Based on record review and interview, the facility failed to inform each resident of the charges for services for which the residents may be responsible for paying for 3 (Resident #3, Resident #28 and Resident #48) of 3 (Resident #3, Resident #28 and Resident #48) sampled residents who received Advanced Beneficiary Notices of Non-Coverage (ABN). Findings: Review of a facility policy on 08/12/2025 at 8:20 a.m. titled, ABN policy dated 00/2024 revealed the following in part.D. Estimated Cost Section: The SNF should enter an estimated total cost or a daily, per item, or per service cost estimate. SNFs must make a good faith effort to insert a reasonable cost estimate for the care. If for some reason the SNF is unable to provide a good faith estimate of projected costs of care at the time of SNF ABN delivery, the SNF should indicate in the cost estimate area that no cost estimate is available. Review of the ABN notices (Form CMS-10055) signed by Resident #3 on 05/26/2025, signed by Resident #28's responsible party on 07/28/2025 and signed by Resident #48 on 04/14/2025 revealed the estimated cost per day/item or service for continuing daily skilled nursing care was not completed and left blank. In an interview and record review on 08/10/2025 at 3:00 p.m., S1 ADM confirmed the above findings. S1 ADM revealed he was unaware why the section for estimated cost per day/item or service for continuing daily skilled nursing care was not completed and left blank. In an interview on 08/11/2025 at 9:36 a.m., S6 Accounts Manager revealed she was responsible for documenting and presenting the SNF ABN form to the residents and obtaining a signature from the resident or responsible party. During a review of the Form CMS-10055 for Resident #3, Resident #28, and Resident #48, S6 Accounts Manager confirmed the estimate cost for services amount per day/item of service was not completed and left blank. S6 Accounts Manager stated she failed to document the cost on the forms. S6 Accounts Manager confirmed she should have documented the estimated cost on the above resident's SNF ABN forms, but did not.

Based on observation, interview, and record review the facility failed to ensure the person-centered care plan was implemented for 1 (Resident #47) resident reviewed for tube feeding.Review of Resident #47's medical record revealed an admission date of 12/13/2017 with diagnoses which included, in part. Dysphagia Following Cerebral Infarction, Dementia, Shortness of Breath, Protein-Calorie Malnutrition, Unspecified Gastrostomy Complication, and Gastro-Esophageal Reflux Disease.Review of Resident #47's Quarterly MDS with an ARD of 05/28/2025 revealed a BIMS Score was not provided because the resident was rarely or never understood. Resident #47 received 51% or more of her total nutrition through tube feeding.Review of Resident #47's physician's orders revealed the following, in part.Jevity 1.2 cal at 50mL/hr with 25mL/hr flush, dated 04/24/2024.Review of Resident #47's care plan revealed the following problem, in part.resident weight loss, declining, not eating or drinking, and PEG Tube placement on 03/23/2024; revised to include risk of malnutrition, NPO, dysphagia, and vomiting episodes on 02/26/2025. Interventions included the following, in part. Monitor and document intake and output, dated 02/17/2025; Intake and output every shift, dated 06/06/2025; and Jevity 1.2 cal at 50mL/hr continuous per pump with 25mL/hr flush, dated 06/30/2025.Review of Resident #47's Task: Fluid Intake - Tube Feed revealed intake of tube feeding, as care-planned, was not documented each shift on 07/14/2025, 07/15/2025, 07/16/2025, 07/19/2025, 07/20/2025, 07/21/2025, 07/22/2025, 07/24/2025, 07/31/2025, 08/02/2025, 08/03/2025, 08/09/2025, and 08/10/2025.Review of Resident #47's Task: Fluid Intake - Flush revealed intake of flush, as care-planned, was not documented each shift 07/14/2025, 07/15/2025, 07/16/2025, 07/19/2025, 07/20/2025, 07/21/2025, 07/22/2025, 07/24/2025, 07/31/2025, 08/02/2025, 08/03/2025, 08/06/2025, 08/09/2025, and 08/10/2025.Interview with S5LPN on 08/11/2025 at 2:47 p.m. revealed Resident #47's was care-planned for documenting the intake of tube feeding and flush each shift. S5LPN confirmed Resident #47's intake of tube feeding and flush had not been documented each shift, but should have been. Interview with S2DON on 08/11/2025 at 3:00 p.m. confirmed Resident #47's intake of tube feeding and flush had not been documented each shift, but should have been.

Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 2 (Resident #4 and Resident #47) of 3 (Resident #4, Resident #15, and Resident #47) sampled residents reviewed for respiratory care. The facility failed to ensure:The oxygen concentrator's flow meter was set to the proper rate as ordered for Resident #4; andRespiratory equipment was properly labeled for Resident #47.Resident #47 Review of Resident #47's medical record revealed an admit date of 12/13/2017 with diagnoses which included, in part . Shortness Of Breath, Acute Respiratory Failure, Dysphagia, Cerebral Infarction, and Dementia. Review of Resident #47's physician’s orders revealed, in part…may suction as needed related to Dysphagia Following Cerebral Infarction and Shortness of Breath, dated 07/23/2025. Review of Resident #47's Care Plan revealed, in part…the hospice nurse was notified of Resident #47 gurgling and Resident #47’s interventions were updated to include may suction as needed on 07/23/2025. Observation on 08/10/2025 at 10:02 a.m. revealed a suction canister, suction tubing, and Yankauer suction tip connected and available for use on Resident #47’s bedside table. There was no visible label or date on the equipment. Observation on 08/11/2025 at 9:07 a.m. revealed the suction canister, suction tubing, and Yankauer suction tip remained on Resident #47’s bedside table. There was no visible label or date on the equipment. Interview with S2DON on 08/11/2025 at 3:15 p.m. revealed all respiratory care equipment was to be labeled with the date it was opened, and changed every 7 days. Observation of Resident #47 on 08/11/2025 at 3:00 p.m. accompanied by S5LPN revealed the suction canister, suction tubing, and Yankauer suction tip were connected and available for PRN use on Resident #47’s bedside table. S5LPN confirmed the equipment was not labeled with the date it was opened, but should have been. Resident #4 A review of Resident #4's medical record revealed an admit date of 09/04/2021 with diagnoses that included, in part, Chronic Obstructive Pulmonary Disease, Heart Failure, Unspecified Dementia, and Schizoaffective Disorder. A review of Resident #4's physician’s orders revealed, in part, oxygen at 2 liters per minute via nasal cannula, continuous, dated 12/06/2021. A review of Resident #4's current Care Plan revealed, in part, oxygen as ordered. A review of Resident #4’s Quarterly MDS (Minimum Data Set) with an ARD of 06/25/2025, Section O, revealed, in part, that the resident receives oxygen therapy. On 08/10/2025 at 9:35 a.m., Resident #4 was observed asleep in a geriatric chair in her room, receiving oxygen via nasal cannula. The oxygen concentrator’s flow meter was set at 3.5 liters per minute. On 08/10/2025 at 3:29 p.m., Resident #4 was observed awake in a geriatric chair in her room receiving oxygen via nasal cannula. The oxygen concentrator was still set at 3.5 liters per minute. On 08/11/2025 at 8:50 a.m., Resident #4 was in the dining/day room. Resident #4 was sitting in a geriatric chair facing the television, receiving oxygen via nasal cannula. The resident's oxygen concentrator was beside her chair and set to 3.5 liters. On 08/11/2025 at 4:15 p.m., Resident #4 is in her room in her bed receiving oxygen via nasal cannula with the head of the bed elevated. The resident's oxygen concentrator was beside her bed and still set to 3.5 liters per minute. On 08/11/2025 at 4:16 p.m., S5LPN was outside of Resident #4's room and stated that she was the nurse for Resident #4. S5LPN verified on her computer that Resident #4's oxygen concentrator should be set to 2 liters per minute per the physician's order. S5LPN then verified that the oxygen concentrator was set at 3.5 liters per minute and that it should be turned down to 2 liters. S5LPN then set Resident #4's oxygen concentrator to 2 liters per minute as ordered. On 08/11/2025 at 4:25 p.m., S12ADON verified that Resident #4's oxygen order stated Resident #4's oxygen concentrator should be set at 2 liters per minute.

Based on record review and interview the facility failed to electronically submit payroll information for direct care staffing as required. Review of the facility's Payroll Based Journal (PBJ) Staffing Data Report for FY Quarter 1 2025 (October 1 - December 31) revealed triggers for the following: One Star Staffing Rating, Excessively Low Weekend Staffing, No RN Hours, and Failed to have Licensed Nursing Coverage 24 Hours/Day. The facility failed to submit RN hours every day during Quarter 1, which was a total of 92 days. The facility failed to submit documentation of Licensed Nursing Coverage 24 Hours/Day every day during Quarter 1, which was a total of 92 days. Interview with S1ADM on 08/10/2025 at 11:36 a.m. revealed he was responsible for submitting PBJ information. S1ADM confirmed he did not accurately submit mandatory direct care staffing information to CMS for FY Quarter 1 2025, but should have.

Based on interview and record review the facility failed to ensure residents' rights to be free from mental and verbal abuse, for 2 (Resident #1 and Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. The facility failed to protect Resident #1 and Resident #2 from mental and verbal abuse by S3 CNA. 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: Review of the facility policy on 09/18/2024, with a revision date of 09/2022 titled: Abuse, Neglect, Exploitation or Misappropriation Prevention Program, read in part Policy Statement: Residents have the right to be free from abuse. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse. Mental and Verbal Abuse: 3. Examples of Mental and Verbal abuse included, but are not limited to: a. harassing a resident; b. mocking, insulting, ridiculing; c. yelling or hovering over a resident , including but not limited to, depriving a resident of care . Resident #1 Review of Resident #1's medical records revealed an admit date of 06/10/2024, with diagnoses that included: Parkinson's Disease, Unspecified Intellectual Disabilities, Unspecified Mood Disorder, Epilepsy, Type 2 Diabetes Mellitus, Unspecified Dementia, and Major Depressive Disorder. Review of Resident #1's admission MDS with an ARD 6/19/2024, revealed a BIMS score of 04, indicating severely impaired cognition. The MDS revealed Resident #1 was dependent on staff for all ADL's due to impairment to upper and lower extremities, Interview on 09/19/2024 at 1:45 p.m. with Resident #1, revealed on 08/27/2024, S3 CAN spoke to her in a rude manner, which made her cry. Resident #2 Review of Resident #2's medical records revealed an admit date of 09/03/2020, with diagnoses that included: Dysphagia following Cerebral Infarction, Unspecified Dementia, Contraction of right and left ankle, Memory deficient following Cerebral Infarction, Schizoaffective Disorder, Bipolar Disorder, Epilepsy, and Chronic Obstructive Pulmonary Disease. Review of Resident #2 Quarterly MDS with an ARD of 08/07/2024, revealed a BIMS score of 8, indicating moderately impaired cognition. Interview on 09/18/2024 at 10:18 a.m. with Resident #2 revealed on 08/27/2024, when the incident occurred with S3 CNA and Resident #1, S3 CNA also spoke to him in a rude manner, and that it upset him. Review of video footage of the incident on 08/27/2024 at 12:24 p.m., revealed Resident #1 and Resident #2 sitting in Hall X's dining area, and S3 CNA sitting to the left side of Resident #1. Resident #1 shifted her body in the chair, and moved the pillow that had been repositioned by S3 CNA on 3 different occasions. S3 CNA was again observed to put the pillow back in position. S3 CNA was heard telling Resident #1 you aren't going to get a diet coke if you keep moving the pillow, and go ahead and take that pillow off, but you are not getting any coke. At 12:25:45 seconds, the video footage revealed that Resident #1 moved her pillow, and S3 CNA grabbed Resident #1's arm and pushed it up in order to put the pillow in place, then placed Resident #1's arm back down, while telling Resident #1, you don't need a coke, you need to keep that pillow under your arm. At this point Resident #2 was heard telling S3 CNA You're going to get fired. S3 CNA aggressively replied, that doctor put that in her chair, and want it with her. Yes, that's my job to keep her safe. I'm not being fired; I'm being safe and cautious. S3 CNA asked Resident #2 are you okay over there? Resident #2 replied, my back hurts. S3 CNA stated do you want to go to bed? S3 CNA then shook her head and said, You going to have to wait until someone else comes right here. Interview on 09/18/2024 at 1:45 p.m. with S4 ADON, revealed she was in her office located directly across from Hall X's dining area, when she heard Resident #2 tell S3 CNA, you need to stop that, or you are going to get fired. S4 ADON stated she immediately walked over and asked S3 CNA what was going on. S3 CNA stated Resident #1 kept throwing her pillow on the floor. S4 ADON stated that at that point, Resident #1 looked back at me and stated She (S3 CNA) hit me. S4 ADON stated she assisted Resident #1 away from S3 CNA, and notified S1 Administrator and S2 DON of the allegation. During an interview on 09/19/2024 at 12:45 p.m., S1 Administrator stated from observing the video footage of the incident that occurred on 08/27/2024, S3 CNA spoke to Resident #1 and Resident #2 in an aggressive, antagonizing manner. S1 Administrator stated S3 CNA taunted Resident #1 by telling her that if she moved her pillow, she would not get a coke; and deprived Resident #2's request to go back to bed in an aggressive manner, when he complained of back pain. The facility has implemented the following actions to correct the deficient practice: 1. S3 CNA was terminated on 08/27/2024 due to Abuse. 2. Body Audit was conducted on Resident #1 and Resident #3 on 08/27/2024. 3. Body Audits were completed on all residents being care for on the hall that S3 CNA worked on 08/27/2024. 4. Life safety rounds completed on all residents in the facility on 08/27/2024 with 2 questions: Do you feel safe living here? Have you felt threatened by anyone here? 5. In-servicing on Abuse policy and PTSD for all staff began on 08/27/2024 and was completed on 09/03/2024. 6. Post Traumatic Stress Disorder psychiatric evaluations completed for Resident #1 and Resident #2 by Psychiatric Nurse Practitioner on 08/29/2024. 7. Resident Council meeting held on 08/29/2024, where residents were educated on Abuse/Neglect, Exploitation/Misappropriation Prevention. 8. QAPI/PIP initiated on 08/27/2024 for Abuse, and is ongoing. Facility correction Date of 09/03/2024

Based on observations, interviews, and record reviews the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings as evidenced by failing to ensure enteral feeding tubing/supplies were changed at least every 24 hours in accordance with manufacturer guidelines for 1 (Resident #34) of 1 resident reviewed for tube feeding in a total sample size of 29 residents. Findings: Review of the facility policy titled: Enteral Tube Feeding via Continuous Pump, revealed in part .General Guidelines 4. Hang times: Follow manufacturer guidelines for closed systems, other systems change every 24 hours. Review of Resident #34's clinical record revealed an initial admission date of 04/10/2019 with diagnoses that included Hemiplegia and Hemiparesis following other Non-traumatic Intracranial Hemorrhage, Dementia, Dysphagia following Cerebral Infarction, and Chronic Obstructive Pulmonary Disease. Observation on 05/07/2024 at 07:45 a.m. revealed Resident #34 reclined in a Geri chair at his bedside watching television. Resident #34 was noted wearing supplemental oxygen via nasal cannula at 2L and receiving a tube feeding of Jevity 1.5 at 40ml per hour per pump. Tube feeding bag and flush bag labeled 05/06/2024 at 4:00 a.m. Observation on 05/07/2024 at 9:35 a.m. revealed S2 DON and S3 MDS Nurse performing wound care to Resident #34's left great toe. Observation revealed Resident #34's tube feeding bag labeled Jevity 1.5 at 40ml per hour, 05/06/2024 at 4:00 a.m. Approximately 700ml noted in feeding bag and 200ml noted in water flush bag. Interview at the time of observation with S3 MDS nurse revealed tube feeding syringes where changed out nightly and feeding setups were good for so many hours and then changed out. S3 MDS Nurse confirmed Resident #34's tube feeding setup had been hanging longer than 24 hours and should have been changed out, but had not been.

Based on record review and interviews the facility failed to electronically submit payroll information for direct care staffing as required. Findings: Review of the facility's PBJ (Payroll Based Journal) staffing Data Report for FY (Fiscal Year) Quarter 1 2024 (October 1-December 31) revealed triggers for the following: One star staffing rating, Low weekend staffing, No RN coverage for 8 consecutive hours per day and No Licensed Nursing Coverage 24 Hours/Day. Review of the facility's CMS Payroll Based Journal submission report dated 02/13/2024 revealed the facility's submission had been received and would be checked for errors within 24 hours. Review also revealed the submission report stated in part . this is a reminder to check CASPER for a system generated PBJ Final File Validation Report (FFVR) within 24 hours. If no FFVR appears, run a PBJ Submitter Final File Validation Report. Run the PBJ 1702D (by Employee) or 1703D (by Job Type) reports to verify the quarterly PBJ data reflects your records. Review of the facility's CMS Submission Report PBJ Submitter Final File Validation Report generated by S3 MDS Nurse on 05/07/2024 at 11:29 a.m. and provided to the Surveyor by S1 Administrator revealed on 02/13/2024 the number of files processed was 4, number of files accepted as 0, and number of files rejected as 4. Report message stated invalid file: Files must end in .xml to be accepted. Cause: A file was submitted that did not end in .xml. Action: Correct file extension and resubmit. Interview on 05/07/2024 at 11:30 a.m. with S1 Administrator revealed he and S3 MDS Nurse were responsible for submitting PBJ information. S1 Administrator confirmed that after uploading the FY Quarter 1 2024 (October 1-December 31) PBJ information he nor S3 MDS nurse went back to check the final file validation report after 24 hours to ensure the facility staffing information had been submitted and accepted as required and should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents' rights to be free from verbal abuse for 2 (Resident #1 and Resident #3) of 3 (Resident #1, Resident #2, Resident #3) sampled residents. The facility failed to protect Resident #1 and Resident #3 from verbal abuse by Resident #2. The facility implemented corrective actions which were completed prior to the State Agency's Investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility policy titled: Resident to Resident Altercations read in part . All altercations, including those that may represent resident to resident abuse, are investigated and reported to the nursing supervisor, the director of nursing services and to the administrator. Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents, family members, visitors, or to the staff. Behaviors that may provoke a reaction by residents or others include: verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidating. Resident #1 Review of Resident #1's EHR revealed an admit date of 09/28/2020. Resident had diagnoses that included in part . Malignant Neoplasm of Central Portion of Left Male Breast, COPD, Epilepsy, Major Depressive Disorder, Dementia without Behavioral Disturbance, Schizophrenia, Type 2 Diabetes Mellitus, and Anxiety Disorder. Review of Resident #1's Quarterly MDS with an ARD of 08/23/2023 revealed Resident had a BIMS of 5, which indicated severe cognitive impairment. The MDS revealed Resident #1 required 1 person physical assist for bed mobility, transfers, dressing, personal hygiene, and toileting. Review of Resident #1's Care Plan revealed there was no problems identified regarding resident to resident abuse. Review of Resident #1's nursing notes revealed the following in part . On 10/17/2023 at 5:19 p.m., S2 DON documented she was called into the dining room per S3 Social Worker. Resident #1 was eating in the dining room while Resident #2 was staring at him. Resident #2 cursed at Resident #1, You mother-fu---r. Interview on 11/01/2023 at 10:12 a.m. with Resident #1 revealed on 10/17/2023, Resident #2 cursed at him in the dining room. Resident #1 stated Resident #2 kept cursing, and he raised a fork to her, to get her quiet. Resident #1 stated he was not going to hurt Resident #2, he wanted her to stop cursing him. Resident #1 stated he could not recall what exactly Resident #2 said, and stated She just kept cursing me. Resident #2 Review of Resident #2's EHR revealed an admit date of 02/11/2023. Resident #2 had diagnoses that included in part . Hemiplegia and Hemiparesis CVA affecting Left Non Dominant Side, Hydrocephalus, Schizophrenia, Impulse Disorder, Major Depressive Disorder, Seizures, and Anxiety. Review of Resident #2's Quarterly MDS with an ARD of 08/09/2023 revealed Resident had a BIMS of 8, which indicated moderate cognitive impairment. The MDS revealed Resident #2 required extensive 2 person physical assist for bed mobility, and was totally dependent on staff for transfers, dressing, and toileting, and personal hygiene. The MDS revealed Resident #2 used a wheelchair for mobility. Review of Resident #2's Care Plan revealed there were no problems identified regarding resident to resident abuse prior to 10/17/2023. Review of Resident #2's nursing notes revealed the following in part . 10/17/2023 at 5:31 p.m. - S3 Social Worker documented: called in the dining room by staff. Resident #2 noted yelling obscenities at several residents. Resident #2 was cursing and yelling at any resident walking past her. Resident #2 was calling them mother f--[NAME], wh--e, stupid b--ch, black b--ch, etc. Resident #2 was yelling very angrily and loudly. Resident #2 was taken outside to smoke and was calmed down. After several attempts Resident #2 was able to be redirected. 10/17/2023 at 7:59 p.m. - S2 DON documented: Physician notified of Resident #2 cursing at Resident #1 and of Resident #1 threatening her with a fork. Informed physician Resident #2 under 1:1 surveillance, Resident #2 unharmed with incident. Attempting psych placement for Resident #2 this evening. 10/17/2023 at 11:47 p.m. - S5 LPN documented: Resident #2 transferred to behavioral hospital per ambulance, in stable condition at this time. Resident #3 Review of Resident #3's EHR revealed an admit date of 12/29/2017. Resident had diagnoses that included in part . Type 2 Diabetes Mellitus, Muscle wasting and Atrophy to Left and Right Shoulder, Muscle Weakness, and Hypertension. Review of Resident #3's Quarterly MDS with ARD of 09/20/2023 revealed Resident had a BIMS of 6, which indicated moderate cognitive impairment. The MDS revealed Resident #3 was functionally independent for bed mobility, transfers, eating, walking, personal hygiene, toileting, and dressing. Review of Resident #3's Care Plan revealed there was no problems identified regarding resident to resident abuse. Interview on 11/01/2023 at 10:33 a.m. with Resident #3 revealed on 10/17/2023, Resident #2 cursed at her in the dining room because she did not have a cigarette. Resident #3 stated Resident #2 stated to her f--k you b--ch multiple times, and you stupid wh--re! Resident #3 stated she did not say anything back, and went to get S3 Social Worker to report the incident. Interview on 11/01/2023 at 1:22 p.m. S4 Dietary worker revealed she witnessed the altercation between Resident #1 and Resident #2 that occurred on 10/17/2023. S4 Dietary stated she was washing dishes and she heard someone say mother fu--er really loud, so she went out to the dining area to see what was going on. S4 Dietary worker stated she saw Resident #2 in a wheelchair and Resident #1 was standing next to her. S4 Dietary worker stated she witnessed Resident #2 cursing Resident #1, and then the two Residents began cursing back and forth. S4 Dietary stated she removed Resident #2 from the dining area immediately. The surveyor was unable to interview S2 DON, as she was unavailable for interview at the time of survey. Interview on 11/01/2023 at 11:10 a.m. with S3 Social Worker revealed Resident #1 and Resident #2 had no previous altercations with any Resident prior to the incident on 10/17/2023. S3 Social Worker stated she had not witnessed what occurred prior to her entering the dining room on 10/17/2023 when Resident #3 summoned her there, but staff immediately separated Resident #1 and Resident #2. S3 Social Worker stated the altercation between Resident # 2 and Resident #3 occurred approximately a few minutes before 5:00 p.m. in the dining area. S3 Social Worker stated the altercation between Resident #1 and Resident #2 occurred as Resident #3 was summoning her (S3 Social Worker) to the dining area. S3 Social Worker stated she presented to the dining area immediately. S3 Social Worker stated Resident #1 and Resident #2 were placed 1:1 and both were sent for psych evaluations. S3 Social Worker stated Resident #1 had returned to facility on 10/31/2023 and had no behaviors present. S3 Social Worker stated the facility continues to monitor for Resident to Resident altercations. The facility implemented the following actions to correct the deficient practice: 1. Resident #1 and Resident #2 were placed on 1:1 monitoring immediately on 10/17/2023. 2. Resident #2 was sent to a behavioral hospital on [DATE] and remains hospitalized . 3. Resident #1 was sent to a behavioral hospital on [DATE], and returned to the facility on [DATE]. No further behavioral issues have been noted from Resident #1 since his return from the behavioral hospital. 4. Resident interviews conducted related to feeling safe or threatened by anyone in the facility by S2 DON beginning on 10/17/2023-10/18/2023. All residents interviewed had negative findings. 5. Abuse policy was reviewed with no changes required to the facility's Abuse policy. 6. Facility in-services completed by S2 DON were started on 10/17/2023, and completed on 10/24/2023 concerning the facility's Resident to Resident Altercations Policy and the Abuse Policy: types of abuse, recognizing signs and symptoms of abuse, neglect. All staff employed by the facility have received training on the above policy as of 10/24/2023. 7. QA committed met on October 18, 2023 to discuss resident to resident incidents that occurred on 10/17/2023. Resident to Resident altercations will be monitored by the DON as part of the facility's QAPI. Monitoring began on 10/17/2023. Monitoring will occur every day for 2 weeks, then 3 times a week for 1 month, and will continue monthly thereafter for 3 months. 8. There have been no other incidences of abuse in the facility, and monitoring continues as noted above. Facility correction date of 10/24/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician was notified when a resident had a change in condition for 1 (Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. The facility failed to ensure S6 LPN notified Resident #5's physician immediately when an incident that resulted in injury occurred. Findings: Review of the facility's policy titled Accidents and Incidents - Investigating and Reporting revealed in part . Policy Statement All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. Policy Interpretation and Implementation 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: a. The date and time the accident or incident took place; b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The name(s) of witnesses and their accounts of the accident or incident; f. The injured person's account of the accident or incident; g. The time the injured person's attending physician was notified, as well as the time the physician responded and his or her instructions; h. The date/time the injured person's family was notified and by whom; i. The condition of the injured person, including his/her vital signs; j. The disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work, etc). Review of Resident #5's Medical Record revealed an admit date of 09/04/2021 with diagnoses that included: Polyosteoarthritis, Generalized Anxiety Disorder, Fracture of Nasal Bones, Heart Failure, Shortness of Breath, Unspecified Dementia with Behavioral Disturbance, Schizoaffective Disorder, Essential Hypertension; and Pain. Review of Resident #5's Quarterly MDS with an ARD of 05/31/2023 revealed a BIMS was not conducted. Resident #5 was coded as rarely/never understood, had a memory recall ability of staff names and faces, and had moderately impaired cognitive skills for daily decision making. Resident #5 was coded as total dependence with 2+ persons physical assist for bed mobility, transfer, dressing, toilet use, and bathing; and coded as total dependence with 1 person physical assist for eating and personal hygiene. Resident #5 had bilateral ROM impairment of upper and lower extremities. Review of Resident #5's Care Plan with a Target Date of 09/06/2023, revealed the following problems in part . 1. ADL self-care deficit related to upper and lower extremity contractures, and cerebral atrophy. Interventions included in part .I am totally dependent on 2 staff for repositioning and turning in the bed, and I am totally dependent on 1 staff for eating. 2. Medial displaced nasal fracture initiated on 06/15/2023. Interventions included in part .administer my pain medication as ordered, monitor and document side effects and effectiveness; assess breathing status as ordered; assess nose for bleeding, increased swelling, pain, difficulty breathing, vomiting, any difficulty eating; assess for nonverbal pain; follow up with ENT; I will be handled gently when moving or positioning; and staff to keep bedside table on the side of the bed. Review of an Incident Report dated 06/15/2023 at 10:31 a.m. for Resident #5 revealed in part . Incident Location: Resident #5's room Description: Attempted to interview resident, resident was unable to give description. Full head to toe assessment performed by S2 DON. No bruising, redness, scratches, or pressure areas noted on any other areas of her body. Notified physician of above. OK to send resident to ER for evaluation and treatment. EMS called for transport. Pericare and brief change provided by staff. RP notified. Level of Pain: PAINAD: 1 - Occasional moan or groan. Low level of speech with negative quality. Witnesses: no witnesses found Nursing Description: I (S3 ADON) was called to resident's room by S4 Assessment Nurse and S5 Social Services. Resident had dried blood on nostrils, bruising and swelling to her nose. Unable to determine at this time the cause of the injury. Review of Resident #5's Nurses Progress Notes documented by S3 ADON revealed in part . 06/15/2023 at 10:49 a.m. Late Entry - I was called to resident's room by S4 Assessment Nurse and S5 Social Services. Resident had dried blood on nostrils, bruising and swelling to her nose. Attempted to interview resident, resident was unable to give description. Full head to toe assessment performed by S2 DON. No bruising, redness, scratches, or pressure areas noted on any other areas of her body. Notified physician of above. OK to send resident to ER for evaluation and treatment. EMS called for transport. Review of Resident #5's EMS Report dated 06/15/2023 revealed in part . Physical Examination: Bilateral eye socket bruising. Narrative: Nursing stated patient was found this morning with bilateral bruising around each eye socket. No fall was witnessed by nursing staff, so an investigation was underway. Review of Resident #5's emergency room records revealed in part . Arrival Date: 06/15/2023 Arrival Time: 11:34 a.m. HPI: bruises around eyes and nose. The quality is acute. The severity is moderate. The duration is unable to be obtained. Orders: CT Maxillofacial without Contrast Impression: 1. Mildly Displaced Communited Fracture of the Nasal Bones. There is overlying soft tissue swelling and small foci of soft tissue emphysema. 2. Focal soft tissue edema greatest on right. Diagnosis: Contusion of Face, Fracture of Nasal Bones. Interview on 08/08/2023 at 9:57 a.m. with S7 CNA revealed she worked 6:00 a.m. to 6:00 p.m. S7 CNA stated on 06/15/2023, she came in for 6:00 a.m. and made rounds. S7 CNA reported she checked Resident #5 around 7:00 a.m. to see if Resident #5 needed a brief change, but Resident #5 was dry. S7 CNA stated Resident #5's right side faced the window, and her bed was against the wall, so she was unable to fully see her face. S7 CNA stated she did not see any bleeding or anything abnormal at the time. S7 CNA reported when she was preparing to give Resident #5 a shower, she put the shower bed in the doorway of Resident #5's room to get it out of the hall, and went to get the bed lift. S7 CNA stated she did not look at the resident at that time. S7 CNA reported when she returned with the bed lift, S4 Assessment Nurse and S5 Social Services walked pass Resident #5's room and said it looked like Resident #5's nose was bleeding, so they asked her (S7 CNA) to check on Resident #5. S7 CNA stated Resident #5's right eye and nose were blue, purple, black and swollen, and her nose looked broken. S7 CNA stated after she saw Resident #5's face, she immediately reported it to S4 Assessment Nurse and S5 Social Services who came into the room and then they notified S1 Asst. ADM. S7 CNA stated Resident #5 was unable to move herself in the bed, and could only move her arms a little without assistance. Telephone interview on 08/08/2023 at 12:03 p.m. with S6 LPN revealed she fed Resident #5 breakfast on 06/15/2023 around 8:00 a.m. S6 LPN stated Resident #5 was chanting loudly continuously, making it difficult to get her to eat and drink. S6 LPN stated she repositioned Resident #5 to where she was not facing the window to try to feed her. S6 LPN reported the resident continued to look out of the window and she went to reposition her again. S6 LPN reported she had the bedside table too high and over the bed too much, and when she repositioned the resident, she stated I bumped her face across the bridge of her nose. S6 LPN stated Resident #5's nose started to bleed after her nose hit the bedside table. S6 LPN reported she pinched the bridge of Resident #5's nose to stop the bleeding, and after the bleeding stopped, she cleaned the Resident #5's nose, then left to do her medication pass. S6 LPN reported she went back to the Resident #5's room a few minutes later to administer her medication, and she had no bleeding, swelling, or bruising, and took the medication without difficulty. S6 LPN stated it took a while for her to come forward and admit what had happened because she was ashamed and afraid. S6 LPN confirmed she should have reported the incident immediately, but did not. When asked how the swelling, bruising, and blood was noted to Resident #5's eye and nose later, S6 LPN reported the administrative team noticed it. S6 LPN stated they questioned all staff that went in Resident #5's room, and that was when she told them what had happened. Interview on 08/08/2023 at 1:07 p.m. with S6 LPN revealed she did not check on Resident #5 after she gave her medication. S6 LPN stated she did not go back in Resident #5's room again on 06/15/2023 until after she was questioned about what had happened, but could not remember what time. Interview on 08/08/2023 at 1:23 p.m. with S4 Assessment Nurse revealed on 06/15/2023 (cannot remember what time), she and S5 Social Services were moving a bed across the hall, and S5 Social Services thought she saw blood under Resident #5's nose. S4 Assessment Nurse stated S5 Social Services asked S7 CNA to go in and check on Resident #5. S4 Assessment Nurse reported S7 CNA checked Resident #5 and came right out and said You need to come see her. I don't know what is going on with her. S4 Assessment Nurse reported when she went in, Resident #5's eye and nose were bruised, her nose was swollen, and she had dried blood on her chin. Interview on 08/08/2023 at 1:20 p.m. with S7 CNA revealed Resident #5 always responded to her questions either with yes or no, or by shaking her head yes or no. S7 CNA reported on 06/15/2023 after the injury, she asked Resident #5 if she was in pain and Resident #5 would not shake her head or answer her. S7 CNA stated the resident just stared at her. Interview on 08/08/2023 at 1:40 p.m. with S5 Social Services revealed on 06/15/2023 she was with S4 Assessment Nurse moving beds on the hall, and Resident #5 looked like she had dried blood on her face under her nose. S5 Social Services reported she asked S7 CNA to go look at Resident #5's face. S7 CNA reported to her and S4 Assessment Nurse that something was not right with Resident #5, and that they needed the go see her. S5 Social Services stated Resident #5 had dried blood on her nose, a black eye starting on right eye and nose, and dried blood on her nose and chin. S5 Social Services reported the resident did not appear to be in pain. S5 Social Services stated she asked Resident #5 if she was in pain, but Resident #5 gave no response. Interview on 08/09/2023 at 12:30 p.m. with S1 Asst. ADM revealed on 06/15/2023 at 3:45 p.m. during a conference call with S6 LPN, S2 DON, and S5 Social Services, S6 LPN came forward and said she was adjusting Resident #5 to feed her, and when she turned her, her face hit the bedside table. S1 Asst. ADM reported S6 LPN told him the table was high and over the bed, so when she turned her, her face got the table. Interview on 08/09/2023 at 1:37 p.m. with S2 DON, S3 ADON, and S5 Social Services revealed they could not recall the time they first questioned S6 LPN on 06/15/2023, but it was in the morning before lunch. S6 LPN reported everything was fine when she last saw Resident #5. S5 Social Services stated the time she noticed the blood on Resident #5's nose was at approximately 9:56 a.m., right before the time S6 LPN was seen entering her room on the camera footage, which was at 9:57 a.m. so it had to have been at 9:56 a.m. S2 DON stated she called S6 LPN on 06/15/2023 at 2:15 p.m. when S6 LPN was on her way home after clocking out for the day. S2 DON reported S6 LPN turned around and came back to the facility. S5 Social Services stated they (S2 DON, S3 ADON, and herself) met with S6 LPN around 3:15 p.m. S2 DON, S3 ADON, and S5 Social Services all reported S6 LPN did not come forward at that time, and kept insisting that it was not her, she felt like they were accusing her, and got upset and left. S2 DON and S5 Social Services stated they called S1 Asst. ADM and S6 LPN. S2 DON and S5 Social Services reported S6 LPN eventually said that she had hit Resident #5's face when turning her. Interview on 08/10/2023 at 11:26 a.m. with S6 LPN revealed she called report to the ER on [DATE] for Resident #5. S6 LPN stated when she called report, she reported to the ER nurse that Resident #5 was being sent for an X-ray of her face. S6 LPN reported that she did not report anything else to the ER.

Based on observation and interview the Facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident #32) out of a total sample of 30 Residents. The facility failed to ensure staff did not stand while assisting Resident #32 during meal service. Findings: Review of Resident #32's medical record revealed an admit date of 09/04/2021 with diagnoses which included: Hemiplegia and Hemiparesis following non-traumatic Subarachnoid Hemorrhage affecting left non-dominant side, Seizures, Unspecified Protein-Calorie Malnutrition, and Sudden Visual loss Left Eye. Review of Resident #32's care plan with a target date of 06/27/2023 revealed a potential for a nutritional problem Dysphagia, swallowing problems, with approaches for staff to assist with meals. Observation on 05/21/2023 at 12:10 p.m. from the hallway revealed Resident #32 in his room in bed. S10 CNA was observed standing on the right side of Resident #32's bed feeding him. Observation on 05/22/2023 at 11:43 a.m. from the hallway revealed Resident #32 in his room in bed. S10 CNA was observed standing on the right side of Resident #32's bed feeding him. Interview on 05/22/2023 at 11:57 a.m. with S10 CNA confirmed she stood to feed Resident #32 and she should not have. Interview on 05/23/2023 at 1:15 p.m. with S6 ADON confirmed staff should not have been standing to feed any residents.

Based on observation, interview, and record review, the facility failed to ensure a resident received services in the facility with reasonable accommodation of resident needs for 1 (#26) of 1 (#26) resident reviewed for environment. The facility failed to ensure Resident #26 had a call light in reach in order to call for assistance. The total sample size was 30. Findings: A review of Resident #26's medical record revealed an admit date of 01/25/2021 with diagnoses that included in part: Primary Generalized Osteoarthritis, Unspecified Convulsions, Contracture of Muscle- Left Hand, Hemiplegia- Affecting Left Non-dominant Side, Dysphagia, and Contracture of Muscle- Left Lower Leg and Left Upper Arm. A review of Resident #26's Minimum Data Set (MDS) with an ARD of 04/19/2023 revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident had intact cognition. Resident #26 was totally dependent on staff and required 2 person physical assistance with bed mobility, dressing, bathing and toileting. A review of Resident #26's Care Plan with target date of 07/26/2023 revealed in part . High risk for falls. Approaches included face plate call system, and call light within reach with encouragement to use call light for assistance as needed. A review of Facility policy titled Answering the Call Light read in part . 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Observation of Resident #26 on 05/21/2023 at 9:59 a.m. revealed Resident #26 was paralyzed and had contractures to his left side. Resident was observed lying on his right side, with wedges in place on both sides of him. Resident had an adaptive call light that was located on left upper corner of bed. Resident stated he could not reach the call light to call for help if needed because he could not move his left side, and he could not raise his right arm high to reach call light. Observation of Resident #26 on 05/21/2023 at 12:15 p.m. revealed Resident #26 was in the same position as previous observation on 05/21/2023 at 9:59 a.m. The adaptive call light remained unreachable by Resident and remained located on left upper corner of bed. Observation of Resident #26 on 05/21/2023 at 2:05 p.m. revealed Resident #26 was in the same position as previous observations on 05/21/2023 at 9:59 a.m. and 12:15 p.m. The adaptive call light remained unreachable by Resident, and remained located on left upper corner of bed. Observation of Resident #26 on 05/21/2023 at 3:39 p.m. revealed Resident #26 was in the same position as previous observations on 05/21/2023 at 9:59 a.m., 12:15 p.m., and 2:05 p.m. The adaptive call light remained unreachable by Resident, and remained located on left upper corner of bed. Resident stated he could not reach the call device. Observation of Resident #26 on 05/21/2023 at 4:06 p.m. revealed Resident #26 was in the same position as previous observations on 05/21/2023 at 9:59 a.m., 12:15 p.m., 2:05 p.m., and 3:39 p.m. The adaptive call light remained unreachable by Resident, and remained on the left upper corner of bed. This surveyor summoned S13 LPN to Resident #26's room. Interview on 05/21/2023 at 4:06 p.m. with S13 LPN revealed Resident #26 required an adaptive call light which she stated was a face plate call device. S13 LPN stated the device must be located close enough to the Resident, so he could apply pressure using his face or another body part to engage the device. S13 LPN confirmed Resident #26's adaptive call light had not been in reach of Resident, and it should be.

Based on observation and interview the facility failed to protect the Resident's Right to personal information by failing to ensure 3 Resident's (Resident #29, Resident #38 and Resident #39) of 30 sampled residents, name and medical appointments were not posted in a public area within the Facility. Findings: Observation on 05/22/2023 at 2:30 p.m. of X hall and Y hall bulletin board (across from the nurse's station) revealed a sheet titled Today's Scheduled Medical Doctor's Appointments, with Resident #29, Resident #38 and Resident #39's first and last name, appointment time, and destination (all 3 Residents were going to Dialysis). Observation and interview on 05/22/2023 at 2:53 p.m. with S9 LPN revealed the sheet titled Today's Scheduled Medical Doctor's Appointments, was a communication tool posted on the bulletin board in the hallway to relate the following information to staff: Resident name, appointment time, what time to have the resident ready and the destination. Observation and interview on 05/22/2023 at 2:55 p.m. with S1 Administrator confirmed the sheet titled Today's Scheduled Medical Doctor Appointments was posted in a visible area to the public and contained personal and medical information for Resident #29, Resident #38 and Resident #39 and it should not have been.

Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide baths, shaving, and nail care to dependent residents for 1 (Resident #5) of 1 Residents sampled for ADL's. Findings: Review of the facility policy titled: Fingernails/Toenails, Care of, revealed in part . The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. 1. Nail care includes daily cleaning and regular trimming. Review of Resident #5's Quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 03/22/2023 revealed Resident #5 had severe cognitive impairment, did not reject care, and was totally dependent on the assistance of 1 person for personal hygiene. Review of Resident #5's Physician Orders revealed in part . RN (Registered Nurse) to trim toenails monthly and PRN (as needed) one time a day every 30 days for nail care. Start date 08/07/2020. RN to trim toenails monthly & PRN as needed for nail care. Start date 08/06/2020. Review of Resident #5's Treatment Administration Record for 04/2023 and 05/2023 revealed toenail trimming had been last documented as completed on 04/24/2023 by S2 DON (Director of Nursing). Observation on 05/22/2023 8:07 a.m. revealed Resident #5 seated in a wheelchair in the facility's dayroom area. Resident #5 was well groomed, neatly dressed and wearing tennis shoes. Interview with Resident #5 at the time observation revealed he had been bathed, and had his fingernails cut but his toenails were still long. Resident #5 stated his toes were getting sore in his shoes. Resident #5 stated his toenails had not been cut in about 2 months. Observation on 05/22/2023 at 3:05 p.m. of Resident #5's toenails accompanied by S4 LPN revealed Resident #5's toenails on both feet were 1/2 to 3/4 inch long, thick and curling over the ends of his toes. Observation on 05/22/2023 at 3:08 p.m. of Resident #5's toenails accompanied by the S2 DON confirmed the above observations. S2 DON stated Resident #5's toenails had not been trimmed on 04/24/2023 because she thought Resident #5 was on the list to see the Podiatrist. S2 DON stated Resident #5's toenails had not been trimmed and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #26 A review of Resident #26's medical record revealed an admit date of 01/25/2021 with diagnoses that included in part: Primary Generalized Osteoarthritis, Unspecified Convulsions, Contracture of Muscle- Left Hand, Hemiplegia- Affecting Left Non-dominant Side, Dysphagia, and Contracture of Muscle- Left Lower Leg and Left Upper Arm. A review of Resident #26's Minimum Data Set (MDS) with an ARD of 04/19/2023 revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident had intact cognition. Resident #26 was totally dependent on staff and required 2 person physical assistance with bed mobility, dressing, bathing and toileting. A review of Resident #26's Care Plan with target date of 07/26/2023 revealed in part . Potential for Further Skin Breakdown: Limited Mobility, Unable to Reposition Self, Incontinent. Update to identified problem on 07/26/2022 revealed: Does not stay positioned as scheduled. Approaches included reposition every two hours while in bed. A review of Resident #26's turning schedule located in Resident's room revealed Resident was to be repositioned every 2 hours, rotating from back to left side. A review of Facility policy titled Repositioning read in part .General Guidelines. 3. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. Interventions. 1. A turning/repositioning program includes a continuous consistent program for changing the resident's position and realigning the body. 3. Residents who are in bed should be on at least an every two hour (q 2 hour) repositioning schedule. Observation of Resident #26 on 05/21/2023 at 9:59 a.m. revealed Resident #26 was paralyzed and had contractures to his left side. Resident was observed lying on his right side, with bed bolsters in place on both sides of him. Resident was facing the doorway in bed. Bed was positioned with the head of bed against wall, and the right side of bed was closest to doorway/hall. Resident #26 stated he was unable to reposition himself in bed and required assistance from staff to turn in bed. Resident had a turn schedule posted above head of bed for turning every two hours, rotating from back to left side. The turn schedule did not include Resident to be positioned on right side. Resident stated staff did not turn him every two hours. Observation of Resident #26 on 05/21/2023 at 12:15 p.m. revealed Resident #26 was in the same position as previous observation on 05/21/2023 at 9:59 a.m. He remained on his right side. Resident stated staff had not been in to turn him. Observation of Resident #26 on 05/21/2023 at 2:05 p.m. revealed Resident #26 was in the same position as previous observations on 05/21/2023 at 9:59 a.m. and 12:15 p.m. He remained on his right side. Resident stated staff had not been in to turn him in a while. Observation of Resident #26 on 05/21/2023 at 3:39 p.m. revealed Resident #26 was in the same position as previous observations on 05/21/2023 at 9:59 a.m., 12:15 p.m., and 2:05 p.m. He remained on his right side. Resident stated staff had not repositioned him since this morning. Observation of Resident #26 on 05/21/2023 at 4:06 p.m. revealed Resident #26 was in the same position as previous observations on 05/21/2023 at 9:59 a.m., 12:15 p.m., 2:05 p.m., and 3:39 p.m. He remained on his right side. This surveyor summoned S13 LPN to Resident #26's room. Interview on 05/21/2023 at 4:06 p.m. with S13 LPN revealed Resident #26 was totally dependent on staff for positioning every two hours. S13 LPN stated the CNA's are responsible for repositioning, and she would have a CNA reposition the Resident. Interview on 05/21/2023 at 4:15 p.m. with S15 CNA in Resident #26's room revealed the Resident required total assistance for positioning, bathing, eating, and toileting. S15 CNA stated he began his shift at 3:00 p.m. and was here to change and reposition Resident. S15 CNA stated he does not have another staff member assist him with Resident #26, and the only time he had another staff member assist him was when Resident #26 got up with a lift. S15 CNA then changed and repositioned Resident. Observation on 05/22/2023 at 7:50 a.m. revealed Resident #26 was lying on his back. Bed bolsters was observed on each side of Resident. Resident's adaptive call light was within reach, lying on top of Residents lap area. Observation on 05/22/2023 at 8:56 a.m. revealed Resident #26 was in the same position as previous observation on 05/22/2023 at 7:50 a.m. He remained on his back. Resident's head of bed was elevated. Turning schedule above Residents head of bed revealed Resident should be positioned to left side at 8:00 a.m. Resident was observed on back. Observation on 05/22/2023 at 10:00 a.m. revealed Resident #26 was in the same position as previous observations on 05/22/2023 at 7:50 a.m. and 8:56 a.m. He remained on his back. Resident stated staff had not turned him since early this morning. Observation on 05/22/2023 at 12:00 p.m. revealed Resident #26 was lying on left side. Resident stated staff had turned him not long ago. Observation on 05/22/2023 at 2:00 p.m. revealed Resident #26 was in the same position as previous observation on 05/22/2023 at 12:00 p.m. He remained lying on left side. Resident stated staff had not been in room since around lunch. When asked if Resident wanted to be turned he stated yes. Interview on 05/22/2023 at 2:14 p.m. with S2 DON regarding ADL care and repositioning of Resident #26 revealed S2 DON stated she was aware Resident refused oral care and nail trimmings, but was not aware of any other refusals Resident had voiced. Observation on 05/22/2023 at 2:14 p.m. of Resident #26 with S2 DON in Resident's room revealed Resident #26 was lying on his left side. This surveyor informed S2 DON that Resident was monitored for positioning, and Resident #26 voiced he had not been turned every two hours. This surveyor informed S2 DON Resident #26 was observed to be turned once today, 05/22/2023 at 12:00 p.m., and once yesterday 05/21/2023 at 4:15 p.m. during the time this surveyor was present in facility. S2 DON confirmed Resident #26 should be turned every two hours, and turned according to his turn schedule posted above head of bed. S2 DON then asked Resident #26 if staff had come into his room today and offered to turn him. Resident #26 stated No. S2 DON then asked Resident #26 if he would allow staff to turn him. Resident #26 stated yes. S2 DON informed Resident #26 she would speak with staff, and have them come in to turn him. Observation on 05/22/2023 at 2:20 p.m. revealed Resident #26 was positioned on his right side. Interview with S16 CNA at time of observation revealed she had turned the Resident. Interview on 05/22/2023 at 2:50 p.m. with S14 CNA and S2 DON revealed S14 CNA stated she repositioned Resident #26 around the time she came on shift, which was 6:00 a.m. S14 CNA stated when she went to reposition Resident #26 around 10:00 a.m. the dentist was here, and Resident was on his back, so she could not turn him because the dentist was in room. S14 CNA stated after lunch she then turned Resident #26 to his left side. S2 DON stated she turned Resident #26 at 2:18 p.m. after she spoke to surveyor in room. S2 DON stated she positioned Resident to his right side. S14 CNA stated she repositioned Resident #26 according to the turn schedule in Resident's room, and asked S2 DON if this was the correct process. S2 DON confirmed CNA's are to turn Resident's according to their turn schedule. S2 DON confirmed Resident #26 was not turned every two hours, but should have been. Based on observation, record reviews, and interview the facility failed to ensure resident's received treatment and care in accordance with professional standards of practice for 1 (#17) of 1 resident reviewed for hospice services, and 1 (#26) of 3 (#12, #26, and #32) residents reviewed for positioning. The facility failed to ensure a resident's (Resident #17) hospice orders for comfort medications were transcribed, and failed to ensure a resident (Resident #26) was repositioned every 2 hours. Findings: Review of the clinical record revealed Resident #17 admitted to the facility on [DATE] with diagnoses that included: Hypertensive Heart Disease with Heart Failure, Alzheimer's disease, Type II Diabetes Mellitus, Acute on Chronic Combined Systolic and Diastolic Heart Failure, Paroxysmal Atrial Fibrillation, COPD (Chronic Obstructive Pulmonary Disease), and Chronic Respiratory Failure. Review of Resident #17's CPOC (Comprehensive Plan Of Care) with target date 07/02/2023 revealed in part 03/28/2023 Family requested to switch hospice providers. Diagnosis: CHF (Congestive Heart Failure) Hospice Supplies: Bariatric Bed, Diapers, Wipes, Pads, Oxygen concentrator, M6 tank with conserving device, Acetaminophen, Klonopin, Ativan, Losartan, Metolazone, Milk of Magnesia, Miralax, Morphine, Tylenol, Zinc Oxide, Zoloft, Aldactone, Bisacodyl, Colace, Coreg, Potassium, Protonix, Remeron, Senna, and Torsemide. Review of Resident #17's Hospice Client Medication Report revealed in part Hyoscamine 0.125mg sublingual tablet every 4 hours prn secretions. Morphine concentrate 100mg/5ml (20mg/ml) oral solution 0.25ml every 3 hours prn SOB. Review of Resident #17's Medication Administration Record and Physician's Orders revealed there were no orders for Hyoscamine or Morphine. Interview on 05/22/2023 at 1:10 p.m. with S3 LPN revealed she was the nurse assigned to Resident #17. S3 LPN confirmed there was no Physician Orders in the computer nor were Hyoscamine or Morphine solution on Resident #17's MAR. S3 LPN also confirmed Hyoscamine and Morphine were included in Resident #17's Hospice Client Medication Report. Interview on 05/22/2023 at 1:28 p.m. with S2 DON confirmed the above findings. S2 DON stated Morphine and Hyoscamine should have been ordered and placed on Resident #17's MAR for administration as needed for comfort measures and had not been.

Based on interview and record review, the facility failed to provide and maintain documentation of offering education on the benefits, and risk of the COVID-19 vaccine for 8 (S9 LPN, S11 Dietary Cook, S12 Housekeeping, S17 CNA, S18 Social Worker, S19 Housekeeping Supervisor, S20 OT, and S21 PTA) of 8 staff who were interviewed for COVID-19 vaccination status. Findings: Review of the Facility's Policy titled Coronavirus Disease (COVID-19) Vaccination of Staff read in part- Tracking, documentation and reporting; 3. The facility maintains documentation related to staff COVID-19 vaccination that includes at a minimum b. That the staff were provided education regarding the benefits and potential risk associated with COVID-19 vaccine. Review of the facility's COVID-19 matrix revealed documentation of the employees' vaccinations status and exemptions. There were no documentations available for review on the offering, education, benefits of COVID-19 vaccinations to the employees. Interview on 05/21/2023 at 4:22 p.m. with S17 CNA revealed she has a religious exemption for COVID-19 vaccination. S17 CNA stated she have never been told about the side effects and risk of the COVID-19 vaccine. Interview on 05/22/2023 at 4:00 p.m. S19 Housekeeping Supervisor revealed she was vaccinated against COVID-19. S19 Housekeeping Supervisor stated she has never been told by anyone of the risk and/or potential side effects of the COVID-19 vaccine. Interview on 05/22/2023 at 4:50 p.m. with S9 LPN revealed she is vaccinated against COVID-19. S9 LPN stated she could not recall even being informed of the benefits, risk and/or side effects of the COVID-19 vaccine. Interview on 05/23/2023 at 10:45 a.m. with S20 OT Director revealed he is contracted by the facility and has been vaccinated against COVID -19. S20 OT stated the facility have never provided him with any information on the COVID-19 vaccine. Interview on 05/23/2023 at 10:53 a.m. with S21 PTA revealed he is contracted by the facility and has been vaccinated against COVID -19. S21 PTA stated the facility has never provided him with any information on COVID-19 or educated him on the COVID-19 vaccination. Interview on 05/23/2023 at 11:09 a.m. with S12 Housekeeping revealed he has been employed at the facility for about 1 month. S12 Housekeeping stated he was offered the COVID-19 vaccine but declined for religious reason. S12 Housekeeping stated he was never educated on the benefits and/or risk factors of the COVID vaccination. Interview on 05/23/22023 at 11:50 a.m. with S11 Dietary [NAME] revealed she had been employed at the facility for approximately 5 months. S11 Dietary [NAME] stated the COVID vaccine was offered to her upon hire and has not been offered since. S11 Dietary [NAME] stated she was never informed of the risk/benefits of the COVID vaccination. Interview on 05/23/2023 at 11:56 a.m. with S18 Social Worker revealed her date of hire was 06/24/2022. S18 Social Worker stated she had a religious exemption for the COVID -19 vaccination. S18 Social Worker stated that she was unable to recall if S6 ADON had ever informed her of benefits, and risk of the COVID-19 vaccination. Interview on 05/23/2023 at 1:20 p.m. with S6 ADON revealed she was also the Infection Preventionist for the facility. S6 ADON stated that she was responsible for maintaining documentation of all the full time and contract employees COVID-19 vaccinations and exemptions. S6 ADON stated, S11 Dietary Cook, S12 Housekeeping, S17 CNA and S18 Social Worker were not vaccinated against COVID-19. S6 ADON stated S9 LPN, S19 Housekeeping Supervisor, S20 OT, and S21 PTA were vaccinated against COVID-19. S6 ADON stated that all unvaccinated employees full-time and/or contract staff are offered the COVID-19 vaccine monthly and reminded of the risk factors of not being vaccinated. S6 ADON confirmed she did not have the documentation that education had been provided to S9 LPN, S11 Dietary Cook, S12 Housekeeping, S17 CNA, S18 Social Worker, S19 Housekeeping Supervisor, S20 OT, and S21 PTA and should have been.

Based on observation and interview the facility failed to post Nurse Staffing Information on a daily basis that included the total number and actual hours worked by RNs, LPNs and CNA staff directly responsible for resident care per shift. Findings: Observation on 05/21/2023 at 9:04 a.m. revealed staffing posted on a white board outside the facility Z Hall nurses' station dated 05/18/2023. Observation on 05/21/2023 at 9:06 a.m. revealed staffing posted on a white board at the Y Hall nurses' station dated 05/18/2023. Observation on 05/21/2023 at 9:46 a.m. revealed staffing posted on a bulletin board on the facility X Hall dated 05/21/2023. Review of the posting revealed the 6:00 a.m. to 2:00 p.m. staffing for Sunday, 05/21/2023, included: (1) DON, (1) ADON and (1) Assessment Nurse. Interview on 05/21/2023 at 9:50 a.m. with S5 Assessment Nurse and S6 ADON revealed they both had come in at 9:30 a.m. Interview on 05/21/2023 at 9:53 a.m. with S2 DON revealed she was not in the facility at 6:00 a.m. this morning. S2 DON confirmed the posted staffing information on Y and Z Halls had not been updated. S2 DON also confirmed the staffing posted on the facility X Hall was not accurate, as it did not reflect actual staff on duty for the 6:00 a.m.-2:00 p.m. shift on 05/21/2023 and should have.

Based on observation and interview the facility failed to maintain a clean, sanitary environment and failed to ensure food was stored in accordance with professional standards for food service safety. Findings: Observation on 05/21/2023 at 9:00 a.m. of the walk in freezer/cooler and pantry revealed: 1. 1 bag of cut green beans open to air. 2. 1 bag of corn dogs open to air. 3. 1 box of breaded squash open to air 4. 2 packs of dinner rolls open and undated. Interview at the time of observation with S8 Dietary [NAME] revealed the Dietary Manager was responsible for storing and labeling of food items. S8 Dietary [NAME] confirmed the above listed items were open to air and or not dated and they should have been. Interview on 05/21/2023 at 10:50 a.m. with S7 Dietary Manager stated once a food item is opened it should be placed in a zip lock bag and dated. S7 Dietary Manager revealed the employee who opens a food item is responsible for storing and labeling that food item properly.

Based on record review and interviews the facility failed to electronically submit payroll information for direct care staffing as required. Findings: Review of the PBJ (Payroll Based Journal) staffing Data Report for FY (Fiscal Year) Quarter 1 2023 (October 1-December 31) revealed triggers for the following: Failed to submit data for the quarter, One Star Staffing Rating, Excessively Low Weekend Staffing, No RN Hours and Failed to have Licensed Nursing Coverage 24 Hours/Day. Interview on 05/22/2023 at 1:38 p.m. with S1 Administrator revealed FY Quarter 1 2023 (October 1-December 31) PBJ data was submitted by S5 Assessment Nurse because he did not have access. Interview on 05/22/2023 at 1:45 p.m. with S1 Administrator and S5 Assessment Nurse revealed there was no documentation that a PBJ submission had been completed for FY Quarter 1 2023 (October 1-December 31).