**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status for 1 (#19) of 19 sampled residents reviewed for MDS. Findings: Review of Resident #19's Clinical Record revealed he was admitted to the facility on [DATE]. Further review revealed Resident #19 was diagnosed with Glaucoma. Review of Resident #19's quarterly MDS with an ARD of 11/06/2024 revealed in part, the following: B0600: Speech Clarity: Clear Speech checked B1000: Vision: Adequate checked Review of Resident #19's therapy progress notes revealed treatment diagnoses of Dysarthria and Anarthria with Low Vision Precautions in place. An interview was conducted on 12/10/2024 at 9:45 a.m. with Resident #19. Resident #19 had slurred speech throughout the interview, and was difficult to understand. An interview was conducted on 12/11/2024 at 12:40 p.m. with S10PT. S10PT stated Resident #19 did not have adequate vision, had slurred speech, and was difficult to understand. An interview was conducted on 12/11/2024 at 12:41 p.m. with S11OT. S11OT stated Resident #19 did not have adequate vision, had slurred speech, and was difficult to understand. An interview was conducted on 12/11/2024 at 12:42 p.m. with S12ST. S12ST stated Resident #19 did not have adequate vision, had slurred speech, and was difficult to understand. An interview was conducted on 12/11/2024 at 12:52 p.m. with S8ADON. S8ADON stated Resident #19 had slurred speech and had some vision loss. S8ADON stated all MDS assessments should be accurately coded for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews, the facility failed to provide residents necessary respiratory care and services in accordance with accepted professional standards of practice for 1 (#3) of 1 (#3) resident reviewed for respiratory services. The facility failed to change Resident #3's oxygen tubing and humidifier bottle out weekly. Findings: Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Chronic Obstructive Pulmonary Disease and Mild Intermittent Asthma. Review of Resident #3's current Physician Orders revealed the following, in part: Oxygen: change oxygen tubing and water bottle every night shift every Sunday and as needed for contamination. On 12/09/2024 at 8:25 a.m., an observation was made of Resident #3's oxygen tubing and humidifier bottle. Both the oxygen tubing and humidifier bottle were labeled 12/01/2024. On 12/09/2024 at 8:43 a.m., an interview was conducted with S5LPN. She stated she was assigned to Resident #3. She stated oxygen tubing and humidifier bottles were changed weekly on Sunday nights. At that time, an observation was made of Resident #3's oxygen tubing and humidifier bottle with S5LPN. S5LPN confirmed Resident #3's oxygen tubing and humidifier bottle were dated 12/01/2024. She confirmed Resident #3's oxygen tubing and humidifier bottle should have been changed on Sunday night, 12/08/2024, and was not. On 12/09/2024 at 8:57 a.m., an interview was conducted with S2DON. She stated S5LPN notified her Resident #3's oxygen tubing and humidifier bottle were not changed Sunday night, 12/08/2024. She confirmed all resident's oxygen tubing and humidifier bottles were to be changed every Sunday night, and Resident #3's should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure a resident's Medication Administration Record (MAR) was accurately documented for 2 (#3 and #290) of 19 residents reviewed in the final sample. Findings: Resident #3 Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Chronic Obstructive Pulmonary Disease and Mild Intermittent Asthma. Review of Resident #3's current Physician Orders revealed the following, in part: Oxygen: change oxygen tubing and water bottle every night shift every Sunday and as needed for contamination. Review of Resident #3's December 2024 Medication Administration Record (MAR) revealed S7LPN documented Resident #3's oxygen tubing and humidifier bottle were changed on Sunday, 12/08/2024. On 12/09/2024 at 8:25 a.m., an observation was made of Resident #3's oxygen tubing and humidifier bottle. Both the oxygen tubing and humidifier bottle were labeled 12/01/2024. On 12/09/2024 at 8:43 a.m., an observation was made of Resident #3's oxygen tubing and humidifier bottle with S5LPN. S5LPN confirmed Resident #3's oxygen tubing and humidifier bottle were dated 12/01/2024. She confirmed Resident #3's oxygen tubing and humidifier bottle should have been changed on Sunday night, 12/08/2024, and was not. On 12/11/2024 at 1:47 p.m., an interview was conducted with S7LPN. She verified she worked Sunday 12/08/2024. She stated oxygen tubing and humidifier bottles were to be changed weekly on Sundays. She reviewed Resident #3's December 2024 MAR and verified she documented she changed Resident #3's oxygen tubing and humidifier bottle on Sunday 12/08/2024. She was notified of the observation of Resident #3's oxygen tubing and humidifier bottle on 12/09/2024, which were dated 12/01/2024. She confirmed she should not have documented Resident #3's oxygen tubing and humidifier bottles were changed if they were not. On 12/11/2024 at 1:53 p.m., an interview was conducted with S2DON. She reviewed Resident #3's December 2024 MAR and verified S7LPN documented she changed the oxygen tubing and humidifier bottle on 12/08/2024. She confirmed S7LPN should not have documented Resident #3's oxygen tubing and humidifier bottle were changed on 12/08/2024 if she did not change them. Resident #290 Review of Resident #290's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Long Term Use of Anticoagulants. Review of Resident #290's Physician Orders revealed the following, in part: Lab: PT/INR weekly every Wednesday. Start date 10/09/2024. Review of Resident #290's October 2024 MAR revealed S15LPN documented Resident #290's PT/INR was collected on Wednesday, 10/16/2024. Review of Resident #290's lab results dated October 2024 revealed no PT/INR results for 10/16/2024. On 12/11/2024 at 10:28 a.m., an interview was conducted with S15LPN. S15LPN stated if her initials were documented on the MAR in the PT/INR section, it meant the task was collected and completed. She stated if labs were refused by Resident #290 the MAR should have accurately reflected a refusal and should not have been signed off as completed. She stated she was unaware if the PT/INR was collected on 10/16/2024. On 12/11/2024 at 11:53 a.m., an interview was conducted with the facilities laboratory representative. The laboratory representative confirmed the only dates of services provided to Resident #290 were on 10/09/24 and 10/23/2024. She stated there was no record of labs being collected on 10/16/2024. On 12/11/2024 at 10:52 a.m., an interview was conducted with S2DON. S2DON reviewed Resident #290's October 2024 MAR and confirmed S15LPN documented the PT/INR was collected on 10/16/2024. S2DON stated she was unable to provide documentation to confirm Resident #290's PT/INR was collected on 10/16/2024. S2DON confirmed all residents MARs should accurately reflect services provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 1 (#23) of 5 (#2, #23, #55, #57, and #85) residents reviewed for infection control. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing direct care for a resident who was on Enhanced Barrier Precautions (EBP). Findings: Review of the facility's policy titled Categories of Transmission Based Precautions revised on 09/2022, revealed the following, in part: 5. Appropriate notification is placed on the room entrance door so that personnel are aware of the need for and the type of precautions. a. The signage informs the staff of instructions for the use of PPE. Review of Resident #23's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Paraplegia, Neuromuscular Dysfunction of the Bladder, and Ileostomy Status. An observation was made on 12/11/2024 at 10:02 a.m. of the Enhanced Barrier Precautions sign posted on Resident #23's door which revealed the following, in part: Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities. Dressing, transferring. An observation was made on 12/11/2024 at 10:05 a.m. of S13CNA and S14CNA dressing, emptying urostomy bag, and transferring Resident #23. S13CNA and S14CNA did not wear a gown while performing Resident #23's direct care. An interview was conducted on 12/11/2024 at 10:11 a.m. with S13CNA. S13CNA confirmed when a resident was on EBPs, staff should wear a gown while performing direct care and she did not. An interview was conducted on 12/11/2024 at 10:12 a.m. with S14CNA. S14CNA confirmed when a resident was on EBPs, staff should wear a gown while performing direct care and she did not. An interview was conducted on 12/11/2024 at 11:54 a.m. with S2DON. S2DON confirmed when a resident was on EBPs, staff should wear a gown while performing direct care. An interview was conducted on 12/11/2024 at 11:55 a.m. with S9IP. S9IP confirmed when a resident was on EBPs, staff should wear a gown while performing direct care.

Based on interviews and record review, the facility failed to employ staff with appropriate competencies and skills sets to carry out the functions of the food and nutrition service by failing to have a certified dietary manager on staff. This deficient practice had the potential to affect the 84 residents who consumed food from the kitchen. Findings: On 12/09/2024 at 9:06 a.m., an interview was conducted with S3DA. S3DA stated the Dietary manager was fired 2-3 weeks ago and he has been acting manager until the facility was hired a new dietary manager. He stated he did not have certification in food service or dietary management. On 12/09/2024 at 11:22 a.m., an interview was conducted with S1ADM. S1ADM further confirm him nor did any other staff in the facility have a certificate in food service or dietary management.

Based on record review, observations, and interviews, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to effect 84 residents who were served meals from the kitchen. Findings: On 12/08/2024 at 8:40 a.m., observations were conducted of the kitchen food preparation area, the following items were found to be expired: 1-14oz opened container of cayenne pepper with open date of 10/25/2022 and manufacture expiration date of 5/27/2024. 1-6oz opened container of Italian seasoning with open date of 01/30/2024 and manufacture expiration date of 09/22/2024. 1-12oz opened container of crushed red pepper with open date of 10/25/2022 and manufacture expiration date of 02/05/2024. 1-6oz opened container of sage rub with open date of 10/20/2023 and manufacture expiration date of 10/11/2024. Review of the facility's policy, titled Food Receiving and Storage, revealed: Foods shall be received and stored in a manner that complies with safe food handling practices. Revised 2014. On 12/08/2024 at 8:55 a.m., an interview was conducted with S1ADM. S1ADM confirmed 84 residents eat from the kitchen. He confirmed the above observations, and also confirmed the above expired items should have been discarded and were not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status for 1 (#4) of 4 (#1, #2, #3, and #4) residents reviewed for MDS. Findings: Review of Resident #4's Clinical Record revealed he was admitted to the facility on [DATE]. Further review revealed Resident #4 was diagnosed with Major Depressive Disorder on 03/02/2024. Review of Resident #4's quarterly MDS with an ARD of 03/14/2024 revealed Major Depressive Disorder was not coded as an active diagnosis in Section I. An interview was conducted on 04/18/2024 at 1:11 p.m. with S2MDS. She stated she was responsible for residents' MDS assessments. She stated when the MDS assessment was performed, all diagnoses should have been coded accurately for every resident. She reviewed the quarterly MDS for Resident #4 and confirmed the MDS was not coded accurately for active diagnoses in Section I. An interview was conducted on 04/18/2024 at 1:20 p.m. with S1DON. She confirmed if a resident had an active diagnosis, the MDS should have been coded accurately with those diagnoses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 1 (#3) of 4 (#1, #2, #3, and #4) residents reviewed. The facility failed to ensure S10LPN documented administered narcotic medications on Resident #3's Medication Administration Record. Findings: Resident #3 Review of Resident #3's Clinical Record revealed she was re-admitted to the facility on [DATE] and had diagnoses, which included Polyosteoarthritis, Lack of Coordination, Muscle Wasting, Dementia, and Difficulty in Walking. Review of Resident #3's Narcotic drug log for Morphine revealed Morphine 0.25mL was removed from stock on 04/04/2024, by S10LPN. Review of Resident #3's Medication Administration Record revealed no documentation Morphine 20mg/mL was administered on 04/04/2024. On 04/23/2024 at 11:24 a.m., a phone interview was conducted with S10LPN. She confirmed she was Resident #3's nurse on 04/04/2024. S10LPN stated Resident #3 complained of pain during brief change on 04/04/2024. She stated she could not recall if she documented the administered medication on the Resident #3's MAR, but she administered it. S10LPN confirmed if she administered a medication she should have signed it out and documented the administered medication on the MAR. On 04/23/2024 at 11:28 a.m., an interview was conducted with S1DON. After reviewing the MAR, S1DON confirmed she expected staff to document on the MAR any medication which have been administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to designate a member of the facility's interdisciplinary team to be responsible for working with hospice representatives to coordinate care as evidence by the facility failing to ensure hospice binders were up to date for 1(#3) of 1(#3) resident reviewed for hospice care. Findings: Review of the facility's policy titled Hospice Program, reviewed on 04/22/2024, dated 07/2017 revealed the following, in part: Policy Interpretation and Implementation: 12. Our facility has designated, Name and Title, to coordinate care provided to the resident by our facility staff and the hospice staff. He or she is responsible for following: d. Obtaining the following information from hospice: (1) the most recent hospice plan of care specific to each resident Review of Resident #3's Clinical record revealed she was re-admitted to the facility on [DATE] and admitted to hospice services on 01/02/2024. Review of the Hospice Binder for Resident #3 revealed no plan of care documents. On 04/22/2024 at 2:25 p.m., an interview was conducted with S3LPN. She stated she would refer to hospice binder for plan of care. On 04/18/2024 at 1:45 p.m., an interview was conducted with S1DON. She stated there is not a designated staff member responsible to coordinate care with hospice and should have. After review of the hospice binder, S1DON confirmed there were no plan of care documents in Resident #3's hospice binder and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure services were provided to meet quality professional standards for 2 (#1 and #3) of 3 (#1, #2, and #3) residents reviewed for falls. The facility failed to ensure staff documented neurological assessments after unwitnessed falls. Findings: Review of the facility's policy titled Falls-Clinical Protocol revealed the following: 2. In addition, the nurse shall asses and document/report the following as needed: e. Neurological status; Resident #1 Review of Resident #1's clinical record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Repeated Falls, Cerebrovascular Disease, Cerebral Infarction due to Unspecified Occlusion or Stenosis of Right Middle Cerebral Artery, Unspecified Osteoarthritis, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, and Other Lack of Coordination. Review of the facility's Fall Investigation Reports for Resident #1 revealed he had unwitnessed falls on 12/25/2023, 01/09/2024 and 02/04/2024. Review of Resident #1's clinical record revealed there was no documented neurological assessments following the unwitnessed falls on 12/25/2023, 01/09/2024 and 02/04/2024. On 04/22/2024 at 3:03 p.m., a telephone interview was conducted with S5LPN. S5LPN stated she was taking care of Resident #1 when he had unwitnessed falls on 12/25/2023 and 01/09/2024. She stated she performed neuro checks following both falls and the documentation would be in the back of the narcotic book. On 04/23/2024 at 08:20 a.m., a telephone interview was conducted with S6LPN. She verified neuro checks should be done after all unwitnessed falls. After reviewing the fall which occurred on 02/04/24, she stated she more than likely completed neuro checks. She stated she would have documented the neuro checks if I didn't forget. On 04/23/2024 at 11:28 a.m., an interview was conducted with S1DON. S1DON confirmed she was unable to provide documentation of neurological assessments for the above dates. Resident #3 Review of Resident #3's clinical record revealed she was re-admitted to the facility on [DATE] and had diagnoses, which included Polyosteoarthritis, Lack of Coordination, Muscle Wasting, Dementia, and Difficulty in Walking. Review of the facility's Fall Investigation Reports for Resident #3 revealed she had unwitnessed falls on 03/10/2024, 03/14/2024 at 10:15 a.m. and at 10:30 p.m., 03/20/2024 at 3:00 p.m. and 6:00 p.m. Review of Resident #1's clinical record revealed there was incomplete documentation of neurological assessments following the unwitnessed falls on 03/10/2024, 03/14/2024 at 10:15 a.m. and at 10:30 p.m., 03/20/2024 at 3:00 p.m. and 6:00 p.m On 04/23/2024 at 11:28 a.m., an interview was conducted with S1DON. She stated neuro checks are completed for all unwitnessed falls and/or if a resident hits their head. S1DON stated the neuro checks should be completed and documented every fifteen minutes for one hour, every thirty minutes for two hours, every hour for four hours, every four hours for sixteen hours, and then every shift to complete 72 hours. After reviewing Resident #3's Neurological assessment flowsheets dated 03/10/2024, 03/14/2024, and 03/20/2024, she confirmed the documentation on the flowsheets were incomplete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents' drug regimens were free from unnecessary psychotropic medications for 1 (#3) of 3 (#1, #2, and #3) residents reviewed for unnecessary psychotropic medications. The facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days and indicated the duration for the PRN order for Resident #3. Findings: Review of the facility's policy titled Tapering Medications and Gradual Dose Reduction, reviewed on 04/22/2024, dated 04/2007 revealed the following, in part: Policy Interpretation and Implementation: 10. Residents who use antipsychotic drugs shall receive gradual reductions. Review of Resident #3's clinical record revealed he was re-admitted to the facility on [DATE] and had diagnoses, which included Dementia, Schizophrenia, Major Depressive Disorder, and Anxiety. Review of Resident #3's active Physician Orders revealed the following: Start Date: 12/29/2023-Lorazepam 1mg by mouth every 4 hours prn for anxiety. Start Date: 12/29/2023-Temazepam 15mg one by mouth every 24 hours prn for insomnia. Further review revealed neither order had a documented end date. Review of Resident #3's Psychoactive Gradual Dose Reduction Form dated 01/16/2024 revealed the following: 1. Lorazepam 1mg q4h PRN anxiety 2. Temazepam 15mg q24h PRN insomnia 3. Psychotropic medications that are PRN are limited to 14 days and require the prescriber to evaluate the resident prior to extending the order and provide a duration for the pharmacotherapy. On 04/22/2024 at 12:00 p.m., an interview was conducted with Consultant Pharmacist. The Consultant Pharmacist confirmed orders for PRN psychotropic medications should be limited to 14 days and required the prescriber to evaluate the resident prior to extending the order and provide a duration for the pharmacotherapy. On 04/23/2024 at 11:28 a.m., an interview was conducted with S1DON. She could not answer to whether or not hospice PRN medications were limited to 14 days.

**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 the necessary services to maintain good grooming and personal hygiene for 1 (#12) of 3 (#12, #53, and #76) residents reviewed for ADLs. Findings: Review of the facility's policy titled, Care of Fingernails/ Toenails revealed the following: Purpose: The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. General Guidelines: 1. Nail care includes daily cleaning and regular trimming. Review of the clinical record for Resident #12 revealed he was admitted to the facility on [DATE] and had diagnoses which included Rheumatoid Arthritis, Unspecified Osteoarthritis, Systemic Disorders of Connective Tissue, and Weakness. Review of Resident #12's Quarterly MDS with an ARD of 09/19/2023 revealed he had a BIMS of 12, which indicated he had moderate cognitive impairment. Further review revealed he required extensive assistance, one person assist with personal hygiene needs. On 11/29/2023 at 8:44 a.m., an observation was made of Resident #12's fingernails. Resident #12's fingernails were observed to be long, thick, yellow and brown discolored with curvature to nails due to length. He stated his fingernails had not been trimmed since admission. He stated he was unable to grip things with his long nails and would like for them to be trimmed. He stated he was unable to clip his own fingernails due to having arthritis. On 11/29/2023 at 9:10 a.m., an interview was conducted with S3RN. She stated she first noticed Resident #12's long fingernails when she was hired in September. She described his fingernails as being long and thick, with a buildup of food and/or dirt under his nail bed. She stated she did not report this to anyone because she assumed nursing staff already knew about his fingernails being long. She stated the facility's process was to report identified nail care needs to the wound care nurse and she did not. On 11/29/2023 at 9:38 a.m., an interview was conducted with S6CNA. She stated she noticed Resident 12's long dirty fingernails a month ago. She stated she reported this to S5LPN. S5LPN was attempted to be interviewed via telephone but contact was unsuccessful. On 11/29/2023 at 10:20 a.m., an observation was conducted with S2DON of Resident #12's fingernails. She described Resident #12's fingernails as being long and thick with discoloration underneath the nail bed. She confirmed his nails were extended past the nail bed at least 1 inch after measuring with the wound care ruler. She stated she expected her nursing staff to identify the need for personal grooming needs for dependent residents and report these finding to the appropriate staff member. She stated nursing staff could report these findings to the floor nurse, supervisor and/ or wound care services. She confirmed nail care should have been performed on Resident #12 and was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to protect the resident's right to be free from physical abuse by an employee for 3(#1, #2, #3) of 5 (#1, #2, #3, #4, and #5) residents reviewed for abuse. 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 and Neglect-Clinical Protocol revealed the following, in part: The facility will ensure that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a safe resident environment and protect residents from abuse. Staff to Resident Abuse of any Types: o The facility assumes the responsibility upon admission of ensuring safety and well-being of the resident. o Staff are expected to be in control of their behavior and behave professionally. Definitions Verbal Abuse- the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Mental Abuse-this includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. A review of the facility's Self-Reported Incident Report, dated 06/26/2023, revealed the following, in part: Victim: Resident #1 Accused: S3LPN Allegations: Verbal Abuse A review of the clinical record for Resident #1 revealed he was admitted to the facility on [DATE] with diagnoses, which included Anxiety Disorder, Schizoaffective Disorder, Depression, and Post-Traumatic Stress Disorder. A review of the current MDS with an ARD of 07/12/2023 revealed Resident #1 had a BIMS of 14, which indicated he was cognitively intact. A review of the clinical record for Resident #2 revealed he was admitted to the facility on [DATE] with diagnoses, which included Hemiplegia, Anxiety Disorder, Depression, and Post-Traumatic Stress Disorder. A review of the current MDS with an ARD of 08/01/2023 revealed Resident #2 had a BIMS of 15, which indicated he was cognitively intact. A review of the clinical record for Resident #3 revealed he was admitted to the facility on [DATE] with a readmission on [DATE]. Resident #3's diagnoses included Major Depressive Disorder, Schizophrenia, and Paraplegia. A review of the current MDS with an ARD of 07/12/2023 revealed Resident #3 had a BIMS of 15, which indicated he was cognitively intact. A review of the signed written statement by S3LPN revealed the following, in part: When S3LPN went to assess Resident #1, he was sitting up in a chair smoking a cigarette. Resident #1 presented in a drowsy, unpleasant mood and stated, I want to leave the facility because I'm not satisfied. S3LPN stated she asked Resident #1 to politely remove his cigarette so S3LPN could do a full assessment. Resident #2 continued to offer Resident #1 a cigarette stating it's keeping him calm right now! S3LPN did not noted any signs/symptoms of anxiety. Resident #1 reported to S3LPN his anxiety medication causes him to feel this way. S3LPN informed Resident #1 if he felt uncomfortable his medical doctor may discontinue the medication and prescribe another one. S3LPN advised Resident #1 if the discomfort persisted it needed to be reported to his medical doctor. S3LPN advised Resident #2 that Resident #1 was calm and Resident #2 did not need to continue to offer cigarettes. S3LPN continued to assess Resident #1, but he did not respond promptly due to drowsiness. S3LPN requested Resident #1 to respond if he could hear her, and Resident #1 did not respond. S3LPN stated she repeated the question with a slight elevation of voice to ensure Resident #1 could hear her and understand. Resident #1 responded to S3LPN. Resident #2 raised his voice to S#LPN aggressively stating Don't yell at him. S3LPN informed Resident #2 she was not yelling, but was trying to ensure Resident #1 was responsive. Resident #1 refused all care. A review of the written statement by Resident #1 revealed the following, in part: Resident #1 stated, she is a b***h. Resident #1 stated S3LPN came out to smoker's porch and immediately started yelling at him to stand up when he could not do it she accused him of smoking weed. S3LPN said he need to go to the emergency room so he could be drug tested and she would call the doctor to stop some of his current medications because he is too weak. Resident #1 stated S3LPN listed out several of his medications she was going to have stopped. Multiple attempts were made from 08/15/2023 through 08/18/2023 to contact Resident #1 and S3LPN. All attempts were unsuccessful. On 08/16/2023 at 9:00 a.m., an interview was conducted with Resident #2. Resident #2 stated he recalled the incident he reported about S3LPN. He stated Resident #1 was having trouble getting out of a chair outside on the smoking porch and he witnessed Resident #1's legs tremor and shake when trying to get out of the bed. He stated he told Resident #1 he would go get the nurse for evaluation. When he arrived at the nursing station, he was told by S3LPN the nurse caring for Resident #1 and Resident #2 was on break and would not be available for a few minutes. Resident #2 stated S3LPN fussed under her breath and went to evaluate Resident #1. He stated S3LPN was very rude to Resident #1 by treating him like an animal, not a human, and stated Resident #1 was not her resident to care for. He stated he felt bad for Resident #1 and asked the nurse to leave and to quit talking down to Resident #1. He stated he told S3LPN they would wait on the nurse assigned to them. Resident #2 stated he considered S3LPN's action towards Resident #1 as verbal abuse and should not have to be tolerated by anyone. On 08/17/2023 at 12:15 p.m., an interview was conducted with Resident #3. He stated he was present for the incident on the smoking patio with Resident #1. Resident #3 stated Resident #1 was weak and he could not get up. He stated Resident #2 went to get their nurse to assess Resident #1. He stated the nurse was on break, and S3LPN had to stop her medication pass to come assess Resident #1. He stated when S3LPN came to the smoking patio she started throwing up accusations saying Resident #1 must have done something he shouldn't have. He stated himself and Resident #2 tried to tell S3LPN Resident #1 was weak and could not get up, but S3LPN did not want to listen. He stated S3LPN was rude, obnoxious, and yelling. He stated it made him uncomfortable and he felt S3LPN was being verbally abusive to Resident #1. He stated S3LPN spoke to them like they were children not grown men. He stated Resident #2 tried to tell S3LPN she was being abusive to them, but she did not listen. He stated the tone S3LPN used made him feel degraded, belittled, talked down too, intimidated, and it was abusive. On 08/17/2023 at 1:52 p.m., an interview was conducted with S2DON. She stated the incident concerning Resident #1 was reported to her by another resident. She stated the other resident reported S3LPN told Resident #1 he needed some medications discontinued, and he should not be out smoking since he was weak. She stated Resident #1, Resident #2, and Resident #3 told her S3LPN was being abusive. She stated S3LPN was suspended pending the investigation, and was terminated after the investigation. She stated with witnesses to the incident, the incident was substantiated as verbal abuse. On 08/17/2023 at 3:12 p.m., an interview was conducted with S1ADMIN. S1ADMIN stated Resident #2 was the one who complained to him about the incident with S3LPN and Resident #1. S1ADMIN verified the allegations of verbal abuse were substantiated related to all three residents were consistent in their statements regarding S3LPN's behavior. He stated S3LPN was terminated after the incident. He stated he could not have staff being abusive to residents. Throughout the survey from 08/15/2023 to 08/18/2023, staff interviews revealed staff received training on the facility's abuse policies and procedures, 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. Staff using inappropriate/unprofessional verbal language a. Initiate audit to ensure any other suspicion or allegation is investigated and reported Date assigned: 06/26/2023 Person Responsible NFA Expected date of completion: 07/26/2023 Resolved: yes b. Investigate and report any findings from initial audit Date assigned: 06/26/2023 Person Responsible NFA Expected date of completion: 06/26/2023 Resolved: yes c. In-Service DON & NFA regarding abuse/neglect investigation and reporting guidance Date assigned: 06/26/2023 Person Responsible: QI Expected date of completion: 06/26/2023 Resolved: yes d. RPP (Resident Priority QA Program) rounds 2 times a week for 4 weeks, and indefinitely as needed Date assigned: 06/26/2023 Person Responsible NFA/IDT Expected date of completion: 07/26/2023 Resolved: Yes, 07/26/2023 e. Monitor results of RPP (Resident Priority QA Program) two times weekly and times 4 weeks for results Date assigned: 06/26/2023 Person Responsible NFA/IDT Expected date of completion: 07/26/2023 Resolved: yes, 07/26/2023 f. In-service staff on abuse/neglect reporting, employee burnout Date assigned: 06/26/2023 Person Responsible DON/SD Expected date of completion: 06/23/2023 Resolved: yes g. Monitor grievances Monday-Friday in morning meeting Date assigned: 06/26/2023 Person Responsible NFA/IDT Expected date of completion: 07/26/2023 Resolved: yes, 07/26/2023 h. Monitor 24-hour shift report for complaints/concerns r/t abuse/neglect Monday-Friday Date assigned: 06/26/2023 Person Responsible NFA/IDT Expected date of completion: 07/26/2023 Resolved: yes, 07/26/2023 i. Monitor social and activity assessments for complaints of abuse/neglect weekly in high risk times 4 weeks Date assigned: 06/26/2023 Person Responsible: IDT Expected date of completion: 07/26/2023 Resolved: yes, 07/26/2023 j. Monitor resident council meeting monthly for complaints of abuse/neglect times 2 months Date assigned: 06/26/2023 Person Responsible NFA/DON Expected date of completion: 07/26/2023 Resolved: yes, 07/25/2023 k. Employee accused suspended pending investigation Date assigned: 06/26/2023 Person Responsible NFA/DON/HR Expected date of completion: 06/26/2023 Resolved: yes l. Employee terminated at conclusion of investigation for policy violation Date assigned: 06/30/2023 Person Responsible NFA/DON/HR Expected date of completion: 06/30/2023 Resolved: yes Compliance date: 07/26/2023

Based on record reviews and interviews the facility failed to provide services to meet professional standards for 1(#3) of 5(#1, #2, #3, #4 and #5) residents sampled for receiving pain medication. The facility failed to ensure the following: 1. Administered medications were documented on the Medication Administration Record (MAR) and 2. Physician's orders were obtained for PRN pain medication. Findings: Review of the facility's policy Documentation of Medication Administration revealed the following, in part: Policy Statement The facility shall maintain a medication administration record to document all medications administered. Policy Interpretation and Implementation 1. A nurse shall document all medications administered to each resident on the resident's medication administration record (MAR). 2. Administration of medication must be documented after (never before) it is given. 3. Documentation must include, as a minimum: a. Name and strength of the drug; b. Dosage; c. Method of administration (e.g., oral, injection (and site), etc.); d. Date and time of administration; f. Signature and title of the person administering the mediation; and g. Resident response to the medication, if applicable (e.g., PRN, pain medication, etc.). Review of Resident #3's medical record revealed an admit date of 05/09/2022 with diagnoses, which included: Idiopathic Progressive Neuropathy, Primary Generalized Osteoarthritis, Pain, Major Depressive Disorder, and Pain in Throat. A review of the Yearly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/24/2023 revealed a Brief Interview for Mental Status (BIMS) of 11 which indicated Resident #3 was moderately cognitively impaired. Review of the current Physician's Orders dated 05/01/2023-06/21/2023 revealed the following, in part: Start date: 06/19/2023: Tylenol 325mg Caplet -Take 2 Caplets as needed orally every 6 hours for pain/headache. Review of the MAR dated 05/01/2023-6/21/2023 revealed the following, in part: Percocet 10/325 mg take one tablet by mouth every six hours as needed for pain. Tylenol 325mg Caplet -Take 2 Caplets as needed orally every 6 hours for pain/headache. Order Date: 06/19/2023 Start date: 06/19/2023 6/20/2023 at 12:37 p.m. given 06/19/2023 at 3:13 p.m. an interview was conducted with S2LPN. She stated Resident #3 took Norco twice daily and also had a pain patch. She stated she gave Tylenol daily which seemed to work best for Resident #3's pain. She confirmed she gave Tylenol 650mg once daily in the evening. She confirmed she did not have an order but would get one. On 06/20/2023 at 09:17 a.m. an interview was conducted with S2LPN. She confirmed she did not chart the Tylenol given since she did not have an order. 06/20/2023 at 10:35 a.m. an interview was conducted with S2LPN. She stated she started giving Resident #3 Tylenol in May when her pain increased. 06/20/2023 at 10:40 a.m. an interview was conducted with S1DON. She stated the nurse was required to place medication orders from the Physician in the electronic chart and document on the MAR when medication was given. S1DON confirmed Tylenol was not documented on the MAR when given and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure the residents' right to formulate an advanced directive was properly reflected in the resident's record for 1 (#90) of 32 residents reviewed in the initial pool. The facility failed to ensure all records regarding code status consistently reflected the resident's wishes. Findings: Review of the facility's policy titled Advance Directives revealed the following: 10: The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. Resident #90 Review of Resident #90's clinical record revealed the following: admission face sheet dated [DATE] revealed the resident was identified as a full code. Physician orders dated [DATE] in Electronic Records revealed Resident #90 was a DNR. LaPost signed by the physician dated [DATE] revealed the resident was a DNR. Resident Consent for Cardiopulmonary Resuscitation form signed [DATE] revealed Resident #90 was a full code. An interview was conducted with S6LPN on [DATE] at 2:27 p.m. She stated she first checks the Resident Consent for Cardiopulmonary Resuscitation form and then verified the consent with the physician order. She confirmed the physician's order revealed Resident #90 was a DNR. She then confirmed the Resident Consent for Cardiopulmonary Resuscitation revealed resident's wishes were to receive CPR. S6LPN verified these two documents did not coincide. An interview was conducted with S10MSW on [DATE] at 12:15 p.m. She confirmed she was responsible for verifying the LaPost and the Resident Consent for Cardiopulmonary Resuscitation coincide. An interview was conducted with S2DON on [DATE] at 11:14 a.m. She verified Resident #90's Advance Directive documents were not consistent. She confirmed that all documents on the residents' clinical record should reflect the resident's most current wishes regarding Advance Directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to implement a comprehensive person centered care plan to meet a resident's medical needs for 1 (#90) of 20 sampled residents reviewed for care plans. The facility failed to ensure Resident #90 had a landing mat at bedside. Findings: Resident #90 Review of the medical record for Resident #90 revealed the resident was admitted to the facility on [DATE] with diagnoses, which included: Muscle Wasting and Atrophy, Disorder of Bone Density, Vitamin D Deficiency, Protein-Calorie Malnutrition, and Osteoporosis. Review of the Quarterly MDS with an ARD of 10/28/2022 revealed Resident #90 had a BIMS of 15, which indicated he was cognitively intact. Review of the Physician Orders dated December 2022 for Resident #90 revealed the following in part: Start/order date: 11/20/2022-Landing mat at bedside Review of the current Care Plan for Resident #90 revealed the following: Problem: 08/16/2022 I have the potential for falls due to impaired mobility Fall: 10/16/2022 with fracture Fall: 11/20/2022 Approaches: 11/20/2022 Landing Mat at bedside An observation was made on 12/05/2022 at 2:07 p.m. of Resident #90. She was lying in her bed. There was not a landing mat in place. An observation was made on 12/06/2022 at 9:00 a.m. of Resident #90. She was lying in her bed. There was not a landing mat in place. An observation was conducted on 12/06/2022 at 11:25 a.m. of Resident #90. There was no landing mat next to her bed. An interview was conducted with Resident #90 at that time. She stated she had never had a landing mat at her bedside. An interview was conducted on 12/06/2022 at 11:32 a.m. with S6LPN. She stated she was not aware of a physician's order for a landing mat for Resident #90. S6LPN reviewed Resident #90's physician orders at that time. She confirmed Resident #90 had a physician's order to have a landing mat at bedside beginning on 11/20/2022. She confirmed Resident #90's landing mat was not present. An interview was conducted on 12/06/2022 at 11:47 a.m. with S4ADON. She confirmed Resident #90 had a physician's order for a landing mat at her bedside. She stated the nurse assigned to the resident was responsible for implementing the physician's orders and care plans. An interview was conducted on 12/07/2022 at 11:10 a.m. with S7LPN. She confirmed she updated Resident #90's care plan daily per physician orders. She confirmed she was responsible for making rounds three times a week to ensure the care plan was implemented. She confirmed Resident #90's landing mat was not in place and should have been. An interview was conducted on 12/08/2022 at 11:43 a.m. with S2DON. She confirmed the nurse was responsible to implement physician orders and care plans. She confirmed a landing mat should have been next to Resident #90's bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident with a urostomy or indwelling urinary catheter received appropriate treatment and services to prevent urinary tract infections. The facility failed to ensure 1 (#41) of 5 (#15, #38, #41, #69, and #86) residents observed with a urostomy and indwelling urinary catheter did not have the drainage bag and tubing on the floor. Findings: Review of the facility's policy entitled, Catheter Care, Urinary revealed the following, in part: Purpose: The purpose of this policy is to prevent catheter-associated urinary tract infections. Infection Control: 4. Be sure the catheter tubing and drainage bag are kept off the floor. Review of the clinical record revealed Resident #41 was admitted to the facility on [DATE] with diagnoses which included, in part: Paraplegia, Complete; Pressure Ulcer of Sacral Region, Stage 4; Encounter for Attention to Ileostomy; Neuromuscular Dysfunction of Bladder, Unspecified; and Incontinence Without Sensory Awareness. Review of Physician's orders dated December 2022 revealed the following, in part: 05/10/2021: Ostomy: Change GU catheter, bag and accessories every 30 days and as needed. Review of the Infection Log from 11/01/2022 to 12/04/2022 for Resident #41 revealed the following: 11/06/2022 Urinary infection, pathogen not identified, treated with antibiotic, status resolved. On 12/04/2022 at 9:30 a.m., an observation was made of Resident #41's urinary catheter bag and tubing on the floor next to the right side of his bed. On 12/04/2022 at 2:13 p.m., an observation was made of Resident #41's urinary catheter bag and tubing on the floor on the right side of his bed. On 12/05/2022 at 9:40 a.m., an observation was made of Resident #41's urinary catheter bag and tubing lying on the floor. On 12/05/2022 at 9:55 a.m., an interview was conducted with S5LPN in Resident #41's room. She confirmed Resident #41's urinary catheter bag and tubing were on the floor and should not have been. She stated urinary catheter bags and tubing should be kept off of the floor. On 12/05/2022 at 9:58 a.m., an interview was conducted with S3RN in Resident #41's room. S3RN confirmed Resident #41's urinary catheter bag and tubing were on the floor and should not have been.

Based on observations and interviews, the facility failed to store, prepare food and maintain kitchen equipment under sanitary conditions by failing to ensure: 1. Food items were properly stored in the walk-in refrigerator; 2. Food items were properly stored in the food prep area; 3. Raw, uncooked food items were properly stored in the food prep area; and 4. Stationary equipment used in the kitchen was clean and free from debris. This deficient practice had the potential to affect 96 residents who ate from the facility's kitchen. Findings: Record Review of Policy titled Food Storage revealed, in part: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Procedure: 1. Dry Storage rooms d. To ensure freshness, store opened and bulk items in tightly covered containers. All container must be labeled and dated. 2. Refrigerators d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. Record Review of Policy and Procedure titled Sanitization revealed, in part: Policy Statement: The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation 3. All equipment, food contact surfaces and utensils shall be washed to removed or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. 11. For fixed equipment or utensils that do not fit in the dishwashing machine, washing shall consist of the following steps: a. Equipment will be disassembled as necessary to allow access of the detergent/solution to all parts; b. Removable components will be scraped to removed food particle accumulation and washed according to manual or dishwashing procedures. Record Review of Policy titled Food Preparation and Handling revealed, in part: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be prepared and handled according to the state and US Food Codes and HACCP guidelines. Procedure: 1. General Guidelines a. Use clean, sanitized surfaces, equipment and utensils. 2. Thawing Foods a. Thaw meat, poultry, and fish in a refrigerator at 41 degrees or less. On 12/04/22 at 8:50 a.m., an initial tour of the facility's kitchen was conducted with S9DC who confirmed the following items were opened and undated in the facility's kitchen: Prep table area: Lemon Pepper Salt seasoning- opened, undated 2- Ground Cumin seasonings- opened, undated 1- Grape Jelly- opened, undated Loaf of Sandwich bread- opened, undated Loaf of Potato bread, opened, undated Package of buns, opened, undated Loaf of Raisin bread, opened, undated Package of Hamburger buns, opened, undated Walk-in Refrigerator: 4 Fruit cups in styrofoam containers, undated 2- 8 ounce glasses of apple juice, undated 1- 8 ounce glass of cranberry juice, undated One and one-half pans of cooked dinner rolls, undated Cooked bacon, wrapped in clear plastic wrap, undated Prep area sink: 30-40 pieces of thawed, seasoned chicken in direct contact with stainless steel sink, and not stored on ice or in a container. Stationary Equipment revealed: All four sides of the outer metal frame of the Tip Skillet was covered with a yellowish-brown, sticky substance. A copious amount of a gray fluffy substance covered the rear fan motor of the double ovens. The exterior oven doors were covered with a brownish sticky substance. The Double deep fryers contained a copious amount of a brownish sticky substance on the metal extending 8-10 inches from above both fryers, next to the fryer's exhaust. A copious amount of a brownish, sticky substance was observed on piping extending below both deep fryers down to the floor drain. On 12/04/2022 at 8:55 a.m., an interview was conducted with S9DC who confirmed the chicken should have been stored in the refrigerator until it was time to be prepared for resident's consumption. On 12/4/2022 at 11:20 a.m., a tour of the facility's stationary equipment and interview was conducted with S8DM. She was informed of the above observations made during initial tour conducted with S9DC regarding undated food items found in the food prep area, walk-in refrigerator. She confirmed food items in the food prep area, and walk-in refrigerator were not dated and should have been. She confirmed the raw, thawed chicken observed in the stainless steel sink in the food prep area had not been stored properly. She confirmed all stationary kitchen equipment should be clean and without any food debris.