, but should have.

Based on interview and record review, the facility failed to document discharge planning for a resident who had expressed a desire to discharge. The facility failed to document a referral to an outside entity, and the responses received from the outside entity, for Resident #45. The total sample included 20 residents. Findings: Review of the facility's policy entitled Discharge Summary and Plan, revised 03/2025, revealed, in part .when a resident's discharge is anticipated, a discharge summary is created. The discharge summary includes information necessary for the care of the resident while residing in the facility, and after his/her discharge. The medical record contains a copy of the discharge summary. Referrals made for the purpose of discharge are documented in the medical record. Review of Resident #45's medical record revealed an admission date of 09/18/2023 with diagnoses including, in part .Encounter for surgical aftercare following surgery on the digestive system, MDD, Arthritis, Overactive Bladder, Acute Hepatitis C, Epilepsy, and Metabolic Encephalopathy. Review of Resident #45's Quarterly MDS with an ARD of 04/16/2025 revealed a BIMS Score of 15, indicating intact cognition. Resident #45 participated in the assessment and goal setting. Resident #45 wanted to leave the facility and return to the community. Review of Resident #45's Quarterly Social Services Assessments revealed, in part .Resident #45 indicated she wanted to return to the community with aides to provide assistance with medications and shopping on 10/04/2024, 01/22/2024, and 04/16/2025. Interview with Resident #45 on 06/16/2025 at 10:41 a.m. revealed she had been awaiting discharge since 12/2024. Interview with S4SSD on 06/17/2025 at 9:26 a.m. revealed Resident #45 did not have a documented discharge plan. S4SSD confirmed Resident #45 had requested discharge in 12/2024. S4SSD revealed she had referred Resident #45 to a program on 12/19/2024, and representatives from the program had screened the resident on 03/03/2025. S4SSD received an email from the program on 06/04/2025 which indicated Resident #45 was being assessed by their team to determine if she meets the requirements. S4SSD revealed two representatives from the program visited Resident #45 approximately one-and-a-half weeks ago. S4SSD confirmed Resident #45 did not have a documented discharge plan which included the referral to the program or any of the responses from the program, but should have.

Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene by failing to provide ADL care for 1 (Resident #54) of 24 sampled residents. Findings: Review of the facility's policy titled Activities of Daily Living (ADL) with a revision date of 03/2018 read in part . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care); b. mobility (transfer and ambulation, including walking); c. elimination (toileting); d. dining (meals and snacks); and e. communication (speech, language, and any functional communication systems). Review of Resident # 54's Clinical Record revealed an admit date of 04/19/2024 with diagnoses which included: Alcohol Dependence with Alcohol-Induced Persisting Dementia; Extended Spectrum Beta Lactamase Resistance; Malignant Neoplasm of the Prostate; Cerebral Infarction due to Occlusion or Stenosis of Small Artery; Opioid Abuse; and Encephalopathy. Review of Resident #54's Quarterly MDS with ARD of 06/11/2025 revealed a BIMS score of 7 (indicating severe cognitive impairment). Resident #54 required substantial/ maximal assistance with showering/bathing and dressing his lower body. Review of Resident #54's Care Plan dated 04/19/2024 revealed in part . Resident #54 has an ADL self-care performance deficit. Resident #54 required one person assist with bathing, dressing, and grooming. Observation on 06/16/2025 at 10:02 a.m. revealed Resident #54 lying in bed wearing a hospital gown, dirty non-skid socks, and a hospital arm band to the left wrist. Resident #54's hair appeared oily and unkempt. Resident #54's fingernails were long and observed with brown substance under the nail. Resident #54 stated that he was unsure when he last received a bath. Observation on 06/17/2025 at 12:58 p.m. revealed Resident #54 lying in bed with the same dirty non-skid socks on his feet and continued with long fingernails with brown substance under them. Interview on 06/18/2025 at 11:52 a.m. with Resident #54 confirmed he received a bath yesterday and his gown was changed. Resident #54 reported staff did not change his socks at that time. Interview on 06/18/2025 at 12:10 p.m. with S18 CNA revealed activities of daily living (ADL) care included: bathing, dressing (including changing socks), and linen change. S18 CNA revealed nail care was included in ADLs for all residents except diabetics. Interview on 06/18/2025 at 12:50 p.m. with S19 CNA Supervisor confirmed that Resident #54 should receive a bed bath daily due to isolation precautions. S19 CNA Supervisor confirmed Resident #54's gown, linens, and socks should have been changed with every bath and were not.

Based on observation, and interview the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This deficient practice had the potential to affect all residents that received meals prepared by the kitchen. The facility census was 62. Findings: Review of the facility's policy on 06/18/2025 at 4:00 p.m. titled: Sanitization with a revised date of 11/2022 read in part . The food service area is maintained in a clean and sanitary manner. All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. Observation of the facility's kitchen on 06/16/2025 at 8:48 a.m. accompanied by S11 Dietary Manager revealed: The kitchen's floor was heavily soiled with mud and food items. The kitchen's microwave was unsanitary with dried food splattered on the top and bottom. Interview with S11 Dietary Manager on 06/16/2025 at 8:48 a.m. confirmed the above findings. S11 Dietary Manager stated both the floor and microwave needed to be cleaned.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by: 1. failing to ensure staff performed hand hygiene between residents while feeding dependent residents; and 2. failing to ensure staff followed enhanced barrier precautions while providing direct patient care for Resident #23. Findings: 1. Review of the facility's policy entitled, Assistance with Meals revised 03/2022 revealed, in part .all employees who provide resident assistance with meals shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. Observation of the dining room on 06/16/2025 at 11:46 a.m. revealed S5CNA feeding two residents. S5CNA repeatedly touched the utensils, cups, and clothing protectors of the two residents, without performing hand hygiene. Interview with S5CNA on 06/16/2025 at 12:08 p.m. revealed she was to sanitize her hands between contact with residents, their utensils, cups, and clothing protectors, but did not. Interview with S3ADON on 06/17/2025 at 2:49 p.m. confirmed staff was to use hand sanitizer or hand hygiene between feeding and/or direct contact with residents. 2. Resident #23 On 06/18/2025 at 12:45 p.m. review of facility policy titled, Enhanced Barrier Precautions with revision date of December 2024 revealed in part . Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-resistant organisms (MDROs) to residents. Enhanced barrier precautions apply when a resident has an indwelling medical device. Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheostomies. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include in part . dressing. Review of Resident #23's electronic medical record revealed an initial admit date of 06/01/2020 with admitting diagnoses of Spastic Diplegic Cerebral Palsy, Acute Cystitis without hematuria, Paroxysmal Atrial Fibrillation, Presence of cardiac pacemaker, Sick Sinus Syndrome, Combined Systolic and Diastolic (Congestive) Heart Failure, Severe Protein Calorie Malnutrition, Acute Respiratory Failure with Hypoxia, Acute Hepatitis C without Hepatic Coma, and Dysphagia following Cerebral Infarct. Review of Resident #23's Annual MDS with ARD of 05/28/2025 revealed Resident #23's cognition was severely impaired. Resident #23 was dependent on staff for dressing, transfers, and personal hygiene. Resident #23 had an abdominal Percutaneous Endoscopic Gastrostomy (PEG) tube. On 06/18/2025 at 10:13 a.m. observation revealed S9CNA dressing Resident #23 without wearing a disposable gown. On 06/18/2025 at 10:15 a.m. interview with S9CNA revealed she was familiar with Resident #23 and the care and precautions Resident #23 required. S9CNA confirmed she did not don a disposable gown prior to performing direct patient care for Resident #23 and should have. On 06/18/2025 at 1:20 p.m. interview with S3ADON, whom was also the facility Infection Preventionist (IP), revealed Resident #23 was on enhanced barrier precautions. S3ADON confirmed all staff were required to don gloves and a gown prior to performing direct patient care for Resident #23, dressing included.

Based on record review and interview the facility failed to offer the Pneumococcal Vaccine on admit to the facility for 1 (#45) of 5 (#19, #45, #46, #54 and #60) residents sampled for Influenza, Pneumococcal and COVID-19 immunizations. Findings: Review of the facility's policy with a revision date of 04/2022 titled Pneumococcal Vaccine revealed in part .All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infection. Policy Interpretation and Implementation: 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within 30 days of admission to the facility unless medically contraindicated. Review of Resident #45's clinical record revealed an admission date of 09/18/2023 with diagnoses that included: Encounter for Surgical Aftercare, Major Depressive Disorder, Epilepsy, Chronic Obstructive Pulmonary Disease, and Chronic Viral Hepatitis C. Review of Resident #45's clinical record revealed no evidence that she had received the Pneumococcal vaccine. Resident #45's admission records revealed no consent or declination form for the Pneumococcal vaccine. Interview on 06/18/2025 at 2:20 p.m. with S3 ADON stated that Resident #45 was eligible for the Pneumococcal vaccine. S3 ADON confirmed that Resident #45 had no consent or declination form signed on admission for the Pneumococcal vaccine, but should have.

Based on observation and interview, the facility failed to maintain an effective pest control program by failing to ensure the facility was free from insects. The deficient practice had the potential to affect 62 residents who resided in the facility. Findings: Review of the facility's policy on 06/18/2025 at 4:00 p.m. titled Pest Control with revision date of 05/2008 read in part . Our facility shall maintain an effective pest control program. This facility maintains an on-going pest control program to ensure that the building is free of insects and rodents. Observation of the facility's kitchen on 06/16/2025 at 8:48 a.m. accompanied by S11 Dietary Manager revealed: There were multiple flies observed throughout the kitchen area with flies landing on the kitchen stove and food prep area. The dry food pantry contained 3 large storage bins and within the (1) flour bin there were 3 small black insects. Interview with S11 Dietary Manager on 06/16/2025 at 8:48 a.m. confirmed the above findings. S11 Dietary Manager stated the kitchen should be free of insects, but was not. Observation on 06/16/2025 at 11:14 a.m. of the facility dining area for lunch meal service revealed multiple flies landing on resident's food items during meal service. Observation on 06/17/2025 at 8:13 a.m. of X Hall revealed multiple flies within hallway and Room A. Interview with S8 LPN confirmed the findings and stated Room A almost always had flies within the room, but should not.

Based on record review and interview, the facility failed to transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 2 (Resident #14 and Resident #43) of 2 sampled residents with MDS records over 120 days old. Findings: Review of the facility's MDS transmission report revealed Resident #14's Quarterly MDS Assessment with ARD (Assessment Reference Date) of 03/07/2024 had been submitted on 04/15/2024. Review of the facility's MDS transmission report revealed Resident #43's Annual MDS Assessment with ARD of 02/29/2024 had been submitted on 04/15/2024. Interview on 04/17/2024 at 11:10 a.m. with S3 Corporate RN confirmed Resident #14's and Resident #43's MDS Assessments had not been transmitted timely and should have been. Interview on 04/17/2024 at 12:00 p.m. with S1 Administrator revealed the facility had recently completed a QAPI plan regarding untimely transmissions of MDS Assessment after being cited and cleared. Review of the facility's MDS transmission performance improvement monitoring, accompanied by S1 Administrator, revealed several assessments had been transmitted on 03/22/2024. Review revealed Resident #14's and Resident #43's MDS Assessments had not been transmitted until 04/15/2024. Interview on 04/17/2024 at 12:05 p.m. with S1 Administrator revealed he was not sure why Resident #14 and Resident #43's MDS Assessments had not been transmitted on 03/22/2024. S1 Administrator confirmed Resident #14 and Resident #43's MDS Assessments had not been transmitted timely and should have been.

Based on interview and record review, the facility failed to ensure that a Resident Assessment accurately reflected the cognition status for 1 (Resident #26) Resident. The sample size was 31. Review of Resident #26's EHR revealed an admit date of 12/14/2023 with diagnoses that included: Polyneuropathy, Spinal Stenosis, Urine Retention, Transient Paralysis, and Rhabdomyolysis. Review of the Resident #26's Quarterly MDS with an ARD of 12/21/2023 revealed he was interviewable with a BIMS of 10. Review of the BIMS conducted revealed: Repetition of Three Words-2 words repeated; Temporal Orientation (orientation to year, month, and day) missed by 1 year; What month are we in right now? accurate within 5 days; What day of the week is today? Correct; Going back What was the 3 words I asked you to repeat? answered after cueing; Able to recall blue- yes; Able to recall bed- yes. Total score- 10. Review of Resident #26's Quarterly MDS with an ARD of 03/21/2024 revealed he was interviewable with a BIMS of 01. Review of the BIMS conducted revealed: Repetition of Three Words-2 words repeated; Temporal Orientation (orientation to year, month, and day) missed by 1 year; What month are we in right now? accurate within 5 days; What day of the week is today? Correct; Going back What was the 3 words I asked you to repeat? answered after cueing; Able to recall blue- yes; Able to recall bed- yes. Total score- 10. Interviews conducted on 04/15/2024 at 6:30 a.m., 9:50 a.m., and on 04/16/2024 at 9:00 a.m. and 9:45 a.m. with Resident #26 revealed he was interviewable, able to answer all questions with appropriate answers and able to recall events of his hospital stay and surgery in 12/2023. Interview on 04/16/2024 at 10:00 a.m. with S3 Corporate RN confirmed after reviewing and comparing the Quarterly MDS with an ARD of 03/21/2024 and the Quarterly MDS with an ARD of 12/21/2023, there was no difference and no change in Resident #26's cognition status. S3 confirmed there was a transcription error in data input of Resident #26's BIM score entered on 03/21/2924. S3 Corporate RN stated S7 SSD was responsible for conducting and inputting the BIMS information data into the MDS. S3 Corporate RN stated an Addendum would have to be made and the MDS would have to be re-submitted with the correct data. Interview on 04/17/2024 at 1:58 p.m. with S7 SSD revealed she was responsible for conducting the BIMS and entering the information on the MDS hard copy. S7 SSD confirmed she conducted a BIMS on Resident #26 on 03/21/2024 and the resident scored a 10. She confirmed the score of 01 that appeared on the Quarterly MDS with an ARD of 03/21/2024 was entered in error.

Based on observation, interview and record review, the facility failed to ensure services were provided to meet professional standards of practice as evidenced by failing to deliver oxygen therapy as ordered for 1 (Resident #2) of 1 resident reviewed for respiratory care. The facility census was 63 residents. Findings: Review of the facility's policy titled, Oxygen Administration read in part . The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. Review of Resident #2's Medical Record revealed an admission date of 03/28/2023 with diagnoses that included COPD with (Acute) Lower Respiratory Infection, Legal Blindness, as defined by USA, Dementia, Personal history of Transient Ischemic Attack and Cerebral Infarction, Essential Primary Hypertension, Hyperlipidemia, Angina Pectoris, Acute and Chronic Respiratory Failure unspecified whether Hypoxia or Hypercapnia. Review of Resident #2's Physician's Orders dated 03/28/2023 revealed the following orders in part . Oxygen at 2 liters per nasal cannula continuous every day and night shift and Oxygen concentrator at 2 liters/nasal cannula to maintain oxygen saturation above 92% every morning and at bedtime to maintain oxygenation. Review of Resident #2's MARs for April 2024 revealed documentation of oxygen administered at 2 liters/minute via nasal cannula continuous. Review of Resident #2's Annual MDS Assessment with an ARD of 03/21/2024 revealed a BIMS score of 00 and resident required oxygen therapy. Review of Resident #2's Care Plans with a target date of 07/06/2024 revealed resident with potential for ineffective breathing patterns related to COPD, decreased lung compliance and has oxygen therapy related to ineffective gas exchange related to respiratory illness with goal to have no signs and symptoms of poor oxygen absorption. Interventions included in part . Administer medications, respiratory treatments and oxygen as ordered and Oxygen settings: Oxygen via nasal prongs at 2 liters continuously. Observation on 04/15/2024 at 8:07 a.m. revealed Resident#2 lying in bed with her eyes closed with oxygen in progress at 3 liters per minute per nasal cannula via oxygen concentrator. Observation in Resident #2's room on 04/15/2024 at 2:15 p.m. accompanied by S2 DON verified resident's oxygen was in progress at 3 liters per minute via nasal cannula per oxygen concentrator. S2 DON revealed she would need to check Resident #2's orders, progress notes and with nurse to check if she had altered resident's oxygen concentrator. Interview in Resident #2's room on 04/15/2024 at 2:20 p.m. with S6 Agency LPN revealed that she was not reported any changes with Resident #2 from the nurse she had relieved this morning and she had not adjusted resident's oxygen concentrator today. S6 Agency LPN confirmed Resident #2's physician orders and confirmed that her oxygen concentrator should have been set at 2 liters per minute per nasal cannula continuously and was not. Interview on 04/15/2024 at 2:24 p.m. with S2 DON confirmed Resident #2's oxygen concentrator should have be set to deliver oxygen at 2 liters per minute via nasal cannula continuous as ordered and was not.

Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide oral care and nail care to dependent residents for 3 (Resident #9, Resident #10, and Resident #26) of 3 (Resident #9, Resident #10, and Resident #26) residents sampled for ADL's Findings: Review of the Facility's policy titled: Activities of Daily Living (ADLs), with a revised date of March 2018 revealed in part: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for a resident who is unable to carry out ADLs independently, with the consent of the resident and in accordance with plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, and oral care). A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. Resident #9 Review of Resident #9's EHR (Electronic Health Record) revealed an admission date of 04/29/2026, diagnosis included: Cerebral Infarction, Bipolar Disorder, DM, Intermittent Explosive Disorder, Bipolar Disorder, Unspecified, Anxiety Disorder, and Major Depressive Disorder. Review of Resident #9's Quarterly MDS with an ARD of 01/29/2024 revealed Resident #9 had a BIMS of 05, indicating severely impaired cognition. Resident #9's functional status revealed he required the extensive, physical assistance of one to two persons with all ADLS. Observation of Resident #9 on 04/15/2024 at 9:10 a.m. revealed Resident #9 in a wheelchair in the hallway with ½ inch long, thick, gray, facial hair, and long untrimmed fingernails. Observation of Resident #9 on 04/15/2024 at 2:19 p.m. revealed Resident #9 in a wheelchair in the hallway with ½ inch long, thick, gray, facial hair, and long untrimmed fingernails. Interview on 04/15/2024 at 2:35 p.m., with S2 DON revealed all male residents were bathed and/or showered on Tuesday, Thursday and Saturday. S2 DON stated ADLs included AM care, oral care, skin/hair care, personal care, and nail care. Observation during this interview revealed Resident #9 approached S2 DON and told S2 DON that he needed to be shaved and his fingernails needed to be trimmed S2 DON confirmed that Resident #9 needed to be shaved and his fingernails needed to be trimmed. Resident #10 Review of Resident #10's EHR revealed an admission date of 07/02/2010, diagnosis included: Multiple Sclerosis, Neuromuscular Dysfunction of the Bladder, Quadriplegia, and Hydronephrosis. Review of Resident # 10's Care Plan with a target date of 05/06/2024 revealed Resident #10 has his own teeth and required 1 person staff to inspect and provide oral care and personal hygiene, and required 2 persons assistance with bathing. Review of Resident #10's Annual MDS with an ARD of 01/09/2024 revealed a BIMS score of 06, (severely impaired cognition), with no psychosis and/or behavioral issues. Resident #10 was assessed as being totally dependent on staff to provide care. Observation on 04/15/2024 at 9:50 a.m., revealed Resident #10 lying in bed. Resident #10 was noted to have a chalky colored film on his lips and in the corner of his mouth, with a foul mouth odor present. Resident #10 was also noted to have ½ inch black facial hair with long untrimmed fingernails. Interview with Resident #10 at the time of observation revealed Resident #10 was a quadriplegic and dependent on the staff to perform all of his ADLs. Resident #10 stated no one had offered to brush his teeth before or after breakfast. Observation on 04/15/2024 at 2:07 p.m. of Resident #10 accompanied by S2 DON confirmed Resident #10 needed oral care, nail care, and needed to be shaved. S2 DON stated the CNAs were responsible for providing nail care, oral care and shaving Resident #10 during baths and as needed. S2 DON stated the CNAs should have provided AM care which included oral care to Resident #10 before breakfast and had not. Resident #26 Review of Resident #26's EHR revealed an admit date of 12/14/2023 with diagnoses that included: Polyneuropathy, Spinal Stenosis, Urine Retention, Transient Paralysis, and Rhabdomyolysis. Review of Resident # 26's Care Plan with a target date of 06/28/2024 revealed Resident #26 had a self- care performance deficit with ADLs related to Dementia and Impaired Balance. Resident #26's interventions included: check nail length and trim, and clean on bath day as needed. Review of Resident #26's Quarterly MDS with an ARD of 03/21/2024 revealed a BIMS score of 01, severe cognitive impairment, with no psychosis and/or behavioral issues. Resident #26 was assessed as being totally dependent on staff. Interviews conducted with Resident #26 on 04/15/2024 at 6:30 a.m., 9:50 a.m., and on 04/16/2024 at 9:00 a.m. and 9:45 a.m. revealed Resident #26 was able to answer all questions with appropriate answers. Observation on 04/15/2024 at 6:30 a.m. revealed Resident #26 in bed with, thick, gray, facial hair that was ½ inch in length. Dark dried substance was observed around Resident #26's cuticles and under his fingernail beds. Interview with Resident #26 at the time of observation revealed it had been weeks since he was last shaved, and he was not certain the last time that his fingernails were cleaned. Observation of Resident #26 on 04/15/2024 at 2:12 p.m. accompanied by S2 DON confirmed Resident #26 needed to be shaved and his fingernails needed to be cleaned and had not been.

Based on observation, interview and record review the facility failed to dispose of garbage and refuse properly. The total facility census was 63 residents. Findings: Review of facility's policy titled, Food-Related Garbage and Refuse Disposal read in part . Policy Statement: Food-related garbage and refuse are disposed of in accordance with current state laws. Policy Interpretation and Implementation: 2. All garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use. 5. Garbage and refuse containing food waste will be stored in a manner that is inaccessible to pests. 6. Storage areas will be kept clean at all times, and shall not constitute a nuisance. 7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. Observation on 04/15/2024 at 5:45 a.m. revealed the doors of the facility dumpster were open and several white trash bags were stacked inside. Observation at this time revealed several pieces of paper trash on the ground surrounding the facility's dumpster. Interview on 04/15/2024 at 7:55 a.m. with S4 DM confirmed the above findings. S4 DM confirmed that the facility's dumpster doors should have been closed and were not. S4 DM confirmed the area surrounding the dumpster should have been cleaned and was not. Observation on 04/15/2024 at 8:30 a.m. of the facility dumpster accompanied by S1 Administrator and S2 DON revealed the dumpster doors were open. Interview at this time with S1 Administrator confirmed the facility's dumpster doors were open and should have been closed.

Based on observation, interview and record review, 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. Dry food storage room was clean and free from residue from insects; 3. Kitchen utensils/ scoops were stored under sanitary conditions; 4. Refrigerated food contents were labeled and dated; 5. Kitchen linens were clean and properly stored. The total facility census was 63 residents. Findings: Review of the facility's Policy and Procedure titled, Food Storage read in part . Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry and free from contaminants. Procedure: 1. Storage areas will be free from rodent and insect infestation, and will be treated for pests and vermin on a regular basis. 7. All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. 7. c. Date markings will be visible on all high-risk food to indicate the date by which a ready-to-eat. TCS food should be consumed, sold or discarded. 9. Scoops must be provided for bulk foods (such as sugar, flour and spices). Scoops are not to be stored in food or ice containers, but are kept covered in a protected area near the containers. Scoops are washed and sanitized on a regular basis. Observation on initial tour of the kitchen on 04/15/2024 at 6:05 a.m., accompanied by S4 DM, revealed the following items on the shelf available for use: 1. Four -12 pack of hamburger buns with an expiration date of 10/09/2023; 2. One opened bag undated with 6 hamburger buns left with an expiration date of 10/09/2023; and 3. One opened bag undated with 2 hamburger buns with expiration date of 01/2024. Observation during tour of the kitchen on 04/15/2024 at 11:15 a.m. accompanied by S6 [NAME] revealed: 1. One laundry basket full of soiled kitchen linens; 2. One scoop noted inside of the (Fruit Loops) cereal bin; 3. One scoop noted inside of the flour bin; 4. One small bowl noted inside of the (corn flakes) cereal bin; 5. Two refrigerated containers of chicken noodle soup without a label or date; and 6. One metal container with cream colored batter without a label of contents or date in the refrigerator. Observation of the facility kitchen's dry food storage room on 04/15/2024 at 11:15 a.m. accompanied by S5 [NAME] revealed multiple dark brown droplets of insect droppings noted on top of the storage shelves. S5 [NAME] confirmed the findings of insect droppings on the shelves in the dry food storage room. S5 cook revealed every Thursday after delivery truck comes, the staff put up food and supplies, vacuum the shelves, and move up closer dated items up front for sooner use. S5 [NAME] revealed the staff must not have cleaned the shelves in the dry food storage room. S5 [NAME] revealed the weekend staff had not taken the dirty kitchen towels to laundry to be cleaned. Interview on 04/15/2024 at 12:08 p.m. with S4 DM confirmed the above findings. S4 DM confirmed the signs of pest residue noted on the shelves in the dry food storage area.

Based on observations and interviews and record review, the facility failed to maintain an effective pest control program to ensure residents had a pest free environment. The deficient practice had the potential to affect all 63 residents that resided in the facility. Findings: Review of the facility's policy titled, Pest Control read in part . Policy Statement: Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation: 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 6. Maintenance services assist, when appropriate and necessary, in providing pest control services. Observation during the initial tour of the kitchen on 04/15/2024 at 6:05 a.m. revealed multiple flies flying around in the kitchen. Interview at this time with S4 DM revealed that the weekend staff must have left the door open for the flies to have come in. Observation of the facility kitchen's dry food storage room on 04/15/2024 at 11:15 a.m. accompanied by S5 [NAME] revealed multiple dark brown droplets of insect droppings noted on top of the storage shelves. S5 [NAME] confirmed the findings of insect droppings on the shelves in the dry food storage room. Interview on 04/15/2024 at 12:08 p.m. with S4 DM confirmed the signs of pest residue noted on the shelves in the dry food storage area. Review of the facility's pest control service receipts revealed exterminating services were provided monthly with the last treatment provided on 04/12/2024. Observation on 04/16/2024 at 12:05 p.m. revealed flies flying around in the Activity room. Observation on 04/17/2024 at 7:55 a.m. in Room A revealed a fly flying around in a resident's room. Observation at this time revealed S8 LPN swatting the fly away and S8 LPN confirmed flies flying around the facility. Interview on 04/17/2024 at 5:35 p.m. with S1 Administrator confirmed above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure resident assessments were electronically transmitted in a timely manner by failing to transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 1 (#1) of 3 (#1, #2, and #3) Residents reviewed for resident assessments. Findings: Review of Resident #1's medical record revealed he was admitted to the facility on [DATE]. Resident #1 had diagnoses that included in part .Chronic Obstructive Pulmonary Disease, Dementia, Sleep Apnea, Cerebral Infarction, Depression, and Heart Failure. Review of Resident #1's Discharge/Return Anticipated MDS Assessment with ARD (Assessment Reference Date) of 11/20/2023 and Quarterly MDS Assessment with ARD of 12/05/2023 revealed the assessments had been completed but not transmitted. Interview on 02/29/2024 at 4:33 p.m. with S2 MDS LPN revealed she was responsible for completing and transmitting MDS Assessments. S2 MDS LPN confirmed Resident #1's Discharge/Return Anticipated MDS Assessment with ARD (Assessment Reference Date) of 11/20/2023 and Quarterly MDS Assessment with ARD of 12/05/2023 had been completed, but not transmitted. Review of the facility's MDS transmission reports dated 10/01/2023-03/04/2024 on 03/04/2024 at 12:30 p.m. revealed Resident #1's Discharge/Return Anticipated MDS Assessment with ARD of 11/20/2023 and Quarterly MDS Assessment with ARD of 12/05/2023 had not been transmitted. Interview on 03/04/2024 at 2:02 p.m. with S1 DON revealed Resident #1's Discharge/Return Anticipated MDS Assessment with ARD of 11/20/2023 and Quarterly MDS Assessment with ARD of 12/05/2023 had not been transmitted timely, and should have been.

Based on record review, observation, and interview the facility failed to ensure Resident's person centered plan of care were reviewed and revised to include a focus with interventions/tasks to address the Resident's risk of Elopement/Wandering for 2 (#2, and #3) of 3 (#1, #2, #3) sampled Resident's care plans reviewed. Findings: Review of the facility's current list of Residents considered at risk for Elopement/Wandering with Wander Guard devices in place on 02/29/2024 at 8:55 a.m. revealed Resident #2 and Resident #3 were included on the list. Review of the facility's policy dated 03/2019 titled Wandering and Elopements on 02/29/2024 at 9:02 a.m. read in part .The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Resident #2 Review of Resident #2's clinical record revealed he was admitted to facility on 01/11/2023. Resident #2 had diagnoses that included in part .Cerebral Infarction, Type 2 Diabetes Mellitus, Schizoaffective Disorder- Bipolar Type, Vascular Dementia, Generalized Anxiety Disorder, and Depressive Disorders. Review of Resident #2's Quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 11/16/2023 revealed Resident had a BIMS (Brief Interview for Mental Status) of 12 (Moderate Cognitive Impairment). Resident#2 was dependent on staff for transfers. Review of Resident #2's Care Plan with target completion date of 05/09/2024 revealed it did not indicate or address that Resident #2 was at risk for Elopement/Wandering and utilized a Wander Guard device. Observation on 02/29/2024 at 1:50 p.m. of Resident #2 revealed he had a Wander Guard device secured to the underneath portion of his wheelchair. Resident #3 Review of Resident #3's clinical record revealed he was admitted to facility on 07/03/2023. Resident #3 had diagnoses including in part .Metabolic Encephalopathy, Dementia, Insomnia, Mood Disorder due to known physiological condition with Depressive features, Abnormalities of Gait and Mobility, and Muscle Wasting and Atrophy. Review of Resident #3's Quarterly MDS with ARD of 12/21/2023 revealed Resident had a BIMS of 12. Resident#3 required moderate physical assistance by staff for transfers. Review of Resident #3's Care Plan with target completion date of 04/26/2024 revealed it did not indicate or address that Resident #3 was at risk for Elopement/Wandering and utilized a Wander Guard device. Observation on 02/29/2024 at 2:00 p.m. of Resident #3 revealed he had a Wander Guard device secured to the underneath portion of his wheelchair. Interview on 02/29/2024 at 4:33 p.m. S2 MDS LPN revealed she was responsible for reviewing and revising care plans. S2 MDS LPN confirmed Resident #2 and Resident #3 were not care planned for risk of Elopement/Wandering and use of a Wader Gaurd device, but should have been.

Based on record review and interviews, the facility failed to conduct an annual staff performance review for 2 (S3CNA, S4CNA) out of 3 (S3CNA, S4CNA, S5CNA) CNA personnel records reviewed. Findings: Review of S3CNA's personnel record revealed a hire date of 07/07/2014. Further review revealed no documented evidence that a performance review was conducted. Review of S4CNA's personnel record revealed a hire date of 02/22/1999. Further review revealed no documented evidence that a performance review was conducted. On 04/19/2023 at 1:23 p.m., during an interview S1ADM confirmed the employee annual evaluations have not been completed on the staff identified for personnel file review.

Based on record review and interview, the facility failed to ensure CNA staff completed 12 hours per year in-service training including Dementia and Abuse Prevention for 7 (S3CNA, S4CNA, S5CNA, S8CNA, S9CNA, S10CNA, S11CNA) CNAs (Certified Nursing Assistants) out of 7 (S3CNA, S4CNA, S5CNA, S8CNA, S9CNA, S10CNA, S11CNA) sampled staff reviewed. Findings: Facility did not provide requested Annual Competency Policies by exit conference. Review of S3CNA's personnel file revealed a hire date of 07/07/2014. Further review of the personnel file revealed S3CNA had not completed Abuse Prevention Training within the last twelve months. Review of S4CNA's personnel file revealed a hire date of 02/22/1999. Further review of personnel file revealed S4CNA had not completed Abuse Prevention Training within the last twelve months. Review of S5CNA's personnel file revealed a hire date of 01/27/2023. Further review of personnel file revealed S5CNA had not completed Dementia Training. Review of the in-service logs for Resident Rights dated 01/31/2023, Aggressive Behavior and Redirection dated 03/03/2023 and Dementia training dated 03/20/2023 revealed S8CNA, S9CNA, S10CNA and S11CNA had not attend the in-services. On 04/19/2023 at 12:15 p.m., an interview was conducted with S7BOM, she reported the facility did not keep a personnel file for any agency staff. She confirmed she did not have personnel files including Dementia Training, Abuse Prevention Training or competencies for S8CNA, S9CNA, S10CNA and S11CNA, as the CNA's were Agency staff. She reported S2DON was responsible maintaining competency records. On 04/19/2023 at 12:20 p.m., an interview was conducted with S2DON, she confirmed the facility did not keep the personnel files, containing annual trainings and competencies for the agency staff. On 04/19/2023 at 1:18 p.m., an interview was conducted with S2DON, she confirmed annual training should be done on each employee upon hire and annually thereafter. On 04/19/2023 at 1:23 p.m., an interview was conducted with S1ADM, he confirmed the employee annual competency evaluations had not been completed on the staff identified for review.

Based on record review and interview, the facility failed to have a water management policies, procedures or an assessment of the facility's water system in order to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in order to implement specific measures to prevent the growth of Legionella and other opportunistic waterborne pathogens and how to monitor for them in the building's water systems. The facility's census was 57. Findings: Review of the facility's document titled, Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings revealed it was a CDC (Centers for Disease Control and Prevention) document, and the information contained within the document was not facility specific. Further review failed to reveal documentation that the facility had assessed where Legionella and other opportunistic waterborne pathogens could grow and spread; measures to prevent the growth in the building's water systems; a way to monitor the measures in place; and established ways to intervene when control limits were not met. On 04/19/2023 10:44 a.m., an interview was conducted with S1ADM and S2DON who stated that the facility did not have an assessment of their water system, or a plan that included measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems. He stated he was unaware of this new requirement and inquired about the regulation on water management. On 04/19/2023 10:46 a.m., S1ADM confirmed he did not have any documentation that the facility had assessed where Legionella and other opportunistic waterborne pathogens could grow and spread in the building; measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems that was based on nationally accepted standards; control measures the facility put in place nor a way to monitor the measures; or ways to intervene when control limits were not met.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and interview, the facility failed to protect the resident's right to be free from physical and/or verbal abuse for 3 residents (Resident #2, #R1, #R2) out of 3 (#2, #R1, #R2) residents investigated for abuse. The facility failed to protect: 1. Resident #R2 from verbal abuse when Resident #2 sweared at him on 2/21/23. 2. Resident #2 from physical abuse when Resident #R2 hit him with a closed fist on 2/21/23. 3. Resident #R1 from physical abuse when he was pushed by Resident #2 on 03/04/2023. This had the potential to effect a census of 57 residents. Findings: Review of the facility's policy titled Abuse Prevention read in part: Each resident shall remain free from harm. Reported suspected abuse, the incident will be immediately reported to the charge nurse, the charge nurse will immediately contact the DON (Director of Nursing), the charge nurse will then complete an incident report and the DON and/or Administrator will conduct an investigation per policy and federal/state guidelines. Physical Abuse was defined in part: as any physical motion of action, e.g. hitting, slapping, punching, directed toward the individual. Verbal Abuse was defined in part: as use of oral, written or gestured language by which abuse occurs including: name calling, swearing, taunting . Review of the facility's policy titled Resident-to-Resident Altercation read in part: All altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the nursing supervisor, the DON, and to the Administrator. Facility staff will monitor residents for aggressive behavior toward other residents or to staff. If two residents are involved in an altercation, staff will: Separate the residents, and institute measures to calm the situation; Identify what may have led to the aggressive conduct; document in resident's clinical record all interventions and their effectiveness; complete incident report and document the incident, findings, and any corrective measures taken in the resident's medical records; report incident, findings and corrective measures to appropriate agencies . 1. Resident #R2 Resident #R2, was admitted to the facility on [DATE] with diagnoses including Cerebral Vascular Accident, Bipolar Disorder, Vascular Dementia, Major Depression, Anxiety and Psychotic Symptoms. Review of Resident #R2's annual MDS dated [DATE] revealed Resident #R2 had a BIMS score of 04, indicating resident had severely moderate cognition deficit. Review of the Resident R2's care plan revealed resident had a resident-to-resident altercation on 02/21/2023. Resident had the potential to be physically aggressive related to schizoaffective disorder and impulsive disorder, hitting and pushing other residents. Interventions included in part: provide physical and verbal cues to alleviate anxiety, give positive feedback, encourage seeking out of staff member when agitated Review of nurses' notes by S7LPN for Resident #R2 revealed in part: 02/21/23 at 12:29 pm - Resident sitting apart from Resident #2, nursing staff separated after initial physical (open fist) contact was made. Informed per nursing staff of incident as follows: Resident #2 self-propelled in wheelchair when resident began to exhibit aggressive verbal behaviors such as get the F-away, Resident #R2's 1st failed attempt to grab Resident #2 by clothing, staff was able to separate and calm both residents. After nursing staff turned back, Resident #R2 propelled self to Resident #2 and made contact with closed fist, residents were separated and nurse summoned, reinforced teaching of keeping hands to self and extra activities of liking will be initiated by activities department to provide distractions s/p physical altercations episodes .will follow house protocol. Review of incident report S7LPN for Resident #R2, dated 02/21/2023 at 12:29 p.m., revealed nursing description as above nurses' notes with immediate action: separated and reinforcement of teaching given verbally, extra activities of liking will be initiated by activity department to provide distractions S/P limiting physical altercation episodes. Injury type: no injuries observed at time of incident. On 03/27/2023 at 10:50 a.m., an interview was conducted with S10CNA. She reported Resident #2 has had multiple verbal altercations with Resident #R2. On 03/27/2023 at 2:00 p.m., an interview was conducted with S2DON. She confirmed the resident-to-resident physical altercation between Resident #R2 and Resident #2 had occurred on 02/21/2023. 2. Resident #2 Resident #2 was admitted to facility on 12/18/2017 with diagnoses that included Traumatic Brain Injury, Violence Behavior, Insomnia, Psychosis, Seizures, Clutter headaches, Conduct Disorder, Persistent Mood Disorders, Major Depression, Impulsive Disorder, Extrapyramidal and movement disorder and Psychotic Disorder with Delusions. Review of Resident #2's Quarterly MDS (Minimum Data Set) dated 01/17/2023 revealed the resident's BIMS (Brief Interview for Mental Status) had a score of 04, indicating Resident #2 had moderately impaired cognition. Review of Resident #2's care plan revealed in part: Resident had mood and behavior problems related to psychotic disorder, mood disorder. Interventions included anticipate resident needs; assist resident with developing more appropriate methods of coping and interacting; and intervene as necessary to protect rights and safety of others. Additional interventions included approach/speak in a calm manner; divert attention; remove from situation and take to alternate location; and minimize potential for the resident's disruptive behaviors by offering tasks which divert attention . Review of nurses' notes by S7LPN for Resident #R2 revealed in part: 2/21/23 at 12:29 pm - Resident sitting apart from Resident #2, nursing staff separated after initial physical (open fist) contact was made. Informed per nursing staff of incident as follows: Resident #2 self-propelled in wheelchair when resident began to exhibit aggressive verbal behaviors such as get the F-away, Resident #R2's 1st failed attempt to grab Resident #2 by clothing, staff was able to separate and calm both residents. After nursing staff turned back, Resident #R2 propelled self to Resident #2 and made contact with closed fist, residents were separated and nurse summoned, reinforced teaching of keeping hands to self and extra activities of liking will be initiated by activities department to provide distractions s/p physical altercations episodes .will follow house protocol. Review of Resident #2's nurse's notes for 02/21/23 did not mention the verbal and physical incident that had occurred with Resident #R2. Review of the facility's incident reports from 02/01/2023 to 03/23/2023 failed to reveal any incident for Resident #2 on 02/21/2023. On 03/27/2023 at 1:12 p.m., an attempt to contact S7LPN for phone interview was made. Voice mail was received and a message was left for her to return the phone call. S7LPN had not returned the call by exit of survey On 03/27/2023 at 8:45 a.m., an interview was conducted with S1ADM, he confirmed Resident #2 had been involved in multiple resident-to-resident verbal and/or physical altercations with other residents. He confirmed he was notified of the altercation between Resident #2 and Resident #R2 on 02/21/2023. 3. Resident #R1 Resident #R1 was admitted to the facility on [DATE] with diagnosis that included Dementia with other Behavioral Disturbance, Mood disorder, Depression and Anxiety Disorder. Review of nurse's notes for Resident #2 revealed on 03/04/2023 at 4:08 p.m., Resident #2 was very aggressive and physical toward other residents and 1:1 sitter. He pushed a fellow resident, Resident #R1, against the wall hard. The DON was notified of the incident. Review of Resident #R1's nurses' notes for 03/04/23 did not mention the verbal and physical incident that had occurred with Resident #2. Review of the facility's incident reports from 03/01/2023 to 03/23/2023 failed to reveal any incidents for Resident #R1 or Resident #2 on 03/04/2023. Review of Resident #R1's MDS dated [DATE] revealed a BIMS of 99 indicating resident had moderate cognition deficits. On 03/27/2023 at 10:50 a.m., attempted an interview with Resident #R1. Resident #R1 was unable to understand what was being said to him. On 03/27/2023 at 8:15 a.m., an interview was conducted with S2DON. She confirmed that Resident #2 had a documented behavior of a verbal and physical altercation with Resident #R1 on 3/4/2023. She confirmed Resident #2 pushed a fellow resident (Resident #R1) against the wall. On 03/27/2023 at 8:45 a.m., an interview was conducted with S1ADM, he confirmed Resident #2 had been involved in multiple resident-to-resident verbal and/or physical altercations with other residents. He confirmed he was notified of the altercation between Resident #2 and Resident #R1 on 03/04/2023. On 03/27/2023 at 1:44 p.m., a telephone interview was conducted with S6LPN. She confirmed she was present when the resident-to-resident altercation between Resident #2 and Resident #R1 occurred. She stated that Resident #R1 was sitting in the hallway near Resident #2. Resident #2 became upset about something that was not going his way. When Resident #2 turned to leave area, Resident #R1 was in front of him when Resident #2 pushed him out of the way and into the wall. She reported Resident #R1 only said, Hey and both went on their way.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure alleged violation of abuse were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 2 (#2, #R2) out of 3 (#2, #R1, #R2) sampled residents. This had the potential to effect a census of 57 residents. Findings: Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating read in part: .1. If resident abuse . is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law . Resident #2 Resident #2 was admitted to facility on 12/18/2017 with diagnoses that included Traumatic Brain Injury, Violence Behavior, Insomnia, Psychosis, Seizures, Clutter headaches, Conduct Disorder, Persistent Mood Disorders, Major Depression, Impulsive Disorder, Extrapyramidal and movement disorder and Psychotic Disorder with Delusions. Further review of nurses' notes by S6LPN revealed on 03/04/2023 at 4:08 p.m., Resident #2 very aggressive and physical toward other residents. He pushed a fellow resident, Resident #R2, against the wall hard, cursing staff. The DON was notified of occurrence. Review of Resident #2's nurse's notes for 02/21/23 did not mention the verbal and physical incident that had occurred with Resident #R2. Review of the facility's incident reports from 02/01/2023 to 03/23/2023 failed to reveal any incident for Resident #2 on 02/21/2023. On 03/27/2023 at 1:44 p.m., a telephone interview was conducted with S6LPN, she confirmed she was present when the resident to resident altercation between Resident #2 and Resident #R1. She confirmed she did not identify the incident as an altercation because Resident #R1 was sitting in the hallway, Resident #2 was upset about something that was not going his way. Resident #2 was upset with the nurses trying to redirect him. As Resident #2 turned, Resident #R1 was in front of him, pushed Resident #R1 out of the way, into the wall. She confirmed she did not do any incident report on either resident, which had occurred. Resident #R2 Resident #R2, was admitted to the facility on [DATE] with diagnoses including Cerebral Vascular Accident, Bipolar Disorder, Vascular Dementia, Major Depression, Anxiety and Psychotic Symptoms. Review of nurses' notes by S7LPN for Resident #R2 revealed in part: 2/21/23 at 12:29 pm - Resident sitting apart from Resident #2, nursing staff separated after initial physical (open fist) contact was made. Informed per nursing staff of incident as follows: Resident #2 self-propelled in wheelchair when resident began to exhibit aggressive verbal behaviors such as get the F-away, Resident #R2's 1st failed attempt to grab Resident #2 by clothing, staff was able to separate and calm both residents. After nursing staff turned back, Resident #R2 propelled self to Resident #2 and made contact with closed fist, residents were separated and nurse summoned, reinforced teaching of keeping hands to self and extra activities of liking will be initiated by activities department to provide distractions after physical altercations episodes .will follow house protocol. Review of incident report for Resident #R2, dated 02/21/2023 at 12:29 p.m., revealed nursing description as above nurses' notes with immediate action: separated and reinforcement of teaching given verbally, extra activities of liking will be initiated by activity department to provide distractions after limiting physical altercation episodes. Injury type: no injuries observed at time of incident. On 03/27/2023 at 8:15 a.m., an interview was conducted with S2DON, she confirmed, on 03/04/2023 Resident #2 had a documented behavior of a verbal and physical altercation with Resident #R1. She confirmed, Resident #2 pushed a fellow resident (Resident #R1) against the wall. S2DON also confirmed an investigation of the verbal and physical altercations had not been investigated or reported to the State Survey Agency. On 03/27/2023 at 8:45 a.m., an interview was conducted with S1ADM, he confirmed Resident #2 had been involved in multiple resident-to-resident verbal and/or physical altercations with other residents. He also confirmed the altercations for between Resident #2 and Resident #R1 nor altercation between Resident #2 and Resident #R2 had been reported to the State Survey Agency. On 03/27/2023 at 2:00 p.m., an interview was conducted with S2DON. She confirmed the resident-to-resident verbal and physical altercation between Resident #R2 and Resident #2 had occurred on 02/21/2023 and were not reported to the State Survey Agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct investigations for allegations of physical and/or verbal abuse for 3 (#2, #R1, #R2) of 7 (#1,#2, #3, #4, #5, #R1 and #R2) sampled residents. The facility failed to investigate the following: 1. Resident #R2 verbally abused when Resident #2 swore at him on 2/21/23. 2. Resident #2 physically abused when Resident #R2 hit with a closed fist on 2/21/23. 3. Resident #R1 physical abuse when he was pushed by Resident #2 on 03/04/2023. The facility had a census of 57 residents. Findings: Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating revealed in part . All allegations are thoroughly investigated. The administrator initiates investigations. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of investigation. The individual conducting the investigation as a minimum: reviews the documentation and evidence; reviews the resident's medical record to determine the resident's physical and cognitive status at time of the incident; observed the alleged victim, including his or her interactions with staff and other residents; interviews the person reporting the incident and any witnesses and resident if appropriate; review all events leading to the alleged incident; and document the investigation completely and thoroughly. Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms and provides the completed documentation to the administrator. Physical Abuse was defined in part: as any physical motion of action, e.g. hitting, slapping, punching, directed toward the individual. Verbal Abuse was defined in part: as use of oral, written or gestured language by which abuse occurs including: name calling, swearing, taunting . Resident #R2 Resident #R2, was admitted to the facility on [DATE] with diagnoses including Cerebral Vascular Accident, Bipolar Disorder, Vascular Dementia, Major Depression, Anxiety and Psychotic Symptoms. Review of Resident #R2's annual MDS dated [DATE] revealed Resident #R2 had a BIMS score of 04, indicating resident had severely moderate cognition deficit. Review of nurse's notes by S7LPN for Resident #R2 revealed in part: 02/21/23 at 12:29 pm - Resident sitting apart from Resident #2, nursing staff separated after initial physical (open fist) contact was made. Informed per nursing staff of incident as follows: Resident #2 self-propelled in wheelchair when resident began to exhibit aggressive verbal behaviors such as get the F-away, Resident #R2's 1st failed attempt to grab Resident #2 by clothing, staff was able to separate and calm both residents. After nursing staff turned back, Resident #R2 propelled self to Resident #2 and made contact with closed fist, residents were separated and nurse summoned, reinforced teaching of keeping hands to self and extra activities of liking will be initiated by activities department to provide distractions after physical altercations episodes .will follow house protocol. Review of incident report for Resident #R2, dated 02/21/2023 at 12:29 p.m., revealed nursing description as above nurses' notes with immediate action: separated and reinforcement of teaching given verbally, extra activities of liking will be initiated by activity department to provide distractions after limiting physical altercation episodes. Injury type: no injuries observed at time of incident. Review of the Resident R2's care plan revealed resident had a resident-to-resident altercation on 02/21/2023. Resident had the potential to be physically aggressive related to schizoaffective disorder and impulsive disorder, hitting and pushing other residents. Interventions included in part: provide physical and verbal cues to alleviate anxiety, give positive feedback, and encourage seeking out of staff member when agitated Resident #2 Review of Resident #2's electronic record revealed an admission date of 12/18/2017 with diagnoses that included Traumatic Brain Injury, Violence Behavior, Insomnia, Psychosis, Seizures, Clutter headaches, Conduct Disorder, Persistent Mood Disorders, Major Depression, Impulsive Disorder, Extrapyramidal and movement disorder and Psychotic Disorder with Delusions. Review of Resident #2's Quarterly MDS (Minimum Data Set) dated 01/17/2023 revealed the resident's BIMS (Brief Interview for Mental Status) had a score of 04, indicating Resident #2 had moderately impaired cognition. Review of Resident #2's nurses' notes for 02/21/23 did not mention the verbal and physical incident that had occurred with Resident #R2. Further review of nurses' notes by S6LPN revealed on 03/04/2023 at 4:08 p.m., Resident #2 very aggressive and physical toward other residents and 1:1 sitter. He pushed a fellow resident against the wall hard, cursing staff. DON was notified of occurrence. Review of the facility's incident reports from 02/01/2023 to 03/23/2023 failed to reveal any incident for Resident #2 on 02/21/2023. On 03/27/2023 at 1:12 p.m., an attempted to contact S7LPN, for phone interview, left message for return phone call. No return call by exit of survey. S7LPN provided the documentation for Resident #R2's resident-to-resident altercation that occurred on 02/21/2023. Resident #R1 Resident #R1 was admitted to the facility on [DATE] with diagnosis that included Dementia with other Behavioral Disturbance, Mood disorder, Depression and Anxiety Disorder. Review of resident R1's MDS dated [DATE] revealed a BIMS of 99 indicating resident had moderate cognition deficits. Review of the incident report from 03/01/2023 to 03/23/2023, revealed there was no documented incident report of abuse allegation for Resident #R1. Review of Resident #R1's nurses' notes for 03/04/23 did not mention the verbal and physical incident that had occurred with Resident #2. Review of the facility's incident reports from 03/01/2023 to 03/23/2023 failed to reveal any incident for #R1 or Resident #2 on 03/04/2023. Review of the facility's Grievances/Complaint record from January to March 23, 2023 revealed there were no grievances related to Resident #2 #R1 or #R2. On 03/27/2023 at 8:15 a.m., an interview was conducted with S2DON, she confirmed, on 03/04/2023 Resident #2 had a documented behavior of a verbal and physical altercation with Resident #R1. She confirmed, Resident #2 pushed a fellow resident (Resident #R1) against the wall. S2DON also confirmed an investigation of the verbal and physical altercations had not been investigated. On 03/27/2023 at 8:45 a.m., an interview was conducted with S1ADM, he confirmed Resident #2 had been involved in multiple resident-to-resident verbal and/or physical altercations with other residents. He also confirmed there were no investigations conducted for the altercations for between Resident #2 and Resident #R1 or altercation between Resident #2 and Resident #R2. On 03/27/2023 at 2:00 p.m., an interview was conducted with S2DON. She confirmed the resident-to-resident verbal and physical altercations between Resident #R2 and Resident #2 had occurred on 02/21/2023 and no investigation was completed for the altercation.