**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (#73) of 2 (#73, #76) residents reviewed for positioning and mobility. The deficient practice was evidenced by the facility failing to ensure a resident in a geri chair received proper support of her lower extremities. Findings: Review of the record revealed resident #73 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, atherosclerotic heart disease, hypertension, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 2 indicating that resident #73 was severely cognitively impaired. Further review of the MDS revealed she required extensive 2 person assistance with most activities of daily living. Review of resident #73's active care plan revealed the facility identified the resident needed monitoring related to a history of neck surgery with residual stiffness present. Further review revealed resident #73 may use a geri chair as needed due to her above condition. On 05/05/2025 at 9:52 a.m., resident # 73 was observed in a geri chair in the day area. Further observation revealed her feet were dangling with no support to her lower extremities. On 05/06/2025 at 9:11 a.m. and 3:25 p.m., observations revealed resident #73 was in a geri chair in the day area. Further observation revealed her feet were dangling with no support to her lower extremities. On 5/07/2025 at 9:43 a.m., resident # 73 was observed in a geri chair in the day area. Further observation revealed her feet were dangling with no support to her lower extremities. On 05/07/2025 at 2:15 p.m., the surveyor and S4Licensed Practical Nurse (LPN)/Clinical Manager observed resident # 73 in her geri chair in the day area. Further observation revealed her feet were dangling with no support to her lower extremities. S4LPN/Clinical Manager confirmed her legs and feet should be supported when she is up in the geri chair. On 05/07/2025 at 3:00 p.m., S2Director of Nursing was informed that resident #73 was observed in her geri chair multiple times during the survey with her feet dangling with no support to her lower extremities.

Based on observation and interviews, the facility failed to ensure drugs were accessible to only authorized personnel by failing to ensure a medication remained locked away when not in use by having a medication stored at a resident's bedside for 1 (#66) of 1 (#66) reviewed for medication storage. Findings: On 05/05/25 8:56a.m., observation in the resident's room revealed there was a fluticasone inhaler on the bedside table of resident #66. Interview with resident #66 confirmed the inhaler belonged to her. Resident #66 reported the nurse left the inhaler at her bedside. On 05/05/2025 at 9:02a.m., interview with S5 Licensed Practical Nurse (LPN) confirmed the inhaler belonged to resident #66 and the inhaler should not have been left in the resident's room. On 05/07/2025, interview with S2Director Of Nursing (DON) confirmed the inhaler should not have been left at the bedside of resident #66.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote healing and prevent the development of new pressure ulcers for 2 (#7, #30) of 5 (#7, #30, #61, #66, #136) residents investigated for pressure ulcers. The deficient practice was evidenced by the facility failing to provide pressure reducing devices for a resident with a stage 3 pressure ulcer (#7) and for a resident who was at a moderate risk for developing pressure ulcers (#30). Findings: Review of the facility Pressure Injury Prevention and Management Policy revised 06/21/2024 revealed the following, in part: Policy: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, and prevent the development of additional pressure ulcers/injuries. 4. Interventions for Prevention and to Promote Healing: c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: iii. Provide appropriate, pressure-redistributing, and support surfaces. Resident #7 Review of the record revealed resident #7 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, type 2 diabetes mellitus with diabetic nephropathy, cerebral infarction, chronic obstructive pulmonary disease, polyneuropathy, unspecified dementia, peripheral vascular disease, congestive heart failure, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 3, which indicated she was severely cognitively impaired. Resident #7 required extensive 2 person assistance for most activities of daily living (ADLs). Further review revealed she was at risk for developing pressures and there was no pressure reducing device for her chair. On 05/06/25 at 8:31 a.m., resident # 7 was observed in her wheelchair in her room. S4Certified Nursing Assistant (CNA) confirmed there was no pressure relieving cushion in the seat of resident #7's wheelchair. On 05/06/2025 at 12:00 p.m., resident #7 was observed in her wheelchair in the dining area and there was no pressure relieving cushion noted in the seat of her wheelchair. Review of resident #7's active physician orders revealed she was receiving treatment for a stage 3 pressure injury to her right posterior thigh and a suspected deep tissue injury to her right heel. Review of resident #7's active care plan revealed the facility had identified she was at a high risk for pressure ulcers with an intervention to follow the facility policies and procedures for the prevention and treatment of skin breakdown. On 05/06/25 at 01:53 p.m., S2Director of Nursing (S2DON) was informed there was no pressure relieving cushion in resident # 7's wheelchair. S2DON confirmed resident #7 should have had a pressure relieving cushion in her wheelchair since she currently had a pressure ulcer to her right posterior thigh. Resident #30 Resident #30 was admitted to the facility on [DATE] with diagnoses that included morbid obesity, reduced mobility, muscle weakness and repeated falls. Review of the most recent MDS assessment dated [DATE] revealed resident #30 had a BIMS score of 13 which indicated she was cognitively intact. Resident #30`s most recent weight was measured on 04/07/2025 and revealed a weight of 311 pounds. Review of the most recent quarterly Braden scale for predicting pressure sore risk assessment dated [DATE] revealed resident #30 had a score of 13. The score of 13 indicated resident #30 was at moderate risk for developing pressure ulcers. On 05/05/2025 at 12:13 p.m., observation and interview revealed resident #30 did not have a cushion for her wheelchair as she was sitting at the dining room table for lunch. Resident #30 reported she sat in the wheelchair most of the day because she could not walk. Resident #30 also reported she would like a cushion in her chair but was never offered a cushion. On 05/06/2025 at 08:21 a.m., resident # 30 was observed in the dining room eating breakfast while sitting in wheelchair. There was no pressure relieving cushion observed in her wheelchair. Resident # 30 confirmed there was no cushion and complained of her wheelchair being uncomfortable. On 05/06/2025 at 01:50 p.m., an interview with S2DON confirmed resident # 30 should have a cushion in her wheelchair to reduce risk for developing a pressure ulcer.

Based on record review and interview, the facility failed to maintain acceptable parameters of nutritional status by failing to follow up with the physician in a timely manner to implement the registered dietician's (RD) recommendation for 1 (#14) of 4 (#6, #14, #51, #63) residents reviewed for nutrition. Findings: Review of the medical record for resident #14 revealed an admission date of 07/06/2024 with diagnoses including muscle wasting and atrophy, muscle weakness, cognitive communication deficit, chronic obstructive pulmonary disease, chronic atrial fibrillation, Alzheimer's disease with late onset, and vitamin deficiency. Review of the record revealed that resident #14 had a weight of 179.0 pounds on 01/07/2025 and a weight of 162.5 pounds on 03/06/2025 showing a weight loss of 16.5 pounds. Review of active May 2025 physician orders revealed that resident #14 was not currently taking an appetite stimulant. Review of the medical records revealed on 04/01/2025 the RD sent a note to the physician with the recommendation for resident #14 to receive an appetite stimulant. On 05/06/2025 at 3:10 p.m., an interview with S2Director of Nursing (DON0 confirmed the facility did not follow up with the physician in a timely manner to implement the RD recommendations.

Based on record review and interview the facility failed to have quarterly quality assessment and assurance (QAA) meetings with required members of the QAA committee present. The failed practice was evidenced by the facility`s medical director not being present for the quarterly meetings reviewed. Review of the (QAA) meetings revealed meetings were held on 01/30/2025, 11/12/2024, 07/30/2024, and 03/28/2024. Review of the attendance roster revealed the medical director`s signature was not recorded on the roster. On 05/07/2025 at 02:25 p.m., an interview with S1 Administrator confirmed the medical director was not present for above quarterly QAA meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (#231) of 1 resident reviewed for dignity. The facility failed to respect resident #231's request for a more textured diet. Findings: Review of the medical record revealed the resident was admitted on [DATE] with diagnoses including dysphagia following cerebral infarction, severe protein - calorie malnutrition, muscle wasting and atrophy, malignant neoplasm of lower right lobe, iron deficiency anemia, and abnormal weight loss. Review of the admission Minimum Data Set assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had independent cognitive skills for daily decision making. The resident required set up or clean up assistance with eating. Review of the physician order dated 04/10/2024 revealed the resident's diet was changed from minced and moist to pureed texture. Review of the nurses notes dated 04/20/2024 at 5:47 p.m. revealed the following: ate 50% or less for 2 or more meals in the day, resident accepts supplements, resident complains of having to eat puree. Review of the nurses notes dated 04/21/2024 at 2:29 p.m. revealed the following: ate 50% or less for 2 or more meals in the day, resident refusing to eat the pureed diet prescribed, resident frequently encouraged to eat, given and accepted supplements. Observation of the lunch meal on 04/21/2024 at 12:30 p.m. revealed the resident received a pureed meal. The resident was drinking his health shake. An interview with the resident at this time revealed he did not want a pureed diet. Observation of the breakfast meal on 04/22/2024 at 8:30 a.m. revealed the resident received a pureed meal. An interview with the resident at this time revealed he didn't want his food pureed. An interview with the resident on 04/22/2024 at 1:30 p.m. revealed he makes his own decisions about his medical care. An interview with S3Assistant Director of Nursing (ADON) on 04/22/2024 at 11:28 a.m. confirmed the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had independent cognitive skills for daily decision making. S3ADON further confirmed the resident makes his own decisions. An interview with S1Director of Nursing (DON) on 04/23/2024 at 10:50 a.m. confirmed the resident was competent to make his own decisions. S1DON further confirmed the facility should have offered the resident to sign a waiver for him to eat his diet in a texture he desired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure a resident maintained acceptable parameters of nutrition by failing to provide a diabetic nutritional supplement as ordered by the physician for a resident who had a recent significant weight loss for 1 (#27) of 3 (#25, #27, #231) residents reviewed for nutrition. Findings: Record review revealed resident #27 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, atherosclerotic heart disease, hypokalemia, major depressive disorder, need for assistance with personal care, generalized muscle weakness, muscle wasting and atrophy, dysphagia, and cognitive communication deficit. Review of annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 3 which indicated resident #27 had severe cognitive impairment. Further review revealed resident #27 was dependent on staff for all activities of daily living that required substantial/maximal assistance. Review of resident #27's April 2024 physician orders revealed an active order for a diabetic house supplement two times a day to increase calorie intake due to significant weight loss. Review of resident #27's weights revealed 10/11/2023 = 140.7 pounds, 11/01/2023 = 120.0 pounds, 01/10/2023 = 113.0 pounds, 03/10/2024 = 111.5 pounds, and 04/10/2024 = 115.0 pounds. Review of the April 2024 Electronic Medication Administration Record (EMAR) revealed no documentation of resident #27 receiving the diabetic house supplement twice daily since it was ordered on 04/04/2024. On 04/22/2024 at 1:20 p.m. an interview with S4LPN (Licensed Practical Nurse) confirmed resident #27 had an order for diabetic house supplement twice a day. S4LPN confirmed she did not administer the diabetic house supplement. On 04/22/2024 at 02:25 p.m. an interview with S3ADON (Assistant Director of Nursing) confirmed resident #27 had order for diabetic house supplement two times a day. S3ADON confirmed resident #27 should have received the diabetic house supplement as ordered.

Based on interview and record review, the facility failed to ensure residents were free from unnecessary medication use for 1 (#74) of 5 (#16, #34, #59, #70, #74) sampled residents reviewed for unnecessary medications. The physician failed to ensure a psychotropic medication (Vistaril) was not ordered to be given as needed for a time period greater than 14 days for resident #74. Findings: Record review revealed resident #74 was admitted to the facility 01/27/2024 with diagnoses that include bipolar disorder, major depressive disorder, primary insomnia, unspecified dementia unspecified severity with mood disturbance, fibromyalgia, other forms of scoliosis lumbar region, long term (current) use of opiate, migraine, and anxiety disorder. Review of active April 2024 Physician Orders revealed an order dated 01/28/2024 for Vistaril 50 milligrams (mg) capsule, give one capsule by mouth every 12 hours as needed (prn) for anxiety. Review of the Pharmaceutical Consultant Report dated 02/18/2024 revealed pharmacist recommended that Vistaril prn psychotropic medication should be limited to 14 days. The consultant pharmacist further recommended the physician to provide specific duration/stop date for Vistaril 50 mg q 12 hours prn anxiety. On 04/22/2024 the physician assistant denied the gradual dose reduction, failed to provide a duration/stop date for Vistaril 50 mg every 12 hours prn anxiety, and failed to provide a rationale to continue the medication. Review of the April 2024 (Electronic Medication Administration Record (EMAR) revealed documentation resident #74 received Vistaril 50 mg on the following dates/times: 04/02/2024 at 1553, 04/03/2024 at 1408, 04/04/2024 at 1333, 04/05/2024 at 1550, 04/06/2024 at 1618, 04/07/2024 at 1512, 04/08/2024 at 1538, 04/09/2024 at 1427, 04/10/2024 at 1510, 04/11/2024 1344, 04/12/2024 at 1346, 04/13/2024 at 1332, 04/14/2024 at 1505, 04/15/2024 at 1520, 04/16/2024 at 1403, 04/17/2024 at 1509, 04/18/2024 at 1526, and 04/22/2024. On 04/23/2024 at 1:50 p.m. an interview with S2DON (Director of Nursing) and S3ADON (Assistant Director of Nursing) confirmed that Vistaril (psychotropic) should not be administered as needed greater than 14 days. S3ADON confirmed the physician assistant continued a prn psychotropic medication past 14 days for resident #74 without a documented end date or a rationale for it to be continued.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to protect the resident's right to be free from physical abuse by a visitor for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for abuse. The facility failed to protect resident #1 from physical abuse by a visitor. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: A review of the facility's policy titled, Identifying Types of Abuse with an implementation date of 09/15/2021 revealed the following, in part: Policy Statement As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents. Policy Interpretation and Implementation 1. Abuse of any kind is strictly prohibited. 2. Abuse prevention includes recognizing and understanding the definitions and types of abuse that can occur. 3. It is understood by the leadership in this facility that preventing abuse requires staff education, training, and support, and a facility-wide culture of compassion and caring. 4. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. 5. Abuse toward a resident can occur as: a. resident-to resident abuse; b. staff-to-resident abuse; or c. visitor-to resident abuse. Physical Abuse 1. Physical abuse includes, but is not limited to hitting, slapping, punching or kicking. Resident #1 A review of the medical record for resident #1 revealed an admission date of 04/03/2023 with diagnoses which included Alzheimer's dementia, dementia in other disease classified elsewhere, insomnia, and type 2 diabetes mellitus. A review of the 01/04/2024 Quarterly Minimum Data Set (MDS) assessment revealed resident #1 had a Brief Interview of Mental Status (BIMS) of 3, which indicated she was severely, cognitively impaired. A review of the facility's Self-Reported Incident Report, dated 02/13/2024, revealed resident #1 had a visitor around 5:30 p.m. on 02/12/2024, during the evening meal. On 02/12/2024 around 5:30 p.m. S5CNA (certified nursing assistant) witnessed the visitor tell resident #1 to hush, shut up several times while talking on a cell phone. S5CNA witnessed the visitor forcefully grab resident #1's face with his hand to shut her mouth after he had repeatedly asked her to stop talking while he was on a phone conversation. There were no injuries observed at time of incident. On 03/05/2024 at 9:05 a.m. an observation of resident #1 revealed she was lying in a low bed which was located on the secured unit. Bed was in lowest position with ¼ assist bed rails up x2 and pressure pad call bell within her reach. Screening questions revealed resident #1 was alert and pleasantly confused. Resident #1 was oriented to her name but did not know the date, year, place, or her date of birth . Resident #1 did not recall the incident that had occurred on 02/12/2024. Resident #1 was well kempt and dressed appropriately in a clean night gown. Observations of Resident1's exposed skin (face, neck, lower arms and hands) revealed no bruises or skin tears. On 03/05/2024 at 9:15 a.m. an interview with S6CNA revealed on 02/12/2024 around 5:10 to 5:15 p.m. she was at the dining room table assisting resident #1 eat the dinner meal. S6CNA reported resident #1 had a visitor sitting with her, at the table and was either reading a book or talking on a cell phone. S6CNA reported she asked S5CNA if she could finish feeding resident #1 while she helped another resident. S6CNA reported S5CNA relieved her and helped finish feeding resident #1. S6CNA reported after she finished assisting the other resident around 6:00 p.m. she assisted resident #1 to get into her night clothes and into bed. S6CNA reported resident #1 was calm and she did not observe any redness or bruising on her skin while getting her ready for bed. S6CNA reported she checked on resident #1 again before getting got off work around 7:00 p.m. and she was asleep. S6CNA confirmed she did not witness the visitor physically abuse resident #1. On 03/05/2024 at10:19 a.m. a telephone interview with S4LPN (licensed practical nurse) revealed resident #1 had a visitor during the diner meal on 02/12/2024. S4LPN reported she was at the medication cart passing medication and could not see resident #1 or resident #2 who was also sitting at the table. S4LPN reported she could see the visitor who was also sitting at the table from where she was standing. S4LPN reported that she did hear the visitor tell resident #1 to hush up and to eat a few times. S4LPN reported she observed the visitor talking on a cell phone while sitting at the table. S4LPN reported she did see the visitor walking away from the table while still talking on his cell phone as he left the secured unit and she did not see the visitor again. S4LPN reported she overheard resident #1 ask resident #2 if she (resident #2) saw that man hit her (resident #1). S4LPN reported she went and looked at resident #1 and asked her if anyone hit her. S4LPN reported resident #1 did not report anyone hit her and started talking to resident #2. S4LPN reported she assessed resident #1 and she did not have any redness or bruising noted to her face, arms or hands. S4LPN reported resident #1 did not appear to be in any pain or distress at the time of her assessment. S4LPN reported resident #1 does tend to talk a lot and uses word salads when she talks. S4LPN reported resident #1 is generally confused due to her dementia, and had a history of hallucinating and seeing things that were not there, such as people and animals. S4LPN reported resident #1 did not display any behaviors other than her normal demeanor. S4LPN confirmed she never observed the visitor physically abuse resident #1. S4LPN reported the next morning, 02/13/2024 around 7:30 a.m., she talked to S5CNA and S6CNA about what she heard the evening before regarding resident #1 asking resident #2 if she saw that man hit her. S4LPN asked the CNAs if they heard or saw anything. S4LPN reported S6CNA reported she did not witness anything. S4LPN reported S5CNA revealed she observed the visitor tell resident #1 to shut up and to eat several times while he was talking on a cell phone. S4LPN reported S5CNA revealed she observed the visitor grab resident #1's jaw with his hand forcefully and physically closed her mouth as he told her to shut up and be quiet while at the dinner table. S4LPN reported she went and immediately notified S2DON (director of nursing) of the incident involving resident #1 and the visitor. S4LPN further reported on 02/13/2024 sometime after lunch S8Hospice RN (registered nurse), who was visiting with resident #2, asked S4LPN if that woman and man was okay. S4LPN asked the S8Hospice RN what she (S8Hospice RN) was talking about. S4LPN revealed S8Hospice RN visited with resident#2 on the evening before (02/12/2024 around 5:40 p.m.) and observed the visitor tell resident #1 to shut up and slapped resident #1 on the hand as the visitor was talking on his phone. S8Hospice RN reported the visitor also slapped resident #1 on the back of the head twice as he walked away from the table while talking on his cell phone. S4LPN confirmed S8Hospice RN did not tell her about what she observed on the evening of 02/12/2024 until 02/13/2024. S4LPN immediately notified S2DON about the incident that occurred on 02/12/2024 around 5:40 p.m. witnessed by S8Hospice RN. On 03/05/2024 at 12:50 p.m. a telephone interview with S5CNA revealed 02/12/2024 around 5:25 p.m. she was passing dinner trays and S6CNA was assisting resident #1 with eating. S6CNA asked S5CNA if she could finish feeding resident #1 so she (S6CNA) could go assist another resident. S5CNA reported she relieved S6CNA and assisted with feeding resident #1. S5CNA revealed resident #1 had a visitor sitting at the table with her. S5CNA reported resident #2 was also sitting at the table. S5CNA reported the visitor was talking on a cell phone and told resident #1 to be quiet and shut up and to eat many times, but she continued to talk. S5CNA reported she witnessed the visitor reach and forcefully grab resident #1's lower jaw and shut her mouth with his hand and told her to shut up as he continued to talk on his cell phone. S5CNA reported that resident #1 stayed quiet for a few minutes then started talking to resident #2. S5CNA reported she finished feeding resident #1 and got up to go assist another resident. S5CNA reported when she finished assisting the other resident, the visitor had already left the facility. S5CNA reported the next morning on 02/13/2024 at around 7:15 a.m., S4LPN told S5CNA and S6CNA that she had overheard resident #1 tell resident #2, did you see that man hit me the evening before, and S4LPN asked if we had heard or seen anything. S5CNA reported she informed S4LPN that she witnessed the visitor physically and forcefully grab resident #1's lower jaw and shut her mouth telling her to shut up as he was talking on a cell phone while at the dinner table yesterday evening. The surveyor asked S5CNA why she waited until the next day to notify S4LPN of witnessing the visitor physically abuse resident #1. S5CNA revealed she knew it was not a good excuse, but she had not been a CNA for very long. S5CNA reported she did not feel like it was her place to say anything. S5CNA reported that she received counselling from S2DON on 02/13/2024 and in-service training on abuse neglect and reporting. S5CNA reported she knows now she should have reported what she saw to the nurse immediately. On 03/05/2024 at 11:30 a.m. an interview with S2DON revealed S4LPN came to her office on 02/13/2024 around 7:30 a.m. and informed her of the incident which occurred the prior evening, 02/12/2024 around 5:30 p.m., when S5CNA witnessed the visitor physically and forcefully grab resident #1's lower jaw and shut her mouth with his hand and telling her to shut up as he continued to talk on a cell phone. S2DON reported that she immediately called and notified S1Administrator. S2DON reported she assessed resident #1 and the resident did not recall the incident and denied anyone harming her. Resident #1 did not have any bruises or signs or symptoms of pain. S2DON reported resident #1 was normally confused and tended to hallucinate. S2DON reported she notified resident #1's physician of the incident. S2DON revealed S1Administrator and S7Facility Owner contacted the [NAME] and informed him of the incident. S2DON reported S1Admininstrator and S7Facility Owner met with resident #1's family member and informed the family member of the incident. The family member was made aware of the visitor no longer being able to come back to the facility pending the outcome of the investigation. S2DON reported on 02/13/2024 after lunch S4LPN came to her office and reported S8Hospice RN (Registered Nurse) had just informed her (S4LPN) on the previous evening (02/12/2024 around 5:40 p.m.) she witnessed the visitor slap resident #1 on the hand and also the back of resident#1's head twice. S2DON revealed S8Hospice RN had already left the facility. S2DON revealed she then called S8Hospice RN to investigate the incident between the visitor and resident #1. S8Hospice RN reported on the evening of 02/12/2024 she was visiting with resident #2 who receives hospice services. S8Hospice RN reported resident #2 was sitting at the same table with resident #1 and a visitor. S8Hospice RN reported resident #1 was talking when the visitor received a call on his cell phone. S8Hospice RN reported she witnessed the visitor patted resident #1's hand not like you would do your child, but in a disciplinary manor, and told her to hush up and be quiet. S8Hospice RN reported resident #1 continued to talk and the visitor got up from the table and as he walked away he slapped resident #1 twice in the back of her head with an opened hand as he continued to talk on his cell phone. S8Hospice RN reported the slaps to the back of the head were not like you would do your child, but harder in a disciplinary manor. S2DON revealed she asked S8Hospice RN why she did not immediately inform a staff member of what she witnessed on the evening of 02/12/2024. S2DON revealed S8Hospice RN reported resident #1 was not her patient. S2DON reported she called the Hospice Agency's Administrator and informed her of what had occurred and suggested they provide S8Hospice RN with training on reporting abuse. S2DON reported she notified S1Admininstrator and resident #1's physician of the incident. S2DON reported S1Admininstrator called and informed resident #1 family member of the incident. On 03/05/2024 at 1:09 p.m. a telephone interview with S8Hospice RN revealed she no longer works for the Hospice Agency. Surveyor asked S8Hospice RN what she witnessed on the evening of 02/12/2024 between the visitor and resident #1. S8Hospice RN reported that she was at the facility seeing another resident, but stopped by to check in on resident #2 who had recently had a fall. S8Hospice RN reported resident #2 was sitting at the table with resident #1 and the visitor. S8 Hospice RN revealed on 02/12/2024 around 5:40 p.m. resident #1 was talking when the visitor received a call on his cell phone. S8Hospice RN reported she witnessed the visitor patted resident #1's hand not like you would do your child, but in a disciplinary manor, and told her to hush up and be quiet. S8Hospice RN reported resident#1 continued to talk and visitor got up from the table and as he walked away he slapped resident #1 twice in the back of her head with an opened hand as he continued to talk on his cell phone. S8Hospice RN reported the slaps to the back of the head were not like you would do your child, but harder in a disciplinary manor. S8Hospice RN revealed resident #1 continued to talk to resident #2 as the visitor walked away. S8Hospice RN confirmed she did not tell any staff at the facility what she had witnessed between the visitor and resident #1 until the next day (02/13/2024). S8Hospice RN reported she was at the facility on 02/13/2024 and around 11:00 a.m. she informed S4LPN of what she had witnessed the evening before (02/12/2024) between the visitor and resident #1. S2DON reported she submitted the Self-Reported Incident Report to the State Agency within 2 hours of finding out about the allegation of resident abuse. S2DON interviewed S4LPN, S5CNA, and S6CNA and had them write statements. S2DON reported she personally counselled S5CNA on abuse and reporting. S2DON reported the facility has no video surveillance cameras. S2DON reported all residents were assessed for abuse on 02/14/2024 by her and S3ADON (Assistant Director of Nursing) and there were no signs of abuse or reports of abuse. S2DON reported S3ADON performed in-service training with all staff on the following: abuse, neglect and reporting, on dementia and also HIPAA (Health Insurance Portability and Accountability Act). S2DON reported they had added the resident abuse to the facilities QAPI (Quality Assurance and Performance Improvement) plan and they developed a Plan of Correction (POC). They determined all resident were vulnerable to abuse. They devised an Abuse and Neglect Interview Form to document resident's assessments. S2DON reported she is keeping a log of all the abuse and neglect assessments and she is monitoring the POC by performing two random assessments the week of 02/19/2023 and 02/26/2024. On 03/06/2024 at 9:45 a.m. an interview with S1Admininstrator and S2DON reported all POC areas were put into place. S1Admininstratorm and S2DON confirmed on 02/29/2024 they had the POC completed and addressed all the training and monitoring. Review of the in-services trainings revealed all staff had completed the following computerized training: Abuse, Neglect, and Exploitation, Abuse and Neglect, Dementia Care: Understanding Communication, and Dementia Care: Challenging Behaviors and Direct Care Staff. Throughout the survey on 02/05/2024 and 02/06/2024, observations, record reviews, and staff interviews revealed they received training on the facility's abuse policies and procedures, Abuse, Neglect, and Exploitation, Abuse and Neglect, Dementia Care: Understanding Communication, and Dementia Care: Challenging Behaviors and Direct Care Staff. Observations and interviews with residents throughout the survey revealed there were no issues regarding resident abuse identified. Observations, interviews, and record review, revealed the facility had monitored and was continuing to monitor for abuse, with no further issues identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure that an alleged violation involving physical abuse was reported immediately to the administrator for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for abuse. Findings: A review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating with a revision date 01/09/2023 revealed the following, in part: Policy Statement All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident's property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by the facilities management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the Administrator and to other officials according to state law. 2. The administrator, Director of Nursing Services or the individual making the allegation immediately reports his or her suspicions to the following persons or agencies: a. the state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services as applicable (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 3. immediately is defined as: a. within two hours of an allegation involving abuse or results in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Resident #1 A review of the medical record for resident #1 revealed she was admitted to the facility on [DATE] with diagnoses which included Alzheimer's dementia, dementia in other disease classified elsewhere, insomnia, and type 2 diabetes mellitus. A review of the 01/04/2024 Quarterly Minimum Data Set (MDS) assessment revealed resident #1 had a Brief Interview of Mental Status (BIMS) of 3, which indicated she was severely cognitively impaired. On 03/05/2024 at 9:15 a.m. an interview with S6CNA (certified nursing assistant) revealed on 02/12/2024 around 5:10 to 5:15 p.m. she was at the dining room table assisting resident #1 eat dinner meal. S6CNA reported resident #1 had a visitor sitting who was also sitting at the table at this time and was either reading a book or talking on his cell phone. S6CNA reported she asked S5CNA if she could finish feeding resident #1 while she helped another resident. S6CNA reported S5CNA relieved her and help finish feeding resident #1. S6CNA reported after she finished assisting the other resident around 6:00 p.m. she assisted resident #1 to get into her night clothes and into bed. S6CNA reported resident #1 was calm and she did not observe any redness or bruising on her skin while getting her ready for bed. S6CNA reported she checked on resident #1 again before got off work around 7:00 p.m. and she was asleep. S6CNA confirmed she did not witness the visitor physically abuse resident #1. On 03/05/2024 at10:19 a.m. a telephone interview with S4LPN (licensed practical nurse) revealed resident #1 had a visitor during the diner meal on 02/12/2024. S4LPN reported she was at the medication cart passing medication and could not see resident #1 or resident #2 who was also sitting at the table. S4LPN reported she could see the visitor who was also sitting at the table from where she was standing. S4LPN reported that she did hear the visitor tell resident #1 to hush up and eat a few times. S4LPN reported she observed the visitor talking on his cell phone while sitting at the table. S4LPN reported she did see the visitor walking away from the table while still talking on his cell phone as he left the secured unit and she did not see him again. S4LPN reported she overheard resident #1 ask resident #2 if she (resident #2) saw that man hit her (resident #1). S4LPN reported she went and looked at resident #1 and asked her if anyone hit her. S4LPN reported resident #1 did not report anyone hit her and started talking to resident #2. S4LPN reported she assessed resident #1 and she did not have any redness or bruising noted to her face, arms or hands. S4LPN reported resident #1 did not appear to be in any pain or distress at this time. S4LPN reported resident #1 does tend to talk a lot and uses word salads when she talks. S4LPN reported resident #1 is generally confused due to her dementia, and had a history had a history of hallucinating and seeing things that were not there such as people and animals. S4LPN reported resident #1 did not display any behaviors other than her normal demeanor. S4LPN confirmed she never observed the visitor physically abuse resident #1. S4LPN reported the next morning, on 02/13/2024 around 7:30 a.m., she talked to S5CNA and S6CNA about what she heard the evening before, resident #1 asking resident #2 if she saw that man hit her, and asked if they heard or saw anything. S4LPN reported S6CNA reported she did not witness anything. S4LPN reported S5CNA revealed she observed the visitor tell resident #1 to shut up and to eat several times while he was talking on cell phone. S4LPN reported S5LPN revealed she observed the visitor grab resident #1's jaw with his hand forcefully and physically closed her mouth as he told her to shut up and be quiet while at the dinner table. S4LPN reported she went and immediately notified S2DON (director of nursing). S4LPN further reported on 02/13/2024 sometime after lunch the S8Hospice RN (registered nurse), who was visiting with resident #2, asked S4LPN if that woman and man was okay. S4LPN asked S8Hospice RN what she (S8Hospice RN) was talking about. S4LPN revealed S8Hospice RN visited with resident#2 on the evening before (02/12/2024 around 5:40 p.m.) and observed the visitor tell resident #1 to shut up and slapped resident #1 on the hand as the visitor was talking on his phone. S8Hospice RN reported the visitor also slapped resident #1 on the back of the head twice as he walked away from the table while talking on his cell phone. S4LPN confirmed S8Hospice RN did not tell her about what she observed on the evening of 02/12/2024 until 02/13/2024. S4LPN denied witnessing the visitor slap resident #1. S4LPN immediately notified S2DON about the incident that occurred on 02/12/2024 around 5:40 p.m. that witnessed by S8Hospice RN. On 03/05/2024 at12:50 p.m. a telephone interview with S5CNA revealed 02/12/2024 around 5:25 p.m. she was passing dinner trays and S6CNA was assisting resident #1 with eating. S6CNA asked S5CNA if she could finish feeding resident #1 so she (S6CNA) could go assist another resident. S5CNA reported she relieved S6CNA and assisted with feeding resident #1. S5CNA revealed resident #1 had a visitor sitting at the table with her. S5CNA reported resident #2 was also sitting at the table. S5CNA reported the visitor was talking on his cell phone and told resident #1 to be quiet and shut up and to eat many times, but she continued to talk. S5CNA reported she witnessed the visitor reach and physically and forcefully grab resident #1's lower jaw and shut her mouth with his hand and told her to shut up as he continued to talk on his cell phone. S5CNA reported that resident #1 stayed quiet for a few minutes then started talking to resident #2. S5CNA reported she finished feeding resident #1 and got up to go assist another resident. S5CNA reported when she finished assisting the other resident, the visitor had already left the facility. S5CNA reported the next morning, on 02/13/2024 around 7:15 a.m. S4LPN told her and S6CNA that she had overheard resident #1 tell resident #2, did you see that man hit me, the evening before and asked if we had heard or seen anything. S5CNA reported she informed S4LPN that she witnessed the visitor physically and forcefully grab resident #1's lower jaw and shut her mouth, telling her to shut up as he was talking on his cell phone while at the dinner table yesterday evening (02/12/2024). S5CNA denied witnessing the visitor slap resident #1. Surveyor asked S5CNA why she waited until the next day to notify S4LPN of witnessing the visitor physically abuses resident #1. S5CNA revealed she knew it was not a good excuse, but she had not been a CNA for very long. S5CNA reported she did not feel like it was her place to say anything. S5CNA reported she knows now she should have reported what she saw to the nurse immediately. On 03/05/2024 at 11:30 a.m. an interview with S2DON revealed S4LPN came to her office on 02/13/2024 around 7:30 a.m. and informed her of the incident which occurred the prior evening, 02/12/2024 around 5:30 p.m., when S5CNA witnessed the visitor physically and forcefully grab resident#1's lower jaw and shut her mouth with his hand and told her to shut up as he continued to talk on his cell phone. S2DON further reported on 02/13/2024 after lunch S4LPN came to her office and reported S8Hospice RN (Registered Nurse) had just informed her (S4LPN) on the previous evening (02/12/2024 around 5:40 p.m.) she witnessed the visitor slap resident #1 on the hand and also the back of resident#1's head twice. S2DON revealed S8Hospice RN had already left the facility. S2DON revealed she then called S8Hospice RN to investigate the incident between the visitor and resident #1. S8Hospice RN reported on the evening of 02/12/2024 she was visiting with resident #2 who receives hospice services. S8Hospice RN reported resident #2 was sitting at the same table with resident #1 and a visitor. S8Hospice RN reported resident #1 was talking when the visitor received a call on his cell phone. S8Hospice RN reported she witnessed the visitor patted resident #1's hand not like you would do your child, but in a disciplinary manor, and told her to hush up and be quiet. S8Hospice RN reported resident #1 continued to talk and the visitor got up from the table and as he walked away he slapped resident #1 twice in the back of her head with an opened hand as he continued to talk on his cell phone. S8Hospice RN reported the slaps to the back of the head were not like you would do your child, but harder in a disciplinary manor. S2DON revealed she asked S8Hospice RN why she did not immediately inform a staff member of what she witnessed on the evening of 02/12/2024. S2DON revealed S8Hospice RN reported resident #1 was not her patient. S2DON reported she called the Hospice Agency's Administrator and informed her of what had occurred and suggested they provide S8Hospice RN with training on reporting abuse. On 03/05/2024 at 1:09 p.m. a telephone interview with S8Hospice RN revealed she no longer works for the Hospice Agency. Surveyor asked S8Hospice RN what she witnessed on the evening of 02/12/2024 between the visitor and resident #1. S8Hospice RN reported that she was at the facility seeing another resident, but stopped by to check in on resident #2 who had recently had a fall. S8Hospice RN reported resident #2 was sitting at the table with resident #1 and the visitor. S8Hospice RN revealed on 02/12/2024 around 5:40 p.m. resident #1 was talking when the visitor received a call on his cell phone. S8Hospice RN reported she witnessed the visitor patted resident #1's hand not like you would do your child, but in a disciplinary manor, and told her to hush up and be quiet. S8Hospice RN reported resident#1 continued to talk and the visitor got up from the table and as he walked away he slapped resident #1 twice in the back of her head with an opened hand as he continued to talk on his cell phone. S8Hospice RN reported the slaps to the back of the head were not like you would do your child, but harder in a disciplinary manor. S8Hospice RN revealed resident #1 continued to talk to resident #2 as the visitor walked away. S8Hospice RN confirmed she did not tell any staff at the facility what she had witnessed between the visitor and resident #1 until the next day (02/13/2024). S8Hospice RN reported she was at the facility on 02/13/2024 and around 11:00 a.m. she informed S4LPN of what she had witnessed the evening before (02/12/2024) between the visitor and resident #1. On 03/06/2024 at 11:00 a.m. an interview with S2DON confirmed S5CNA should have immediately notified S4LPN, S2DON, and S1Administrator of the physical abuse of resident #1 she witnessed on 02/12/2024 at 5:30 p.m. S2DON further confirmed S8Hospice RN should have immediately notified a staff member of the facility of the physical abuse of resident #1 she witnessed on 02/12/2024 at 5:40 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and implement a baseline care plan within 48 hours of admission which included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care. The facility failed to develop a baseline careplan within 48 hours of admission for 1 (#61) of 1 (#61) residents investigated for bowel and bladder. Findings Review of the record revealed, Resident #61 admitted to the facility on [DATE]. Further review of the record revealed, in part revealed diagnoses of cerebral infarction, hemiplegia and hemiparesis affecting left non dominant side, Type 2 Diabetes, atherosclerotic heart disease, peripheral vascular disease, and gastroparesis. Review of the care plan in the electronic chart revealed the following problems were addressed: Tobacco use created on 03/21/2023, Personalized Care created on 04/04/2023, Potential for malnutrition created on 03/28/2023, and, Risk for falls created on 03/21/2023. Interview on 04/11/2023 at 10:43 a.m. with Resident #61 revealed he had a stroke about a month ago and had some left side weakness and problem with bladder control upon admit to the facility. Interview on 04/12/2023 at 10:28 a.m., S3MDS (Minimum Data Set) Coordinator revealed she really was not sure where baseline care plans were completed. S3MDS Coordinator confirmed that Resident #61 did not have documented evidence of baseline care plan within 48 hours and that the incomplete comprehensive care plan was not initiated until 04/11/2023. Interview on 04/12/2023 at 10:50 a.m., S2DON (Director of Nurses) revealed she was not aware how the base line care plans were being completed. At this time S4ADON revealed there was a Clinical Assessment the nurses on floor are to complete upon admit. S2DON and S4ADON confirmed that Clinical Assessment on 03/20/2023 for Resident #61 had no documented evidence of the baseline care plan. S2DON further confirmed there was no other documented evidence of the baseline care plan within 48 hours of admit for Resident #61.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for 1 (#47) of 3 (#27, #47 and #66) residents reviewed for skin conditions. The facility failed to have weekly skin assessments and failed to identify a skin condition for resident #47. Findings: Review of the facility's prevention of pressure injuries revealed in part: Monitoring - 1. Evaluate, report and document potential changes in the skin. Review of the medical record revealed the resident was admitted on [DATE] with diagnoses of diabetes, hypothyroidism, insomnia, hypertension, muscle wasting and atrophy, history of other venous thrombosis and embolism, noncompliance with medical treatment and regimen, reduced mobility, congestive heart failure, chronic kidney disease, constipation, non-Hodgkin's lymphoma, and senile degeneration of brain. Review of the Minimum Data Set, dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. The resident was independent with bed mobility, transfers, eating and toilet use. The resident was occasionally incontinent of bowel and bladder. The resident was at risk for pressure ulcers. Review of the current physician orders revealed: 1. float heels while in bed, 2. stage II pressure ulcer to right inner buttocks, cleanse with wound cleanser, pat dry with 4 x 4's, apply Calcium Alginate, cover with small clean dry dressing daily and when necessary until healed, 3. turn and reposition every 2 hours while in bed for pressure relief/preventative measures, and 4. nurse to initial every shift. Review of the care plan revealed: potential for skin integrity impairment related to weakness, decreased mobility, edema, occasional incontinence, tinea unguium, history of stage II pressure ulcer to buttocks. Review of the interventions revealed the following: medications/labs/diet as ordered, notify physician as needed, observe skin daily with routine care for potential problems, hydration/nutrition intervention as needed, offload as needed, pressure relief mattress, incontinent care as needed, reposition as needed, weekly skin audits, turn and reposition as ordered, apply clean dry dressing to buttock for prevention as ordered, moisture barrier to groin as ordered, venous ultrasound Monday 09/19/2022, stage II pressure ulcer to bilateral buttocks, cleanse with wound cleanser, pat dry with 4 x 4s, apply calcium alginate then cover with small clean dry dressing everyday and when necessary until healed and float heels while in bed. Review of the March and April 2023 record revealed the weekly skin assessments were done on 04/01/2023, 03/11/2023 and 03/04/2023. Observation of the resident on 04/11/2023 at 12:35 p.m. revealed the resident was sitting on the side of the bed eating his lunch. Further observation revealed approximately a quarter size excoriated area on the right ankle below the medial malleolus. Observation of the resident's feet on 04/12/2023 at 9:30 a.m. with S9LPN (Licensed Practical Nurse - treatment nurse) revealed a quarter size scabbed area on the right ankle below the medial malleolus. An interview at this time with S9LPN revealed the area on his right ankle was not there on Friday, 04/07/2023. S9LPN reported the nurses perform the weekly skin assessment and CNAs (Certified Nursing Assistants) observe the skin daily. An interview on 04/12/2023 at 10:47 a.m. with S11CNA supervisor revealed she gave him a whirlpool on 04/11/2023 in the am. S11CNA supervisor reported she saw the area on his right ankle on 04/11/2023 and the area was red and irritated. S11CNA supervisor reported that she did not report the area to the nurse on 04/11/2023. S11CNA supervisor reported the resident rubs his feet together so she put a pillow between his heels but he removed the pillow and placed it under his head. An interview with S4ADON (Assistant Director of Nursing - Unit Manager) on 04/12/2023 at 11:10 a.m. revealed the CNAs should report changes in the residents' skin immediately. An interview with S2DON (Director of Nursing) on 04/12/2023 at 11:38 a.m. confirmed the nurses should perform weekly skin assessments and the CNAs should report changes in the resident's skin immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews and interviews, the facility failed to ensure the resident's environment remains as free of accident hazards as is possible by not attempting new approaches after a resident sustained falls for 1 (#37) of 2 (#37 and #66) residents reviewed for falls. Findings: Review of the facility's Falls and Fall Risk policy revealed, in part: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 1. The staff, with the input of the attending physician, will identify appropriate interventions to reduce the risk of falls. Review of the record revealed the resident was admitted on [DATE]. The resident's diagnoses included, but not limited to the following: [NAME] cell carcinoma, low back pain, chronic kidney disease stage 4, hypertension, epilepsy, insomnia, diabetes, muscle weakness, congestive heart failure, hemiplegia, hemiparesis, aortocoronary bypass graft, pain, Chronic Obstructive Pulmonary Disease, atherosclerotic heart disease, sleep apnea, and transient ischemia attack. Review of the Minimum Data Set, dated [DATE] revealed the resident had moderately impaired cognitive skills for daily decision making. The resident required supervision with bed mobility and transfers and one person limited assistance with dressing and toilet use. The resident was occasionally incontinent of bowel and bladder. Review of the fall risk assessments dated 11/11/2022, 01/05/2023, and 03/27/23 revealed the resident was identified as high risk for falls. Review of the care plan revealed the following: falls - potential for related to weakness, decreased mobility, shortness of breath, uses wheelchair for mobility with staff assist, requires staff assist for transfers/bed mobility. Review of the interventions revealed: physical therapy/Occupational therapy as needed, physician as needed, pharmaceutical review of meds as needed, encourage to call for assist as needed, staff to assist as needed, keep bed locked and height appropriate for resident, assist resident to maintain a clutter free environment with adequate lighting, side rail to aid with bed mobility, nonskid socks or bare feet while in bed and while not wearing shoes, 11/11/2022 - slid off bed onto floor - re eval for therapy, and 01/05/2023 rolled out of bed onto floor while sleeping - wing mattress to bed. Review of the Incident and Accident Report dated 03/27/2023 at 2:15 a.m. revealed the following: resident was found on the floor between the bed and the wall, resident was laughing stating he didn't fall, he rolled off the bed. The bed was in the locked and low position, resident was flat on his back with his head on the frame of the bed, resident could not tell if he hit his head. Passive range of motion within normal limits for resident - no pain or discomfort, no visible injuries noted to resident's head, emergency medical services called for transfer to emergency room for possible head injuries. Physician and responsible party notified. Further review revealed there was no documentation of the wing mattress in use. Review of the care plan revealed there was no documentation of a new intervention following the fall on 03/27/2023. Observation on 04/12/2023 at 10:02 a.m. revealed the resident was asleep in his bed. A wing mattress was not observed. An interview on 04/12/2023 at 10:50 a.m. with S11 Certified Nursing Assistant supervisor revealed she didn't think that the resident has had a wing mattress. An interview on 04/12/2023 at 11:45 a.m. with S4 Assistant Director of Nursing (Unit Manager) confirmed the resident has not had a wing mattress. An interview with S8 LPN (Licensed Practical Nurse - Fall program nurse) on 04/12/2023 at 11:55 a.m. revealed she is responsible for updating the care plan with interventions after the falls. S8 LPN confirmed resident #37 did not receive a wing mattress following the fall on 01/05/2023 fall. S8 LPN confirmed there were no new approaches for resident #37 following the falls on 1/05/2023 and 03/27/2023. An interview with S2 DON (Director of Nursing) on 04/12/2023 at 12:45 p.m. confirmed there were no new approaches for resident #37 following the falls on 1/05/2023 and 03/27/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure that a resident maintains acceptable parameters of nutritional status for 1 (#33) of 3 (#33, #47, and #60) residents reviewed for nutrition. The facility failed to notify the physician of the Registered Dietician's recommendation for a resident with significant weight loss. Findings: Review of the medical record revealed the resident was admitted on [DATE] with diagnoses of diabetes, hypothyroidism, insomnia, hypertension, muscle wasting and atrophy, reduced mobility, congestive heart failure, chronic kidney disease, constipation, non-hodgkin's lymphoma, and senile degeneration of brain. Review of the Minimum Data Set, dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. The resident was independent with bed mobility, transfers, eating and toilet use. Review of the weights revealed the following: 08/05/2022 - 210.5 lbs. (pounds) 10/05/2022 - 213 lbs. 10/25/2022 - 208 lbs. 10/31/2022 - 207 lbs. 11/01/2022 - 205.5 lbs. 11/07/2022 - 205.2 lbs. 11/14/2022 - 204 lbs. 11/21/2022 - 204 lbs. 11/28/2022 - 157 lbs. 12/06/2022 - 191 lbs. 12/12/2022 - 189 lbs. 12/19/2022 - 188 lbs. 01/02/2023 - 187 lbs. 02/09/2023 - 187 lbs. 03/12/2023 - 184 lbs. 04/11/2023 - 184 lbs. On 10/05/2022, the resident weighed 213 lbs. On 03/12/2023, the resident weighed 184 pounds which is a -13.62 % Loss. Review of the care plan revealed: 1.) Significant weight loss of 11.5% in 90 days start date 01/11/2023. Further review revealed the following interventions: weigh monthly and as needed, notify physician/registered dietician/family as needed, labs as ordered, observe for signs and symptoms of complications from weight loss, talk with resident/staff/family about the risks involved with weight loss. 2.) Nutrition: general healthy diet, mechanical soft ground meats with diabetic precaution - able to feed self with set up and has a fair appetite. Further review revealed the following interventions: weigh every month and as needed, monitor labs as ordered, observe for chewing/swallowing problems and notify physician/registered dietician/speech therapy as needed, offer acceptable snacks daily, offer alternatives at meal times, resident/family/staff will be instructed/educated on healthy food choices, notify registered dietician/physician of weight changes of 5% or greater monthly and as needed, talk with resident to establish personal dislikes/likes and avoid serving dislike, speech therapy evaluate/treat as indicated and record meal intake. Review of the Registered Dietician's notes dated 02/20/2023 revealed the following: referred for weight change in past 90 days, weight loss of 26 pounds, current weight is 181.5, 102% Ideal Body Weight, patient has stage II pressure ulcer on right inner buttock, diet is Generalized Healthy Diet, mechanical soft with ground meats, by mouth intake is 50 - 75%, encourage protein choices at meals and snacks, offer Ensure if by mouth intake < 50% intake, consider 220 milligrams Zinc and 500 milligrams Vitamin C twice a day, will monitor weight. An interview with S4Assistant Director of Nursing (Unit Manager) on 04/12/2023 at 11:10 a.m. revealed the Dietary Manager sends Registered Dietician's recommendations to the physician. An interview with S14 Consultant Dietary Manager on 04/12/2023 at 11:20 a.m. revealed she thought the Director of Nursing referred the Registered Dietician's recommendations to the physician. An interview with S2DON (Director of Nursing) on 04/12/2023 at 11:38 a.m. revealed the Dietary Manager should have referred the Registered Dietician's recommendations to the physician. S2DON confirmed the physician was not notified of the Registered Dietician's recommendation for resident #33.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #2 Record review revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses include but not limited to the following: Alzheimer's disease, dementia without behavioral disturbance, atelectasis, bronchitis, chronic kidney disease, hypothyroidism, iron deficiency anemia, anxiety, major depressive disorder, osteoarthritis, and chronic pain. Review of Resident #2's April 2023 physician orders revealed the following active orders: O2 (oxygen) at 3 LPM (liters per minute) via nasal cannula to keep oxygen saturation above 90%. Change oxygen tubing and humidifier weekly on Saturday- date bag. Keep tubing in Ziploc when not in use. Ipratropium-albuterol inhalation 0.5-2.5 (3) mg (milligram)/3ml (milliliter) 1 vial inhale via nebulizer every 6 hours as need for shortness of breath. On 04/10/23 at 09:40 a.m. an observation of Resident #2 revealed she was lying in bed with head of bed elevated up 30 degrees, respirations even and unlabored. Resident #2 was receiving humidified O2 at 3 LPM via nasal cannula. There was no date on the humidification bottle which was connected to the oxygen concentrator. There was no date on the nasal cannula, and there was not a dated Ziploc bag available to store the nasal cannula when not in use. There was a nebulizer machine and suction set up sitting on dresser near the head of Resident #2's bed. The nebulizer tubing and nebulizer face mask was lying on the dresser and they were not dated and not covered in a Ziploc bag. There was not a dated Ziploc bag available to store the nebulizer tubing or nebulizer face mask. On 04/11/2023 at 07:50 a.m. an observation of Resident #2 revealed she was lying in bed with head of bed elevated up 30 degrees, respirations even and unlabored. Resident #2 was receiving humidified O2 at 3 LPM via nasal cannula. There was no date on the humidification bottle which was connected to the oxygen concentrator. The nasal cannula was not dated and there was not a dated Ziploc bag available to store the nasal cannula when not in use. The nebulizer tubing and nebulizer face mask was uncovered and lying on the dresser beside the head of Resident #2's bed. There was no dated Ziploc bag available to store the nebulizer tubing or nebulizer face mask. Review of the April 2023 EMAR (electronic medication administration record) revealed documentation Resident #2 received oxygen at 3 LPM via nasal cannula as ordered. Further review revealed documentation Resident #2 received Ipratropium-albuterol inhalation 0.5-2.5 (3) mg/3ml 1 vial inhale via nebulizer on 04/01/2023 at 05:34 a.m. and 03/21/2023 at 06:00PM On 04/11/2023 at 10:48 a.m. an interview and observation conducted with S12LPN (licensed practical nurse) in Resident #2's room. The following observation of Resident # 2's where confirmed with S12LPN: The nasal cannula was not dated and there was no dated plastic bag for storing the nasal cannula. The humidification bottle was not dated. The nebulizer tubing and nebulizer face mask was uncovered and lying on the cabinet beside resident #2's bed. The nebulizer tubing and face mask was not dated. There was no dated plastic bag to store the nebulizer tubing or face mask. S12LPN revealed the humidification bottle should be changed weekly and dated. S12LPN revealed the nebulizer tubing, and nebulizer face mask should be stored in a dated Ziploc bag when not in use. S12LPN further confirmed the nebulizer tubing and nebulizer face mask and dated zip lock bag should be changed weekly. S12LPN confirmed the nasal cannula and the dated zip lock bag to store it is should be changed weekly. On 04/11/2023 at 12:50 p.m. an interview with S2DON (Director of Nursing). S2DON was informed of surveyor's observations that were confirmed by S12LPN. S2DON revealed that Resident #2's nebulizer tubing and nebulizer face mask should be stored in a Ziploc bag when it is not being used. S2DON confirmed the following: The humidification bottle should be dated and changed weekly. The nasal cannula should be changed weekly along with a dated Ziploc bag to store the nasal cannula when not in use. The nebulizer tubing and nebulizer face mask should be changed weekly along with a dated Ziploc bag to store them when not in use. Resident #4 Record review revealed Resident #4 was admitted to the facility on [DATE]. Diagnoses included but not limited to the following: Acute on chronic systolic congestive heart failure, dependence on supplemental oxygen, anemia, chronic obstructive pulmonary disease, unspecified atrial fibrillation, hypertension, epilepsy, dementia, and peripheral vascular disease. Review of Resident #4's April 2023 physician orders revealed the following active orders: O2 (oxygen) at 2 LPM (liters per minute) per NC (nasal cannula) at bedtime. Change 02 tubing every week on Saturday. Date Bag. Keep tubing in Ziploc bag when not in use. Change 02 water humidifier every week on Saturday and date. On 04/10/2023 at 09:30 a.m. an observation of Resident #4 revealed she was lying in bed with head of bed elevated up 60 degrees. Resident #4 was receiving humidified O2 at 2 LPM via nasal cannula. The humidification bottle was dated 04/01/2023. There was a clear plastic bag dated 04/01/2023, that was rolled up and positioned in the handle of the oxygen concentrator. On 04/11/2023 at 07:55 a.m. an observation of Resident #4's room revealed a nasal cannula stored in a clear plastic bag, dated 04/01/2023, that was lying on the oxygen concentrator. The humidification bottle dated was 04/01/2023. On 04/11/2023 at 10:55 a.m. an interview and observation conducted with S12LPN (Licensed Practical Nurse) in Resident #4's room. The following observation where confirmed with S12LPN. The nasal cannula was stored in a clear plastic bag that was dated 04/01/2023. The humidification bottle was dated 04/01/2023. S12LPN revealed the nasal cannula and humidification bottle should have been changed weekly on Saturdays. On 04/11/2023 at 12:55 p.m. an interview with S2 DON (Director of Nursing) confirmed Resident # 4's nasal cannula and dated ziploc bag should be changed weekly on Saturday. S2DON further confirmed that the humidification bottle should also be changed weekly. Resident #273 04/11/2023 at 10:20 a.m., resident #273 was sitting up in her wheelchair, inside of her room. Observation revealed a nebulizer machine sitting on top of a chest of drawers. There was a ziploc bag with the resident's room number written on the outside of the bag. Furthervdhe mouthpiece of the nebulizer was uncovered. Further observation revelealed the mouthpiece and bag were not labeled and dated. Review of the electronic healthcare system revealed resident #273 was admitted to the facility on [DATE] with diagnoses including, in part, chronic systolic (congestive) heart failure, paroxysmal atrial fibrillation, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, cardiomyopathy, unspecified pleural effusion, essential (primary) hypertension, anemia, and dyspnea. Review of the April 2023 physician orders revealed: Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3 ml 1 vial inhale orally two times a day for wheezing. Record treatment minutes. Review of the April 2023 MAR, revealed resident #272 had received the Ipratropium-Albuterol Solution medication on 04/04/2023 at 8:00 p.m., 04/05/2023 through 04/10/2025 at 8:00 a.m., and 04/11/2023 at 8:00 a.m. On 04/12/2023 at 4:00 p.m. S2DON confirmed the nebulizer tubing and bag was to labeled and dated. S1Administrator present and notified of the findings. Resident #37 Review of the record revealed the resident was admitted on [DATE]. The resident's diagnoses included, but not limited to the following: [NAME] cell carcinoma, low back pain, chronic kidney disease stage 4, hypertension, epilepsy, insomnia, diabetes, muscle weakness, congestive heart failure, hemiplegia, hemiparesis, aortocoronary bypass graft, depression, pain, Chronic Obstructive Pulmonary Disease, atherosclerotic heart disease, sleep apnea, and transient ischemia attack. Review of the current physician orders revealed: oxygen at 2.5 Liters per nasal cannula continuous and change oxygen tubing weekly on Saturday, keep in a dated ziplock bag when not in use. Review of the care plan revealed: potential for ineffective gas exchange related to Chronic Obstructive Pulmonary Disease. Further review revealed the following interventions: oxygen at 2.5 Liters per nasal cannula continuous and change oxygen tubing weekly on Saturday and keep in dated ziplock bag when not in use. Observation on 04/10/2023 at 10:33 a.m. revealed the ziplock bag for the nasal cannula was dated 03/24/2023 and there was not a date on the oxygen tubing. An interview on 04/11/2023 at 10:45 a.m. with S10LPN (Licensed Practical Nurse) revealed the oxygen tubing should be changed on Saturdays. An interview with S9LPN/Treatment Nurse on 04/11/2023 at 12:15 p.m., revealed she changed resident #37's oxygen tubing on 04/10/2023 because the nasal cannual needed to be changed. Resident #52 Review of the medical record revealed the resident was admitted on [DATE] with diagnoses of diabetes, anxiety, depression, shortness of breath, obesity, insomnia, chronic pain, paraplegia incomplete, epilepsy and acute and chronic respiratory failure. Review of the current physician orders revealed: oxygen at 2 Liters per nasal cannula continuous and change oxygen tubing weekly on Saturday - keep in a dated ziplock bag when not in use. Review of the care plan revealed potential for ineffective gas exchange related to shortness of breath and morbid obesity. Further review revealed the following interventions: oxygen 2 Liters per nasal cannula continuously and change oxygen tubing every week as ordered. Observation on 04/10/2023 at 9:25 a.m. revealed the resident was lying in bed receiving 2 Liters of oxygen per nasal cannula. Further observation revealed the nasal cannula ziplock was dated 03/24/2023 and the oxygen tubing was not dated. An interview on 04/11/2023 at 10:45 a.m. with S10LPN (Licensed Practical Nurse) revealed the oxygen tubing should be changed on Saturdays. An interview with S9LPN/Treatment Nurse on 04/11/2023 at 12:15 p.m., revealed she changed resident #52's oxygen tubing on 04/10/2023 because the nasal cannula needed to be changed. Based on observations, record reviews, and interviews, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 6 (#2, #4, #37, #52, #273, #373) of 7 (#2, #4, #37, #52, #65, #273, and #373) reviewed for oxygen. The facility failed to ensure: 1) oxygen tubing was changed weekly for residents #4, #37, #52 and #373, 2) hand held nebulizer tubing and face mask was stored properly when not in use for resident #2, 3) humidified water bottle was dated and changed weekly for residents #2 and #4, and 4) nebulizer tubing changed weekly for resident #273. Findings: Resident 373 Review of the facility's Oxygen and HHN (hand held nebulizer) tubing storage policy revealed the following. Policy: It is the policy of this facility to place O2 (oxygen) and HHN tubing in a resealable bag when not in use. These bags will be labeled and dated. Bags will be changed weekly on Saturdays and prn soilage or damage. Bags to be kept at bedside. Review of the medical record for sampled resident #373 revealed an admission date of 03/21/2023 with diagnoses of chronic obstructive pulmonary disease, pulmonary edema, heart failure, muscle weakness, and hypertension. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition for daily decision making and required assistance with activities of daily living. Review of the careplan for resident #373 revealed at risk for impaired gas exchange and for the facility to evaluate blood pressure, and to evaluate for anxiety and the use of accessory muscles while breathing, Review of the physician orders dated 03/21/2023 revealed an order for Oxygen at 2 liters per nasal cannula continuous. Further review of the physician orders revealed an order dated 03/25/2023 for the oxygen tubing to be changed every Saturday. On 04/10/2023 at 10:20 a.m. and 2:00 p.m. observations of resident #373 revealed she had oxygen on at 2 liters per nasal cannula. Further observation of the oxygen tubing revealed no date was on the tubing. An interview on 04/11/2023 at 10:45 a.m. with S10LPN (Licensed Practical Nurse revealed the oxygen tubing should be changed on Saturdays. An interview with S9LPN/Treatment Nurse on 04/11/2023 at 12:15 p.m., reported she changed resident #373's oxygen tubing on 04/10/2023 because there was not a date on the tubing the resident was using.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon for 1 (#31) of 7 (#2, #3, #31, #37, #65, #66 and #69) residents reviewed for unnecessary medications. The pharmacist failed to address labs not obtained as ordered by the physician. Findings: Resident 31 Review of the medical record for resident #31 revealed admit date of 04/15/2015 with diagnoses of cervicalgia, low back pain, sciatica, edema, muscle weakness, dysthymic disorder, dementia, chronic obstructive pulmonary disease, depression, bipolar, anorexia, hypoxemia, osteoporosis, spinal stenosis, vitamin B deficiency, and hypothyroidism. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition for daily decision making and required assistance with activities of daily living. Review of the careplan revealed lab values need for monitoring related to hypothyroidism, vitamin B deficiency, osteoarthritis, hyperosmolality, and hypernatremia. Further review of the care plan revealed comfort altered related to polyneuropathy, chronic pain, cervical disc degeneration, disc displacement sciatica low back pain and frequent complaints of pain. Review of the physician orders dated 02/07/2023 revealed an order for a Complete Blood Count, Comprehensive Metabolic Panel, Thyroid Stimulating Hormone, Free T4 and a Vitamin D level to be obtained. Further review of the physician orders revealed an order dated for Vitamin D3 1000 units give two by mouth every day, 01/09/2019 for Synthroid 25 micrograms give one tablet every day, and 01/30/2018 for Multivitamin give one by mouth every day. Review of the medical record revealed no documented evidence of the labs results for the tests ordered on 02/07/2023. Review of the monthly DRR (drug regimen review) dated 02/23/2023 and 03/19/2023 revealed the pharmacist did not address the labs not obtained for resident #31 as ordered by the physician on 02/072023. An interview with S4ADON (Assistant Director of Nurses) on 04/12/2023 at 9:15 a.m. revealed the pharmacist did not address the labs not drawn as ordered on 02/07/2023 for resident #31. On 04/12/2023 at 12:40 p.m., S2DON (Director of Nurses) was informed of the labs not drawn as ordered on 02/07/2023 and the pharmacist did not address the labs not obtained on the monthly DRR dated 02/23/2023 and 03/19/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #66 Record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses that include but not limited to the following: unspecified atrial fibrillation, cervical spinal stenosis, hypothyroidism, bipolar disorder, depression, anxiety disorder, hypertensive heart disease with heart failure, and chronic peripheral venous insufficiency. Review of Resident #66's April 2023 physician orders revealed an active order for Lasix 20 mg (milligram) tablet give one tablet by mouth every day monitor edema. This order had a start date of 12/09/2022. Review of the March and April 2023 EMAR (Electronic Medication Administration Record) revealed documentation Resident #66 received Lasix 20 mg by mouth every day as ordered as ordered by physician. There was no documentation of Resident #66 being monitored for edema after 03/15/2023. Further review of the medical record reveled no documentation of daily monitoring for edema. On 04/12/2023 at 11:50 a.m. an interview with S8LPN (Licensed Practical Nurse) confirmed there was no documentation of Resident #66 being monitored for edema daily since 03/15/2023. S8LPN revealed the nurses should be able to document edema checks on the EMAR when the Lasix is administered, but whoever entered the order in the computer did not put it in where the nurses could document edema checks on the EMAR. On 04/12/2023 1:35 p.m. an interview with S2DON (Director of Nursing) revealed there was not documentation of Resident #66 being monitored for edema daily since 03/15/2023. S2DON confirmed Resident #66 should be monitored for edema daily. Resident #65 Review of the electronic healthcare records revealed resident #65 was admitted to the facility on [DATE] with diagnoses including, in part, personal history of transient ischemic attack and cerebral infarction without residual deficits, chronic obstructive pulmonary disease, Parkinson's disease, bradycardia, peripheral vascular disease, chronic systolic (congestive) heart failure, dementia, generalized edema, and essential (primary) hypertension. Review of the April 2023 physician orders revealed an order dated 03/15/2023 for resident #65 to have Lasix oral tablet 40 mg (milligrams), Furosemide; give 1 tablet by mouth one time day related to generalized edema and monitor edema. Review of the April 2023 MAR resident #65 received Lasix 40 mg (Furosemide) 1 tablet by mouth on the dates of 04/01/2023 through 04/11/2023. Further review of the MAR revealed there was no documented evidence of resident #65 being monitored for edema as ordered. On 04/12/2023 at 4:00 p.m., S2DON was notified of the findings. After reviewing the electronic healthcare records, S2DON confirmed there was no documented evidence of resident #69 being monitored for edema as ordered by the physician. Resident #69 Review of the electronic healthcare records revealed resident #69 was admitted to the facility on [DATE] with diagnoses including, in part, stroke and chronic systolic (congestive) heart failure. Review of the April 2023 physician orders revealed an order dated 03/31/2023 for Hydrochlorthiazide oral tablet 25 mgl give 1.5 tablet by mouth one time day related to chronic systolic (congestive) heart failure; total dose 37.5 mg. Review of the April 2023 MAR revealed resident #69 received the Hydrochlorothiazed on 04/01/2023 through 04/11/2022. Further review revealed no documented evidence of resident #69 being monitored for edema as ordered. Resident #69 received the medication from 04/01/2023 through 04/11/203, at 8:00 a.m., daily. On 04/12/2023 at 4:00 p.m., S2DON was notified of the findings. After reviewing the electronic healthcare records, S2DON confirmed there was no documented evidence of resident #69 being monitored for edema as ordered by the physician. Based on interviews and record reviews, the facility failed to ensure that each resident's drug regimen was free from unnecceary drugs for 4 ( #31, #65, #66, and #69) of 7 (#2, #3, #31, #37, #65, #66 and #69) residents reviewed for unnecessary medications. The faciltiy failed to 1) monitor residents #65, #66 and #69 for edema when receiving a diuretic, 2) assess resident #31 for pain prior to adminstering a pain medication, and 3) obtain labs to monitor medications as ordered for resident #31. Resident 31 Review of the medical record for resident #31 revealed admit date of 04/15/2015 with diagnoses of cervicalgia, low back pain, sciatica, edema, muscle weakness, dysthymic disorder, dementia, chronic obstructive pulmonary disease, depression, bipolar, anorexia, hypoxemia, osteoporosis, spinal stenosis, vitamin B deficiency, and hypothyroidism. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition for daily decision making and required assistance with activities of daily living. Review of the careplan revealed lab values need for monitoring related to hypothyroidism, vitamin B deficiency, osteoarthritis, hyperosmolality, and hypernatremia. Further review of the care plan revealed comfort altered related to polyneuropathy, chronic pain, cervical disc degeneration, disc displacement sciatica low back pain and frequent complaints of pain. Review of the physician orders dated 02/07/2023 revealed an order for a Complete Blood Count, Comprehensive Metabolic Panel, Thyroid Stimulating Hormone, Free T4 and a Vitamin D level to be obtained. Further review of the physician orders revealed an order dated for Vitamin D3 1000 units give two by mouth every day, 01/09/2019 for Synthroid 25 micrograms give one tablet every day, and 01/30/2018 for Multivitamin give one by mouth every day. Review of the physician orders dated 03/15/2023 revealed an order for Morphine Sulfate 15 milligrams give one by mouth every 4 hours as needed for pain. Special requirements listed on the electronic chart revealed to record the resident's pain level (0-10), and follow up in 60 minutes to evaluate effectiveness. Review of the March 2023 and April 2023 Medication Administration Record (MAR) revealed the resident received Morphine Sulfate tablet 15 milligrams one tablet by mouth every 4 hours as needed for pain on 03/30/2023, 4/06/2023, 04/09/2023 and 04/10/2023. Further review of the March 2023 and April 2023 MAR revealed there was no documented evidence that the resident's pain level was assessed prior to administering Morphine Sulfate. Review of the medical record revealed no documented evidence of the labs results for the tests ordered on 02/07/2023. An interview with S4ADON (Assistant Director of Nurses) on 04/12/2023 at 9:15 a.m. revealed there was no documented evidence that resident #31's pain level was assessed prior to administering the pain medication and the labs were not drawn as ordered. On 04/12/2023 at 12:40 p.m., S2DON (Director of Nurses) was informed of the labs not drawn as ordered on 02/07/2023, and Morphine Sulfate 15 milligrams was given as needed and there was no documented evidence of resident #31's pain level assessed prior to giving the medication.

Based on record review and interview, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for it's residents competently during both day-to-day operations and emergencies. The facility failed to review and update that assessment, as necessary, and at least annually. Review of the Resident Census and Conditions of Residents report revealed the facility's census was 74 residents. Findings: Review of the most recent facility assessment revealed the assessment was dated 02/10/2022. On 04/12/2023 at 3:17 p.m., S1Administrator was notified of the findings regarding the facility assessment. S1Administrator confirmed he had not conducted a facility-wide assessment since 02/10/2022.

Based on review of the QAA (Quality Assessment and Assurance) manual and interview the facility failed to have documented evidence of having QAA meetings at least quarterly. Review of the Resident Census and Conditions of Residents report revealed the facility's census was 74 residents. Findings: Review of the facility's QAA committee manual revealed no documented evidence of quarterly meetings performed for the second, third and fourth quarter of 2022. During an interview on 04/12/2023 at 3:45 p.m., S1 Administrator confirmed QAA Committee meetings were not held for the second, third and fourth quarter for the year of 2022.