**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to ensure each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (#54) of 13 (#3, #4, #14, #20, #26, #30, #33, #39, #54, #61, #65, #67, and #80) residents observed for dignity during incontinence care. The facility failed to ensure staff greeted the resident and explained the care to be provided. Findings: Review of the facility's General admission and Financial Agreement, packet dated 01/2023 revealed the following: IX Educational Material & Consents B. Residents Rights - Every resident in this facility has the right to: 12. Be treated courteously, fairly, and with the fullest measure of dignity. Review of Resident #54's Clinical Record revealed he was admitted on [DATE] with diagnoses which included the following in part; Unspecified Dementia without behavioral disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety, and Cognitive Communication Deficit. Review of Resident #54's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/19/2025 revealed the provider assessed the resident as having a Brief Interview for Mental Status (BIMS) of 3, indicating the resident was severely cognitively impaired. Further review revealed he was incontinent of bowel and bladder and was dependent on staff for toileting hygiene. On 04/29/2025 at 12:40 a.m., an observation was made of S14CNA entering Resident #54's room to perform perineal care. Resident was noted to be asleep, facing the wall away from S14CNA. Without speaking to the resident or explaining the care she would provide, S14CNA removed Resident #54's blanket. Without speaking to the resident, S14CNA turned Resident #54 to his back. Resident #54 began shaking as S14CNA prepared to perform perineal care. On 04/29/2025 at 1:03 a.m., an interview was conducted with S14CNA. She confirmed the above observations and stated she should have announced her presence before startling Resident #54 awake. She stated she should have greeted the Resident #54 and explained the care she would be providing. On 04/29/2025 at 1:28 a.m., an interview was conducted with S2DON. S2DON stated she would expect staff to greet residents when entering the room and explain the care to be provided.

Based on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status. The facility failed to ensure staff accurately coded the correct discharge location for 1 (#93) of 3 (#93, #94, and #95) residents reviewed for closed records. Findings: Review of Resident #93's Discharge Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 01/28/2025 revealed Resident #93 was discharged to a Short-Term General Hospital. Review of Resident #93's January 2025 Physician's Orders revealed the following, in part: 01/24/2025 Discharge home with Home Health. Review of Resident #93's Nurse's Notes revealed the following, in part: 01/28/2025 at 11:10 a.m. Resident exited the facility via manual wheel chair. En route to group home with medications. On 04/30/2025 at 11:40 a.m., an interview was conducted with S15MDS. She reviewed Resident #93's Nurse's Notes and confirmed he discharged to a group home. She reviewed Resident #93's Discharge MDS with an ARD of 01/28/2025 and confirmed it indicated he discharged to a Short-Term General Hospital. She confirmed Resident #93's discharge status was not coded correctly and should have been coded as discharged to home/community. On 04/30/2025 at 1:38 p.m., an interview was conducted with S2DON. She stated she expected MDS nurses to complete all assessments to accurately reflect each residents' discharge status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received fingernail care to maintain good hygiene for 1 (#198) of 3 (#3, #26, and #198) residents reviewed for ADLs. Findings: Review of the facility's policy dated 08/01/2017 and titled, Bath, Bed Policy and Procedure revealed the following, in part: Procedure: 16. Care of fingernails and toenails are part of the bath. Be certain nails are clean. Review of Resident #198's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Malignant Neoplasm of Brain and Traumatic Hemorrhage of Right Cerebrum Without Loss of Consciousness. Further review of the Clinical Record revealed Resident #198 was dependent on staff for ADLs. Review of Resident #198's Bath Documentation dated April 2025 revealed she was scheduled to receive baths on Tuesdays, Thursdays, and Saturdays. Further review revealed she received a bath on 04/29/2025. An observation was made of Resident #198 on 04/28/2025 at 9:04 a.m. Her bilateral fingernails had a black substance underneath. An observation was made of Resident #198 on 04/29/2025 at 8:20 a.m. She was sitting up in bed eating her breakfast. She was eating her French toast stick with her hands. Her fingernails had a black substance under them. An interview was conducted with Resident #198 at that time. She confirmed her fingernails were dirty. She stated she wanted to get in the bath and clean her nails. An observation was made of Resident #198 on 04/29/2025 at 1:11 p.m. Her fingernails had a black substance under them. An interview was conducted with Resident #198 at that time. She stated she had her bath today, but the CNA did not clean under her nails. Resident #198 stated her nails were still dirty. An observation was made of Resident #198's nails with S4LPN present on 04/29/2025 at 1:15 p.m. S4LPN confirmed Resident #198's nails had a black substance underneath them and they needed to be cleaned. S4LPN confirmed Resident #198 was dependent on staff for nail care. An interview was conducted with S5CNA on 04/29/2025 at 1:23 p.m. She stated Resident #198 received a bath today. She stated nail care should have been part of a bath. She confirmed Resident #198 was dependent on staff for ADLs. An interview was conducted with S2DON on 04/29/2025 at 4:04 p.m. She stated the staff should have ensured the cleanliness of residents' nails. She stated resident nail care should have been completed during baths and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident at risk for pressure ulcer development received care consistent with professional standards of practice and based on the comprehensive assessment by failing to float heels while in bed for 1 (#197) of 2 (#8 and #197) residents reviewed with Pressure Ulcers. Findings: Review of the facility's policy dated 11/17/2014 and titled, Pressure Ulcer, Prevention of Policy and Procedure revealed the following, in part: Purpose: To prevent skin breakdown and development of pressure sores. Policy: Pressure Ulcer prevention will be used as ordered and/or as applicable. Procedure: 3. Develop care plan to eliminate or minimize risk factors. d. Pressure relief 7. Use pressure reducing or relieving devices as necessary. Review of Resident #197's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Pressure Ulcer of Sacral Region - Stage 4, Type 2 Diabetes Mellitus without Complications, and Unspecified Severe Protein-Calorie Malnutrition. Review of Resident #197's admission MDS with an ARD of 04/09/2025 revealed a BIMS of 13, which indicated he was cognitively intact. Further review of the MDS revealed he required partial/moderate assistance from staff with rolling from side to side, required substantial/maximal assistance from staff with sitting to lying and lying to sitting, and was at risk for pressure ulcer development. Review of Resident #197's Braden Scale for Predicting Pressure Sore Risk dated 04/16/2025 revealed a score of 15, which indicated he was at risk for pressure ulcer development. Review of Resident #197's current Physician Orders revealed an order to float heels while in bed which started on 04/10/2025. Review of Resident #197's current Care Plan revealed the following, in part: Problem: Risk for impaired skin integrity. Interventions: Utilize pressure relieving devices on appropriate surfaces. An observation was made of Resident #197 on 04/29/2025 at 8:12 a.m. He was lying in bed. His heels were resting on the mattress and not floated. An interview was conducted with Resident #197 at that time. Resident #197 stated the staff had not been floating his heels. An observation was made of S5CNA performing incontinence care on Resident #197 on 04/29/2025 at 9:30 a.m. Resident #197's heels were resting on the mattress and not floated. An interview was conducted with S6CNA on 04/29/2025 at 10:22 a.m. She confirmed she was Resident #197's CNA on 04/28/2025 from 10:00 p.m. to 6:00 a.m. She confirmed Resident #197's heels were not floated on her shift last night. She confirmed Resident #197 did not refuse to have his heels floated and they should have been floated last night. An observation was made of Resident #197 with S4LPN present on 04/29/2025 at 11:04 a.m. He was lying in bed. His heels were resting on the mattress and not floated. An interview was conducted with S4LPN at that time. S4LPN confirmed Resident #197's heels were not floated. An interview was conducted with S4LPN on 04/29/2025 at 11:25 a.m. She confirmed Resident #197 was at risk for pressure ulcer development and had a physician order to float heels while in bed. She stated Resident #197's heels should have been floated while in bed. An interview was conducted with S5CNA on 04/29/2025 at 1:23 p.m. She confirmed she was Resident #197's CNA from 6:00 a.m. to 2:00 p.m. today. She stated she should have floated Resident #197's heels and had not. An observation was made of Resident #197 on 04/30/2025 at 9:06 a.m. He was lying in bed. His heels were resting on the mattress and not floated. An interview was conducted with S3LPN on 04/30/2025 at 9:29 a.m. She stated Resident #197's mobility status put him at risk for additional pressure ulcer development. She stated Resident #197's heels should have been floated while in bed. An interview was conducted with S2DON on 04/30/2025 at 1:45 p.m. She confirmed Resident #197 was at risk for pressure ulcer development. She confirmed Resident #197's heels should have been floated while in bed to help prevent pressure ulcer development.

Based on observations, record review and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. The facility failed to ensure: 1. An insulin pen was labeled with an opened date for Resident #82 during an observation of medication administration; 2. Eye Drops were labeled with an opened date on 1(Med Cart b) of 2 (Med Cart a and Med Cart b) medication carts reviewed; and 3. Insulin pens were labeled with an opened date on 1(Med Cart b) of 2 (Med Cart a and Med Cart b) medication carts reviewed. This deficient practice had the potential to affect all of the 98 residents residing in the facility. Findings: On 04/28/2025 at 11:39 a.m., during an observation of medication pass with S17LPN, Resident #82's Novolog FlexPen Subcutaneous Solution Pen was observed to not contain an opened date. On 04/28/2025 at 11:39 a.m., an interview was conducted with S17LPN. S17LPN confirmed Resident #82's Novolog FlexPen Subcutaneous Solution Pen did not have an opened dated and she did not know when the pen was opened. On 04/28/2025 at 12:00 p.m., an observation was made of Med Cart b with S4LPN which revealed the following: Resident #30's Lantus SoloStar Subcutaneous Solution Pen-Injector was opened and had no opened date; and Resident #147's Latanoprost Ophthalmic Solution 0.005% was opened and had no opened date. On 04/28/2025 at 12:00 p.m., an interview was conducted with S4LPN. S4LPN confirmed there was no opened date on Resident #30's Lantus SoloStar Subcutaneous Solution Pen-Injector. S4LPN confirmed she did not know the date when the pen was opened. S4LPN confirmed insulin pens should have an opened date. S4LPN confirmed Resident #147's Latanoprost Ophthalmic Solution 0.005% had no opened date. On 04/29/2025 at 10:37 a.m., an interview was conducted with S2DON. S2DON confirmed nurses were expected to date insulin pens and eye drops when they are opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure S16LPN completed and accurately documented interventions on the Medication Administration Record (MAR) for 1 (#94) of 3 (#93, #94, and #95) residents reviewed as closed records. Findings: Review of Resident #94's clinical record revealed the resident was re-admitted to the facility on [DATE] and had diagnoses which included Acute Respiratory Failure with Hypercapnia, Anxiety Disorder, Hypertensive Heart Disease without Heart Failure, and Amyotrophic Lateral Sclerosis. Review of Resident # 94's MAR dated February 2025 revealed the following, in part: Catheter - document the amount of urine output every 8 hours total every shift - No documentation for the day shift on 02/22/2025; Catheter - urine clarity . every shift - No documentation for the day shift on 02/22/2025; Catheter - urine color . every shift - No documentation for the day shift on 02/22/2025; Catheter - urine odor . every shift - No documentation for the day shift on 02/22/2025; Document non-pharmacological interventions implemented during shift . every shift - No documentation for the day shift on 02/22/2025; Enteral Feeding Order every shift Enteral: Check and record residuals every (q) shift. Contact physician if residual exceeds 100 cubic centimeter. - No documentation for the day shift on 02/22/2025; Enteral Feed Order every shift Enteral: check the placement before the initiation of formula, medication administration, and flushing tube or at least q 8 hours. - No documentation for the day shift on 02/22/2025; Enteral Feeding Order every shift Enteral: Document the amount of formula and water provided q 8 hours - total intake q 24 hours - No documentation for the day shift on 02/22/2025; Monitor for the following behaviors: itching, picking at skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusal of care every shift. - No documentation for the day shift on 02/22/2025; Observe closely for side effects of Diuretic medication every shift. -No documentation for the day shift on 02/22/2025; and Observe closely for significant side effects of anti-anxiety medication . every shift - No documentation for the day shift on 02/22/2025. Attempts were made to interview S16LPN and were unsuccessful. On 04/30/2025 at 11:08 a.m., an interview was conducted with S2DON. S2DON confirmed S16LPN cared for Resident #94 on the day shift of 02/22/2025. S2DON reviewed Resident #94's February MAR and confirmed S16LPN did not document on the aforementioned findings. S2DON confirmed she expected nurses to document interventions if they completed them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure there was a functioning call system to allow residents to call for staff assistance for 1 (#26) of 5 (#1, #14, #26, #79, and #197) residents reviewed for environment. This deficient practice had the potential to affect any of the 98 residents residing in the facility who utilized the call light system. Findings: Review of the facility's policy titled, Resident Call Light System Policy and Procedure with an effective date of 09/14/2022, revealed the following, in part: Purpose: 1. To provide a communication system with audible or visual signals to allow residents to call for staff assistance from their bedsides . The communication system should relay the call directly to a centralized staff work area. 3. To assure call system is in proper working order. Review of the facility's Daily Maintenance Log dated April 2025 revealed the following, in part: Date of Issue: 04/27/2025, Location: Resident #26's room, Maintenance Issue: Call light won't turn off. Date of Issue: 04/27/2025, Location: Resident #26's room, Maintenance Issue: Light-call keeps going off-Resident #26. Review of Resident #26's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #26's Quarterly MDS with an ARD of 03/19/2025 revealed a BIMS of 14, which indicated she was cognitively intact. Further review revealed Resident #26 required staff assistance with toileting and personal hygiene. On 04/28/2025 at 10:48 a.m., an interview was conducted with Resident #26. She stated her call light stopped working yesterday, on 04/27/2025. She stated staff tried to fix it, but could not. A piece of tape was observed on the call light box on the wall. There were two call light cords observed in Resident #26's room in reach. Each call light was tested by Resident #26 and the surveyor and both were observed not to function or illuminate outside of the room. On 04/28/2025 at 11:35 a.m., an observation was made of Resident #26's call lights with S12CNAS. She stated Resident #26 was oriented and able to use her call light. She tested the call light and confirmed the call light did not function or illuminate outside of the room for Resident #26. She reviewed the Maintenance Log book and confirmed there were two entries dated 04/27/2025 for Resident #26's call light not functioning. She stated staff should have contacted S10MS when Resident #26's call light stopped functioning on 04/27/2025. On 04/28/2025 at 11:47 a.m., an observation was made of Resident #26's call lights with S10MS and S11FT. S10MS and S11FT confirmed the call light did not function or illuminate outside of the room for Resident #26. On 04/29/2025 at 12:50 p.m., an interview was conducted with S10MS. He stated he reviewed the Maintenance Log book on the morning of 04/28/2025 and saw two entries dated 04/27/2025 for Resident #26's call light not functioning. He stated he was not notified by staff on 04/27/2025 about Resident #26's call light. He stated he assessed the call light around 8:30 a.m. on 04/28/2025 and confirmed it was not functioning. He stated staff should have notified him or S1ADM on 04/27/2025 about Resident #26's call light not functioning. On 04/29/2025 at 3:02 p.m., a telephone interview was conducted with S8LPN. She verified she worked on 04/27/2025 from 7:00 p.m. to 7:00 a.m. and was assigned to Resident #26. She stated Resident #26 required staff assistance with ADLs and used her call light. She stated during her shift on 04/27/2025, Resident #26's call light was broken. She stated the call light stayed on, kept alarming and would not turn off. She stated she placed tape on the call light box in Resident #26's room to keep it from alarming. She confirmed she did not contact S10MS or Administrative staff about Resident #26's call light not functioning. She stated she documented the call light issue in the Maintenance Log book knowing S10MS would be at the facility in the morning, on 04/28/2025. On 04/30/2025 at 8:32 a.m., a telephone interview was conducted with S7LPN. She verified she worked on 04/27/2025 from 7:00 a.m. to 7:00 p.m. and was assigned to Resident #26. She stated Resident #26 required staff assistance with ADLs and used her call light. She stated during her shift on 04/27/2025, sometime after lunch, Resident #26's call light broke, would not turn off, she tried to repair it, but could not. She stated she documented the call light issue in the Maintenance Log book at the nurses' station. She confirmed she did not contact S10MS or Administrative staff about Resident #26's call light not functioning. On 04/30/2025 at 12:05 p.m., an interview was conducted with S1ADM and S2DON. S2DON stated when a resident had a non-functioning call light, staff should write the issue in the Maintenance Log book and contact the Maintenance Supervisor. S2DON stated if the Maintenance Supervisor did not answer, S1ADM should be notified. S1ADM and S2DON stated they were made aware of Resident #26's call light not functioning on 04/28/2025 by S10MS after he reviewed the Maintenance Log book. S1ADM and S2DON confirmed staff should have contacted S10MS or S1ADM on 04/27/2025 to address Resident #26's nonfunctioning call light.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to implement a person-centered care plan by failing to perform blood sugar monitoring according to sliding scale and monitor the side effects/effectiveness of medications for 4 (#12, #24, #46, and #70) of 4 (#12, #24, #46, and #70) resident's reviewed. Findings: Resident #12 Review of admission Records for Resident #12 revealed he was admitted to the facility on [DATE] with diagnosis that included, in part: Type 2 Diabetes Mellitus, Major Depressive Disorder, and Anxiety. Review of Quarterly MDS, revealed Resident #12 had BIMS 9, indicating cognitive impairment. Review of Plan of Care for Resident #12 dated 02/24/2025 included, in part: 1. Problem: Resident has Diabetes Mellitus Interventions: Diabetes medications as ordered by the doctor. 2. Problem: Resident uses antidepressant medication Interventions: Administer Antidepressant medications as ordered by physician, monitor and document adverse reactions, side effects and effectiveness as ordered Q Shift. 3. Problem: Resident is on anticoagulant therapy Interventions: Administer Anticoagulant medications as ordered by physician, monitor for side effects and effectiveness. 4. Problem: Resident uses Anxiety medications Intervention: Administer Anti-Anxiety Medications as ordered by physician, monitor for side effects and effectiveness Q Shift. 5. Problem: Resident is on sedative/hypnotic therapy r/t insomnia. Intervention: Administer sedative/hypnotic medications as ordered by physician, monitor for side effects and effectiveness Q Shift. Review of Current Physician's Orders for Resident #12 revealed, in part: 1. Novolin R Injection Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0 ; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD , subcutaneously one time a day related to Type 2 Diabetes Mellitus. 2 Monitor for the following behaviors: itching, picking at skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusal of care every shift. 7. Monitor closely for significant side effects of Anti-Anxiety Medications including drowsiness, slurred speech, dizziness, nausea, aggressive or impulsive behavior every shift. 8. Observe closely for side effects of Anticoagulant medication including discolored urine, black tarry stools, sudden severe headache, nausea or vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status or vital signs, shortness of breath, nose bleeds every shift. 9. Observe closely for side effects of Anti-Depressant medications drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations or other unusual changes in mood or behavior every shift. Review of April 2025 Medication Administration Record for Resident #12 revealed, in part: 1. Novolin R Injection Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0 ; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD , subcutaneously one time a day related to Type 2 Diabetes Mellitus - no blood sugar documented on 04/27/2025 at 8:00 p.m. 2. Monitor for the following behaviors: itching, picking at skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusal of care every shift - not documented as monitored on 04/27/2025 Evening Shift or Night Shift 3. Monitor closely for significant side effects of Anti-Anxiety Medications including drowsiness, slurred speech, dizziness, nausea, aggressive or impulsive behavior every shift - not documented as monitored on 04/27/2025 Evening Shift or Night Shift 4. Observe closely for side effects of Anticoagulant medication including discolored urine, black tarry stools, sudden severe headache, nausea or vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status or vital signs, shortness of breath, nose bleeds every shift - not documented as monitored on 04/27/2025 Evening Shift or Night Shift 5. Observe closely for side effects of Anti-Depressant medications including drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations or other unusual changes in mood or behavior every shift - not documented as monitored on 04/27/2025 Evening Shift or Night Shift On 04/29/2025 an interview was conducted with Resident #12. He stated he did not remember if his blood sugar was checked on 04/27/2025 before bedtime. Resident #24 Review of admission Records for Resident #24 revealed he was admitted to the facility on [DATE] with diagnosis that included, in part: Type 2 Diabetes Mellitus, Schizophrenia, Major Depressive Disorder, Insomnia, and Anxiety Disorder. Review of Quarterly MDS, with ADR 11/16/2024 revealed Resident #24 had BIMS14, indicating he was cognitively intact. Review of Plan of Care for Resident #24 dated 01/28/2025 included, in part: 1. Problem: Resident has risk for behavior problem r/t Schizophrenia Interventions: Administer medications as ordered, monitor for side effects and effectiveness Q Shift. 2. Problem: Resident has Diabetes Mellitus Interventions: Diabetes medications as ordered by the doctor. 3. Problem: Resident uses psychotropic medications r/t Schizophrenia Interventions: Administer medications as ordered, monitor for side effects and effectiveness Q Shift. 4. Problem: Resident uses Anti-Depressant Medications. Interventions: Administer Antidepressant medications as ordered by physician, monitor and document adverse reactions, side effects and effectiveness as ordered Q Shift. Review of Current Physician's Orders for Resident #24 revealed, in part: 1. Humulin R Injection Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0 ; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD , subcutaneously one time a day related to Type 2 Diabetes Mellitus. 2. Monitor for the following behaviors: itching, picking at skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusal of care every shift. 3. Monitor closely for side effects of Antipsychotic medication including dry mouth, constipation, blurred vision, disorientation or confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea or vomiting, lethargy, drooling, EPS symptoms every shift. 4. Observe closely for side effects of Anti-Depressant medications drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations or other unusual changes in mood or behavior every shift. Review of April 2025 Medication Administration Record for Resident #24 revealed, in part: 1. Humulin R Injection Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0 ; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD , subcutaneously one time a day related to Type 2 Diabetes Mellitus - no blood sugar is documented on 04/27/2025 at 8:00 p.m. 2. Monitor for the following behaviors: itching, picking at skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusal of care every shift - not documented as monitored on 04/27/2025 Evening Shift or Night Shift. 3. Monitor closely for side effects of Antipsychotic medication including dry mouth, constipation, blurred vision, disorientation or confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea or vomiting, lethargy, drooling, EPS symptoms every shift - not documented as monitored on 04/27/2025 Evening Shift or Night Shift. 4. Observe closely for side effects of Anti-Depressant medications including drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations or other unusual changes in mood or behavior every shift - not documented as monitored on 04/27/2025 Evening Shift or Night Shift. On 04/12/2025 an interview was conducted with Resident #24, he was unable to provide information. Resident #46 Resident was admitted on [DATE] with diagnosis that included: Cerebral Vascular Disease, Long term use of Insulin, Muscle Weakness, Other lack of Coordination, Type 2 Diabetes Mellitus, and Hypertensive Heart Disease. Review of Quarterly MDS, with ARD of 01/22/2025 revealed he had a BIMS 14 indicating he was cognitively intact. Review of Plan of Care for Resident #46 dated 01/28/2025 included, in part: 1. Problem: Resident has Diabetes Mellitus Interventions: Diabetes medications as ordered by the doctor. 2. Problem: Resident is on anticoagulant therapy. Interventions: Administer Anticoagulant medications as ordered by the physician. Monitor for side effects and effectiveness Q Shift. Review of Current Physician's Orders for Resident #46 revealed, in part: 1. Humulin R Insulin Subcutaneous Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0, if blood sugar is less than 60 give sugar/juice and recheck in 30 minutes and notify MD; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD recheck in 30 minutes, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus. 2. Observe closely for side effects of Anticoagulant medication including discolored urine, black tarry stools, sudden severe headache, nausea or vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status or vital signs, shortness of breath, nose bleeds every shift. Review of April 2025 Medication Administration Record for Resident #46 revealed, in part: 1. Humulin R Insulin Subcutaneous Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0, if blood sugar is less than 60 give sugar/juice and recheck in 30 minutes and notify MD; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD recheck in 30 minutes, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus - no blood sugar documented on 04/27/2025 at 8:00 p.m. 6. Observe closely for side effects of Anticoagulant medication including discolored urine, black tarry stools, sudden severe headache, nausea or vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status or vital signs, shortness of breath, nose bleeds every shift - not documented as monitored on 04/27/2025 Evening or Night Shift. On 04/29/2024 at 9: 30 a.m. an interview was conducted with Resident #46. Resident #46 stated that his blood sugar was not monitored on 04/27/2025 at 8:00 p.m. Resident #70 Review of admission Records for Resident #70 revealed he was admitted to the facility on [DATE] with diagnosis that included, in part: Alzheimer's Disease, Dementia, Type 2 Diabetes Mellitus, Long Term Use of Insulin, Long Term Use of Anticoagulants, and Glaucoma. Review of Quarterly MDS, with ADR revealed Resident #70 had BIMS 9, indicating he had cognitive impairment. Review of Plan of Care for Resident #70 dated 01/28/2025 included, in part: 1. Problem: Resident has Diabetes Mellitus Interventions: Diabetes medications as ordered by the doctor. Review of Current Physician's Orders for Resident #70 revealed, in part: 1. Humalog Subcutaneous Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0, if blood sugar is less than 60 give sugar/juice and recheck in 30 minutes and notify MD; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD recheck in 30 minutes, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus. 2. Observe closely for side effects of Anticoagulant medication including discolored urine, black tarry stools, sudden severe headache, nausea or vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status or vital signs, shortness of breath, nose bleeds every shift. Review of April 2025 Medication Administration Record for Resident #70 revealed, in part: 1. Humalog Subcutaneous Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0, if blood sugar is less than 60 give sugar/juice and recheck in 30 minutes and notify MD; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD recheck in 30 minutes, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus - no blood sugar documented on 04/27/2025 at 8:00 p.m. 2. Observe closely for side effects of Anticoagulant medication including discolored urine, black tarry stools, sudden severe headache, nausea or vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status or vital signs, shortness of breath, nose bleeds every shift - not documented as monitored on 04/27/2025 Evening or Night Shift. On 04/29/2025 attempted interview with Resident #70, he was not able to voice any information about care on 04/27/2025 7:00 p.m. to 7:00a.m. On 04/29/2025 at 2:00 p.m., an interview was conducted with S18LPN. S 18 LPN stated she was working in the facility on 04/27/2025 from 7:00 p.m. to 7:00 a.m. She stated she did not get report and did not know she was assigned to Resident #12, Resident #24, Resident #46, or Resident #70, and did not complete blood sugar monitoring, or observations of these residents. On 04/29/2024 an interview was conducted with S2DON. S2DON stateS2DON stated S18LPN was assigned to Resident #12, Resident #24, Resident #46, and Resident #70. S2DON stated she had spoken with S18LPN who confirmed she did not complete blood sugar monitoring or make observations of Resident #12, Resident #24, Resident #46, or Resident #70 on 04/27/2025 during her 7:00 p.m. -7:00 a.m. shift. S2DON reviewed the Medication Administration Records for Resident #12, Resident #24, Resident #46, and Resident #70 and confirmed there was no documentation of blood sugar checks or monitoring for side effects of medications by S18LPN, and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to provide pharmaceutical services, including procedures that assure the dispensing and administering of all drugs and biologicals to meet the needs of each resident. The facility failed to ensure medications were administered for 4 (#12, #24, #46, and #70) of 4 (#12, #24, #46, and #70) residents reviewed for medication administration. Findings: Resident #12 Review of admission Records for Resident #12 revealed he was admitted to the facility on [DATE] with diagnosis that included, in part: Type 2 Diabetes Mellitus, Hyperlipidemia, and Insomnia. Review of Quarterly MDS (Minimum Data Set), with ARD (Assessment Data Reference) of 01/29/2025 for Resident #12 revealed he had a BIMS of 9, indicating cognitive impairment. Review of Plan of Care for Resident #12 dated 02/24/2025 included, in part: 1. Problem: Resident has Diabetes Mellitus Interventions: Diabetes medications as ordered by the physician. 2. Problem: Resident is on sedative/hypnotic therapy related to insomnia. Intervention: Administer sedative/hypnotic medications as ordered by physician. Review of Current Physician's Orders for Resident #12 revealed, in part: 1. Novolin R Injection Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0 ; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD , subcutaneously one time a day related to Type 2 Diabetes Mellitus. 2. Lantus Solostar 100 u/ml inject 30 units subcutaneously at bedtime related to Type 2 Diabetes Mellitus. 3. Atorvastatin Calcium Oral Tablet 40 mg give one tablet by mouth at bedtime related to Hyperlipidemia. 4. Melatonin oral tablet 5 mg give one tablet by mouth at bedtime for insomnia. 5. Metoclopramide HCL Oral tablet 5 mg give one tablet by mouth at bedtime for nausea. Review of April 2025 Medication Administration Record for Resident #12 revealed, in part: 1. Novolin R Injection Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0 ; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD , subcutaneously one time a day related to Type 2 Diabetes Mellitus - not documented as administered on 04/27/2025 at 8:00 p.m. 2. Lantus Solostar 100 u/ml inject 30 units subcutaneously at bedtime related to Type 2 Diabetes Mellitus not documented as administered on 04/27/2025 at 8:00 p.m. 3. Atorvastatin Calcium Oral Tablet 40 mg give one tablet by mouth at bedtime related to Hyperlipidemia - not documented as administered on 04/27/2025 at 8:00 p.m. 4. Melatonin oral tablet 5 mg give one tablet by mouth at bedtime for insomnia - not documented as administered on 04/27/2025 at 8:00 p.m. 5. Metoclopramide HCL Oral tablet 5 mg give one tablet by mouth at bedtime for Nausea - not documented as administered on 04/27/2025 at 8:00 p.m. On 04/29/2025 at 1:00 p.m., an interview was conducted with Resident #12. He stated he did not remember if he received medications on 04/27/2025 at 8:00 p.m. Resident #24 Review of admission Records for Resident #24 revealed he was admitted to the facility on [DATE] with diagnosis that included, in part: Type 2 Diabetes Mellitus, Schizophrenia, and Hyperlipidemia. Review of Quarterly MDS, with ADR 11/16/2024 for Resident #24 revealed he had a BIMS of 14, indicating he was cognitively intact. Review of Plan of Care for Resident #24 dated 01/28/2025 included, in part: 1. Problem: Resident has Diabetes Mellitus Interventions: Administer Diabetes medications as ordered by the physician. 2. Problem: Resident has risk for behavior problem r/t Schizophrenia Interventions: Administer medications as ordered. 3. Problem: Resident uses psychotropic medications r/t Schizophrenia Interventions: Administer medications as ordered. Review of Current Physician's Orders for Resident #24 revealed, in part: 1. Humulin R Injection Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0 ; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD , subcutaneously one time a day related to Type 2 Diabetes Mellitus. 2. Lantus Solostar 100 u/ml inject 30 units subcutaneously at bedtime related to Type 2 Diabetes Mellitus 3. Atorvastatin Calcium Oral Tablet 20 mg give one tablet by mouth at bedtime related to Hyperlipidemia. 4. Trazadone HCL Oral Tablet 150 mg give one tablet by mouth at bedtime related to Schizophrenia. Review of April 2025 Medication Administration Record for Resident #24 revealed, in part: 1. Humulin R Injection Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0 ; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD , subcutaneously one time a day related to Type 2 Diabetes Mellitus - not documented as administered on 04/27/2025 at 8:00 p.m. 2. Lantus Solostar 100 u/ml inject 30 units subcutaneously at bedtime related to Type 2 Diabetes Mellitus - not documented as administered on 04/27/2025 at 8:00 p.m. 3. Atorvastatin Calcium Oral Tablet 20 mg give one tablet by mouth at bedtime related to Hyperlipidemia - not documented as administered on 04/27/2025 at 8:00 p.m. 4. Trazadone HCL Oral Tablet 150 mg give one tablet by mouth at bedtime related to Schizophrenia - not documented as administered on 04/27/2025 at 8:00 p.m. On 04/12/2025 at 1:10 p.m., attempted an interview was conducted with Resident #24, he was unable to provide information. Resident #46 Review of admission Records for Resident #46 revealed he was admitted on [DATE] with diagnosis that included: Cerebral Vascular Disease, Long term use of Insulin, Muscle Weakness, Other lack of Coordination, Type 2 Diabetes Mellitus, and Hypertensive Heart Disease. Review of Quarterly MDS, with ARD of 01/22/2025 for Resident #46 revealed he had a BIMS of 14 indicating he was cognitively intact. Review of Plan of Care for Resident #46 dated 01/28/2025 included, in part: 1. Problem: Resident has Diabetes Mellitus Interventions: Diabetes medications as ordered by the physician. 2. Problem: Resident is on anticoagulant therapy. Interventions: Administer Anticoagulant medications as ordered by the physician. Review of Current Physician's Orders for Resident #46 revealed, in part: 1. Humulin R Insulin Subcutaneous Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0, if blood sugar is less than 60 give sugar/juice and recheck in 30 minutes and notify MD; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD recheck in 30 minutes, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus. 2. Lantus Solostar 100 u/ml inject 20 units subcutaneously at bedtime related to Type 2 Diabetes Mellitus 3. Eliquis Oral Tablet 2.5 mg give one tablet by mouth two times a day related to Atrial Fibrillation. 4. Atorvastatin Calcium 80 mg tablet give one tablet orally one time a day related to Hyperlipidemia. Review of April 2025 Medication Administration Record for Resident #46 revealed, in part: 1. Humulin R Insulin Subcutaneous Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0, if blood sugar is less than 60 give sugar/juice and recheck in 30 minutes and notify MD; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD recheck in 30 minutes, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus - not documented as administered on 04/27/2025 at 8:00 p.m. 2. Lantus Solostar 100 u/ml inject 20 units subcutaneously at bedtime related to Type 2 Diabetes Mellitus - not documented as administered on 04/27/2025 at 8:00 p.m. 3. Eliquis Oral Tablet 2.5 mg give one tablet by mouth two times a day related to Atrial Fibrillation - not documented as administered on 04/27/2025 at 8:00 p.m. 4. Atorvastatin Calcium 80 mg tablet give one tablet orally one time a day related to Hyperlipidemia - not documented as administered on 04/27/2025 at 8:00 p.m. On 04/29/2024 at 9:30 a.m., an interview was conducted with Resident #46. Resident #46 stated he was not administered medications on 04/27/2025 at 8:00 p.m., including Humulin R Insulin, Lantus, Eliquis, and Atorvastatin. Resident #70 Review of admission Records for Resident #70 revealed he was admitted to the facility on [DATE] with diagnosis that included, in part: Type 2 Diabetes Mellitus, Long Term Use of Insulin, Long Term Use of Anticoagulants, and Glaucoma. Review of Quarterly MDS, revealed he had a BIMS of 9, indicating cognitive impairment. Review of Plan of Care for Resident #70 dated 01/28/2025 included, in part: 1. Problem: Resident has Diabetes Mellitus Interventions: Diabetes medications as ordered by the physician. 2. Problem: Resident is on anticoagulant therapy. Interventions: Administer Anticoagulant medications as ordered by the physician. Review of Current Physician's Orders for Resident #70 revealed, in part: 1. Humalog Subcutaneous Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0, if blood sugar is less than 60 give sugar/juice and recheck in 30 minutes and notify MD; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD recheck in 30 minutes, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus. 2. Lantus Solostar 100 u/ml inject 25 units subcutaneously at bedtime related to Type 2 Diabetes Mellitus 3. Eliquis Oral Tablet 5 mg give one tablet by mouth two times a day related to Chronic Embolism and Thrombosis of Unspecified Deep Veins of Left Proximal Lower Extremity. 4. Latanoprost Ophthalmic Solution 0.005% instill 1 drop in both eyes at bedtime related to Glaucoma. 5. Ropinirole HCL oral tablet 0.5mg give one tablet by mouth at bedtime related to abnormalities of gait and mobility. Review of April 2025 Medication Administration Record for Resident #70 revealed, in part: 1. Humalog Subcutaneous Solution 100u/ML. Inject as per sliding scale: If 0-200 units = 0, if blood sugar is less than 60 give sugar/juice and recheck in 30 minutes and notify MD; 201-250=4 units; 251-300 = 6 units; 301-400 = 8 units; 401-450 = 10 units; 451-999 = 12 units and call MD recheck in 30 minutes, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus - not documented as administered on 04/27/2025 at 8:00 p.m. 2. Lantus Solostar 100 u/ml inject 25 units subcutaneously at bedtime related to Type 2 Diabetes Mellitus - not documented as administered on 04/27/2025 at 8:00 p.m. 3. Eliquis Oral Tablet 5 mg give one tablet by mouth two times a day related to Chronic Embolism and Thrombosis of Unspecified Deep Veins of Left Proximal Lower Extremity - not documented as administered 04/27/2025 at 8:00 p.m. 4. Latanoprost Ophthalmic Solution 0.005% instill 1 drop in both eyes at bedtime related to Glaucoma - not documented as administered on 04/27/2025 at 8:00 p.m. 5. Ropinirole HCL oral tablet 0.5mg give one tablet by mouth at bedtime related to abnormalities of gait and mobility - not documented as given on 04/27/2025 at 8:00 p.m. On 04/29/2025 at 1:15 p.m., attempted an interview with Resident #70; he was not able to voice any information about care on 04/27/2025 7:00 p.m.-7:00 a.m. On 04/29/2025 at 2:00 p.m., an interview was conducted with S18LPN. S18LPN stated she was working in the facility on 04/27/2025 from 7:00 p.m. to 7:00 a.m. She stated she did not get report for Resident #12, Resident #24, Resident #46, or Resident #70, and did not administer medications for any of the above mentioned residents. On 04/29/2024 an interview was conducted with S2DON. S2DON stated she had spoken with S18LPN, and S18LPN confirmed she did not administer medications for Resident #12, Resident #24, Resident #46 , or Resident # 70 during her 7:00 p.m. -7:00 a.m. shift on 04/27/2025. S2DON reviewed the Medication Administration Records for Resident #12, Resident #24, Resident #46, and Resident #70 and confirmed the residents were not administered their 8:00 p.m. medications on 04/27/2025 by S18LPN, and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure staff performed hand hygiene and proper glove use for 11 (#3, #14, #20, #26, #30, #33, #39, #54, #61, #65, and #67) of 13 (#3, #4, #14, #20, #26, #30, #33, #39, #54, #61, #65, #67, and #80) resident's observed for incontinence care. Findings: Review of the facility's policy titled, Perineal Care Policy and Procedure with an effective date of 11/17/2015, revealed the following, in part: Purpose: 2. To prevent infection . Procedure: 5. Wash hands. 6. Put on disposable gloves. 13. Female perineal care. 14. Male perineal care. 20. Remove gloves. Wash hands. 21. Replace top bed linen as appropriate. 22. Make resident comfortable and or reposition resident as appropriate. Review of the facility's policy titled, Hand Hygiene Policy and Procedure with an effective date of 07/01/2020, revealed the following, in part: Purpose: 1. To provide guidance and procedure to hand hygiene when providing direct care to residents. 2. To reduce the potential transmission of germs to residents. Policy: Hand hygiene shall be performed: 3. Before and after direct resident contact for which hand hygiene is indicated by acceptable professional practice. 22. After removing gloves . 23. If hands will be moving from a contaminated body site to a clean body site during patient care. Resident #3 Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #3's Care Plan revealed the following, in part: Problem: 10/15/2024-Bladder incontinence related to Cerebrovascular Accident with left sided hemiplegia Intervention: Clean peri-area with each incontinence episode. On 04/29/2025 at 12:23 a.m., an observation was made of S9CNA performing incontinence care for Resident #3. Without performing hand hygiene, S9CNA donned clean gloves, unfastened Resident #3's brief, cleaned urine from Resident #3's perineal area with perineal wipes, assisted Resident #3 to turn to the right side and cleaned Resident #3's perineum and buttocks with perineal wipes. S9CNA removed the soiled gloves and without performing hand hygiene donned clean gloves. S9CNA applied a clean brief, assisted Resident #3 to turn to the left side, and removed the soiled brief. Wearing the same gloves, S9CNA fastened the clean brief, adjusted the bed linens, placed a pillow under Resident #3's left leg, picked up the bed remote and raised the head of bed, moved the bedside table in reach, removed the gloves, and washed her hands. Resident #14 Review of Resident #14's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #14's Care Plan revealed the following, in part: Problem: 02/21/2025-Risk for Urinary Tract Infection . Intervention: Check at least every 2 hours for incontinence. Wash, rinse and dry soiled areas. On 04/29/2025 at 12:48 a.m., an observation was made of S6CNA performing incontinence care for Resident #14. Without performing hand hygiene, S6CNA donned cleaned gloves, unfastened Resident #14's brief, cleaned urine from Resident #14's perineal area with perineal wipes and assisted Resident #14 to turn to the right side. Wearing the same gloves, S6CNA cleaned feces from Resident #14's perineum and buttocks with perineal wipes and removed her left soiled glove. Without performing hand hygiene, S6CNA donned a clean left glove and continued to clean feces from Resident #14's perineum and buttocks with perineal wipes and removed her left soiled glove. Without performing hand hygiene, S6CNA again donned a clean left glove and continued to clean feces from Resident #14's perineum and buttocks with perineal wipes, removed the soiled brief and placed it in the trash can and removed both soiled gloves. Without performing hand hygiene, S6CNA donned clean gloves, applied a protective barrier cream to Resident #14's buttocks and perineum and placed a clean brief underneath Resident #14. Without performing hand hygiene, S6CNA removed the soiled gloves, donned clean gloves, assisted Resident #14 to turn to the left side, then her back and fastened the clean brief. S6CNA adjusted Resident' #14's bed linens, pillows, elevated the head of the bed and placed the call light in reach. S6CNA removed her gloves, without performing hand hygiene, picked up the trash bag and exited the room, placing the trash bag in a grey barrel and then sanitized her hands. Resident #20 Review of Resident #20's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #20's Care Plan revealed the following, in part: Problem: 01/08/2025 - Resident has bladder incontinence related to activity intolerance Intervention: Change every 2 hours and as needed. Clean peri area with each incontinent episode. Incontinent: check every 2 hours and as required for incontinence. Wash hands, rinse, and dry perineum. On 04/29/2025 at 12:52 a.m., an observation was made of S14CNA performing incontinence care for Resident #20. S14CNA donned clean gloves and removed Resident #20's wet brief. Wearing the same soiled gloves, S14CNA cleaned Resident #20's perineal area, assisted Resident #20 in turning to the opposite side and removed the brief from Resident #20. Without performing hand hygiene or removing soiled gloves, S14CNA placed a clean brief under Resident #20 and assisted Resident #20 in turning back over, fastened both sets of tabs on the brief, straightened Resident #20's gown and pulled the comforter over her. S14CNA removed her gloves and performed hand hygiene before exiting the room. Resident #26 Review of Resident #26's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #26's Care Plan revealed the following, in part: Problem: 02/07/2025-Bowel incontinence Intervention: Provide pericare after each incontinent episode Problem: 02/07/2025-Bladder incontinence Intervention: Clean peri-area with each incontinence episode On 04/29/2025 at 12:32 a.m., an observation was made of S9CNA performing incontinence care for Resident #26. Without performing hand hygiene, S9CNA donned clean gloves, unfastened the brief, assisted Resident #26 to turn to the left side, cleaned feces from Resident #26's perineum with perineal wipes, removed the soiled gloves. Without performing hand hygiene, S9CNA donned clean gloves, placed a clean brief underneath Resident #26, assisted her to turn to the right side, removed the soiled brief and placed it in the trash can. Wearing the same soiled gloves, S9CNA fastened the clean brief, assisted Resident #26 to her back, and adjusted her gown, pillows, linens and head of bed with the bed remote. S9CNA picked up the trash bag, removed her gloves and washed her hands. Resident #30 Review of Resident #30's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #30's Care Plan revealed the following, in part: Problem: 01/31/2025-Bowel incontinence Intervention: Provide pericare after each incontinent episode Problem: 01/31/2025-Bladder incontinence Intervention: Clean peri-area with each incontinence episode On 04/29/2025 at 1:00 a.m., an observation was made of S6CNA performing incontinence care for Resident #30. Without performing hand hygiene, S6CNA donned cleaned gloves, unfastened Resident #30's brief, cleaned urine from Resident #30's perineal area with perineal wipes and assisted Resident #30 to turn to the right side. S6CNA removed the soiled brief, placed it in the trash can and removed the soiled gloves. Without performing hand hygiene, S6CNA donned clean gloves, placed a clean brief underneath Resident #30, applied protectant barrier ointment with her left gloved hand and removed the left soiled glove. Without performing hand hygiene, S6CNA donned a clean glove to her left hand, assisted Resident #30 to turn on her back and fastened the brief. S6CNA removed the gloves, adjusted the height and head of the bed with the bed remote, adjusted the linens, picked up the trash bag and exited the room placing it in the grey barrel in the hall, and then sanitized her hands. Resident #33 Review of Resident #33's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #33's Care Plan revealed the following, in part: Problem: 10/15/2024 - Resident has bladder incontinence related to Alzheimer's Intervention: Clean peri-area with each incontinence episode, Check every 2 hours and as required for incontinence. Wash rinse and dry perineum. Problem: 02/18/2025 - Resident has bowel incontinence Intervention: Check resident every 2 hours and assist with toileting as needed, Provide pericare after each incontinent episode. On 04/29/2025 at 12:25 a.m., an observation was made of S13CNA performing incontinence care for Resident #33. S13CNA performed hand hygiene, donned clean gloves and cleaned Resident #33's perineal area. Wearing the same soiled gloves, S13CNA placed a clean brief beneath Resident #33, fastened the brief's tabs, turned Resident #33 to her other side and fastened the brief's second set of tabs, adjusted Resident #33's gown and placed the comforter over her. S13CNA then removed her gloves and performed hand hygiene. Resident #39 Review of Resident #39's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #39's Care Plan revealed the following, in part: Problem: 02/25/2025 - Resident requires staff assistance for ADL care Interventions: Assist the resident with hygiene and grooming tasks On 04/29/2025 at 12:26 a.m., an observation was made of S13CNA performing incontinence care for Resident #39. S13CNA performed hand hygiene, donned clean gloves, cleaned Resident #39's perineal area, assisted the resident in turning over, and continued to clean feces from Resident #39's buttocks and perineal area, and removed Resident #39's soiled brief. Then using the same soiled gloves and without performing hand hygiene, S13CNA opened a clean brief, placed it beneath Resident #39, and fastened one set of tabs, assisted Resident #39 in turning over, positioned brief fully beneath him, and fastened the second set of tabs. Wearing the same soiled gloves, S13CNA placed the comforter over Resident #39. S13CNA then removed her gloves and performed hand hygiene. Resident #54 Review of Resident #54's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #54's Care Plan revealed the following, in part: Problem: 01/28/2025 - Resident has bladder incontinence related to Dementia Interventions: Clean peri-area with each incontinent episode, Check every 2 hours and prn for incontinence. Wash, rinse, and dry perineum. On 04/29/2025 at 12:40 a.m., an observation was made of S14CNA performing incontinence care for Resident #54. S14CNA donned clean gloves, turned Resident #54 on to his back, and removed Resident #54's wet brief and cleaned Resident #54's perineal area. Wearing the same soiled gloves, S14CNA opened a new brief, placed it beneath Resident #54, and fastened the tabs on one side, turned Resident #54 to the opposite side, positioned the brief fully beneath him, fastened the second set of tabs on the brief and placed the blanket over Resident #54. S14CNA then removed her gloves and performed hand hygiene. Resident #61 Review of Resident #61's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #61's Care Plan revealed the following, in part: Problem: 01/31/2025 - Resident has bowel incontinence Interventions: Check resident every 2 hours and assist with toileting as needed. Provide pericare after each incontinent episode Problem: 01/31/2025 - Resident has bladder incontinence Intervention: Clean peri area with each incontinent episode. Incontinent On 04/29/2025 at 1:00 a.m., an observation was made of S14CNA performing incontinence care for Resident #61. S14CNA donned clean gloves, cleaned Resident #61's perineal area, removed the wet brief. Then using the same soiled gloves and without performing hand hygiene, S14CNA placed the clean brief beneath Resident #61, turned Resident #61 to her other side and fastened the brief's tabs, adjusted Resident #61's gown and covered her with the comforter. S14CNA then removed her gloves and performed hand hygiene. Resident #65 Review of Resident #65's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #65's Care Plan revealed the following, in part: Problem: 09/20/2024-Bladder incontinence Intervention: Clean peri-area with each incontinence episode On 04/29/2025 at 12:10 a.m., an observation was made of S9CNA performing incontinence care for Resident #65. Without performing hand hygiene, S9CNA donned clean gloves, cleaned Resident #65's perineal area with perineal wipes and assisted Resident #65 to turn to the right side, and cleaned feces from Resident #65's perineum and buttocks with perineal wipes. S9CNA removed her soiled gloves, without performing hand hygiene, opened the room door, went to the linen cart and removed more perineal wipes. S9CNA entered Resident #65's room and closed the door. Without performing hand hygiene, S9CNA donned clean gloves and continued to clean feces from Resident #65's perineum and buttocks with perineal wipes. S9CNA removed the soiled brief and placed it in the trash can. Wearing the same soiled gloves, S9CNA applied a clean brief underneath Resident #65, turned the resident to the left side, adjusted the pads and sheets underneath Resident #65, fastened the brief, adjusted Resident #65's gown, bed linens, picked up the bed remote and elevated the height and head of bed. S9CNA removed her soiled gloves, picked the trash bag out of the trash can, opened the room door, placed the bag in the grey barrel and then washed her hands. Resident #67 Review of Resident #67's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #67's Care Plan revealed the following, in part: Problem: 10/04/2024 - Resident has bowel incontinence related to dementia Interventions: Provide pericare after each incontinent episode Problem: 10/03/2024 - Resident has bladder incontinence related to Dementia Intervention: Clean peri-area with each incontinence episode On 04/29/2025 at 12:14 a.m., an observation was made of S13CNA performing perineal care for Resident #67. S13CNA performed hand hygiene, donned clean gloves, cleaned urine from Resident #67's perineal area, and removed Resident #67's wet brief. Then using the same soiled gloves and without performing hand hygiene, S13CNA placed a clean brief beneath Resident #67, turned Resident #67 to her other side, pulled the brief fully beneath her, fastened the tabs, adjusted Resident #67's clothes and pulled the comforter over her. S13CNA then removed her gloves and performed hand hygiene. On 04/29/2025 at 12:33 a.m., an interview was conducted with S13CNA. S13CNA confirmed the above observations for Resident #s 33, 39, and 67 and stated she should have performed hand hygiene and changed her gloves during resident care when going from dirty to clean. On 04/29/2025 at 12:40 a.m., an interview was conducted with S9CNA. S9CNA stated hand hygiene should be performed before, sometimes during, and after resident care. S9CNA confirmed the above observations for Resident #3, Resident #26, and Resident #65. S9CNA confirmed she should have performed hand hygiene before resident care and during resident care when going from dirty to clean. On 04/29/2025 at 1:03 a.m., an interview was conducted with S14CNA. S14CNA confirmed the above observations for Resident #s 20, 54, and 61 and stated she should have performed hand hygiene and changed her gloves during resident care when going from dirty to clean. On 04/29/2025 at 1:05 a.m., an interview was conducted with S6CNA. S6CNA stated hand hygiene should be performed before and after resident care. S6CNA confirmed the above observations for Resident #14 and Resident #30. S6CNA confirmed she should have performed hand hygiene when changing her gloves and during resident care when going from dirty to clean. On 04/29/2025 at 1:30 a.m., an interview was conducted with S2DON. S2DON stated staff should perform hand hygiene before and after incontinence care for residents. S2DON confirmed staff should perform hand hygiene during incontinence care when going from dirty to clean. S2DON stated she would expect staff to change their gloves after providing perineal care and when going from dirty to clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observation, and interviews the facility failed to develop and implement a comprehensive person-centered care plan which met the needs of 2 (#2 and #3) of 3 (#1, #2, and #3) residents reviewed. The facility failed to: 1. Ensure S2ADON followed physician's orders for Resident #2 whom was ordered wheel chair brake extenders; and 2. Ensure Resident #3's care plan was comprehensive and individualized for activities of daily living (ADLs) dependency deficits. Findings: Review of the facility's policy titled, Care Plan Policy and Procedure, dated 05/22/2017 revealed the following, in part: Purpose: The comprehensive plan of care is an interdisciplinary tool used to communicate and address care issues that are relevant to the resident's individual needs. Policy: A comprehensive plan of care will be used to communicate and address care issues that are relevant to the resident's individual needs. 1. Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE], with diagnoses which included Muscle Weakness, Dementia, Alzheimer's Disease, Repeated Falls, and Fracture to Right Femur. Review of Resident #2's active Physician Orders revealed, in part the following: Order date: 11/19/2024-Brake extenders to wheelchair for safety On 01/06/2025 at 11:23 a.m., an observation was made of Resident #2 sitting in dining room. Resident #2 was noted sitting at a table in a wheelchair. An observation of the wheelchair Resident #2 was sitting in revealed no brake extenders. On 01/06/2025 at 11:25 a.m., an interview was conducted with S2ADON. She confirmed she was Resident #2's nurse. She stated nurses were responsible for ensuring brake extenders were in place every shift. S2ADON inspected Resident #2's wheelchair, and confirmed the brake extenders were not in place. S2ADON confirmed the brake extenders should have been in place as physician ordered and they were not. On 01/06/2025 at 2:00 p.m., an interview was conducted with S1DON. She confirmed staff were expected to follow physician's orders and ensure Resident #2's brake extenders were in place as ordered. 2. Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE], with diagnoses which included Fractured R-Femur, Dementia, Pain, and Insomnia. Review of Resident #3's Significant Change MDS with an ARD of 12/25/2024 Section GG revealed, in part the following: Resident #3 was dependent for eating, oral hygiene, toileting, shower/bathe, dressing, and personal hygiene. Review of Resident #3's Care Plan revealed no interventions were developed for ADLs dependency deficits. On 01/07/2025 at 9:29 a.m., an interview was conducted with S3MDS. She stated she was responsible for Care Plans. S3MDS confirmed ADLs dependency deficits should be care planned. S3MDS reviewed Resident #3's Care Plan, and confirmed she was not care planned for her ADLs dependency deficits and should have been. On 01/07/2025 at 2:46 p.m., an interview was conducted with S1DON. She stated residents were to be properly care planned for ADLs dependency deficits. S1DON reviewed Resident #3's Care Plan, and confirmed she was not care planned for ADLs dependency deficits and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure a resident's plan of care was revised by failing to update fall interventions after each fall for 1 (#3) of 3 (#1, #2, and #3) residents reviewed for falls. Findings: Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE], with diagnoses which included Fractured Right Femur, Dementia, Pain, and Insomnia. Review of Resident #3's Nurse's Note dated 12/31/2024 revealed, in part, the following: Nurse called to common lounge area by ward clerk stating resident fell as I entered the area. Resident noted sitting half on wheelchair foot rest with right leg hanging over right foot rest. Resident was seated on lift pad and slid out of wheelchair with some of the pad behind her. Review of the facility's Incident Report dated 12/31/2024 revealed, in part the following: Resident #3 had an unwitnessed fall in lounge. Review of Resident #3's Care Plan revealed it was not revised to include interventions for falls after 12/12/2024. The care plan did not include interventions to address Resident #3's fall that occurred on 12/31/2024. On 01/07/2025 at 9:29 a.m., an interview was conducted with S3MDS. She stated she was responsible for care plans. S3MDS stated she was made aware a resident sustained a fall by reviewing the risk management assessment report which she ran every morning. She stated the report reflected any incident report(s) which had been completed by a nurse. S3MDS stated she was responsible for updating the care plan. She stated an intervention should be updated after each fall. S3MDS reviewed Resident #3's care plan, and confirmed there was no intervention for Resident #3's fall on 12/31/2024 and should have been. On 01/06/2025 at 3:26 p.m., an interview was conducted with S1DON. She stated the Minimum Data Set nurse was responsible for care plan revisions. She stated fall interventions should be updated after each fall. S1DON confirmed Resident #3 did have a fall on 12/31/2024. After reviewing Resident #3's care plan, she confirmed Resident #3's fall on 12/31/2024 should have been care planned with an intervention and was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure services were provided to meet quality professional standards for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for pain medication administration. The facility failed to ensure Resident #1's Oxycodone was documented in the MAR (Medication Administration Record) at the time of administration. Findings: Review of the facility's policy titled, Medication Administration with an effective date of 08/27/2018, revealed the following, in part: Purpose: To define responsibility and delineate processes for safe administration of medications by nursing personnel. Procedure: g. Administer the medication as ordered and document the administration .in the electronic medication administration record as appropriate. Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses of Other Chronic Pain, Opioid Use, Peripheral Vascular Disease, Acquired Absence of Right Leg, Above Knee, and Generalized Abdominal Pain. Review of Resident #1 Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/15/2024 revealed she had frequent pain and was taking an Opioid. Review of Resident #1's Physician Orders dated July 2024 to August 2024 revealed the following, in part: Start Date: 06/19/2024 Oxycodone HCL (Immediate Release) 10 mg tablet one tablet by mouth four times daily related to Other Chronic Pain. Review of Resident #1's MAR for Oxycodone, dated July 2024 to August 2024 revealed the following, in part: Start date: 06/19/2024 Oxycodone HCL (Immediate Release) 10 mg tablet one tablet by mouth four times daily related to Other Chronic Pain. Further review revealed the following documentation errors of Oxycodone by S3LPN: 07/04/2024 4:00 p.m. dose: Signed off by S3LPN on 07/04/2024 at 5:11 p.m.; 07/04/2024 8:00 p.m. dose: Signed off by S3LPN on 07/05/2024 at 1:46 a.m.; 07/06/2024 8:00 p.m. dose: Signed off by S3LPN on 07/07/2024 at 7:32 a.m.; 07/07/2024 8:00 p.m. dose: Signed off by S3LPN on 07/08/2024 at 3:27 a.m.; 07/14/2024 8:00 p.m. dose: Signed off by S3LPN on 07/15/2024 at 6:30 a.m.; 07/15/2024 4:00 p.m. dose: Signed off by S3LPN on 07/15/2024 at 5:40 p.m.; 07/15/2024 8:00 p.m. dose: Signed off by S3LPN on 07/15/2024 at 10:25 p.m.; 07/20/2024 8:00 p.m. dose: Signed off by S3LPN on 07/21/2024 at 8:52 a.m.; 07/21/2024 8:00 p.m. dose: Signed off by S3LPN on 07/22/2024 at 4:44 a.m.; 07/27/2024 8:00 p.m. dose: Signed off by S3LPN on 07/27/2024 at 9:28 p.m.; 07/28/2024 8:00 p.m. dose: Signed off by S3LPN on 07/29/2024 at 6:01 a.m.; 08/04/2024 8:00 p.m. dose: Signed off by S3LPN on 08/04/2024 at 9:31 p.m.; 08/06/2024 8:00 p.m. dose: Signed off by S3LPN on 08/07/2024 at 1:38 p.m.; 08/10/2024 8:00 p.m. dose: Signed off by S3LPN on 08/11/2024 at 6:38 a.m.; 08/17/2024 8:00 p.m. dose: Signed off by S3LPN on 08/18/2024 at 5:28 a.m.; 08/18/2024 8:00 p.m. dose: Signed off by S3LPN on 08/19/2024 at 6:32 a.m.; 08/20/2024 4:00 p.m. dose: Signed off by S3LPN on 08/20/2024 at 6:04 p.m.; 08/20/2024 8:00 p.m. dose: Signed off by S3LPN on 08/21/2024 at 3:25 a.m.; 08/24/2024 8:00 p.m. dose: Signed off by S3LPN on 08/25/2024 at 5:22 a.m.; 08/25/2024 8:00 p.m. dose: Signed off by S3LPN on 08/26/2024 at 5:41 a.m.; 08/27/2024 4:00 p.m. dose: Signed off by S3LPN on 08/27/2024 at 6:01 p.m.; 08/29/2024 8:00 p.m. dose: Signed off by S3LPN on 08/30/2024 at 4:30 a.m.; and 08/31/2024 8:00 p.m. dose: Signed off by S3LPN on 09/01/2024 at 6:48 a.m. On 09/10/2024 at 12:30 p.m., a telephone interview was conducted with S3LPN. She stated Resident #1 was prescribed Oxycodone 10 mg by mouth four times daily. She stated she administered Resident #1's Oxycodone at the time it was due to be given during her shifts, but did not always document on the MAR at the time it was administered. She stated she would wait until later in her shift when she entered all of her other documentation to document Resident #1's Oxycodone medication administration. S3LPN confirmed she had not documented Resident #1's Oxycodone doses as they were administered on the aforementioned dates, and should have. On 09/10/2024 at 3:05 p.m., an interview was conducted with S2DON. She stated she expected the nurses to document medications on the MAR when medication administration was completed. She reviewed Resident #1's MAR dated July 2024 through August 2024 and confirmed S3LPN had not documented Resident #1's Oxycodone doses as they were administered on the aforementioned dates, and should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to maintain accurately documented medical records in accordance with accepted professional standards and practices for 1 (#1) of 3 (#1, #2, and #3) sampled residents reviewed. The facility failed to ensure nursing staff documented on Resident #1's Medication Administration Record accurately. Findings: Review of the Clinical Record revealed Resident #1 was admitted to the facility on [DATE] with the diagnosis which included Major Depressive Disorder. Review of the current Physician Orders for Resident #1 revealed the following, in part: Start date: 11/23/2023 Cymbalta 60mg capsule-one capsule by mouth once a day-targeted behavior: Depressed Mood. Review of the April 2024 MAR for Resident #1 revealed the following on 8:00 a.m. dose of Cymbalta 60mg: 04/01/2024- Sadness-Present- Signed: S2LPN 04/02/2024- Sadness-Present- Signed: S2LPN 04/03/2024- Sadness-Present- Signed: S2LPN 04/04/2024- Sadness-Present- Signed: S2LPN 04/06/2024- Sadness-Present- Signed: S2LPN 04/07/2024- Sadness-Present- Signed: S2LPN 04/08/2024- Sadness-Present- Signed: S2LPN 04/12/2024- Sadness-Present- Signed: S2LPN On 04/18/2024 at 9:50 a.m., a telephone interview was conducted with S2LPN. She stated Resident #1 never displayed signs and symptoms of sadness or depressed mood. She stated she documented sadness for monitoring on the Medication Administration Record because the system wouldn't allow her to click anything else on the Electronic Record. She stated she never witnessed Resident #1 having sadness or depression. On 04/18/2024 at 11:30 a.m., an interview was conducted with S1DON. She reviewed Resident #1's April 2024 Medication Administration Record and confirmed staff documented the monitoring for depressed mood inaccurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident's advanced directive was honored for 1 (#1) of 3 ( #1, #2, and #3) residents reviewed for advanced directives. Findings: Review of the facility's policy and procedure titled, Cardiopulmonary Resuscitation (CPR) read in part: Procedure: 1) Assess the resident to determine if he/she is unconscious. While checking for responsiveness, check to see if the patient is apneic or only gasping, assume that he/she is in cardiac arrest. 2) Delegate a specific individual to check the resident's advance medical directive, orders and care plan for CPR or no CPR order; have individual call paramedics, attending physician and administrative personnel per facility procedure and report back to you as soon as possible. 3) If CPR is not elected on resident's advance medical directives, follow advance medical directives and stay with resident as appropriate until emergency medical personnel (EMT, Paramedics, etc.) arrive. Review of Resident #1's Clinical Record revealed the resident was admitted to the facility on [DATE]. Review of Resident #1's Physician Orders for [DATE] revealed a code status of DNR with a start date of [DATE]. Review of Resident #1's Care Plan revealed: Care Plan Description: I have an Advance Directive. I am a DNR. Start date: [DATE] Care Plan Goal: The staff will adhere to my choices made in my Advance Directive. Review of Resident #1's Advance Directive Consent dated [DATE] revealed Resident #1 expressed wishes for a do not resuscitate status. Review of Resident #1's progress notes revealed an entry by S4LPN on [DATE] at 3:40 p.m. that read in part: Nurse went to Resident #1's room and found Resident #1 in seated position with back against posterior closet wall and unresponsive. S3LPN noticed a black belt around Resident's neck extending from the closet bar. S3LPN removed belt from resident's neck and lowered him into supine position of floor and CPR initiated. On [DATE] at 1:30 p.m., an interview was conducted with S3LPN. She stated on [DATE] she walked into Resident #1's room and found him unresponsive with a belt around his neck in the closet of his room. She stated she picked Resident #1 up, removed the belt from around his neck, lowered him to the floor, and checked for a pulse. She stated she panicked because the pulse was absent and initiated CPR before checking for code status. On [DATE] at 10:20 a.m., an interview was conducted with S1DON. She confirmed CPR was initiated on Resident #1. She stated she expected her nurses to check the chart first for code status and then follow the advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to promote and facilitate resident self-determination through support of the resident's choice of when to get out bed for 1 (#28) of 4 (#1, #28, #53, and #89) residents reviewed for resident rights. Findings: Review of Resident #28's Clinical record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Hemiplegia Following Unspecified Cerebrovascular Disease Affecting Left Non-dominant Side, Cerebral Infarction, and Generalized Muscle Weakness. Review of Resident #28's MDS with and ARD of 03/20/2024 revealed a BIMS of 10, which indicated moderate cognitive impairment. Further review revealed she required extensive assistance with transfers. Review of Resident #28's current Care Plan revealed the following, in part: Problem: I require staff assistance with ADLs. Interventions: I require assistance with transfers; and Transfer me on my strong side An interview was conducted with S5CNA on 04/11/2024 at 2:23 p.m. She stated Resident #28 told her she needed to be out of bed at 10:00 a.m. She confirmed Resident #28 was not out of bed. She confirmed Resident #28 was not assisted out of bed when she requested. An observation was made of Resident #28 on 04/11/2024 at 2:30 p.m. She was seated in her wheelchair and her family member was present in her room. An interview was conducted with Resident #28 and her family member on 04/11/2024 at 2:30 p.m. Resident #28 stated she liked to get up at 10:00 a.m. daily. Resident #28 stated this morning she asked S5CNA to assist her into her wheelchair. Resident #28 stated a staff member never came to assist her out of bed. Resident #28's family member stated she just arrived to the facility and Resident #28 was still in bed. Resident #28's family member stated she transferred the resident from the bed into the wheelchair. An interview was conducted with S4LPN on 04/11/2024 at 2:27 p.m. She stated Resident #28 required assistance of one staff member for transfers. She stated during medication pass on 04/11/2024, S5CNA notified her S5CNA was unable to assist Resident #28 out of bed independently. She stated she told S5CNA to go get another CNA for assistance. She stated she just realized S5CNA did not get Resident #28 out of bed. She confirmed Resident #28's family member transferred her from the bed to her wheelchair. She confirmed Resident #28 should have been assisted out of bed when she requested. An interview was conducted with S3CNAS on 04/11/2024 at 4:08 p.m. She stated Resident #28 wanted to get out of the bed daily between 9:30 a.m. and 10:00 a.m. She stated Resident #28 reported S5CNA did not transfer her out of bed this morning, 04/11/2024. She stated Resident #28 should have been transferred out of the bed when she requested. An interview was conducted with S2DON on 04/11/2024 at 4:43 p.m. She stated Resident #28 should have been transferred out of bed by staff when requested and should not have had to wait until her family member arrived.

Based on interviews and record review the facility failed to ensure residents received mail on Saturdays for 4 (#6, #51, #53 and #66) of 17 residents reviewed for mail during resident council. This deficient practice had the potential to affect 92 residents residing in the facility. Findings: Review of the facility's General admission & Financial Agreement, reviewed on 04/09/2024, dated 01/2023, revealed, in part: Mail: The resident has the right to privacy in written communications including the right to: a. Send and promptly receive mail that is unopened. During the resident council meeting on 04/08/2024 at 2:00 p.m. Resident #6, Resident #51, Resident #53 and Resident #66 all stated mail was not delivered on Saturdays and was held until the following Monday. An interview was conducted with S5AD on 04/08/2024 at 2:10 p.m. She stated she and S4FIN were responsible for distributing resident's mail. She verbalized she works Monday through Friday and there was no one present to deliver mail to residents on Saturdays. She confirmed all mail and packages delivered to the facility on the weekends were held and distributed to residents on the following Monday. An interview was conducted with S4FIN on 04/09/2024 at 1:42 p.m. She stated she serves as backup to S5AD for distributing resident's mail. She confirmed she works Monday through Friday and there was no employee present to deliver mail to residents on Saturdays. She confirmed all mail and packages delivered to the facility on the weekends were held and distributed to residents on the following Monday. S4FIN defined promptly as within 24-hours.

Based on record review and interviews, the facility failed to initiate and resolve grievances for 1 (#11) of 2 (#11 and #67) residents reviewed for grievances. Findings: Review of grievance policy titled, Grievance Policy and Procedure; effective 10/10/2022, reviewed on 04/11/2024; revealed the following: Purpose: to support each resident, family member to voice grievances (e.g . lost clothing ) and to assure that after receiving a grievance the facility actively seeks resolution and keeps the individual filing the grievance appropriately apprised of its progress toward resolution. Policy: The resident has the right to and the facility must make prompt efforts to resolve grievances. Documentation: 1. Document grievances made by a resident, resident's family member . the grievance shall include: a. Date the grievance was received. b. A summary statement of the grievance. c. Steps taken to investigate the grievance. d. A summary of the pertinent findings or conclusions regarding the concerns. i. Record the grievance on the facility's Grievance log. Follow Up/Resolution: 1. The grievance official/compliance liaison or designee will follow up with the complainant with a resolution within 5 business days of the date that the grievance was filed. Review of the Quarterly MDS with ARD of 02/28/2024 revealed Resident #11 had a BIMS of 2 which indicated severe cognitive impairment. Review of the facility's Grievance Log for March 2024 revealed no grievances were filed for Resident #11. On 04/08/2024 at 10:03 a.m., an interview was conducted with Resident #11's RP. She stated in March 2024 she reported a missing phone charger to the nurse. She stated the nurse looked for the phone charger on the unit but did not find it. On 04/09/2024 at 8:35 a.m., an interview was conducted with S6CNA. She stated on March 29 2024, Resident #11's RP reported a missing phone charger and she reported it to S7LPN. On 04/09/2024 at 8:55 a.m., an interview was conducted with S7LPN. She stated on March 29, 2024, S6CNA reported Resident #11's phone charger was missing and she looked for it but it was not found. She confirmed she did not report the missing phone charger to administration. On 04/11/2024 at 12:22 p.m., an interview was conducted with S2DON. She confirmed she was not made aware of Resident #11's missing phone charger. She stated missing items should be reported to administration. On 04/11/2024 at 12:30 p.m., an interview was conducted with S1ADM. He confirmed he was not aware of Resident #11's missing phone charger and should be. He stated all staff were aware to report missing items to administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good hygiene for 2 (#75 and #88) of 5 (#28, #34, #67, #75, and #88) residents reviewed for ADLs. The facility failed to ensure Resident #75 and Resident #88 received incontinence care timely. Findings: Resident #75 Review of Resident #75's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Muscle Wasting and Atrophy and Unspecified Dementia. Review of Resident #75's current Care Plan revealed the following: Problem: I am incontinent of bowel. Staff provides perineal care every two hours and as needed. Problem: I am incontinent of urine. Staff provides perineal care every two hours as needed. Review of Resident #75's Yearly MDS with an ARD of 02/07/2024 revealed a BIMS of 3, which indicated severe cognitive impairment. Further review revealed she was always incontinent of bowel and bladder and was dependent on staff for toileting hygiene. An observation was made of Resident #75 on 04/11/2024 at 11:38 a.m. She was lying in bed. There was a strong urine odor in her room. An observation was made of Resident #75 on 04/11/2024 at 1:15 p.m. There was a strong urine odor in her room. An observation was made of S5CNA performing incontinence care for Resident #75 on 04/11/2024 at 1:41 p.m. There was a strong urine odor in Resident #75's room. Resident #75's incontinence brief, incontinence pad, and fitted sheet were saturated with urine. Resident #75 had stool on her buttocks. S5CNA confirmed Resident #75's incontinence brief, incontinence pad, and fitted sheet were soiled with urine. Resident #88 Review of Resident #88's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Parkinson's Disease, Other Abnormalities of Gait and Mobility, Muscle Wasting and Atrophy, Unspecified Lack of Coordination, and Generalized Muscle Weakness. Review of Resident #88's MDS with and ARD of 01/17/2024 revealed a BIMS of 13, which indicated intact cognition. Review of Resident #88's current Care Plan revealed the following: Problem: I need assistance with ADLs. Problem: High Risk for Skin Breakdown. Interventions: Keep skin clean and dry An observation was made of Resident #88 on 04/11/2024 at 11:38 a.m. She was lying in bed. There was a strong urine odor in her room. An observation was made of Resident #88 on 04/11/2024 at 1:15 p.m. There was a strong urine odor in her room. An interview was conducted with Resident #88 on 04/11/2024 at 1:55 p.m. She stated the CNA had not been in her room to provide incontinence care today, and she needed to be changed. An interview was conducted with S5CNA on 04/11/2024 at 1:20 p.m. She confirmed she was assigned to Residents #75 and #88 from 6:00 a.m. to 2:00 p.m. today, 04/11/2024. She stated Residents #75 and #88 were both incontinent and she had not provided incontinence care to either one of them during her shift today. She stated she had not been able to perform her duties timely and had not reported that to anyone or asked for assistance. An observation was made of S5CNA performing incontinence care for Resident #88 on 04/11/2024 at 2:08 p.m. Resident #88's incontinence brief, incontinence pad, and top sheet were saturated with urine. S5CNA confirmed Resident #88's brief, incontinence pad, and top sheet were soiled with urine. An interview was conducted with S5CNA on 04/11/2024 at 2:23 p.m. She stated Resident #75 and Resident #88 should have been changed every two hours and should have been changed prior soiling through their linens. An interview was conducted with S3CNAS on 04/11/2024 at 4:08 p.m. She stated Resident #75 was incontinent. She stated if Resident #75 was soiled through her brief, incontinence pad, and fitted sheet, she had gone too long without incontinence care. She stated Resident #88 was usually incontinent but would sometimes go to the bathroom if staff assisted her. She stated if Resident #88 was soiled through her brief, incontinence pad, and top sheet, she had gone too long without incontinence care. She stated incontinence rounds should have been performed every two hours. She stated S5CNA not changing a resident until the end of her shift was unacceptable and if she was unable to complete her tasks, she should have asked for assistance. An interview was conducted with S2DON on 04/11/2024 at 4:43 p.m. She stated incontinence care should have been provided every two hours and not providing incontinence care until the end of a 6:00 a.m. to 2:00 p.m. was unacceptable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure residents were assessed for risk of entrapment from bedrails and obtain informed consent for bed rails prior to installation for 1 (#41) of 2 (#41 and #49) residents identified for having side rails in use. Findings: Review of the facility's policy titled Side Rail Policy and Procedure, effective 11/25/2014, revealed the following, in part: Policy: We use side rails as appropriate to resident need in creating better bed mobility and positioning, as ordered by physician. Procedure: 1. Obtain . consent for use of side rails. Resident #41 Review of Resident #41's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Other Specified Extrapyramidal and Movement Disorders, History of Falling, Unspecified Dementia Unspecified Severity with Other Behavioral Disturbances, Generalized Muscle Weakness, and Unspecified Lack of Coordination. Review of Resident #41's MDS with an ARD of 03/20/2024 revealed she had a BIMS of 99, which indicated she was unable to be interviewed. Further review revealed she required substantial/max assist with bed mobility. Review of Resident #41's current Physician Orders revealed the following, in part: Start date 08/24/2023: may use quarter side rails as needed for bed mobility and repositioning. Review of Resident #41's MAR dated November 2023 to April 2024 revealed the following, in part: Start date 08/24/2023: may use quarter side rails as needed for bed mobility and repositioning, marked as implemented daily at 6:00 a.m., 2:00 p.m., and 10:00 p.m. Review of Resident #41's Clinical Record revealed no documentation of Entrapment Risk Assessments for side rails. Review of Resident #41's Clinical Record revealed no documentation of a Consent for side rails. An observation was made of Resident #41 on 04/09/2024 at 2:52 p.m. lying in bed with two quarter side rails raised and attached to the bed. An interview was conducted with S10CNA on 04/09/2024 at 2:54 p.m. She stated anytime Resident #41's was in bed her side rails were raised. An interview was conducted with S9LPN on 04/09/2024 at 12:20 p.m. She stated on 03/19/2024, she assessed Resident #41's side rails for proper function but had not assessed for risk of entrapment. An interview was conducted with S2DON on 04/11/2024 at 12:19 p.m. She stated she was unable to provide any documentation to indicate Resident #41's representative had given consent for the quarter side rails as ordered on 08/24/2023. She stated she was unable to provide any documentation of an entrapment risk assessment being performed for Resident #41's side rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure each nurse aide was able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 2 (#28 and #34) of 5 (#28, #34, #67, #75, and #88) residents reviewed for ADLs. Findings: Review of the Certified Nursing Assistant (CNA) Orientation Proficiency Form, dated effective 12/4/2017, revealed the following, in part: Print out each policy pertaining to each topic that is applicable in policy tech and ensure the employee reviews the policy. Further review revealed the following topics, in part: Scheduled Care Monitor: Documentation of ADLs, how to code ADLs, how to use Kiosk, scheduled care and unscheduled care, Keeping residents dry (changing gown, diaper and linens), Perineal Care, Transferring Residents (two person assist, Hoyer lift, stand up life safety with transfers) and AM/PM Care. Resident #28 Review of Resident #28's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Hemiplegia Following Unspecified Cerebrovascular Disease Affecting Left Non-dominant Side, Cerebral Infarction, and Generalized Muscle Weakness. Review of Resident #28's MDS with an ARD of 03/20/2024 revealed she had a BIMS of 10, which indicated moderate cognitive impairment. Further review revealed she required extensive assistance with transfers. Review of Resident #28's current Care Plan revealed the following, in part: Problem: I require staff assistance with ADLs. Interventions: I require assistance with transfers; and Transfer me on my strong side An interview was conducted with S5CNA on 04/11/2024 at 2:23 p.m. She stated Resident #28 reported she needed to be out of bed at 10:00 a.m. She confirmed she did not transfer Resident #28 out of bed. She stated she went into the room to assist Resident #28 out of bed, and she was unable to get her up by herself. She stated Resident #28 asked her to get another staff member to assist. She stated she informed S4LPN she was unable to get Resident #28 out of bed by herself but she did not ask for assistance. She stated she was unsure how to identify a resident's transfer status or how much assistance they required with ADLs. She stated she would ask the resident or assess the resident. An interview was conducted with S4LPN on 04/11/2024 at 2:27 p.m. She stated, this morning during medication pass, S5CNA notified her she was unable to assist Resident #28 out of bed independently. She stated Resident #28 required assistance of one staff member for transfers. She stated she told S5CNA to get another CNA for assistance. She stated she now realized S5CNA did not get Resident #28 out of bed. An interview was conducted with Resident #28 and her family member on 04/11/2024 at 2:30 p.m. She stated this morning, she asked S5CNA to get her up into her wheelchair. She stated S5CNA told her she did not know how to transfer her. She stated she felt S5CNA was incompetent to assist with the transfer and asked S5CNA for assistance of another staff member. Resident #34 Review of Resident #34's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Fracture of Neck of Left Femur, Idiopathic Progressive Neuropathy, Generalized Muscle Weakness, and Morbid Obesity. Review of Resident #34's MDS with and ARD of 01/10/2024 revealed she had a BIMS of 14, which indicated she was cognitively intact. Further review revealed she required partial/moderate assistance with bathing. Review of Resident #34's current Care Plan revealed the following, in part: Problem: I require extensive to dependent assistance times 1-2 staff for ADL's. Staff assist me with ADL's. Interventions: I prefer a bed bath; Assist me with bathing. An interview was conducted with Resident #34 on 04/11/2024 at 1:38 p.m. She stated she asked S5CNA this morning to give her a bath. She stated when S5CNA gave her the bed bath S5CNA asked her with every step of the bath now what should I do? She stated S5CNA was very inexperienced. An interview was conducted with S5CNA on 04/11/2024 at 1:04 p.m. She stated she was assigned to Resident #34 today, on 04/11/2024, from 6:00 a.m. to 2:00 p.m. She stated she was hired on 04/08/2024 and had not received a computer login or training on the facility's computer system. She stated without computer access, she would not know what care the residents needed unless she asked the nurse or S3CNAS. She stated on her first day of training she was with the CNA on the hall observing care. She stated on her second day she participated in resident care with another CNA, but did not have to return demonstrate care. She stated today, 04/11/2024 she was by herself caring for the residents. She stated neither of the CNAs she worked with, nor S3CNAS did check offs or watched her demonstrate care. She stated she identified what care each resident needed by observing the residents and asking the residents what they needed. She stated Resident #34 requested a bath this morning and she provided the bed bath by herself. She stated no staff or S3CNAS had observed her provide a resident a bed bath. She stated she did not ask any other staff member or S3CNAS for assistance during her shift. An interview was conducted with S3CNAS on 04/11/2024 at 4:05 p.m. She stated Resident #28 reported to her she felt S5CNA was incompetent to transfer her. She stated S5CNA should have been able to identify how much assistance each resident needed for transfers. She stated S5CNA should have retrieved assistance from another staff member to transfer Resident #28 out of the bed when she requested. She stated she was unaware when S5CNA gave Resident #34 a bath today, S5CNA asked the resident how to provide the bath. She stated S5CNA should have been competent to perform a bed bath. She stated this morning was S5CNA's fourth day working at the facility and she was by herself on the hall. She stated she was aware S5CNA did not have a computer login or access to the resident records. She reviewed the CNA Orientation Proficiency Packet and stated it was the check off list for the CNAs' training. She confirmed she completed and signed the CNA Orientation Proficiency Packet for S5CNA on 04/08/2024, and by signing the form, she was saying S5CNA was competent. She stated she did not observe S5CNA return demonstrate providing care or bathing the residents to ensure competency. An interview was conducted with S2DON on 04/11/2024 at 4:42 p.m. She stated S3CNAS was responsible for going over all competencies with the CNAs upon hire. She reviewed the CNA Orientation Proficiency Checklist for S5CNA dated 04/08/2024, and confirmed S3CNAS signed off and documented S5CNA's orientation was complete and that she was competent in all CNA tasks. She stated without computer access, the CNA did not have access to the resident's clinical record, which included the assistance each resident required. She stated S5CNA should not have provided care to residents without knowing how much assistance each resident required for the specific task and/or ADL. She stated she was unaware Resident #34 reported S5CNA did not know how to give her a bed bath and that she asked the resident what to do during care. She confirmed S5CNA should have been competent in performing bed baths and transfers prior to working independently. An interview was conducted with S1ADM on 04/11/2024 at 5:10 p.m. He stated S3CNAS was responsible for training the CNAs and to ensure they were competent. He stated S3CNAS was responsible to follow-up, review, and sign off the CNA Orientation Checklist after ensuring the CNA's competence. He reviewed the CNA Orientation Proficiency checklist for S5CNA dated 04/08/2024. He confirmed by S3CNAS signing off the checklist, she was saying S5CNA was competent in the lsited task. He stated he expected staff working with residents to have computer access to know what care each resident required. He stated S2DON should follow up and make sure the CNA staff were competent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident residing in the facility. The facility failed to have an effective system in place to ensure S5CNA was competent in skills and techniques for 2 (#28 and #34) of 5 (#28, #34, #67, #75, and #88) residents reviewed for ADLs. Findings: Resident #28 Review of Resident #28's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Hemiplegia Following Unspecified Cerebrovascular Disease Affecting Left Non-dominant Side, Cerebral Infarction, and Generalized Muscle Weakness. Review of Resident #28's current Care Plan revealed the following, in part: Problem: I require staff assistance with ADLs. Interventions: I require assistance with transfers; and Transfer me on my strong side An interview was conducted with S5CNA on 04/11/2024 at 2:23 p.m. She stated Resident #28 reported she needed to be out of bed at 10:00 a.m. She confirmed she did not transfer Resident #28 out of bed. She stated she went into the room to assist Resident #28 out of bed, and she was unable to get her up by herself. She stated Resident #28 asked her to get another staff member to assist. She stated she informed S4LPN she was unable to get Resident #28 out of bed by herself but she did not ask for assistance. She stated she was unsure how to identify a resident's transfer status or how much assistance they required with ADLs. Resident #34 Review of Resident #34's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Fracture of Neck of Left Femur, Idiopathic Progressive Neuropathy, Generalized Muscle Weakness, and Morbid Obesity. Review of Resident #34's current Care Plan revealed the following, in part: Problem: I require extensive to dependent assistance times 1-2 staff for ADL's. Staff assist me with ADL's. Interventions: I prefer a bed bath; Assist me with bathing. An interview was conducted with S5CNA on 04/11/2024 at 1:04 p.m. She stated she was hired on 04/08/2024, had not received a computer login or training on the facility's computer system. She stated without computer access, she would not know what care the residents needed unless she asked the nurse or S3CNAS. She stated, on her first day of training, she was with the CNA on the hall observing care. She stated on her second day, she participated in resident care with another CNA, but did not have to return demonstrate care. She stated today, 04/11/2024, she was by herself caring for the residents. She stated neither of the CNAs she worked with, she was unsure of their names, nor S3CNAS did check offs or watched her demonstrate care. She stated she identified what care each resident needed by observing the residents and asking the residents what they needed. She stated Resident #34 requested a bath this morning, and she provided the bed bath by herself. She stated no staff or S3CNAS had observed her provide a resident a bed bath prior to giving Resident #34 a bed bath this morning. She stated she worked alone today and did not ask any other staff member or S3CNAS for assistance during her shift. An interview was conducted with S3CNAS on 04/11/2024 at 4:05 p.m. She stated Resident #28 reported to her she felt S5CNA was incompetent to transfer her. She stated she was unaware when S5CNA gave Resident #34 a bath today, S5CNA asked the resident how to provide the bath. She stated this morning was S5CNA's third day working at the facility and she was by herself on the hall. She stated she was aware S5CNA did not have a computer login or access to the resident records. She reviewed the CNA Orientation Proficiency Packet and stated it was the check off list for the CNAs' training. She confirmed she completed and signed the CNA Orientation Proficiency Packet for S5CNA on 04/08/2024, and by signing the form, she was saying S5CNA was competent. She stated she did not observe S5CNA return demonstrate providing care or bathing the residents and should have before signing her CNA Orientation Proficiency Packet. An interview was conducted with S2DON on 04/11/2024 at 4:42 p.m. She stated S3CNAS was responsible for going over all competencies with the CNAs upon hire. She reviewed the CNA Orientation Proficiency Checklist for S5CNA dated 04/08/2024, and confirmed S3CNAS signed off and documented S5CNA's orientation was complete and that she was competent in all CNA tasks. She stated without computer access, the CNA did not have access to the resident's clinical record, which included the assistance each resident required. She stated S5CNA should not have provided care to residents without knowing how much assistance each resident required for the specific task and/or ADL. She confirmed S3CNAS should have ensured S5CNA was competent in performing bed baths and transfers prior to working independently. She stated she and S8ADON were S3CNAS supervisors. She stated she and S8ADON did not check behind S3CNAS to ensure the CNA staff were trained effectively and competent. An interview was conducted with S1ADM on 04/11/2024 at 5:10 p.m. He stated S3CNAS was responsible for training the CNAs and to ensure they were competent. He stated S3CNAS was responsible to follow up, review, and sign off the CNA orientation checklist after ensuring the CNA's competence. He reviewed the CNA Orientation Proficiency checklist for S5CNA dated 04/08/2024. He confirmed by S3CNAS signing off the checklist, she was saying S5CNA was competent in the listed tasks. He stated staff working with residents should have computer access to ensure they are aware what each resident required when providing care to them. He stated S2DON should follow up and make sure the CNA staff were competent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's right to be free from sexual abuse for 1(#1) of 9 (#1, #2, #4, #5, R1, R2, R3, R4, and R5) sampled residents reviewed for abuse. The facility failed to protect Resident #1 from being inappropriately touched and kissed by Resident #2. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: A review of the facility's policy titled, Abuse-Prevention and Prohibition Policy and Procedure revealed the following, in part: Purpose: Each Resident has the right to be free from abuse. No one shall abuse a resident. This policy applies to other residents . Policy: 2. Sexual Abuse is non-consensual sexual contact of any type with a resident A review of the facility's Self-Reported Incident Report, dated 08/02/2023, revealed the following, in part: Victim: Resident #1 Accused: Resident #2 Allegations: Sexual Abuse Resident #1 A review of the Clinical Record for Resident #1 revealed she was admitted to the facility on [DATE]. The resident had diagnoses which included Unspecified Dementia and Aphasia. A review of the current Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/30/2023 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 0, which indicated she had severe cognitive impairment. A review of the Nurse's Note for Resident #1 revealed the following: 08/02/2023- S4CNA at 11am went into Resident #1's room and noted Resident #2 in room kissing Resident #1 and had hand placed on breast on top of shirt. S4CNA immediately removed Resident #2 from room and immediately notified S3SSD. S3SSD notified S5Admin, S1DON, and S2NP. Resident #1 was evaluated and was sitting in room in wheelchair with no signs of distress noted. -Signed, S1DON Resident #2 A review of the Clinical Record for Resident #2 revealed he was admitted to the facility on [DATE]. The resident had diagnoses which included Vascular Dementia and Other Sexual Dysfunction not due to a Substance or Known Physiological Condition (08/15/2023). A review of the current Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/19/2023 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 14, which indicated he was cognitively intact. A review of the Nurse's Note for Resident #2 revealed the following: 08/02/2023- S4CNA reported to me she witnessed Resident #2 in Resident #1 room kissing and touching her breast. -Signed, S3SSD 08/02/2023- S4CNA at 11am went into Resident #1 room and noted Resident #2 in room kissing Resident #1 and had hand placed on breast on top of shirt. -Signed, S1DON A review of the Nurse Practitioner Progress Notes revealed the following, in part: 08/02/2023- Seen today after a Certified Nursing Assistant witnessed Resident #2 in a female resident's room kissing and touching her breast over clothes. He does admit to this behavior and states he knows he was wrong and it will not happen again. -Signed, S2NP A review of the written statement by S4CNA stated I S4CNA witnessed Resident #2 standing over kissing and touching Resident #1 on top of her breast I than immediately removed him from her room On 08/28/2023 at 9:34 a.m., an interview was conducted with S4CNA. She stated on 08/02/2023, she observed Resident #2 wandering down Hall (a). She stated Resident #2 entered Resident #1 room. She stated upon entering Resident #1 room, she observed Resident #2 standing over Resident #1 kissing her with his hands placed on top of her breast. She stated Resident #1 was nonverbal and unable to consent to any of these actions. She stated Resident #2 was cognitive and knew what he was doing. On 08/28/2023 at 11:38 a.m., an interview was conducted with S2NP. She stated she interviewed Resident #2 post incident. She stated Resident #2 admitted to kissing and touching the breast of a resident but was unable to provide a name. She confirmed Resident #1 was unable to consent due to being cognitively impaired. She confirmed Resident #2 was cognitively intact and was well aware of the actions he had performed as being inappropriate. On 08/30/2023 at 12:15 p.m., an interview was conducted with S1DON. She stated if inappropriate touching involved a resident who had the inability to consent, she would consider this a form of sexual abuse. She confirmed inappropriate touching as being a form of sexual abuse. She confirmed Resident #1 as being vulnerable due to mental status and unable to consent to any sexual advances. She confirmed Resident #2 was cognitive and aware of his actions. Throughout the survey from 08/24/2023 to 08/30/2023, observations, record reviews, and staff interviews revealed staff received training on the facility's abuse policies and procedures, increase in awareness of residents wandering on hall, redirecting residents out of other resident's rooms, and reporting any possible abuse allegation to the appropriate staff member. All staff were knowledgeable of the types of abuse, and were aware abuse should be reported to administration immediately. The facility has implemented the following actions to correct the deficient practice: 1. Corrective actions were accomplished for resident found to be affected by the alleged deficient practice include: a) Resident #2 was immediately removed from Resident #1's room and placed on 1:1 supervision until exiting the facility on 08/02/2023. b) S5Admin and S1DON notified of the allegations immediately. c) Body Audit performed of Resident #1 on 08/02/2023. d) Resident #1 placed on every two hour safety monitor checks for emotional distress for 72 hours on 08/02/2023, completed on 08/05/2023. e) Resident #2 referred to Mental Health services for evaluation and treatment on 08/02/2023. f) In-Serviced all staff on reporting any possible abuse as well as being aware of activity on hallway and notifying supervisor if anything is observed on 08/02/2023, Completion of all staff in-serviced on 08/03/2023. 2. Other residents who have the potential to be affected by the alleged deficient practice include all residents in the facility. Corrective actions for those residents include: a) Resident #2 placed on 1:1 supervision immediately. Resident #2 sent out for mental health services for evaluation and treatment on 08/02/2023; returned to facility on 08/14/2023 where he remains on 1:1 supervision. b) Resident interviews conducted to assess if Resident #2 had ever made sexual advances toward them. c) Additional in-services were performed on Facilities Abuse Policy and Procedure. d) Quality Assurance rounds were conducted weekly to ensure maintained compliance. Compliance Date: 08/05/2023

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that a resident with an identified mental health diagnosis was referred for a Preadmission Screening Resident Review (PASRR) Level II evaluation as required for 1(#15) of 4 (#15, #24, #56, #64) sampled residents records reviewed for PASRR. Findings: Review of the Clinical Record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses which included: Bipolar Disorder. Further review revealed additional medical diagnoses of Anxiety disorder (02/23/2012), Schizoaffective Disorder (05/22/2013), Bipolar II Disorder (08/23/2018) Other Specified Depressive Episodes (01/30/2019). On 05/17/2023 at 11:13 a.m. an interview was conducted with S3SW. She stated when a resident acquired a new mental health diagnosis she submitted a Resident Review form to the Office of Behavioral Health for a PASRR Level II referral. She stated on 05/16/2023 she called the Office of Behavioral Health and was informed there was no Level II Resident Review form for Resident #15. On 05/17/2023 at 11:17 a.m. an interview was conducted with S2DON. She confirmed that Resident #15 acquired a new diagnosis of Schizoaffective Disorder in May of 2013 and Bipolar II in August of 2018. She confirmed a Resident Review form should have been submitted to the Office of Behavioral Health, upon receiving these diagnoses, for a PASRR Level II referral. She confirmed there was no PASRR Level II on file. On 05/17/2023 at 11:26 a.m. an interview was conducted with S1ADM. He confirmed if a resident received a newly acquired mental health diagnosis a Resident Review form should have been submitted to the Office of Behavioral Health for evaluation and determination for Level II services. He confirmed there was no Level II PASRR in the clinical record.

Based on observations and interviews, the facility failed to ensure garbage and waste were properly contained in the outdoor dumpster. Findings: On 11/01/2022 at 9:35 a.m., an observation was made of the area around the facility dumpster. The following was observed: There were approximately 14 discarded gloves, 1 snack cake plastic wrapper, 1 empty hand sanitizer bottle, 14 sugar packets, 4 coffee stirrers, 2 milk cartons, 3 cigarette packs, 1 plastic cup, 1 cracker packet, 2 empty blister packs, 1 gelatin snack, 1 sauce packet, 3 empty grocery bags, 1 reusable plastic storage bag, 1 potato chip bag, 2 chocolate candy bag, 1 USB charger, 6 foam cups, 1 water bottle. On 11/01/2022 at 9:37 a.m., an observation was made of the area around the residency closest to the facility. There was a fence between the resident's home and the facility's dumpster. Located in the resident's yard along the fence closest to the facility were 7 sugar packets, 1 discarded glove, and 1 empty grocery bag. On 11/01/2022 at 9:20 a.m., an interview was conducted with S5DM. She stated kitchen staff was responsible for removing kitchen trash and housekeeping staff was in charge of taking out other facility trash. She stated maintenance staff was responsible for cleaning trash around the dumpsters daily. On 11/01/2022 at 9:40 a.m., an observation was made with S2MAIN and S3MAINA. Both confirmed the above observations of trash being present around the dumpster bin. Both confirmed the trash above observed in the resident's yard along the fence line closest to the facility. On 11/01/2022 at 9:41 a.m., an interview was conducted with S2MAIN. He stated he was in charge of cleaning around the dumpster bins. He stated his expectations were for the dumpster area to be cleaned every morning between 8:00-8:30 a.m. He verified a second walk through was not performed post dumpster pickup, and confirmed a second clean up should be conducted post dumpster pickup. On 11/01/2022 at 9:45 a.m., an interview was conducted with S3MAINA. He stated he assisted with trash pickup around the dumpster bins in the mornings around 8:00 a.m. He verified he swept around the dumpsters, but did not sweep the area right past the dumpster. He confirmed there was trash located past the dumpster, which should be swept daily. On 11/01/2022 at 10:25 a.m., an interview was conducted with S4HSK. She stated housekeeping staff was responsible for taking out any trash related to housekeeping. She confirmed maintenance staff and the grounds keeper were in charge of cleaning around the bins daily. On 11/01/2022 at 11:25 a.m., an interview was conducted with S1ADMIN. He stated dietary and maintenance staff were in charge of cleaning around the dumpster bins daily. He stated his expectations were for trash to be cleaned on facility grounds in the mornings and as needed. He confirmed trash being present on the ground could potentially blow into other residencies' yards in the neighborhood. He confirmed trash was only being swept once a day, and should be swept as needed.