**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to assess 1(#12) out of 1 sampled residents for self-administration of medication in a final sample of 35 residents. Findings: On 03/24/2025, a review of the facility's policy titled, Resident Self-Administration of Medications with a las review date of 12/30/2024 revealed in part, Policy: It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team had determined which medications may be self-administer safely. Policy Explanation and Compliance Guidelines: .4. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record . Resident #12 was admitted to the facility on [DATE] with diagnoses that included essential hypertension and dermatitis. Review of Resident #12's quarterly MDS (Minimum Data Set) dated 02/24/2025 revealed the resident had a BIMS (Brief Interview of Mental Status) score of 15, which indicated he was cognitively intact. Review of Resident #12's Medication Administration Record (MAR) revealed an order with a start date 06/07/2024 for Miconazole Nitrate 2% (percent) powder (antifungal medication)-apply to affected area every 8 hours as needed. On 03/24/25 at 1:28 PM, Resident #12 was observed sitting in his wheelchair in his room. A clear medication cup with a white powdery substance was observed on the resident's bedside dresser. Resident #12 stated that it was a powder that he had to apply to his abdominal folds for itching. A review of Resident #12's electronic and paper medical record revealed no documented evidence that a medication self-administration assessment was conducted. On 03/25/2025 at 9:25 AM, an interview and review of Resident #12's electronic medication administration record was conducted with S12LPN (Licensed Practical Nurse). She confirmed that Resident #12 had an order for Miconazole Nitrate 2% powder to apply to affected every 8 hours as needed to his groin or abdominal folds when he develop a yeast-like rash in those areas. On 03/25/2025 at 9:30 AM, an observation of the resident's room was conducted with S12LPN. A clear medication cup with a white powdery substance was noted on Resident #12's bedside dresser. Resident #12 stated that someone had put the medication cup in one of the drawers of the table. S12LPN confirmed that there was a clear medication cup with a white powdery substance on the resident's bedside dresser. On 03/25/2025 at 9:40 AM, an interview was conducted with S13TN (Treatment Nurse) She stated that she was responsible for applying the Miconazole Nitrate powder to Resident #12's abdominal and/or groin area when needed if the resident develops a rash. She confirmed that Resident #12 was not assessed for self-administration of his medications. She also confirmed that she may have left the medication cup in the resident's room and that she should not have left it in the resident's room. On 03/25/2025 at 10:10AM, record review and interview was conducted with S11DON (Director of Nursing). S11DON reviewed the resident's paper chart. She confirmed that Resident #12 had not been assessed for self-administering his own medications. She also confirmed that the medication cup with the Miconazole Nitrate 2% powder should not have been left at the resident's room because he was not assessed for self-administering his own medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and interviews, the facility failed to report to the administrator of the facility a resident report of sexual abuse for 1(#85) of 1 resident sampled for abuse. This had the potential to affect the 95 residents that reside in the facility. Findings: A review of the facility's policy titled Abuse and Neglect with a last reviewed date of 12/30/2024 read in part, Identification- A) Any staff member receiving a complaint of abuse, neglect, or an injury of unknown origin whether it is from the resident, a family member or staff, should listen to the complaint, writing down the date, and time complaint is being received, and any details given D) Administrator or his designee should be notified as soon as possible. Resident #85 was admitted to the facility on [DATE] with a diagnoses which included, but were not limited to cerebral infarction, unspecified psychosis, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of Resident #85's Quarterly MDS (Minimum Data Set) dated 12/17/2024, revealed the resident had a BIMS (Basic Interview for Mental Status) of 15, indicating his cognition was intact. On 03/24/25 at 10:00 AM, an interview was conducted with Resident #85. He stated about four weeks ago, a young, black CNA (Certified Nursing Assistant) Punched him in the nuts while changing his diaper. He stated that he had informed multiple staff including S14SSD (Social Service Director) and S11DON (Director of Nursing) of the incident. Resident #85 stated that S14SSD and S11DON had continued to report to him that they had been looking into it. On 03/25/25 at 02:41 PM, an interview was conducted with S16CNA (Certified Nursing Assistant). S16CNA stated about 1 and 1/2 months ago, Resident #85 reported to her that he had been sexually assaulted by a CNA. S16CNA stated that Resident #85 reported to her that S17CNA had pushed on his scrotum too hard while changing him. S16CNA stated that she reported the resident's claim to S18LPN (Licensed Practical Nurse). S16CNA stated that the day after Resident #85's claim of abuse, S16CNA had a discussion with S11DON about the resident's claim of sexual assault. On 03/25/25 at 04:41 PM, a phone interview was conducted with S17CNA. S17CNA stated that within the last few months, she was performing perineal care for Resident #85 in his room when he began to yell out Sexual Battery and refused to let her proceed with care. She stated she was only wiping him like she usually done. S17CNA requested that S16CNA come in the resident's room with her to complete care, because of Resident #85's accusations. She stated that S16CNA had informed her that she had reported the resident's allegation to the nurse. S17CNA stated the next day, she completed a written statement of the resident's accusations at the request of S11DON. S17CNA stated that the facility no longer allowed her to care for Resident #85 due to the resident's accusation. On 03/26/25 at 01:28 PM, an interview was conducted with S19ADM (Administrator) and S20AADM (Assistant Administrator). Both S19ADM and S20AADM stated that they had not been informed of Resident #85's claim of sexual abuse and should have been. Both stated that they would have reported this claim to the appropriate state agency if they had been made aware of the claim.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow the care plan for Resident #80 as evidenced by failing to offer the resident a visit with the in house dental consultant for 1 (#80) out of 35 sampled residents. Findings: Resident #80. On 03/24/2025 at 10:11 AM, an interview was conducted with the resident. The resident stated that he had some broken and missing teeth and he wanted to see a dentist. The resident stated that no one discussed dental services with him. Review of the resident's clinical record revealed the resident was admitted to the facility on [DATE]. Review of the resident's admission MDS (Minimum Data Set) assessment dated [DATE] revealed the resident was coded to have obvious or likely cavity or broken natural teeth and inflamed or bleeding gums or loose natural teeth. Review of the resident's care plan revealed that it addressed the resident having carious teeth and gum inflammation. An intervention included to offer the resident a visit with the in house dental consultant if needed or asked. Review of the resident's clinical record and social service notes revealed no evidence the resident was offered a visit with the in house dental consultant. On 03/25/2025 at 1:35 PM, an interview was conducted with S14SSD (Social Service Director). S14SSD stated that the residents who did not purchase dental insurance would be seen by S15RDH (Registered Dental Hygienist). S14SSD stated the process was that S15RDH would receive the census list of all the residents in the facility without dental insurance and from that list he would select the residents he would visit on the day he was in the facility. S14SSD stated S15RDH would visit the facility once a month and see the residents at least once a year. S14SSD stated the resident did not have dental insurance and confirmed that she did not have evidence S15RDH saw the resident and evaluated his oral care. On 03/26/2025 at 11:58 AM, a telephone interview was conducted with S15RDH. He confirmed that he did not evaluate the resident's oral care until 03/25/2025 when it was brought to his attention. S15RDH stated that he thought the resident had dental insurance to see the dentist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that services were provided to meet professional standards of quality as evidenced by S13TN (Treatment Nurse) leaving medication at the bedside for 1 (#12) out of 1 resident, who was not assessed for self-administration of his medication, out of a total sample of 35 residents. This deficient practice had the potential to affect the 95 residents in the nursing home. Findings: Resident #12 was admitted to the facility on [DATE] with diagnoses that included essential hypertension and dermatitis. Review of Resident #12's quarterly MDS (Minimum Data Set) dated 02/24/2025 revealed the resident had a BIMS (Brief Interview of Mental Status) score of 15, which means cognitively intact. On 03/24/25 at 1:28 PM, Resident #12 was observed sitting in his wheelchair in his room. A clear medication cup with a white powdery substance was observed on the resident's bedside dresser. Resident #12 stated that it was a powder that he used to apply to his abdominal folds for itching. On 03/25/2025 at 9:40 AM, an interview was conducted with S13TN (Treatment Nurse) She stated that she was responsible for applying the Miconazole Nitrate powder (antifungal medication) to Resident #12's abdominal and/or groin area when needed if the resident develops a rash. She confirmed that she may have left the medication cup in the resident's room and confirmed that she should not have left it in the resident's room. On 03/25/2025 at 10:10AM, record review and interview was conducted with S11DON (Director of Nursing). S11DON confirmed that S13TN should not have left the medication cup with the Miconazole Nitrate 2% powder in Resident #12's room.

Based on record review and interview, the facility failed to ensure that staffing data posted daily included resident census and total number of hours worked. Findings: On 03/25/2025 at 12:35 PM, an observation of staffing data posted revealed the following: Staffing for: 03/25/2025 6-2 (6:00 AM to 2:00 PM): 2 RN (Registered Nurse) @ 16 HRS (hours), 5 LPN (Licensed Practical Nurse) @ 40 HRS, 23 CNA (Certified Nursing Assistant) @ 184 HRS. Further review revealed the census and total number of hours worked were missing. During an interview with S2WC (Ward Clerk) on 03/25/2025 at 1:30 PM, she stated she was responsible for completing and posting the staffing sheet. S2WC confirmed that the census number and total number of hours worked were left blank, and stated she had never included that information when she posted the staffing. On 03/26/2025 at 8:00 AM an observation of staffing data posted revealed the following: Staffing for: 03/26/2025 6-2: 2 RN @ 16 HRS, 5 LPN @ 40 HRS, and 24 CNA @ 192 HRS. Further review revealed the census and total number of hours worked were missing. During an interview with S3WC (Ward Clerk) on 03/26/2025 at 8:15 AM, she stated that she was responsible for completing and posting the staffing sheet. S3WC confirmed that the census and total number of hours worked were left blank, and stated she had never included that information when she posted the staffing. During an interview with S4PR (Payroll Clerk) on 03/26/2025 at 8:20 AM, she stated that the ward clerks were responsible for completing the staffing sheet with the census and hours and posting it on the board daily. She stated that she pulled the staff clock-ins at the end of the day and completed the actual hours provided and the difference. She stated that on 03/24/2025 and 03/25/2025, she had to fill in the census and total number of working hours because the ward clerks had not included it on the staffing sheets posted for either days and should have.

Based on observation, record review and interview, the facility failed to ensure all drugs and biologicals were stored in locked compartments as evidenced by the nurse leaving the medication cart unlocked and unattended during the medication pass on Hall B. Findings: Review of the facility's policy and procedure titled, Medication Administration last reviewed on 12/30/2024 read in part, .Medication cart locked if left unattended in resident care area . On 03/25/2025 at 7:55 AM during the medication pass, S10LPN (Licensed Practical Nurse) was observed locking the medication cart on Hall B. During this observation, a nurse walked up to the medication cart and pulled on the bottom compartment of the cart and it opened. The bottom compartment had medications stored in it. S10LPN stated that she was not aware that the bottom compartment did not lock. S10LPN confirmed the bottom compartment had medications stored in it and that the compartment should have been locked when she left the medication cart unattended.

Based on observations, interviews and infection policy review, the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections as evidenced by failing to: 1. Appropriately handle and transfer soiled laundry; 2. perform proper hand hygiene; 3. appropriately remove PPE (Personal protective equipment); and 4. sanitize dirty scissors before re-using. Findings: 1. On 03/24/2025, a review of the facility's policy titled Laundry, with a last reviewed date of 12/30/2024, read in part: Policy: The facility launders linens and clothing in accordance with current CDC (Centers for Disease Control) guidelines to prevent transmission of pathogens .Policy Explanation and Compliance Guidelines: 1. Aligning with principles of standard precautions, staff shall consider all previously worn clothing and used linen as potentially contaminated .4. Soiled laundry shall be handled as little as possible, with minimum agitation to avoid contamination of air, surfaces, and persons. a. Linens shall be bagged separately from resident's clothing at the point of use. On 03/24/2025 at 09:25 AM, S5CNA (Certified Nursing Assistant) was observed walking out of Room D into Hall A with bed linen held in front her. The linen was not in a bag and S5CNA was not wearing any PPE. During an interview with S5CNA on 03/24/2025 at 9:30 AM, she confirmed that the linen was dirty and not in a bag. She further stated that she should not to wear gloves in the hallway, and was not sure if she should have bagged the linen. During an interview and review of infection control policies with S8ADONIP (Assistant Director of Nursing, Infection Preventionist) on 03/24/2025 at 12:01 PM, she stated that S5CNA should have bagged the laundry at the bedside before removing it from the resident's room. She also stated the CNA should have treated the laundry as contaminated, which meant handling the dirty laundry with gloves. 2. On 03/24/2025, a review of the facility's policy titled Handwashing, with a last reviewed date of 12/30/2024, read in part: Handwashing: Wash your hands even though you were wearing gloves, and washing your hands between residents is an absolute necessity to prevent from spreading germs/virus. During an observation on HALL A on 03/24/2025 at 09:25 AM, S5CNA walked into Room D with clean bed linen, made the bed closest to the door then immediately moved to Room C without performing hand hygiene. During an interview with S5CNA on 03/24/2025 at 9:30 AM she confirmed not performing hand hygiene after making the bed in Room D and before touching the beds in Room C and stated that she should have. On 03/24/2025 at 10:03 AM an observation was made of S6HSKP (Housekeeper) walking out of Room E bathroom with gloved hands. He walked into the hallway and disposed of the gloves in the trash bag on the housekeeping cart. Further observation revealed S6HSKP changed into a clean pair of gloves without performing hand hygiene then walked back into Room E. During an interview with S7HSKPSup (Housekeeping Supervisor) on 03/24/2025 at 10:05 AM, she stated S6HSKP should have washed his hands before using gloves and after removing the gloves. During an interview and review of the facility's hand hygiene policy with S8ADONIP on 03/24/2025 at 12:01 PM, she confirmed that hand hygiene should be performed according to the facility's policy above. 3. On 03/26/2025, a review of the facility's policy titled Donning and Doffing, with a revised date of 11/2024 read in part, Policy: Donning and Doffing. Purpose: Preventing the spread of infectious diseases and protecting healthcare workers and patients .Removing the gown as well as all other PPE (personal protective equipment). Remove your gloves first by pinching the glove in the palm of your hand and pulling the glove slowly downward .Then remove your gown . On 03/25/2025 at 10:34 AM, an observation was made of S9RNTX (Treatment Nurse/Treatment Nurse) performing a dressing change on Resident #25. After completing the dressing change S9RNTX was observed reaching behind her neck with her dirty gloved hands and removed her gown, then she removed her dirty gloves. During an interview with S9RNTX on 03/25/2025 at 10:34 AM, she confirmed removing her gown before her dirty gloves and stated she should have removed her dirty gloves first. During an interview with S8ADONIP on 03/26/2025 at 3:30 PM, she stated S9RNTX should have removed her dirty gloves before her gown according to the facility's policy. 4. On 03/25/2025 at 10:34 AM, an observation was made of S9RNTX performing a dressing change on Resident #25. S9RNTX removed the resident's old dressings by cutting the gauze wraps with a pair of reusable metal scissors. She placed the scissors on the far side of her treatment table without sanitizing them. Further observation revealed S9RNTX used the dirty scissors to cut the clean gauze that she used to wrap the resident's wound on her right leg. During an interview with S9RNTX on 03/25/2025 at 10:34 AM, she confirmed using the dirty scissors to cut Resident #25's clean dressing and stated she should have sanitized the scissors before using them. During an interview with S8ADONIP on 03/26/2025 at 3:30 PM, she stated that S9RNTX should have sanitized the scissors after using it to cut the resident's old dressing and before cutting the new dressing.

Based on observation, interview, and policy review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure: 1. food was dated after opening; and 2. food was properly sealed and stored. The facility had a census of 95 residents. Findings: On 03/24/2025, a review of the facility's policy titled, Correct Food Storage with a revised date of 12/30/2024, read in part, all foods shall be stored in a manner to ensure First-in - ''First- Out use and all items shall be labeled, dated and sealed. On 03/24/2025 at 9:01 AM, an observation was made of the dry storage area with S1DM (Dietary Manager). S1DM confirmed the following observations: -1 partially used bottle of imitation vanilla with no opened date; -1 partially used bottle of imitation banana with no opened date; -1 opened unsealed bag of corn flakes with no opened date; -1 opened and unsealed box of quick oats opened with no opened date; -1 opened and unsealed bag of grits with no opened date. On 03/24/2025 at 9:07 AM, an interview was conducted with S1DM. S1DM confirmed all opened items should be sealed and labeled with an opened date.

Based on observations, interviews and record reviews, the facility failed to ensure that certified nursing aides (CNAs) who transported residents in the facility's van were trained and competent on the proper and safe procedure for securing the resident's wheelchair in the van according to the manufacturer's instructions. This deficient practice was evidenced by 1 (S2TransportationCNA) of 2 transportation CNAs observed improperly securing Resident R1 in the facility's transportation van. Findings: On 07/16/2024 at 10:00 a.m., S1ADM (Administrator) was asked to provide the manufacturer's instruction manual for securing a resident in the facility's transportation van. He stated the facility's van was purchased in 2016, and a conversion was put into the van by a third party company. That company demonstrated to staff how to properly secure residents in the van once, when the conversion was put into the van in 2016. He stated the previous transportation drivers trained the new transportation drivers how to secure residents' wheelchairs in the van, and he was not sure if the new drivers were trained on the manufacturer's instructions. S1ADM stated he would look for the manufacturer's instruction manual as he did not know if the facility still had it. On 07/16/2024 at 11:00 a.m., an observation was made with S1ADM of S2TransportationCNA as she secured Resident R1 in the facility's van for transportation. S2TransportationCNA wheeled Resident R1 into the back of the van via the van's ramp, locked the wheelchair, then secured the resident with the rear tie down straps. She then entered through the front of the van, secured the resident with the seatbelt, then proceeded to use the J- hooks at the front of the van to secure the front of the resident's wheelchair. S2TransportationCNA secured the J- hooks to the left and right front wheels of the wheelchair, and not to the frame or welded junction of the frame of the wheelchair. On 07/16/2024 at 1:30 p.m., S1ADM provided the manufacturer's instruction manual for securing a resident in the facility's van. He stated that the L- track system was installed in the van, and confirmed that the instructions provided were how residents should be properly and safely secured in the van. Review of the manufacturer's instructions for the facility's transportation van wheelchair strapping system provided by S1ADM revealed the following in part: With either the manual or retractable straps, it is important to make sure that you securely attach the pin to the floor anchor or L- track , and the J- hooks are placed properly and tightened so that the chair does not move. W19 wheelchairs feature securement points to attach the straps to. On a non- W19 wheelchair, attach the straps to welded junctions of the frame, or to places where the frame is bolted. Never attach straps to moving or adjustable parts of the wheelchair. Review of the facility's training and in-service records revealed an attestation signed by S2TransportationCNA stating that she participated in an in-service training for van drivers on 12/14/2023, 04/28/2024, and 05/16/2024. There were no training materials attached to show what procedures she was trained on or that she was trained to properly restrain residents in wheelchairs according to the manufacturer's instructions for the van's strapping system. On 07/16/2024 at 3:50 p.m., S1ADM did not confirm or deny that during the observation, S2TransportationCNA secured the J- hooks to the wheels of the resident's wheelchair instead of the frame of the wheelchair as the instructions indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that all alleged violations of abuse were reported immediately to the administrative staff for 2 (#1 and #2) out of 3 (#1, #2, and #3) sampled residents. Findings: Review of the facility's Abuse and Neglect policy and procedure that was updated 01/2024 per S2AsstAdm (Assistant Administrator) read in part: Policy: It is the policy of this facility to provide an environment for our residents that is free of abuse, neglect, extortion, self-neglect or misappropriation of funds . 4. Identification-Any staff person receiving a complaint of abuse, neglect, or an injury of unknown origin whether it is from the resident, a family member or staff, should listen to the complaint, writing down the date, and time complaint was received, time, and any details given .The charge nurse then notifies the administrator or his designee immediately even if this is a weekend or at midnight . 1. Resident #1. Review of the resident's clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Muscle Spasm, Age-Related Osteoporosis, and Other Specified Disorders of Bone Density. Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 7, indicating her cognition was severely impaired. Review of the facility's incident report that was entered on 03/31/2024 at 8:28 p.m. revealed that on 03/30/2024 S7CNA (Certified Nursing Assistant) explains to Resident #1's RP (Responsible Party) that Resident #1 told her that she hurt her hands when helping her stand up . Review of the facility's incident report investigation revealed, On 04/05/2024 at 10:45 a.m., S2AsstAdm (Assistant Administrator) wrote: Resident #1 03/31/2024 S7CNA approached Resident #1's RP son of Resident #1) telling him that she was assisting Resident #1 the day before (03/30/2024) to stand and Resident #1 said she hurt her hands and bruised them . Interview with S8LPN, S7CNA never reported any incident on 03/30/2024 regarding Resident #1 to the nurse in charge or the supervisor. She reported to S8LPN at 5:45 p.m. on 03/31/2024 the conversation she had with Resident #1's RP was the first notification of this incident . Review of S8LPN's handwritten statement that was not dated revealed, 03/31/2024 at 5:45 p.m. On the above date and approximately time S7CNA called facility and stated that Resident #1 had informed her son that she had been abusive towards her. S7CNA stated that Resident #1's RP questioned her about this and she told him that she was helping the Resident #1 stand up with her hands clasping Resident #1 hard. Resident #1 alleged that she was hurt in the process . Three attempts were made to contact S7CNA via phone on 05/01/2024 at 2:00 p.m., at 2:20 p.m., and at 2:40 p.m. S7CNA failed to return any phone calls and was unable to be interviewed. On 05/01/2024 at 2:50 p.m., a telephone interview was conducted with S8LPN. S8LPN stated she was the nurse and S7CNA was the CNA for Resident #1 on 03/30/2024 and 03/31/2024. S8LPN stated that she received a telephone call on 03/31/2024 at around 5:45 p.m. from S7CNA who stated on 03/30/2024 that Resident #1 complained that S7CNA clasped her hands too tight while transferring her and hurt her hands. S8LPN confirmed that all alleged cases of any type of abuse has to be reported immediately to the charge nurse or supervisor and S7CNA did not report the case of alleged abuse to S8LPN until the next day. On 05/02/2024 at 8:51 a.m., a joint interview was conducted with S4Adm (Administrator) and S2AsstAdm. S2AsstAdm stated she initiated the facility incident report and completed the investigation regarding Resident #1's complaint. S4Adm and S2AsstAdm stated that they were notified of the allegation of abuse from S8LPN on 03/31/2024 in the evening around 6:30 p.m. They were told by S8LPN that S7CNA called the facility and told S8LPN that Resident #1 told her on 03/30/2024 that S7CNA clasped her hands to tight while transferring her and her hands were hurt and bruised. S4Adm and S2AsstAdm confirmed that S7CNA did not report the alleged abuse until the next day on 03/31/2024 and S7CNA should have immediately reported the alleged abuse to the charge nurse or administration staff.2. Resident #2. Review of the resident's clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Unspecified Dementia, Unspecified Severity, With Other Behavioral Disturbance, Anxiety Disorder, and Dysphagia. Review of the resident's significant change MDS (Minimum Data Set) dated 03/27/2024 revealed the resident was assessed as being severely impaired for cognition. Review of the facility's incident report that was entered on 03/11/2024 at 4:41 p.m. revealed that on 03/11/2024 at 4:15 p.m. the resident's daughter entered the administration office. The resident's daughter stated that she was at the facility on Friday evening after supper and an aide came to take her mother, Resident #2, to bed. The resident's daughter stated that the CNA handled her mother really rough and did not want that CNA to provide care to her mother again. An investigation was assigned and started by the S2AsstAdm. Review of the facility's incident report investigation revealed, Incident Investigation: On 03/12/2024 at 4:23 p.m., S2AsstAdm wrote: 03/08/2024 S4CNA stated that S5CNA was assigned to care for Resident #2. After supper, the resident's daughter asked to have Resident #2 put to bed. S5CNA approached the resident and grabbed her hands and pulled her to stand, then S4CNA intervened and said she needs to go slow when helping her as she can't stand well. The resident's daughter then said that she doesn't want that aide taking care of her mother . Review of S4CNA's handwritten statement that was not dated revealed, I S4CNA worked 03/08/2024 . with another agency CNA (S5CNA). After supper, the resident's daughter wanted her to be put in bed for the night. The CNA that had assigned to her went to yank on her in process of getting her up out chair to stand. I, myself, and the daughter got up and told the CNA she can't do that and she has to go slow with her in order to get her to stand and catch her balance . the daughter called me to the room and told me the other aide was very ruff (rough) handling her mother for me to get the nurse. I went to nurse S3LPN. She went talk with the daughter and I was told to care for resident. After that, the daughter didn't want the other aide in her mother's room or touching her . On 05/01/2024 at 3:50 p.m., a telephone interview was conducted with S4CNA. The CNA stated that she was working with S5CNA when the CNA attempted to get the resident out of the chair. S4CNA stated after supper one evening, the resident's daughter requested that the resident be put back to bed. S4CNA stated that S5CNA was observed handling the resident very rough. Surveyor asked, what do you mean the CNA was rough? S4CNA stated that S5CNA was pulling and yanking the resident's hands hard and fast to pull her up out of the chair. S4CNA stated that she and the resident's daughter told S5CNA no, you can't do that and that you have to go slow with her in order to get her up and out of the chair to stand up. S4CNA stated that the resident's daughter told her that she did not want S5CNA to take care of her mother because she did not like the way she was handling her mother. S4CNA stated that S3LPN was there and was informed about the incident. On 05/01/2024 at 4:01 p.m., an interview was conducted with S3LPN. She stated that Resident #2's daughter reported to her that she did not like the way the assigned CNA (S5CNA) was handling her mother during a transfer. S3LPN stated that she asked the resident's daughter if the CNA hurt her mother and the daughter replied that she did not want the CNA caring for her mother. The surveyor asked S3LPN if she reported the incident to the administrative staff. S3LPN stated that she did not report the incident to the administrative staff. On 05/01/2024 at 4:34 p.m., an interview was conducted with S2AsstAdm. She stated that she initiated the facility incident report concerning the resident's daughter's complaint that S5CNA was rough with her mother. S2AsstAdm stated that staff did not report the incident to her on 03/08/2024. S2AsstAdm stated that the resident's daughter reported the incident to her on 03/11/2024, which was 3 days after the incident occurred. On 05/02/2024 at 7:40 a.m., an interview was conducted with S1DON (Director of Nursing). S1DON stated S2AsstAdm was responsible for completing the facility incident reports and investigations. S1DON stated that she was not involved with the facility incident report or investigation concerning the incident involving the CNA handling the resident in a rough manner. S1DON stated that she would have expected S4CNA, S5CNA or S3LPN to report the incident to the administrative staff when the incident occurred on 03/08/2024. S1DON confirmed that the resident's daughter and not the staff members reported the incident to the S2Asst Adm on 03/11/2024, which was 3 days after the incident occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure an alleged violation of abuse was reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 1 (#21) out of 2 (#21 and #94) residents investigated for abuse. Findings: Review of the facility's policy, Abuse and Neglect, revealed in part, the following, Policy: It is the policy of this facility to provide an environment for our residents that is free of abuse, neglect, exportation, self neglect or misappropriation of funds . Physical abuse is the hitting, slapping, pinching, burning, jerking, or shoving of a resident. Physical contact is abusive whenever touching a resident is not helpful . H) Reporting all alleged violations and all substantiated incidents to the states agency as per state policy. Report will be made to all applicable agencies in the time manner as applicable. Resident #21: Review of Resident #21's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Lack of Coordination, Parkinson's Disease, and Low Back Pain. Review of Resident #21's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 14, indicating her cognition was intact. Review of the facility's form titled, Complaint Form, completed by S2ADMAsst (Assistant Administrator) dated 02/07/2024, revealed in part, the following, Complaint: Complained that S10CNA (Certified Nursing Assistant) hit her in the face with some pants . Review of SIMS (Statewide Incident Management System) log for the last 6 months provided by the facility did not reveal Resident #21 on the log for the date of the incident on 02/07/2024. On 03/05/2024 at 3:27 p.m., a joint interview was conducted with S1ADM (Administrator) and S2ADMAsst. S2ADMAsst stated she conducted an investigation of alleged abuse for Resident # 21 on 02/07/2024. S1ADM and S2ADMAsst stated they did not report this alleged abuse to their state agency. After review of regulations with S1ADM and S2ADMAsst they confirmed they should have reported the allegation of abuse immediately, but not later than 2 hours to their state agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records reviewed, the facility failed to identify and provide resident centered care and services in order to attain the highest practicable well-being for 1 (# 200) resident out of a finalized sample of 44 residents. This deficient practice was evidenced when the facility's staff failed to accommodate Resident # 200's smoking preference while he was on Contact isolation precautions. Findings: Review of Resident # 200's electronic health record revealed he was admitted to the facility on [DATE] with the following pertinent diagnoses: Major Depressive Disorder, Anxiety Disorder, and Tobacco Use. Review of Resident # 200's Safe Smoking assessment completed on 02/16/2024 by S11MDS (Minimum Data Set Coordinator) revealed the resident was able to make decisions regarding tasks of daily life. Further review revealed he had adequate eyesight and was determined to be a safe smoker. Review of Resident # 200's Activity Admit assessment completed on 02/19/2024 by S12RAD (Resident Activity Director) revealed the resident was his own responsible party. Further review revealed he used tobacco, was able to read and write, was alert and had a great attention span. The resident was also assessed as being able to verbally express self. Review of Resident # 200's Preferences for Customary Routine and Activities interview completed on 02/28/2024 by S12RAD revealed the resident was able to complete the interview. The resident gave a response of 1. Very important to the following, in part: While you are in this facility .F. how important is it to you to do your favorite activities? G. how important is it to you to go outside to get fresh air when the weather is good? Review of Activities progress note completed on 02/28/2024 by S12RAD revealed, in part .admitted to facility on 02/16/2024 .Resident enjoys .sitting outside when the weather is nice to smoke .sitting in the dining area with other residents . Review of Resident # 200's March 2024 physician's orders revealed an order entry dated 03/02/2024 to place in isolation Dx (Diagnosis): ESBL (Extended Spectrum Beta-Lactamase) in urine. Further review of Resident # 200's health record failed to include interventions and/or alternatives to accommodate the resident's smoking preferences while on isolation. On 03/04/2024 at 1:35 p.m., an interview was conducted with Resident # 200. The resident stated he was an every day smoker and had not been able to go outside to smoke a cigarette because he was on isolation for ESBL- an infection in his urine. The resident denied the facility staff offered him any alternatives to satisfy his smoking preferences. On 03/05/2024 at 12:53 p.m., an interview was conducted with S9CNA (Certified Nursing Assistant). S9CNA stated she was caring for Resident # 200 and that the resident was on contact precautions due to bacteria in his urine. She confirmed the resident did not have a foley catheter and used a urinal. S9CNA further confirmed the resident was a smoker and had not been able to go outside to smoke because he was on isolation. On 03/05/2024 at 12:56 p.m., a second interview was conducted with Resident # 200. The resident stated he had not been offered any alternative to smoke while on isolation. The resident stated he would really like to go outside because all he had was his television and that he feels as if he was in jail. On 03/06/2024 at 10:45 a.m., an interview was conducted with S8LPN (Licensed Practical Nurse). S8LPN stated she was familiar with Resident # 200 and that the resident was able to verbalize his needs and wants. S8LPN confirmed the resident was an every day smoker and had not been able to smoke because he was on isolation due to bacteria in his urine. S8LPN stated she was not sure why an alternative was not considered. On 03/06/2024 at 12:34 p.m., an interview was conducted with S12RAD who confirmed Resident # 200 was an every day smoker. S12RAD further confirmed she completed the admission activity assessment for the resident and identified that he enjoyed being outside to smoke a cigarette and visit with other residents. S12RAD denied any alternative being offered to the resident while he (the resident) was on isolation. On 03/06/2024 at 12:45 p.m., an interview was conducted with S5ADON. S5ADON stated she was also the facility's Infection Preventionist and confirmed Resident # 200 was on contact isolation precautions due to bacteria in his urine. S5ADON confirmed the resident had not been outside to smoke since being placed on isolation precautions. S5ADON further confirmed there were no alternatives to accommodate the resident's smoking preferences while on isolation precautions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to properly store respiratory equipment for 1 resident (#57) out of 3 residents (#91, #10, and #57) investigated for respiratory care. Findings: Review of the facility's policy titled Policy: Nebulizer Mask, O2 (Oxygen) Tubings read in part, Policy: Equipment will be changed a minimum of monthly and prn (as needed), placed in a plastic bag with date changed. A. Respiratory Equipment: Place in plastic bag, (a zip lock bag is acceptable) with date changed . Resident #57 A review of Resident #57's clinical record revealed he was admitted on [DATE] with diagnoses that included Malignant Neoplasm of Upper Lobe, Left Bronchus or Lung, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Hypertension, COPD (Chronic Obstructive Pulmonary Disease) and Centrilobular Emphysema. A review of Resident #57's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/05/2023 revealed a BIMS (Brief Interview for Mental Status) of 15, indicating he was cognitively intact. Further Review of Resident #57's MDS Section O, Special Treatments, Procedures and Programs revealed he was coded for using oxygen during the 7 day lookback period. Review of Resident #57 revealed a physician's order dated 02/29/2024 that read in part, Oxygen at 2 liters per minute via mask at hs (hour of sleep) every evening shift for Hypoxemia and Dyspnea. On 03/04/24 at 10:05 a.m., an observation and interview was conducted with Resident #57. Resident #57's oxygen mask was uncovered on his oxygen tank and not place in a dated bag. He stated the mask was never placed in a bag when not being used. There was no bag observed in resident's room. On 03/05/2024 at 10:26 a.m., an interview was conducted with S5ADON (Assistant Director of Nursing) and she confirmed that Resident #57's oxygen mask was not in a bag on the morning of 03/04/2024 and that it should have been in a bag and dated with the date changed.

Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) provided services for 8 consecutive hours a day, 7 days a week for 4 of 14 days reviewed for RN hours. Findings: Review of the facility's staffing documents from 02/18/2024 through 03/02/2024 revealed the RN did not work 8 consecutive hours on the following dates: On 02/18/2024 (Sunday) the RN worked 7.9 hours On 02/24/2024 (Saturday) the RN worked 6.7 hours On 02/25/2024 (Sunday) the RN worked 7.5 hours, and On 03/02/2024 (Saturday) the RN worked 7.6 hours. On 03/05/2024 at 11:40 a.m., an interview and review of the facility's staffing documents from 02/18/2024 through 03/02/2024 was conducted with S6AP (Accounts Payable). She stated that the weekend RN Supervisors were scheduled to work 8 hours, but 30 minutes were subtracted for lunch. S6AP confirmed the RNs did not work 8 consecutive hours on 02/18/2024, 02/24/2024, 02/25/2024, and 03/02/2024. On 03/05/2024 at 11:50 a.m., an interview was conducted with S7RN. She stated that she worked on 02/18/2024 as the weekend RN Supervisor. She confirmed that she did not work 8 hours that day because 30 minutes were subtracted for lunch.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide a safe, clean, and homelike environment as evidenced by failing to complete maintenance rounds to identify and repair the following: 1. Resident # 21's Chest of Drawer was broken 2. Resident # 63's bathroom toilet paper dispenser was broken 3. Resident # 19's bathroom toilet was loose 4. Resident # 250's headboard was loose and not working properly 5. Residents # 9, # 57, and # 93's hot water faucet produced only cold water Findings: Review of the facility's policy and procedure titled, Safe and Homelike Environment, read in part: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximized resident independence and does not pose a safety risk .3 Maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment .9 .e. Report any furniture in disrepair to Maintenance promptly . Resident #21 1. Review of the facility's maintenance log for 03/04/2024 for Resident #21's hall revealed no notes under Chester drawers section. On 03/04/2024 at 9:00 a.m., an observation was made of Resident # 21's room. The observation revealed the facing of the bottom drawer of Resident #21's chest of drawers, was falling off. On 03/05/2024 at 9:28 a.m., a follow up observation was made of Resident #21's chest of drawers. The bottom drawer facing remained falling off. On 03/05/2024 at 11:26 a.m., an interview and observation was conducted with S3MaintSup (Maintenance Supervisor). S3MaintSup verified that the front facing of the bottom drawer of chest of drawers for Resident #21 was broken. S3MainSup stated that is was his responsibility to complete a daily round through each resident room to inspect for anything in need of repair, and arrange for repair. Resident #19 Review of Resident #19's medical records revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Unsteadiness on Feet, Unspecified Lack of Coordination and Other Abnormalities of Gait and Mobility. On 03/04/2024 at 1:19 p.m., an observation was conducted of Resident #19's bathroom. The resident's toilet bowl was very loose. On 03/05/2024 at 10:05 a.m., an interview, review of maintenance logs, and observation of Resident #19's toilet was conducted with S3MaintSup (Maintenance Supervisor). There was no documented evidence that the resident's toilet was checked the week of 03/04/2024. S3MaintSup confirmed that Resident #19's toilet bowl was loose and needed repair. Resident #250 Review of Resident #250's clinical record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Weakness, Hypertension and Other, Retention of Urine. On 03/04/2024 at 11:47 a.m., an interview was conducted with Resident #250. The resident stated that the headboard on his bed was broken. An observation revealed the headboard was loose and leaned toward the head of the mattress. On 03/05/2024, at 8:45 a.m., a follow-up interview and observation was conducted with Resident #250. The resident stated that his headboard was not repaired, and had been broken since his admission about three weeks ago. He also stated that the head of his bed did not go up. On 03/05/2024 at 10:10 a.m., an interview, review of daily maintenance log and observation of Resident # 250's bed was conducted with S3MaintSup (Maintenance Supervisor). There was no documented evidence that Resident #250's headboard was identified. S3MaintSup confirmed that the headboard was broken and needed to be repaired. Resident #9 A review of Resident #9's clinical record revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Unspecified Traumatic Intracerebral Hemorrhage, Major Depressive Disorder and Diabetes Mellitus. On 03/04/2024 at 2:11 p.m., an observation of Resident #9's bathroom revealed that there was no hot water in the bathroom sink. On 03/05/2024 at 10:01 a.m., an interview, review of daily maintenance log and observation of Resident #9's bathroom was conducted with S3MaintSup (Maintenance Supervisor). There was no documented evidence that Resident #9's issue with hot water was identified for the week of 03/04/2024. S3MaintSup confirmed that Resident #9's water was not hot and should have been. Resident #57 A review of Resident #57's clinical record revealed he was admitted on [DATE] with diagnoses that included, but were not limited to, Malignant Neoplasm of Upper Lobe, Left Bronchus or Lung, Type 2 diabetes Mellitus with Diabetic Polyneuropathy, Hypertension, COPD and Centrilobular Emphysema. A review of Resident #57's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/05/2023, revealed a BIMS (Brief Interview for Mental Status) of 15, indicating he was cognitively intact. On 03/04/24 at 10:09 a.m., an interview was conducted with Resident #57. The resident stated that the water in his bathroom was not hot enough, and that he had reported it to maintenance. An observation of Resident #57's hot water revealed it was cold. 03/05/2024 at 10:00 a.m., an interview and observation of Resident #57's water in his bathroom was conducted with S3MaintSup (Maintenance Supervisor). S3MaintSup confirmed that the water in Resident #57's bathroom was cold and stated that it should have been hot. Resident #93 Review of Resident #93's clinical record revealed she was admitted to the facility on [DATE] with diagnoses that included, but was not limited to, Orthostatic Hypotension, Hypertension, Pre Diabetes and Cognitive Communication Deficit. On 03/04/2024 at 9:44 a.m., an observation of Resident #93's bathroom revealed there was no hot water in the bathroom sink. On 03/05/2024 at 10:01 a.m., an interview, review of daily maintenance log, and observation of Resident #93's bathroom sink was conducted with S3MaintSup (Maintenance Supervisor). There was no documented evidence that Resident #93's hot water issue had been identified for the week of 03/04/2024. S3MaintSup confirmed that Resident #93's water was cold and should have been hot. Resident #63 Review of Resident #63's electronic health record revealed she was admitted to the facility on [DATE]. Review of Resident #63's quarterly MDS assessment dated [DATE], revealed a BIMS (Basic Interview for Mental Status) score of 13 that indicated the resident was cognitively intact. Review of the facility's maintenance logs for the week of 03/04/2024 revealed no documented evidence that the resident's toilet paper holder was checked or reported to be broken. On 03/04/2024 at 9:18 a.m., an interview was conducted with Resident # 63. Resident # 63 stated that the toilet paper dispenser's plastic covering sometimes fell off in the middle of the night, awakening her from her sleep. An observation of the resident's bathroom revealed a large toilet paper dispenser mounted on the bathroom wall. Closer observation revealed the plastic covering of the dispenser was secured with duct tape. On 03/05/2024 at 12:46 p.m., a follow up observation was made of Resident # 63's bathroom. The plastic covering of the large toilet paper dispenser was still secured with duct tape. On 03/06/2024 at 9:47 a.m., a third observation was made of Resident # 63's bathroom, which revealed the large toilet paper dispenser had not been repaired. On 03/06/2024 at 10:35 a.m., an interview and observation of Resident #63's bathroom was conducted with S3MaintSup. S3MaintSup confirmed the large wall mounted toilet paper dispenser's plastic covering was broken and required replacement.

Based on record review and interview, the facility failed to refer residents who had a qualifying diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (Resident #70) of 1 resident sampled for PASARR. The deficient practice had the potential to affect a total census of 99. Findings: Review of Resident #70's record revealed an admission date of 03/01/2023 with diagnoses that included; in part, Unspecified Psychosis. Review of Resident #70's records revealed no evidence that a Level II PASARR had been re-submitted to the appropriate state-designated authority that indicated he had the qualifying diagnosis of Unspecified Psychosis. On 03/05/24 at 10:26 a.m., an interview was conducted with S4SSD (Social Services Director). S4SSD confirmed the residents admission date as well as the date of the qualifying diagnosis. S4SSD confirmed the PASARR should have been resubmitted for re-review and had not been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility's staff failed to notify the resident's representative of a change in the resident's condition by failing to: 1. Immediately inform the resident's (#1) representative that the resident was admitted inpatient to the hospital for urinary tract infection; and failing to; 2. Immediately inform the resident's (#3) representative of the residents return to the facility from the hospital for 1 ( #3) out of 4 sampled residents. This deficient practice has the potential to affect all the residents residing in the nursing facility. The total census was 100. Findings: Review of the facility's policy, Notification of Changes revealed in part: The facility will inform the resident and consult with the resident's physician. Appropriate, when changes occur, if known. The facility shall also notify the resident's legal representative or interested family member. Notification of changes shall include: 3. A need to alter treatment significantly (A need to discontinue an existing form of treatment due to adverse, consequences, or to start a new form of treatment). Review of the facility's policy, Assessment for Admit or readmit revealed in part: Notification of changes shall include: 7. Notification of responsible party upon admit to hospital or readmit to facility. Resident #1 Review of Resident #1's record revealed he was admitted to the facility on [DATE]. The resident had diagnoses including Type 2 diabetes mellitus, Schizoaffective disorder, Bipolar type, and Generalized Anxiety disorder. Review of the resident's quarterly MDS (Minimum Data Set) dated 10/13/2023 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 14, indicating the resident was cognitive. Review of the resident's admission record revealed the resident had a responsible party (RP) that should be notified of any changes in the resident's condition and of any new orders. Review of the facility Emergency Transfer Log dated 10/24/2023 revealed in part: Resident #1 transferred to local hospital on [DATE] for slurred speech, tremors, and returned to the facility on [DATE]. Review of Resident #1's nurses notes dated 10/16/2023 at 7:10 p.m., revealed in part: New order to send resident to emergency for Stroke evaluation. Resident assessed, speech slurred mildly. At 7:20 p.m., ambulance called, and report given to receiving facility. At 8:25 p.m., resident transferred to local hospital via ambulance, and RP was made aware of the need to transport. Further review of the nurse's notes did not reveal that the resident's RP was notified of Resident #1's admittance into the hospital. On 10/24/2023 at 9:25 a.m., a phone interview was conducted with Resident #1's RP, who stated no one notified her that her mother had been admitted into the hospital. On 10/24/2023 at 2:20 p.m., an interview was conducted with S6LPN (Licensed Practical Nurse) who stated that she works from 2:00 p.m., to 10:00 p.m. She confirmed that she worked with Resident #1 on 10/16/2023. She stated the resident was sent out to a local hospital. She stated that when she left her shift, she was not aware the resident had been admitted the hospital, and S6LPN confirmed she did not call the hospital before her shift ended to find out the status of the resident. She stated that usually S3QA (Quality Assurance), S4QA, and S5SSD (Social Services Director) follow up with the hospital the next day. On 10/24/2023 at 3:20 p.m., an interview was conducted with S5SSD, S3QA, and S4QA. S5SSD stated usually the QA nurses or herself will call the hospital to find out what happened with the resident. A continued interview was conducted with S3QA, and S4QA, who both stated that they did not call the hospital to find out what had happened to the resident. S3QA, S4QA, and S5SSD agreed that the nurse was responsible. The facility was not able to provide documentation that Resident #1's RP had been notified of her admission to the hospital. S3QA, S4QA, and S5SSD confirmed that the nurse is was responsible for informing the family of the resident's return to the facility. On 10/25/2023 at 7:35 a.m., an interview was conducted with S1DON (Director of Nursing) who stated that during business hours which were 8:00 a.m., to 4:30 p.m., S5SSD or S3QA, and S4QA were the nurses that follow up with the hospital to find out the status of the resident. S1DON stated that S4QA informed her on 10/17/2023 approximately 7:30 a.m. that Resident #1 was admitted to the hospital Resident #3 Review of Resident #3's record revealed he was admitted to the facility on [DATE]. The resident had diagnoses including Alzheimer's disease, Dysphagia, and oropharyngeal phase. Review of the resident's quarterly MDS dated [DATE] revealed the resident had a BIMS score left blank which indicated he was severely impaired. Review of the resident's care admission record revealed the resident had a responsible party (RP) that should be notified of any changes in the resident's condition and of any new orders. Review of the facility's transfer logs revealed Resident #3 was transported and admitted to the hospital on [DATE] for arrhythmia's, and returned to the facility on [DATE]. Further review of the log revealed that the resident was transported to a local hospital on [DATE] for arrhythmias and returned to the facility on [DATE]. On 10/24/2023 at 1:10 p.m., a phone interview was conducted with Resident #3's RP, who stated the facility did not inform her the resident was back in the facility on 09/27/2023. She stated that she went to the hospital looking for him on 09/27/2023, and was informed by hospital staff the resident had been discharged back to the facility. She added that when Resident #3 went to the hospital on [DATE], she called the facility on 10/13/2023 and was informed the resident had returned to the facility. On 10/25/2023 at 7:45 a.m., another interview was conducted with S1DON who confirmed that it was the responsibility of the facility to inform the family when the resident was admitted to the hospital, and when the resident returns to the facility from a hospital stay.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an observation, record reviews and interviews, the facility failed to ensure nursing staff demonstrated competencies to provide care, assure residents' safety, and maintain the residents' highest practicable physical well-being. The facility failed to assure the facility failed to assure that each resident received an accurate assessment by failing to: 1. Complete an accurate weekly skin assessment/body audit for 1 (Resident #1) of 4 (#1, #2, #3, #4) residents sampled for weekly body audits, and 2. Complete a readmit assessment for Resident #3 after returning to the facility from the hospital on [DATE]. Findings: Review of facility document Policy Skin Assessment read in part: 1. Skin assessment/body audits are done weekly, and as needed. Review of facility document Skin Condition read in part: using the diagrams provided indicate all body marks such as bruises, discoloration, abrasions, pressure ulcers, or questionable markings. Indicate size, depth, color and drainage. Review of facility document Policy: Assessment for Admit or Readmit read in part: 8. Use readmit or admit form for assessment on resident (little man sheet). Review of Resident #1's Medical Record revealed the resident was admitted to the facility on [DATE] with diagnoses including Type 2 diabetes mellitus, and Chronic kidney disease. Review of the Quarterly MDS (Minimum Data Set) dated 10/13/2023 revealed a BIMS (Brief Interview of Mental Status) score of 14 indicating cognitive intact. Review of facility document titled Resident Admission-Nursing Assessment Form: Skin Condition dated 10/20/2022 revealed that Resident #1 had seven areas with noted bruising, one area of redness on the sacrum. Review of Treatment Administration Record dated 10/1/2023- 10/31/2023 revealed that on 10/24/2023, S8LPN (Licensed Practical Nurse) documented that Resident #1's skin was clear. On 10/25/2023 at 11:25 a.m., an interview was conducted with S8LPN who stated that she was the temporary treatment nurse. She stated that she conducted Resident #1's skin audit on 10/24/2023 and her skin was clear. On 10/25/2023 at 11:30 a.m., an observation of Resident #1's skin was conducted with S8LPN, who observed areas of bruising to the resident's abdomen, right antecubital area, left lower arm, and a slow blanchable are to the sacrum. An immediate interview was conducted with S8LPN, who stated that she did not remove the adult brief or turn Resident #1 during her assessment on 10/24/2023, and confirmed that the assessment was inaccurate. Resident #3: Review of Resident #3's Medical Record revealed the resident was admitted on [DATE] with diagnoses of Alzheimer's disease, Unspecified dementia, Gastrostomy status, Dysphagia, oropharyngeal phase. Review of the facility Emergency Transfer Log revealed Resident #3 was transferred to a local hospital on [DATE] and returned to the facility on [DATE]. Review of the facility nurses notes dated 09/22/2023 revealed at 11:10 a.m., Resident #3 was sent out to the emergency room for Tachycardia (fast heart rate). Further review of the nurse's notes did not reveal a re-admission assessment for 09/27/2023, when the resident returned to the facility. On 10/24/2023 at 2:10 p.m., an observation of Resident #3's medical record was conducted with S2ADON (Assistant Director of Nursing). Nurse's notes were reviewed for re-admission assessment for 09/27/2023. S2ADON was unable to provide documentation that a re-admission assessment had been completed when the resident returned to the facility. S2ADON confirmed that when Resident #3 returned from the hospital the nurse should have assess the resident and document when the resident returned to the facility. On 10/25/2023 at 7:35 a.m., an interview was conducted with S1DON (Director of Nursing) who confirmed that the nurses are responsible for completing a re-admit assessment when a resident returns from the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to implement the resident's care plan for 2 (#11, #19) residents in the final sample of 40 residents. This deficient practice was evidenced by staff failing to: 1. accurately assess and document Resident #11's meal percentage intake; and 2. monitor Resident #19 for side effects of antipsychotic medications. Findings: 1.Resident #11 Resident #11 was admitted on [DATE] with diagnoses that included Anxiety, Hypertension, Hypothyroidism, and weight loss. Review of the facility's document titled, Weights revealed Resident #11's weight was 161 pounds on 8/17/2022, 158 pounds on 9/19/2022, 154 pounds on 10/11/2022, 150 pounds on 11/9/2022, 149 pounds on 12/7/2022, and 144 pounds on 1/4/2023. Review of Resident #11's care plan dated 12/12/2022 read in part . I have a history of losing weight and not having a good appetite. Interventions included record my meal intake every day. On 1/30/23 at 11:09 a.m., an observation of Resident #11 was conducted in the dining room during her lunch meal. The resident was served mashed potatoes with gravy, baked chicken, carrots, milk, shake and ice cream. Upon completion of her lunch meal, another observation was conducted of the meal tray. It was observed that the resident consumed 30% of her meal. Further observation revealed that S12CNA (Certified Nursing Assistant) had documented the resident's meal percentage intake of 75% prior to the resident completing her meal. On 1/30/23 at 11:30 a.m., an interview was conducted with S12CNA who confirmed that she should have documented the resident's meal intake percentage after the resident finished eating. On 2/01/23 at 07:20 a.m., another observation of Resident #11 was conducted in the dining room during her breakfast meal. The resident was served grits, sausage, eggs and toast. The resident also had orange juice, coffee and milk. Upon further observation the resident was still eating and had eaten one of two sausages, and most of her toast bread. She had also consumed all of her coffee, milk and orange juice. On 2/01/23 at 07:25 a.m., upon further observations were conducted in the dining room during the breakfast meal. S8CNA was observed recording meal intake percentages while residents ate their meals. An immediate interview was conducted with S8CNA who stated that Resident #11 had eaten 50% of her meal. S8CNA was asked how does the facility determine what percentage of meal intake is documented. S8CNA stated that if the resident eats 25% or less, then the nurse is notified and the resident should be offered something else to eat. S8CNA added that she is supposed to record the meal percentage after the residents have completed their meal. S8CNA was asked why she recorded Resident #11's meal percentage when the resident had not completed her meal. S8CNA confirmed that she should have recorded Resident #11's meal intake after the resident finished eating. On 2/01/23 at 07:40 a.m., an interview and observation of Resident #11's meal tray was conducted with S9LPN (License Practical Nurse) and S8CNA. S9LPN confirmed that Resident #11's meal percentage intake should have been recorded as 25% and not 50%. On 2/01/23 at 07:49 a.m., an interview was conducted with S2DON (Director of Nursing) who confirmed that staff should record meal percentages after the residents completed their meals. 2.Resident #19 Resident #19 was admitted on [DATE] with diagnoses that included Anxiety disorder, Schizoaffective disorder, and Bipolar disorder. Review of Physician Orders dated 1/2023 read in part Risperdal 1.5 mg two times per day. Review of Resident #19's care plan read in part . history of anxiety - observe me for signs and symptoms of anxiety such as shortness of breath, trembling, pallor, nausea/vomiting and sweating . History of psychosis - observed me for signs and symptoms of possible psychosis such as strange posturing, staring without blinking or blinking incessantly, rapid speech, sudden social withdrawal, changes in usually sleep . I have been diagnosed with schizoaffective disorder - observed me for delusion, hallucinations, disorganized speech, thinking behaviors, changes in normal sleep pattern flight of ideas . I have a diagnosis of bipolar - observe for excessive talking, changes in sleep pattern, changes in mood, irritability. Review of Resident #19's Medication Administration Record (MAR) dated November 2022 - January 2023, no evidence the resident was monitored for signs and symptoms of anxiety, psychosis, schizoaffective disorder or bipolar disorder. On 2/01/23 at 10:20 a.m., an observation and interview was conducted with S2DON (Director of Nursing). Resident #19's electronic Medication Administration Record (MAR) was reviewed with S2DON that the resident was prescribed Risperdal 1 mg for psychosis related to Schizophrenia. S2DON confirmed that since the resident is on Risperdal she should have had a behavioral and side effect monitoring tool for the medication.

Based on observation, and interviews the facility failed to destroy narcotic medications that had been removed from the original individual dose blister packages they had been dispensed in for 3 (#42, #84, and #74) residents. This deficient practice had the potential to affect all of the residents in the facility that were prescribed controlled medications. Findings: On 1/31/2023 at 9:01 a.m., the narcotic count of Hall#1 medication cart with S13LPN (Licensed Practical Nurse). She confirmed Resident #42's (Prescription #C0790135) Tramadol HCL (Hydrochloric) 50 milligram (mg) blister package had one section, blister #19, that had been busted open then covered with tape to contain the medication in the opened, damaged package. On 01/31/23 at 9:11 a.m., S2DON (Director of Nursing) confirmed Client #42's Tramadol HCL narcotic medication had a tablet that had been returned to the opened blister package and secured with tape where the package was damaged. S3DON stated the facility's policy was that the narcotic medication should be properly discarded, not returned nor taped back into an opened damaged blister package. On 1/31/23 at 9:14 a.m., a narcotic count on Hall#2 medication cart with S9LPN confirmed Resident #84 (Prescription C07970823) Diazepam 5 mg count was 7. Resident #84's Narcotic sheet was documented to have 8 Pills. She stated the count was inaccurate and stated she did not give this pill. She looked in the bottom of the narcotic bend and found the pill. At this time she was asked what would she do with this narcotic medication. S9LPN stated she would tape the narcotic medication back into its original blister. On 1/31/23 at 9:31 a.m., during a narcotic count of Hall #3 medication cart, S11LPN confirmed Resident #74's Hydromorphone 2 milligram blister package had three (#9, #30, and #59) single dose blisters that had tape applied to cover the opened, damaged compartments.

Based on observations and interviews, the facility failed to ensure food items were stored in accordance with professional standards for food service safety. The facility failed to maintain the integrity and cleanliness of the walk-in food storage refrigeration and freezer units. This deficient practice had the potential to affect a total of 96 residents who consumed food prepared and served from the kitchen in a facility with a census of 96. Findings: A review of the facility's policy and procedure titled, Infection Control Cleaning of Cooler read in part: A) Racks, floors and ceilings will be wiped with an approved disinfectant at least monthly to prevent unwanted dust accumulation and unwanted bacteria. Allow area to dry before reusing. On 01/30/2023 at 08:45 a.m., an observation of the walk-in cooler revealed a build-up of dust and grime on the fans, ceiling, and refrigeration lines inside the walk-in cooler. Observations of the walk-in freezer revealed a build-up of ice and condensation dripping. A large piece of ice build-up was observed in corner of the freezer. An accumulation of ice build-up was observed on the shelving, packages and boxes containing food items, the floor, and on the ceiling with condensation dripping. An interview was conducted with S4DM (Dietary Manage) at this time revealed that the facility's maintenance personnel was in charge of cleaning the walk-in cooler. S4DM said she was also aware of the build-up of ice in the walk-in freezer and she had called maintenance personnel to fix the problem. On 01/30/2023 at 5:00 p.m., S1Administrator (Adm), advised the team that maintenance was cleaning inside the walk-in cooler at the time. An additional interview and observation of the walk-in cooler and freezer was conducted with S4DM on 01/31/2023 at 02:38 p.m. S4DM stated the facility's maintenance personnel had cleaned the inside of walk-in cooler and calked some areas of the freezer yesterday (01/30/2023) evening. S4DM confirmed the build-up of dust and grime remained on the fans, ceiling, and refrigeration lines inside walk-in cooler. The dust and grime was easily displaced/removed with light touch. S4DM said the maintenance personnel did not clean those areas that remained with the build-up of dust and grime. S4DM also said the walk-in freezer remained with a build-up of ice and condensation dripping within the freezer and onto packages of frozen food items. On 1/31/2023 at 02:42 p.m., an interview conducted with S7Maint (Maintenance) revealed he had cleaned the walk-in cooler yesterday (01/30/2023) by washing the shelves and had caulked some areas which were allowing hot outside air to enter the walk-in freezer. S7Maint made an observation of the walk-in cooler and freezer at this time. S7Maint stated the build-up of dust and grime in the walk-in cooler and the ice build-up and dripping condensation remained in the walk-in freezer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure hospice agencies, Hospice #1 and Hospice #2, communicated with facility staff, maintained and updated the residents' medical record that reflected the services provided for 2 (#9 and #74) of 3 (#9, #60 and #74) residents that were provided Hospice Services. This deficient practice had the potential to affect the 96 residents who resided in the facility. Findings: Hospice #1 Record review of the contract between the facility and Hospice#1 dated 03/02/22, read in part, 3. Responsibility of Hospice .Hospice shall retain responsibility for coordinating, evaluating and administering the hospice program .which shall include coordination of facility services .The hospice representative shall be responsible for communicating with the facility representatives and other health care providers who participate in the care of a hospice patient's terminal illness and related conditions to ensure quality of care for hospice patients and their families . Provision of Information .at a minimum, Hospice shall provide the following information to facility for each hospice patient residing at Facility: Plan of Care, Medication and Orders .Election Form .Certification .Contact Information .On-Call System. Record review of Resident #9's admission Record revealed she was admitted to the facility on [DATE] with continued services from Hospice #1. Her cumulative diagnoses were in part, Alzheimer's, Dementia with Behavior Disturbance, Hypothyroidism, Type 2 Diabetes, Psychosis, Major Depression and Anxiety. Record review of Resident #9's medical record revealed Hospice #1recertification order dated 8/15/2022 for patients prognosis for life expectancy of 6 months or less if the terminal illness runs it normal course. The Skilled Nurse was to visit once per week and three as needed visits for symptoms management, Social worker to visit once per month for psychosocial support, C.N.A. (Certified Nursing Assistant) three times per week, and the Chaplin once per month for spiritual support. There were no documentation of an updated care plan RN, C.N.A., Social Worker, or Chaplin Visits in the facility's medical binder. On 01/30/23 at 2:25 p.m., an observation was made of Hospice #1 C.N.A. entering Resident #9's room. An interview with Hospice #1 C.N.A. revealed she assessed Resident #9's skin and condition when she bathed the resident three times a week. She stated she was to report any changes in the resident condition to facility staff. On 01/31/23 at 11:20 a.m., S13LPN (Licensed Practical Nurse) confirmed Resident #9 had been receiving hospice services since she was admitted to the facility on [DATE] and did not have a Hospice binder like the other hospice residents who resided in the facility. She stated Hospice #1 C.N.A. provided hospice services of bathing Resident #9 every other day. S13LPN stated on 01/30/2023 Hospice #1's C.N.A. provided services for Resident #9 but had not informed the LPN or facility's C.N.A. what she had done for the resident or if the resident had any changes in her condition. S13LPN explained that Hospice #1 Nurse visited the facility once or twice a month and provided hospice services to Resident #9 but had not communicated to facility staff her assessment findings or any changes in the resident's condition. She stated Hospice #1's staff had not left documentation in the facility of hospice services provided to Resident #9. On 01/31/2023 at 11:46 a.m., S2DON (Director of Nursing) reported the facility had a contract with Hospice #1. S2DON confirmed Resident #9 received hospice services from Hospice #1 and that Hospice #1 had not left a binder with documentation of services provided to Resident #9. She stated the Hospice Nurse assessed Resident #9 once a week and the C.N.A. bathed her two or three times a week. She stated the Hospice Nurse should talk to the nurses on the hall, DON and or ADON (Assistant Director of Nursing) regarding any change in condition, plan of care or medications provided to Resident #9. S2DON confirmed Hospice #1 was to keep the notes and assessments in the facility as required by their contract. S2DON reviewed Resident #9's medical record and confirmed Hospice #1 had not provided documentation of the RN (Registered Nurse), C.N.A, Social Service or Chaplin services provided from admission [DATE]) to present (01/31/2023). On 02/01/23 at 12:09 p.m., Hospice #1 C.N.A was observed in Resident #9's room. An interview was conducted with Hospice #1 C.N.A and she confirmed she bathed the resident three times a week and the hospice RN visited two times per week. She stated Social Services and the Chaplin were to visit the Resident. She stated she wrote her assessment on her tablet and had not left Resident #9's assessment in facility because Hospice #1's RN was to deliver Resident #9's assessments to the facility. On 02/01/23 at 12:34 p.m., Hospice #1Business Office Manager confirmed the Hospice staff should leave their documents in the facility. She stated the Hospice Nurse and C.N.A were responsible for communicating with the Facility staff any findings for Resident #9. On 02/01/23 at 1:24 p.m., Hospice #1Director of Operation revealed his staff had not provided any documentation to the facility of hospice services provided to Resident #9. He stated Resident #9 had been a patient of Hospice #1 since 06/24/21. He stated the agency recertified the patients every two months (60 Days) and updated the patients care plans every two weeks. He stated the nurses assessed the residents two times a week and the C.N.A. bathed the residents three times a week in the facility. He also confirmed Hospice #1's Social Services and Chaplin assessed the resident once a month. He stated the last time Resident #9's care plan was updated was on 01/26/2023. He confirmed Hospice #1 had not provided documentation of services provided for Resident #9 to the facility and should have. On 02/01/2023 at 1:59 p.m., S13LPN confirmed Hospice #1 C.N.A. bathed Resident #9 today and had not notified her that she was in the facility or if there were any changes in the Resident's condition. On 02/01/23 at 2:04 p.m., S14C.N.A confirmed she was working with Resident #9 today. She stated Hospice #1 C.N.A bathed Resident #9 and denied Hospice #1 C.N.A. communicated with facility staff about hospice services provided. Hospice #2 A review of the hospice service agreement between Hospice #2 provider for Resident #74 and the facility dated 08/26/13 read in part Article III Facility Services Section 3.5: The Facility shall . 4) Obtain the following information from Hospice. The most recent hospice plan of care specific to each patient. Section 4.3: Hospice shall establish communication process including the development of appropriate document between hospice and facility to ensure that the needs of the resident are addressed and met 24 hours per day. Article V Hospice Plan of Care Section 5.4: Hospice will review and revise plan of care at intervals specified in the plan by the hospice's medical director or the resident's attending physician and the IDT (Interdisciplinary Team), or sooner, if necessary, to reflect the Resident's changing care needs. These reviews must be documented in the medical record maintained by the facility and by the hospice. A review of Resident #74's records (facility record and hospice record) revealed she was admitted to hospice on 03/31/21 with diagnoses that included Malignant Neoplasm of Kidney, Chronic Kidney Disease Stage Three, Hypertension, Type 2 Diabetes Mellitus, and Dementia with Behavior Disturbances. Further review of Resident #74's record revealed a form labeled IDG Report dated 01/12/22. There was no evidence of documentation of hospice services provided after 01/12/22. An interview and record review on 01/31/23 at 1:00 p.m., with S3Quality Assurance/LPN (QA), confirmed the most recent documented record in Resident #74's record from Hospice #2 was the IDG form dated 01/12/22. On 01/31/23 at 4:00 p.m., a phone interview was conducted with Hospice #2 Registered Nurse who reported the most recent hospice visit with Resident #74 was on 01/30/23. Hospice#2 RN stated she was unable to locate the resident's hospice chart within the facility during her visit. She stated the documentation from hospice staff visits were sent to the facility every 2 weeks, the hospice plan of care was documented every week and a meeting with all disciplines was conducted every 2 weeks. On 01/31/23 4:35 p.m., a phone interview with Hospice #2 DON (Director of Nursing) revealed the hospice provider was faxing documentation of Resident #74's visits to the facility during the COVID pandemic. She further stated for the past month, the hospice provider had hand delivered resident visits and consultation notes to the facility every two weeks. On 1/31/23 at 4:35 p.m., S2DON provided documents faxed from Resident #74's hospice provider with a fax date and time of 01/31/23 at 4:35 p.m. The faxed information included Hospice #2's Physician's Plan of Care for Resident #74 with the frequency of visits for the hospice nurse was one time per week and two-three times PRN (as needed). An additional interview and review of Resident #74's record on 02/01/23 at 10:03 a.m. with S3QA confirmed the most recent hospice notes on file at the facility were dated 01/12/2022. S3QA stated the facility should have ensured the hospice record was maintained and updated with the current documentation of care and services provided by Hospice #2.