**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure a resident's plan of care was implemented for 1 (Resident #51) out of 32 sampled residents. The facility failed to ensure Resident #51's splint was applied on her left hand. Findings: A review of Resident #51's admission Record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, cerebral infarction. A review of Resident #51's Order Summary Report revealed a physician's order, dated 02/06/2025 that read, left hand splint to be worn during the day, take off at night and for showers. A review of Resident #51's Care Plan Report revealed a care plan intervention initiated on 02/07/2025 that read, left hand splint to be worn during the day, take off at night and for showers. On 03/18/2025 at 9:27 AM, an observation was made of Resident #51 in her room. No splint was observed on her left hand. On 03/18/2025 at 10:07 AM, a second observation was made of Resident #51 in her room. No splint was observed on her left hand. A concurrent interview and observation was conducted with S5CNA (Certified Nursing Assistant), S5CNA confirmed there was no splint on Resident #51's left hand. On 03/18/2025 at 10:40 AM, an observation and interview was conducted with S3LPN (Licensed Practical Nurse). S3LPN confirmed that Resident #51's splint was not on her left hand and it should have been.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility's policy and procedure, the facility failed to ensure all allegations of injuries of unknown source with serious bodily injury was reported immediately, or within 2 hours of the allegation to the state survey agency for 1 (#1) of 4 (#1, #2, #3 and #R1) residents sampled with facility reported incidents. Findings: On 09/10/2024, a review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating with a last reviewed date of 03/11/2024 read in part: Policy Statement: All reports of resident abuse (including injuries of unknown origin) . are reported to local, state and federal agencies (as required by current regulations) . 1. If resident . 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 or the individual making the allegation immediately reports his or her suspicion to the following applicable persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility . 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury . Review of Resident #1's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Fracture of Right Femur, Muscle Wasting and Atrophy, and Heart Failure. Review of Resident #1's Significant Change Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 3 indicating his cognition was severely impaired. Review Resident #1's Incident Report completed on 08/19/2024 at 1:50 p.m. by S4LPN (Licensed Practical Nurse), read in part: . Informed by CNA (Certified Nursing Assistant) that resident was found on the floor in supine position; Head to toe assessment performed and bruising noted to the L (left) and R (right) hand; skin tear to R upper and c/o (complaints of) pain w/ (with) guarding to the R hip area . Review of the investigation submitted for Statewide Incident Management System (SIMS) Incident ID: 206829 revealed, in part . Entered: 08/21/2024, 11:13 a.m. 08/20/2024, 12:00 p.m. Review of Resident #1's right hip x-ray results revealed the following in part: examination date 08/19/2024 at 10:24 p.m.; reported date: 08/20/2024 at 7:35 p.m. an acute intertrochanteric femoral fracture with mild displacement with varus angulation. Review of Resident #1's progress notes documented by S5LPN revealed the following in part: 08/20/2024 at 1:23 a.m., S5LPN received Xray results. Right hip Acute intertrochanteric femoral fracture with mild displacement with varus angulation . New order to send resident to the ER (Emergency Room) for treatment . I called the on-call number. No one answered . Multiple attempts were made to contact S5LPN via phone for interview on 09/09/2024 at 2:50 p.m., at 3:54 p.m., and at 4:08 p.m., and on 09/10/2024 at 8:44 a.m., at 9:40 a.m., and at 11:00 a.m. S5LPN failed to return any phone calls and was unable to be interviewed. On 09/10/2024 at 11:10 a.m. an interview was attempted with Resident #1. Resident #1 is not able to be interviewed due to unable to answer questions appropriately and he does not remember the cause of his right femur fracture. On 09/10/2024 at 11:26 a.m., an interview was conducted with S3ADON (Assistant Director of Nursing). S3ADON stated she was on call on 08/20/2024. She stated S5LPN did call the on call phone, but she (S3ADON) did not answer the phone due to her not hearing it. She stated on 08/20/2024 she called the facility at around 6:45 a.m. and was notified that Resident #1 sustained a right hip fracture and was sent to the ER. She confirmed that she notified S1ADM (Administrator) verbally of Resident #1's right femoral fracture on 08/20/2024 at around 8:15 a.m. in a morning meeting at the facility. She stated she did not have access to report incidents to the state survey agency. Multiple attempts were made to contact S1ADM via phone for interview on 09/10/2024 at 2:12 p.m., at 2:27 p.m., and at 3:12 p.m. S1ADM failed to return any phone calls and was unable to be interviewed. On 09/10/2024 at 3:39 p.m., an interview was conducted with S2DON (Director of Nursing). S2DON stated that S1ADM was currently on vacation and may not be able to take calls. She stated she reviewed Resident #1's x-ray results on 08/20/2024 before coming to work at around 8:00 a.m. and she forwarded the x-ray results to S1ADM on 08/20/2024 at around 8:00 a.m. She confirmed the right femur fracture was an injury of unknown origin and that's why an in-service was completed with staff after this incident on 08/21/2024 to report all injury of unknown origin to the administrator or DON immediately because these must be reported to LDH (Louisiana Department of Health) within 2 hours. She stated S1ADM entered the facility reported incident to the state survey agency on 08/21/2024 at 11:13 a.m. S2DON confirmed this should have reported to the state survey agency within 2 hours of notification for resident #1's injury of unknown source with serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) assessment accurately reflected the status of 1 (Resident #2) out of 3 (Resident #1, #2, and #3) sampled residents by failing to ensure that Resident #2 was coded correctly for the use of a wander guard. Findings: Resident #2 Review of Resident #2's health record revealed that she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's Disease, Peripheral Vascular Disease, and Hypertension. Review of Resident #2's most recent Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 99, indicating the resident was unable to cooperate. Further Review of Resident #2's most recent MDS dated [DATE] Section P - Restraints and Alarms, P0200 Alarms, E. Wander/elopement Alarm, revealed it was coded as 0. Not used. Review of the Wandering Risk Scale dated 03/16/2024 revealed in Section E. History of Wandering 2. Has history of wandering. Further review of Section J. Comments, Wander guard remains in place. No concerns noted. Review of Resident #2's active physician's orders dated June 2024 revealed an order on 06/23/2024 read in part, Wander Alert Bracelet (Wanderguard) Check for placement with skin intact every shift, census check every 1 hour every shift. On 06/04/2024 at 10:22 a.m., an interview and record review was conducted with S2MDSC (Minimum Data Set Coordinator). She confirmed that Resident #2 was using wanderguard daily because she had a history of wandering. S2MDSC also confirmed that Resident #2's MDS dated [DATE] had not been coded for using a wanderguard daily and should have been.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infections as evidence by S3CNA failing to: 1. utilize the proper PPE (Personal Protective Equipment) while providing care to Resident #2 who was on Contact Precautions. 2. perform hand hygiene before entering and exiting Resident #2's room. 3. disinfect the vital sign machine and blood pressure cuff after use. The facility had a census of 88. Findings: On 06/04/2024, a review of the facility's policy, Isolation - Categories of Transmission-Based Precautions, with a last reviewed date of 03/08/2024, revealed in part, the following, . Contact Precautions: . 2. Contact precautions are also used in situations when a resident is experiencing wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and suggest an increased potential for extensive environmental contamination and risk of transmission of a pathogen, even before a specific organism has been identified . 7. Staff and visitors wear gloves (clean, non-sterile) when entering the room . b. Gloves are removed and hand hygiene performed before leaving the room . 8. Staff and visitors wear disposable gown when entering the room and remove before leaving the room . Review of facility's sign posted on the outside of Resident #2's room, revealed in part, the following, Contact Precautions . 2. Gloves - wear gloves when entering the room . removed gloves before leaving patients room. 3. Wash hands - with soap and water immediately after glove removal and before leaving patients room, 4. Gown - wear if you anticipate that your clothes will have contact with the patient, environmental surfaces or items in the patient's room or if the patient has any of the following: incontinent, diarrhea . removed gown before leaving the patient's environment . 6. If common equipment is used, clean and disinfect . Review of Resident #2's physician's orders revealed an order dated 06/03/2024 that read, Contact isolation precautions from now until 3 days after symptoms of Norovirus have resolved. Contact precautions include wearing gown and gloves in resident's room. Perform hand hygiene with soap and water before and after donning PPE. Limit resident transport. On 06/04/2024 at 9:14 a.m., S3CNA was observed entering Resident #2's room with the vital sign machine and blood pressure cuff. She did not wear gloves or gown before entering Resident #2's room. S3CNA obtained Resident #2's vitals and exited the room. S3CNA did not perform hand hygiene prior to entering Resident #2's room or after exiting the room. S3CNA did not sanitize the vital sign machine or the blood pressure cuff after use. On 06/04/2024 at 9:16 a.m., an interview was conducted with S3CNA. She confirmed Resident #2 was having diarrhea, and did not notice the Contact Precaution sign on Resident #2's door. She stated that she did not sanitize her hands before or after contact with Resident #2 and did not don PPE before entering into Resident #2's room. S3CNA also stated that she did not sanitize the vital sign machine or the blood pressure cuff prior to or after use. S3CNA stated that she should have sanitized vital sign machine and blood pressure cuff prior to entering Resident #2's room. She stated that she should have sanitized her hands, wore gloves and gown prior to entering Resident #2's room. S3CNA also stated that she should have sanitized the vital sign machine and blood pressure cuff after use. On 06/04/2024 at 10:10 a.m., an interview was conducted with S1ICRN (Infection Control Registered Nurse). S1ICRN stated that when Contact Precautions are in place for residents staff should perform hand hygiene before entering and upon exiting the resident's room. S1ICRN also stated that proper PPE should be utilized which consist of donning gloves and gown before entering into the room. She also stated that the vital sign machine and blood pressure cuff should be sanitized before and after use and between residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure consent was obtained from the Resident's Representative prior to purchasing a burial policy for a resident who did not have the mental capacity to consent for 1 (#51) out of 1 sampled residents in a final sample of 30 residents. Findings: Review of Resident #51's medical record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's Disease, Schizoaffective Disorder, Manic Episode Severe with Psychotic Symptoms, Anxiety Disorder, Peripheral Vascular Disease, and Hypertension. Review of Resident #51's Annual MDS (Minimum Data Set) admission assessment with an ARD (Assessment Reference Date) of 12/2022 revealed a BIMS (Brief Interview for Mental Status) score of 06, which indicated severe cognitive impairment. Review of Resident #51's facesheet revealed the resident had a Resident Representative. Review of Personal Funds Statement dated 1/01/2023-3/12/2023 revealed a charge withdrawn on 2/18/2023 of $1529.81 to burial insurance policy. Review of Resident #51's signed Burial Insurance Policy form revealed Resident #51's signature on both signature lines. Review of Burial Insurance Policy form revealed the following statement in part .Has the proposed insured ever been diagnosed, treated, tested positive for, on been given medical advice by a member of the medical profession for any of the following conditions? . Alzheimer's ; Resident #51 signed attesting that the answer was no to the question. On 3/12/2024 at 10:34 a.m., an interview was conducted with S10BOA (Business Office Assistant). She recalls purchasing a burial policy with the previous business office manager. S10BOA stated the Residents funds could not exceed $2000 so they had Resident #51 sign the policy. She stated she does not recall them contacting the Resident Representative for notification of the purchase. On 3/13/24 at 9:11 a.m., a phone interview was conducted with Resident#51's daughter. She stated she and the resident's representative were unaware the facility purchased a burial policy for their mother. She stated the only reason she realized her mother had that the policy was because her quarterly statement listed the withdrawal. The daughter also stated the burial insurance policy form was filled out inaccurately. The Resident Representative's name on the policy was spelled incorrectly. The policy was signed indicating she did not have Alzheimer's and she did have Alzheimer's disease. Resident #51's daughter further stated that the resident has been confused since her admission to the facility. On 3/13/2024 at 9:53 a.m., an interview was conducted with S1ADM (Administrator). She confirmed the burial policy was filled out inaccurately, because the Resident did have a diagnosis of Alzheimer's Disease in 2023, and also confirmed the Contingent Beneficiary's name was spelled incorrectly. S1ADM could not provide evidence that the previous business office manager obtained consent from Resident #51's Resident Representative prior to purchasing the policy on behalf of the resident. On 3/13/2024, a phone interview was conducted with the Resident Representative. She stated she was not informed that the facility was going to be purchasing a burial policy for the Resident. Resident Representative further stated after the policy was purchased without her knowledge, she reviewed the paperwork and identified that the funeral home, and the contingent beneficiary were both incorrect. She also stated she does not believe that Resident #51 signed the paperwork, because the Resident does not remember how to read or write.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to properly label respiratory equipment for 1 resident (#6) out of 1 (#6) resident investigated for respiratory care. Findings: Review of Resident #6's medical record revealed that she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Lobar Pneumonia. Review of Resident #6's physician's orders revealed an order dated 01/15/2024 that read: O2 (oxygen) at 2L/MIN (liters per minute) continuously/titrate as needed. On 03/11/2024 at 9:47 a.m., an observation was made of the Resident in her room using oxygen via nasal cannula. The oxygen tubing was not labeled with a date. On 03/11/2024 at 9:52 a.m., an interview was conducted with S7LPN (Licensed Practical Nurse). S7LPN was unsure of the date that the tubing was changed. She confirmed the Resident's oxygen tubing did not have a label on it and it should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure appropriate care and services had been provided for 1 (Resident #21) of 1 resident investigated for dialysis. The facility failed to ensure Resident #21 was accurately assessed and monitored for the care of his dialysis access site following dialysis. Findings: Review of the facility's policies on 3/13/2024 revealed policy dated 3/2024, titled Hemodialysis read in part, Policy: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. 8. The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications. Review of Resident #21's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease, Type 2 Diabetes Mellitus with Diabetic Secondary to Chronic Kidney Disease, Thrombocytopenia and Anemia in Chronic Kidney Disease. Review of Resident #21's Significant Change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/28/2024 revealed he had a BIMS (Brief Interview for Mental Status of 14, indicating he was cognitively intact. Section O (Special Treatment, Procedures and Programs) revealed he was coded for receiving Dialysis while a resident. Review of Resident #21's communication form titled Resident Dialysis Form read in part, Drsng (Dressing) C/D/I (Clean/Dry/Intact) with a Yes or No box that indicated if this assessment had been done. On 2/22/2024, 2/24/2024, 2/27/2024 and 3/09/2024 dressing assessment post dialysis was incomplete. There were no boxes checked that indicated an assessment had been completed. 03/12/2024 at 12:11 p.m., interview was conducted with Resident #21 who was cognitively intact. He stated that he went to dialysis on Tuesdays, Thursdays and Saturdays. He stated that no one checked his dialysis access site when he returned from dialysis. On 03/12/2024 at 12:30 p.m., an interview and record review with S2DON (Director of Nursing) was conducted and she confirmed that Resident #21's dialysis site had not been assessed after dialysis on 02/22/2024, 02/24/2024, 02/27/2024 and 03/09/2024.

Based on observation and interview, the facility failed to ensure medications were stored according to professional standards of practice as evidenced by loose pills found in the bottom of medication cart drawers for 1 (Cart B) of 2 medication carts (Cart B, Cart C ) reviewed. Findings: Review of the facility's policy titled Medication Labeling and Storage dated 03/08/2024 and reviewed on 03/13/2024 read in part .Medication Storage . 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. On 03/13/2024 at 9:40 a.m., an observation was made of Medication Cart B with S6LPN (Licensed Practical Nurse). Observation of the second drawer of the medication cart revealed 6 loose pills at the bottom of the drawer. The pills included the following: 1 red oblong tablet, 2 large white round tablets, 1 small white round tablet, 1 blue round tablet, and 1 orange round tablet. S6LPN could not identify the loose pills. S6LPN also stated that the nurses were responsible for ensuring the medication carts were free from loose pillls. S6LPN confirmed that the loose pills should not have been in the medication cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and implement a comprehensive patient-centered care plan for 2 residents (Resident # 6 and Resident # 84) out of a total sample of 30 residents. Findings: On 03/13/2024, a review of the policy dated 03/2024 titled Care Plans, Comprehensive Person-Centered read in part, Policy Statement, A comprehensive, person-centered care plan that includes measureable objectives and timetable to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident. Resident #6 Review of Resident #6's medical record revealed that she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Lobar Pneumonia. Review of Resident #6's physician's orders revealed an order dated 01/15/2024 that read: O2 (oxygen) at 2L/MIN (liters per minute) continuously/titrate as needed. Review of Resident #6's Comprehensive Care Plan failed to reveal a care plan had been developed for oxygen use. Observation on 03/11/2024 at 9:47 a.m. revealed Resident #6 in bed with oxygen via nasal cannula in place. Observation on 03/12/2024 at 9:35 a.m. revealed Resident #6 in bed with oxygen via nasal cannula in place. On 3/12/2024 at 10:09 a.m., an interview was conducted with S8MDSLPN (Minimum Data Set, Licensed Practical Nurse). She reviewed Resident #6's medical record and confirmed the resident had an order for oxygen on 01/15/2024. S8MDSLPN then reviewed the care plan and confirmed Resident #6 had not been care planned for use of the ordered oxygen with appropriate interventions, and should have been. Resident #84 Review of Resident #84's EHR (Electronic Health Record) revealed the resident was admitted to the facility on [DATE] with diagnoses including: Unspecified Dementia and Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease Affecting Left Non - Dominant Side. Further review of Resident #84's EHR revealed a physician's order dated 07/13/2023 that read: Pt. (Patient) to have divided plate with all meals. On 03/11/2024 at 12:00 p.m., an observation was made of Resident #84 eating lunch. The resident did not have a divided plate. 03/11/2024 at 12:15 p.m., an interview was conducted with S9LPN (Licensed Practical Nurse). S9LPN confirmed Resident #84 had an order for a divided plate with all meals. S9LPN then observed the resident's lunch plate and confirmed the resident did not have a divided plate and should have had a divided plate.

Based on observation, interview, and policy and procedures review, the facility failed to ensure menus met the nutritional needs of the residents and were followed as evidenced by: 1. No menu posted in resident areas, in a position and in print large enough for resident to read them. 2. The kitchen staff failing to have knowledge of recipes to be followed when preparing pureed foods. This deficient practice had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs and weight loss for the 14 residents who consumed pureed diets. Findings: Review of the facility's policy, Menu, last reviewed on 03/2024, revealed in part, the following: Policy Statement: Menus are developed and prepared to meet resident choices including religious, culture and ethnic needs while following established national guidelines for nutritional adequacy. On 03/11/2024 at 9:57 a.m., an observation was made of S5DC (Dietary Cook) preparing pureed lunch meals. S5DC prepared an unmeasured amount of chicken by blending pieces of chicken into the blender and added an unmeasured amount of water. Next, S5DC was observed transferring an unmeasured amount of brussel sprouts from the container to the blender and then added and unmeasured amount of water and blended all the ingredients. There were no recipe(s) present during the observed pureed lunch meal preparation by S5DC. On 03/11/2024 at 10:35 a.m., an interview was conducted with S5DC who confirmed she was one of the cooks at the facility and she often prepared puree meals. She stated there were 14 residents in the building that required pureed meals. She stated that she was never notified that she had to follow a recipe when preparing puree meals and confirmed she prepared puree meals for residents based off of her judgement. On 03/11/2024 at 11:15 a.m., an interview was conducted with S4DM (Dietary Maneger). S4DM stated she had received recipes for puree diets and the recipes were currently kept in a binder in her office. She confirmed that she and the dietary cooks had never followed recipes while preparing puree meals. She stated that the recipe binder was the first time I have this binder. On 03/11/2024 at 12:23 p.m., a phone interview was conducted with S3RD (Registered Dietician). She stated that the menu for the therapeutic diets also came with a recipe. She states she sends the facility recipes for therapeutic diets every six months. She confirmed that when the dietary cooks or dietary manager were preparing puree meals, a puree recipe should be followed to ensure the nutritional needs were met for the residents who consumed puree meals. On 03/11/2024 at 4:30 p.m., an observation was made of the dining area and there was not a menu posted for residents. At this time, an interview was conducted with S4DM. S4DM stated she puts the menu on the large white board in the dining area but did not today because she did not have time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review and interview, the facility failed to complete an accurate facility-wide assessment that reflected the resident population. This was evidenced by failure to address or include Mexican ethnic or cultural factors for 1(#48) out of a total sample of 30 residents. The facility's census was 92 residents. Findings: On 03/12/2024 at 2:05 p.m., a record review was conducted of __________Facility Assessment March 2024 with a review date of 03/08/2024. The facility assessment revealed in part: Ethnic, cultural, or religious factors . Further review of the facility's assessment failed to include ethnic or cultural factors that reflected the Mexican resident population. On 03/13/2024 at 12:21 p.m., a review of the facility's Facility Assessment Policy which was reviewed per annual policy and procedure review in March 2024 revealed: Policy Statement. A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment. Policy Interpretation and Implementation .3. The facility assessment includes a detailed review of the resident population. This part of the assessment includes .d. religious, ethnic or cultural factors that affect the delivery of care and services, such as .(4) language translation requirements. Resident # 48 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Unspecified Dementia and Major Depressive Disorder. A review of Resident # 48's quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 02/21/2024 revealed in Section A1005. Ethnicity. B., an answer of Yes to Mexican, Mexican American, Chicano/a. A review of Resident # 48's plan of care with a revision date of 05/23/2023 revealed that she was care planned for having a communication problem r/t (related to) language barrier and that she communicated via Spanish. On 03/12/2024 at 11:35 a.m., an observation was made of Resident # 48 in the communal dining room. The resident was observed wearing a clothing protector during lunch. S11CNA (Certified Nursing Assistant) was observed attempting to remove the resident's clothing protector when she was finished eating, but the resident appeared resistant to S11CNA. Resident # 48 was observed crossing her arms across her chest and said no, no, no. S11CNA was unable to communicate to the resident the reason for removing the clothing protector because she did not speak the resident's language. On 03/12/2024 at 12:16 p.m., an interview and review of _______ Facility Assessment March 2024 was conducted with S1ADM (Administrator). S1ADM confirmed that the assessment failed to address any ethnic, cultural, or religious factors for residents who did not speak English. She also confirmed there was no language translation requirements to address how to communicate with Resident # 48, who communicated via Spanish.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #61: Resident #61 was admitted to the facility on [DATE] with diagnoses including, but were not limited to, Chronic Kidney Disease, Morbid Obesity Due to Excess Calories, and Aphasia Following Cerebral Infarction. On 03/12/2024 at 11:58 a.m., an observation was made of S13CNA (Certified Nursing Assistant) delivering Resident #61's lunch tray to her room. The resident's paper wrapped straw fell from her tray and onto the floor. S13CNA picked up the straw, placed it on the resident's tray and delivered the tray to the resident. On 03/12/2024 at 12:00 p.m., an interview was conducted with S13CNA. S13CNA confirmed that she picked up the paper wrapped straw from the floor and placed it on Resident # 61's tray and delivered it to the resident. S13CNA stated she should have discarded the straw and not given it to the resident. On 03/12/2024 at 12:14 p.m., an interview was conducted with S2DON (Registered Nurse, Director of nursing, Infection Preventionist). S2DON stated the CNAs are in-serviced on infection control, and that S13CNA should not have picked up a straw from the floor, place it on the resident's tray, and deliver the tray to the resident. Based on observations, review of policy and procedure and interviews, the facility failed to store, distribute, and serve food in accordance with professional standards for food service safety by failing to follow appropriate food handling practices as evidenced by: 1. One opened package of bread on the counter not labeled with the date. 2. Food residue noted on the deep fryer and layer of oil and debris noted on the floor underneath the deep fryer. 3. Food storage: A. Walk-in cooler: 1. A container of onion mix not labeled with the date it had been prepared. 2. Two bags of ham opened and placed in a zip log bag not labeled with the date. 3. One bag of lettuce opened and not labeled with the date. 4. Four cucumbers with texture changes indicated the items were spoiled. 4. Failure to distribute food under sanitary conditions for Resident #61. The total amount of residents that ate out of the kitchen was 89 residents. Findings: Review of the facility's policy, Sanitization, last reviewed on 03/2024, revealed in part, the following, Policy Statement: The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation: . 2. Equipment are kept clean . 3. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions . Review of the facility's policy, Refrigerators and Freezers, last reviewed on 03/2024, revealed in part, the following, Policy Statement: This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation and will observe food expirations guidelines. Policy Interpretation and Implementation: . 7. use by dates are indicated once food is opened. On 03/11/2024 at 8:20 a.m., an initial tour of the facility's kitchen was conducted with S4DM (Dietary Manager). S4DM confirmed the above mentioned items were not labeled or dated and should have been, and spoiled items should not be in the walk-in cooler. S4DM stated the deep fryer was last used on 03/08/2024 and it should have been cleaned after it was used and confirmed that oil and debris should not be under the deep fryer and that should have been cleaned. On 03/11/2024 at 2:03 p.m., a follow up observation of the facility's kitchen was conducted with S1ADM (Administrator). S1ADM confirmed that after food items are opened they should be labeled with the date, spoiled food items should not be in the walk-in cooler, the deep fryer should be cleaned after every use and oil and debris should have been cleaned from under the deep fryer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure that charges were not imposed against the personal funds of a resident for personal liability for 1 (#1) out of 5 sampled residents. Findings: Review of Resident #1's record revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, Aphasia, Schizoaffective disorder, Bipolar type, Manic episode, Severe with psychotic symptoms, and Cognitive communication deficit. Review of the resident's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 04, indicating severe cognitive impairment. Reviewed a document titled Provider Decision Letter dated 03/03/2023 which read in part: You must pay part of the cost for your nursing facility/waiver services each month.01/01/2023 - 02/28/2023 monthly amount $1,650.00. Further review revealed payment as of 03/03/2023 - continuing was $1,501.00. Review of a document titled Trust Transaction History dated 03/03/2023 - 05/25/2023 revealed on 03/03/2023 - 03/06/2023 payment from Resident #1's trust was $1,650.00, a $149.00 overture, and on 04/05/2023 - 04/05/2023 resident paid $1,644.40 a $143.40 overture. Review of a document titled A/R (Account Receivable) by Service Date from 01/2023 - 08/2023 did not reveal that Resident #1's account was credited for 03/2023 or 04/2023 withdrawals. On 09/12/2023 at 11:34 a.m., an interview was conducted with S3BA (Business Assistant) who confirmed that Resident #1's account was supposed to be charged $1,501.00, and that the account had not been credited for previous withdrawals on 03/2023 and 04/2023. On 09/13/2023 at 10:50 a.m., during the exit interview, S1ADM (Administrator) confirmed that Resident #1's account had not been credited for the 03/2023 and 04/2023 withdrawals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility's staff failed to notify the resident's representative and/or the resident's physician of a change in the resident's condition for 1 (#1) of 5 (#1 - #5) sampled residents. Findings: Review of the facility's policy, Change in a Resident's Condition or Status revealed in part: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) .The nurse will notify the resident's attending physician on call when there has been a(an): accident or incident involving the resident; discovery of injuries of an unknown source; .need to transfer the resident to a hospital/treatment center; .specific instruction to notify the physician of changes in the resident's condition .a nurse will notify the resident's representative when: the resident is involved in any accident or incident that results in any injury including injuries of an unknown source; there is a significant change in the resident's physical, mental, or psychosocial status .it is necessary to transfer the resident to a hospital/treatment center .Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. Resident #1 Review of Resident #1's medical record revealed she was admitted on [DATE]. The resident had diagnoses including Alzheimer's disease, Peripheral vascular disease, Moderate protein-calorie malnutrition, and Schizoaffective disorder, Bipolar type. Review of the resident's quarterly MDS (Minimum Data Set) dated 06/13/2023 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 04, indicating severe cognitive impairment. Review of the resident's care plan revealed the resident had a responsible party (RP) that should be notified of any changes in the resident's condition and of any new orders. On 09/12/2023 at 7:40 a.m., an observation of Resident #1 was conducted with S4TX (Treatment Nurse) which revealed a reddened area to the right inner ankle. S4TX palpated the area, and the resident denied any pain at that time. S4TX stated that she had not observed this change before, and added that she would notify the physician. On 09/13/2023 at 9:02 a.m., an observation of Resident #1's electronic record was conducted with S2ADON (Assistant Director of Nursing). S2ADON was asked if any new orders were written for the resident, and she stated that no new orders were written on 09/12/2023. Observation of the nurse's notes did not reveal any documentation of a new wound or skin changes on 09/12/2023. Review of skin assessment did not reveal any documentation of new skin issues on 09/12/2023. Further observation and interview was conducted with S2ADON, who observed the reddened area to Resident #1's right inner ankle. Upon palpation, the resident withdrew her leg away from S2ADON. S2ADON asked the resident if the area was painful. The resident stated yes, the area was painful. S2ADON confirmed that S4TX should have notified the physician, documented the finding in the nurse's notes, and notified the resident's responsible party. On 09/13/2023 at 9:24 a.m., an interview was conducted with S4TX who confirmed that she did not notify the physician, document the change in condition, or notify the resident's responsible party, and that she should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to ensure a resident who was unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 2 (#2, #4) of 5 (#1- #5) residents reviewed for ADLs. The facility failed to provide baths/showers for Resident #2, and #4. Findings: Review of a facility document titled Bath, Shower/Tub read in part: Documentation: 1. Date and time the shower/tub bath was performed 2. Name and title of the individual(s) who assisted the resident. 5. If the resident refused, the reason why and intervention taken. Reporting: 1. Notify the supervisor if resident refuses the shower/tub bath. Review of Resident #2's clinical record revealed he was admitted on [DATE] and had diagnoses of Blindness of the right eye, Diabetes Mellitus, Chronic kidney disease, stage 3, Atherosclerotic heart disease, and Dementia. Review of Resident's care plan dated 12/15/2022 read in part, ADL self-care performance deficit related to Dementia with interventions that included bathing/showering, physical assist required. Review of Resident's Minimum Data Set (MDS) dated [DATE] read in part: Brief Interview for Mental Status (BIMS) score of 04 which indicated severe cognitive impairment. Functional status - personal hygiene requires extensive assistance with one person assist. Review of a facility document titled Shower Schedule which revealed Resident #2's bath/shower days were on Tuesday's, Thursday's, and Saturday's. Review of a facility document titled Documentation Survey Report v2 dated 07/2023 - 09/11/2023 revealed that on 07/06/2023, 07/11/2023, 07/14/2023, 07/15/2023, 08/24/2023, and 09/05/2023 Resident #2 did not receive a bath/shower. On 09/12/2023 at 2:00 p.m., an interview was conducted with S2ADON (Assistant Director of Nursing) who confirmed that on the above listed days, Resident #2 did not receive a bath/shower per his bath schedule nor was there documentation that Resident #2 refused a bath/shower. Resident #4 Review of Resident #4 electronic record revealed an admit date of 01/18/2023 with diagnoses including Portal hypertension, Cirrhosis of liver, Metabolic encephalopathy, and Alcohol dependence. Review of Resident's care plan dated 02/02/2023 read in part, ADL self-care performance deficit related to Dementia with intervention that included bathing/showering assist with one person assist. Review of Resident's Minimum Data Set (MDS) dated [DATE] read in part: Brief Interview for Mental Status (BIMS) score of 05 which indicated severe cognitive impairment. Functional status - personal hygiene requires oversight, encouragement or cueing, with setup assistance only. Review of a facility document titled Shower Schedule which revealed Resident #4's bath/shower days were on Monday's, Wednesday's, and Friday's. Review of a facility document titled Documentation Survey Report v2 dated 07/2023 - 09/11/2023 revealed that on 07/10/2023, 07/12/2023, 07/14/2023, 07/17/2023, and 07/19/2023 Resident #4 did not receive a bath/shower per his bath schedule. On 09/12/2023 at 2:00 p.m., an interview was conducted with S2ADON who confirmed that on the above listed dates, the resident did not receive his bath/shower as scheduled nor was there documentation that Resident #4 refused a bath/shower.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure appropriate nursing competencies to assure resident safety and maintain the highest practicable physical well-being for one (#1) of 5 (#1- #5) sampled residents. Findings: Review of a facility document titled Prevention of Pressure injuries read in part: Skin Assessment - 3. Inspect the skin on a daily basis when performing or assisting with personal care or Activities of Daily Living (ADL's). a. identify any signs of developing pressure injuries (i.e non blanchable skin). Monitoring: 1. Evaluate, report and document potential changes in the skin. Review of Resident #1's medical record revealed he was admitted on [DATE] with diagnoses including Alzheimer's disease, Aphasia, Schizoaffective disorder, Bipolar type, Manic episode, Severe with psychotic symptoms, Peripheral vascular disease, and Cognitive communication deficit. Review of the resident's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 04, indicating severe cognitive impairment. Review of a facility document titled Documentation Survey Report v2 dated 08/01/2023 - 08/23/2023 read in part: Skin Observation which did not reveal any skin issues during this time. Review of nurses notes dated 08/23/2023 at 8:05 p.m. which read in part, that Resident #1's daughter was upset that she had which she referred to as a burn on her left and right upper thigh. Review of physician orders dated 09/2023 read in part: New wounds: yes or no, every day shift, every Sunday. Document any abnormal findings in nurse's notes. Review of a document titled Skin Only Evaluation dated 08/24/2023 read in part: right anterior thigh small dry scabbed area. Band aid applied. Left anterior thigh small round brown discolored area noted. Further review revealed right thigh measured 0.5 cm (centimeter) x 1 x 0, and the left thigh 0.4 cm x 0.4 cm. Review of Resident #1's Medication Administration Record (MAR) dated 08/2023 did not reveal any new wounds or skin abnormalities were observed during weekly skin assessments. On 09/11/2023 at 1:00 p.m., a phone interview was conducted with Resident #1's daughter, who stated that on 08/23/2023 while visiting she observed two marks on the residents left and right upper thighs. She stated that the marks looked like burn marks. On 09/12/2023 at 7:40 a.m., an interview was conducted with S4TX (Treatment Nurse) who stated that she was informed of the wound on Resident #1 on 08/24/2023, and that is when she completed her assessment. On 09/12/2023 at 1:00 p.m., an interview was conducted with S4CNA (Certified Nursing Assistant) who stated that she had been working with Resident #1 for approximately three months. S4CNA stated that when she observed the wounds on the right and left thigh, they were not opened, and so she did not report it to the nurse. On 09/12/2023 at 2:31 p.m., an interview was conducted with S6LPN (License Practical Nurse) who stated that she was not aware that the resident had a wound on her thighs. On 09/12/2023 at 3:18 p.m., a follow up interview was conducted with S2ADON (Assistant Director of Nursing) who confirmed that the wound was not identified by staff and documented. She confirmed that in order for a scab to develop, then at some point the wound was opened and no one identified it and they should have.

Based on record review, and interview the facility failed to provide quarterly statements for resident personal funds for 1 (#1) resident out of 1 resident (#1) reviewed for personal funds. Findings: Resident #1 MDS (Minimum Data Set) dated 06/13/2023 revealed that a Brief Interview for Mental Status (BIMS) score of 04 which indicated severe cognitive impairment. Review of the facility's policy titled Resident Trust Fund revealed, in part: Policy Interpretation and Implementation: 4. Quarterly statements reflecting the interest earned and balance of the account are to be mailed to all residents and or responsible party. Review of Resident #1's Medical Chart revealed her daughter as the Responsible Party (RP). During a phone interview on 09/11/2023 at 1:00 p.m., Resident #1's daughter stated that she and her sister who is the responsible party, were not aware of how much the resident pays monthly for services. She stated that when she asked S3BA (Business Assistant) about the resident's bank statement, she was told she couldn't receive that information. During an interview on 09/12/2023 at 8:10 a.m., an interview was conducted with S3BA (Business Assistant) who stated that she had spoken with Resident #1's daughters and explained that they need to obtain a Power of Attorney (POA) before they could receive the quarterly financial statements. S3BA confirmed that she had not sent out any quarterly financial statements to the resident's responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to implement care plan interventions for 1 (#2) of 4 (#1, #2, #3, #5) residents investigated for falls in a sample of 6 (#1, #2, #3, #4, #5, #R1) residents. Findings: Review of Resident #2's record revealed she was admitted to the facility on [DATE]. The resident had diagnoses including Amnesia, Systemic Lupus Erythematosus, Anxiety disorder, age related Osteoporosis, overactive bladder, Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominate side, and a fracture of the upper end of left humerus on 07/11/2023. The resident also had impaired visual function related to blindness. Review of the resident's significant change MDS (Minimum Data Set) dated 7/18/2023 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 7, indicating her cognition was severely impaired. The resident had impairment on one side of her upper and lower extremities. She required limited one person assistance for bed mobility; and extensive one person physical assistance for transfers, walking in room, and toileting. Her balance was not steady when moving from seated to standing position, turning around and facing the opposite direction while walking, moving on and off toilet, surface to surface transfers between bed and chair or wheelchair. She was only able to stabilize her balance with staff assistance. Review of the facility's incidents/accidents June 2023 - August 2023 revealed Resident #2 had a fall on 06/27/2023 and 06/28/2023. Review of Resident #2's progress notes and fall incident reports revealed the resident fell on [DATE] because the resident ambulated and transferred herself to the toilet without staff assistance. On 06/28/2023 Resident #2 had an unwitnessed fall. Resident #2 reported to staff, I was trying to get back in my chair and I fell. Review of Resident #2's care plan revealed the resident ambulated and transferred without staff assistance and fell on [DATE], 03/27/2023, 06/27/2023 and 06/28/2023. Further review revealed the resident was at risk for falls and needed a safe environment .bed at lowest locked position. On 08/14/2023 at 11:53 a.m., an observation was made of Resident #2 in her room lying in bed. Her bed was not observed in lowest position. Resident #2 said that she got out of bed a few times without calling staff for help and ended up falling. On 08/14/2023 at 12:04 p.m., S6CNA (Certified Nursing Assistant) entered Resident #2's room and fed the resident lunch. After finishing meal service, S6CNA exited the resident's room and left the resident's door open. The resident's bed was observed high off the floor. On 08/14/2023 at 12:13 p.m., an interview was conducted with S6CNA. S6CNA stated that Resident #2 was at risk for falls because the resident was visually impaired. She stated that although Resident #2 needed staff assistance with ambulation and transfers, the resident was able to get out of her bed on her own. She observed Resident #2's bed height and confirmed it was not in the lowest position. On 08/14/2023 at 12:52 p.m., S12CNA stated that Resident #2 would not call for staff assistance for ambulation and transfers. Resident #2 had impaired memory and was not always cognitive. She would have her roommate, who was also her sister, assist her with walking and transferring, resulting in multiple falls. She stated that Resident #2 was mobile in bed and able to roll and reposition herself without assistance. On 08/14/2023 at 01:22 p.m., another observation was made of Resident #2 lying in her bed high off the floor. On 08/14/2023 at 03:26 p.m., an interview was conducted with Resident #2's nurse S3LPN (Licensed Practical Nurse). S3LPN stated that Resident #2 was weak on her left side and required staff assistance for walking and transfers. She stated that Resident #2 had multiple falls in the facility because she would get out of bed without staff assistance and transfer with assistance from her roommate. An observation of Resident #2 was conducted with S3LPN at this time. Resident #2 was observed lying in her bed with her sister in the room. Resident #2's bed was not in a low position. S3LPN stated that Resident #2's bed was high off the floor and that it should not be that high. She confirmed that the resident's bed should be in the lowest position for her safety to prevent her from falling. On 08/15/2023 at 03:24 p.m., an interview was conducted with S2ADON (Assistant Director of Nursing) who reviewed Resident #2's care plan. She confirmed that the resident had multiple falls in the facility and acknowledged care plan indicated that bed was to be at lowest position. S2ADON stated that staff should monitor to ensure the resident's bed remains in the lowest position at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident was administered pain medication as ordered for 1 (#2) of 6 (#1-#5, #R1) sampled residents. Findings: Review of Resident #2's record revealed she was admitted to the facility on [DATE]. The resident had diagnoses including Amnesia, Systemic Lupus Erythematosus, Anxiety disorder, age related Osteoporosis, overactive bladder, Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominate side. She also had impaired visual function related to blindness. The resident was diagnosed with a fracture of the upper end of left humerus on 07/11/2023. Review of the resident's physician orders revealed an order dated 02/06/2023 assess and document resident's pain level q (every) shift. Review of the facility's Standing Orders revealed in part, Pain: Acetaminophen 325 mg (milligrams) take 2 tabs by mouth every 6 hours PRN (as needed) for mild pain . Review of Resident #2's MAR (Medication Administration Record) for July 2023 S3LPN (Licensed Practical Nurse) documented the resident reported a pain level of 5 out of 10 on 07/07/2023 pain. Further review of the MAR revealed no evidence that Resident #2 was administered Tylenol. On 08/15/2023 at 5:03 p.m., an interview and review of Resident #2's record was conducted with S3LPN. She stated that Resident #2 complained of pain in her left arm 5 out of 10 on 07/07/2023. She stated that she could not recall if she administered Tylenol and confirmed there was no evidence in the resident's medical record that Tylenol was administered on 07/07/2023. On 08/15/2023 at 5:18 p.m., an interview and review of Resident #2's record was conducted with S1DON (Director of Nursing) and S2ADON (Assistant Director of Nursing). S2ADON stated that nurses should follow and implement the physician's standing orders for pain medicine if resident is in pain. S1DON confirmed that according to Resident #2's record, the resident complained of pain 5 out of 10 on 07/07/2023. She confirmed there was no documentation in the resident's record that Resident #2 received any Tylenol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility's staff failed to notify the resident's representative and/or the resident's physician of a change in the resident's condition for 4 (#1, #2, #4, #R1) of 6 (#1-#5, #R1) residents in a final sample of 6 residents by failing to: 1. Immediately inform the resident's (#1) representative of a fall with injury which resulted in the resident having to be transferred to the hospital for evaluation; 2. Immediately inform the resident's (#4) representative that the resident was transferred to the hospital and admitted inpatient to the hospital for abnormal labs; 3. Immediately inform the resident's (#R1) representative of abnormal lab results and of a new medication order; and 4. Immediately inform the resident's (#2) physician when the CNA (Certified Nurse Assistant) reported to the nurse on 07/07/2023 a bruise of unknown origin and the resident's complaint of pain to her left arm. This deficient practice has the potential to affect all the residents residing in the nursing facility. The total census was 85. Findings: Review of the facility's policy, Change in a Resident's Condition or Status revealed in part: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) .The nurse will notify the resident's attending physician on call when there has been a(an): accident or incident involving the resident; discovery of injuries of an unknown source; .need to transfer the resident to a hospital/treatment center; .specific instruction to notify the physician of changes in the resident's condition .a nurse will notify the resident's representative when: the resident is involved in any accident or incident that results in any injury including injuries of an unknown source; there is a significant change in the resident's physical, mental, or psychosocial status .it is necessary to transfer the resident to a hospital/treatment center .Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. Resident #1 Review of Resident #1's record revealed he was admitted to the facility on [DATE]. The resident had diagnoses including Parkinson's disease, Anxiety disorder, Post Traumatic Stress Disorder, Dysphagia, and Bipolar disorder. Resident #1 was on hospice and received enteral tube feedings. Review of the resident's quarterly MDS (Minimum Data Set) dated 08/04/2023 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 0, indicating resident was rarely/never understood. Review of the resident's care plan revealed the resident had a responsible party (RP) that should be notified of any changes in the resident's condition and of any new orders. Review of Resident #1's progress notes revealed in part: On 08/05/2023 at 14:15 (2:15 p.m.) the CNA (Certified Nursing Assistant) found Resident #1 on the floor and called the nurse to the resident's room. The nurse and CNA assisted the resident off the floor and sat him on his bed. The resident's lip was busted; he was bleeding from lip and teeth. The resident's front tooth was loose. Hospice was notified who ordered to have the resident transferred to the hospital. The progress note further revealed that the hospice nurse would notify Resident #1's RP. There was no documentation of the facility's nurse attempt to contact the resident's RP. The ambulance arrived at facility and left with the resident at 1515 (3:15 p.m.) Progress note dated 08/06/2023 at 22:12 (10:12 p.m.) revealed, late entry-patient's family arrived and was unaware of his condition, stated that hospice did not call them about his fall . Review of Resident #1's grievances revealed the resident's RP phoned the facility on 08/07/2023 to report that no one called her to report that Resident #1 fell and was transported to the ER (emergency room). Review of the follow-up note revealed in part that staff should call the family as well as hospice. Resident #4 Review of Resident #4's record revealed he was admitted to the facility on [DATE]. The resident had diagnoses including weakness and Alzheimer's disease. He was diagnosed with Hyperosmolality and Hypernatremia on 06/01/2023. Review of the resident's quarterly MDS dated [DATE] revealed the resident had a BIMS score indicated he was rarely/never understood. Review of the resident's care plan revealed the resident had a responsible party (RP) that should be notified of any changes in the resident's condition and of any new orders. Review of the facility's transfer logs revealed Resident #4 was transported and admitted inpatient to the hospital on [DATE] for abnormal lab values, sodium 160. (Normal level 135-145) Review of the resident's progress notes revealed in part: 05/25/2023 at 13:53 (1:53 p.m.) Resident is cold and clammy. Refusing to eat and drink. New orders to send to hospital for evaluation. Further review revealed that on 05/25/2023 at 2:18 p.m., the resident was transported to the hospital and returned from the hospital on [DATE] where he was treated for hypernatremia. Review of Resident #4's grievances revealed the resident's RP phoned the facility on 06/02/2023 to report that she was not notified when Resident #4 was sent to the hospital. Review of the investigation for the grievance revealed in part that the resident's nurse and oncoming shift nurse were busy getting paperwork together for the resident's transfer. Both nurses reported they had not notified the resident's RP of the resident's impending transfer to hospital. Further review of the follow-up notes revealed in part that it was the facility's policy that family be notified of a change in resident's status. On 08/15/2023 at 10:20 a.m. an interview and review of Resident #1 and #4's grievances was conducted with S1DON (Director of Nursing). S1DON stated the resident's RP must be notified of changes in the resident's status. A change in status included changes in medications, new physician orders, changes in resident physical conditions, especially when the resident requires evaluation at the hospital. Unless the issue is life threatening, the family should be notified before completing transfer paperwork. If the issue occurs at shift change both nurses are responsible for verifying that the family was notified. If a resident is hospice, it is the facility's nurses' responsibility to notify the family. She confirmed that even though the resident's nurse expected hospice to notify Resident #1's RP of the incident, Resident #1's nurse should have called the RP. She confirmed the nurses failed to notify Resident #4's RP of his fall and hospital transfer. Resident #R1 Review of Resident #R1's record revealed he was admitted to the facility on [DATE]. The resident had diagnoses including, Chronic atrial fibrillation, Hypertension, Type 2 diabetes mellitus, slurred speech, anemia, BPH (benign prostatic hyperplasia), and cerebral infarction d/t embolism of basilar artery. He was diagnosed with Acute kidney failure on 06/03/2023. Further review of the resident's record revealed his family member was listed the RP and as having POA (power of attorney) for care. Review of the resident's care plan revealed the resident had a responsible party (RP) that should be notified of any changes in the resident's condition and of any new orders. Review of the resident's progress notes revealed in part: 05/21/2023 14:00 (2:00 p.m.) resident stated that he had blood in his urine .doctor ordered a C&S (urine culture and sensitivity) . 05/21/2023 21:36 (9:36 p.m.) Resident now complaining of pain in his left side .Urine sample has been collected . Review of the resident's urinalysis result revealed the specimen was collected on 05/21/2023, received 05/22/23 verified/printed on 05/25/2023. Urine culture noted abnormal values. A progress note dated 05/25/2023 14:45 (2:45 p.m.) revealed an order entered for Bactrim DS oral tablet 800-160 mg 1 tablet by mouth two times a day for UTI (urinary tract infection) for 7 days. Further review of the resident's progress notes revealed no documentation of notifications to the RP of the resident's urine test results and that resident prescribed an antibiotic to treat his UTI. Review of Resident #4's grievances revealed his RP emailed a complaint to the facility on [DATE] stating that she was not being informed when there were medication changes or tests completed or with the test results. Review of the attached email from the RP read in part, Why am I not being called by certain people when something goes on with him. Also I don't appreciate his nurse not calling me back about his urine test that was drawn .But again I'm not being notified when he has a med change or a test done . On 08/15/2023 at 11:50 a.m., another interview was conducted with S1DON. She reviewed Resident #R1's grievance, lab results, and progress notes. She confirmed the resident's urine test was collected on 05/21/2023 and resulted and faxed to facility on 05/25/2023. She confirmed there was no evidence in the resident's record that the nurse notified the resident's RP of the urine test results once results were made available to facility. S1DON confirmed Resident #R1 was prescribed Bactrim for a UTI and that the nurse should have informed the resident's RP of the new medication the resident was ordered. Resident #2 Review of Resident #2's record revealed she was admitted to the facility on [DATE]. The resident had diagnoses including Amnesia, Systemic Lupus Erythematosus, Anxiety disorder, age related Osteoporosis, overactive bladder, Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominate side. She also had impaired visual function related to blindness. The resident was diagnosed with a fracture of the upper end of left humerus on 07/11/2023. Review of the resident's significant change MDS (Minimum Data Set) dated 07/18/2023 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 7, indicating her cognition was severely impaired. Review of the resident's incident investigation report dated 07/11/2023 revealed in part that the resident was complaining of pain to the left arm. Bruising was noted over entire upper left arm. An x-ray was done and showed the resident had a fracture in the neck of the humerus. The resident was taken to ER. A SIMS (Statewide Incident Management System) report and investigation was initiated for an injury of unknown origin. Review of the MAR (Medication Administration Record) for July 2023 revealed the resident reported pain 9 out of 10 on 07/06/2023; pain 5 out of 10 on 07/07/2023; pain 5 out of 10 and pain of 10 out of 10 on 07/10/2023. Review of the staff witness statements obtained as part of the facility's investigation into Resident #2's injury of unknown origin revealed in part: No date/time - S10CNA - reported she noticed bruise on Resident #2's arm when she returned to work on Friday 07/07/2023. She reported it to the nurse. On Saturday 07/08/2023 she stated she reported to S4LPN that resident was having arm pain. No date/time - S11CNA - reported that resident #2 had bruise on her left arm when she cared for her on Saturday 07/08/2023. No date/time - S9CNA -reported she noticed a bruise on Resident #2's arm on Sunday 07/09/2023 and reported it to S4LPN. She stated that on Monday 07/10/2023 the resident told her the pain in her arm was much worse. No date/time - S4LPN - reported that Resident #2 wanted to stay in bed because her tail bone hurt. She didn't feel that resident's complaint of pain was unusual since the resident frequently had generalized pain. Review of S3LPN's witness statement dated 07/11/2023 revealed S3LPN reported the CNAs reported to her that Resident #2 complained of severe pain to her left arm. The doctor was notified and a portable xray was done. Review of the resident's progress notes revealed no documentation that the physician was notified of the resident's condition when it was discovered by S10CNA on 07/07/2023. On 08/15/2023 at 10:20 a.m., an interview was conducted with S1DON who stated when a resident has an incident or accident, nurses must notify the doctor. A change in status included changes in resident physical conditions, especially when the resident requires evaluation at the hospital. On 08/15/2023 at 04:20 p.m., a phone interview was conducted with S10CNA who stated that on Friday 07/07/2023 she worked the 2p-10p shift. She stated she noticed Resident #2 had a dark purple bruise to her left upper arm. Resident #2 complained of pain so she reported bruise and complaint of pain to S4LPN. S10CNA said on Saturday 07/08/2023 Resident #2 complained of arm pain and she reported it to S4LPN. Phone interview attempted with S4LPN was unsuccessful. On 08/15/2023 at 4:44 p.m., a phone interview was conducted with S5LPN who stated that she worked on Monday 7/10/23 she was passing resident's med and resident stated to her that her arm was hurting. Resident #2 had not previously complained of any pain. She stated she did not assess the resident's arm and she did not notify the physician at that time. On 08/15/2023 at 5:03 p.m., an interview and review of Resident #2's record was conducted with S3LPN. She stated the resident complained of pain in her left arm on 07/06/2023 and on 07/07/2023 on her shift. She further stated that Resident #2's complaint of pain was not typical of her. She stated that she did not assess the resident's arm or call the physician to report this change in her condition. S3LPN stated that she should have assessed the resident's arm and notified the physician on 07/06/2023. She stated that she did not report the resident's pain to the physician until 07/10/2023. An x-ray done on 07/11/2023 found the resident had a fractured left arm. On 08/15/2023 at 05:18 p.m., an interview and review of Resident #2's record was conducted with S1DON and S2ADON. They both confirmed that the resident's report of pain began on 07/06/2023. They read the witness statements and confirmed that S10CNA reported to S4LPN that Resident #2 had a bruise and was complaining of pain in her left arm on 07/07/2023. They further confirmed that there was no evidence that the nurse reported this to the physician. S1DON confirmed that the resident continued to complain of arm pain with multiple staff observing and reporting a bruise to the nurse. S1DON stated that an x-ray was done on 07/11/2023, which showed the resident had a fractured left arm. She confirmed that the nurse should have immediately reported the resident's change in condition to the physician immediately upon discovery.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assess, document and report the resident's condition which resulted in a delay in the resident's transfer to the hospital for treatment of an injury of unknown source for 1 (#2) of 6 (#1-#5, #R1) sampled residents. Findings: Review of the facility's policy, Acute Condition Changes - Clinical Protocol revealed in part: The nurse shall assess and document/report the following baseline information: .current level of pain, and any recent changes in pain level; onset, duration, severity; .and all current medications. Direct care staff including nursing assistants will be trained in recognizing subtle but significant changes in the resident for example .changes in skin color or condition and how to communicate these changes to the nurse. The nursing staff will contact the physician based on the urgency of the situation. Staff will monitor and document the resident's progress and responses to treatment and the physician will adjust accordingly. Review of the facility's policy, Change in a Resident's Condition or Status revealed in part: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) .The nurse will notify the resident's attending physician on call when there has been a(an): accident or incident involving the resident; discovery of injuries of an unknown source; .need to transfer the resident to a hospital/treatment center; .specific instruction to notify the physician of changes in the resident's condition .a nurse will notify the resident's representative when: the resident is involved in any accident or incident that results in any injury including injuries of an unknown source; there is a significant change in the resident's physical, mental, or psychosocial status .it is necessary to transfer the resident to a hospital/treatment center .Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. Review of Resident #2's record revealed she was admitted to the facility on [DATE]. The resident's diagnoses included Amnesia, Systemic Lupus Erythematosus, Anxiety disorder, age related Osteoporosis, overactive bladder, Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominate side. She also had impaired visual function related to blindness. The resident was diagnosed with a fracture of the upper end of left humerus on 07/11/2023. Review of the resident's significant change MDS (Minimum Data Set) dated 07/18/2023 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 7, indicating her cognition was severely impaired. Review of the resident's incident investigation report dated 07/11/2023 revealed in part that the resident was complaining of pain to the left arm. Bruising was noted over entire upper left arm. An x-ray was done and revealed the resident had a fracture in the neck of the humerus. The resident was taken to ER (Emergency Room). A report to the State Agency and investigation was initiated for an injury of unknown origin. Review of the MAR (Medication Administration Record) for July 2023 revealed the resident reported pain 9 out of 10 on 07/06/2023; pain 5 out of 10 on 07/07/2023; pain 5 out of 10 and pain of 10 out of 10 on 07/10/2023. Review of the staff witness statements obtained as part of the facility's investigation into Resident #2's injury of unknown origin revealed in part: No date/time - S10CNA - reported she noticed bruise on Resident #2's arm when she returned to work on Friday 07/07/2023. She reported it to the nurse. On Saturday 07/08/2023 she stated she reported to S4LPN that resident was having arm pain. No date/time - S11CNA - reported that resident #2 had bruise on her left arm when she cared for her on Saturday 07/08/2023. No date/time - S9CNA -reported she noticed a bruise on Resident #2's arm on Sunday 07/09/2023 and reported it to S4LPN. She stated that on Monday 07/10/2023 the resident told her the pain in her arm was much worse. No date/time - S4LPN - reported that Resident #2 wanted to stay in bed because her tail bone hurt. She didn't feel that resident's complaint of pain was unusual since the resident frequently had generalized pain. Review of S3LPN's witness statement dated 07/11/2023 revealed S3LPN reported the CNAs reported to her that Resident #2 complained of severe pain to her left arm. The doctor was notified and a portable x-ray was done. Review of the Resident's progress notes revealed no documentation of any nursing assessments on the resident's arm. There was no documentation that the physician was notified of the resident's condition when it was discovered by S10CNA on 07/07/2023. On 08/15/2023 at 10:20 a.m., an interview was conducted with S1DON who stated when a resident has an incident or accident, nurses must notify the doctor. A change in status included changes in resident physical conditions, especially when the resident requires evaluation at the hospital. On 08/15/2023 at 04:20 p.m., a phone interview was conducted with S10CNA who stated that on Friday 07/07/2023 she worked the 2p-10p shift. She stated she noticed Resident #2 had a dark purple bruise to her left upper arm. Resident #2 complained of pain so she reported bruise and complaint of pain to S4LPN. S10CNA stated that on Saturday 07/08/2023 Resident #2 complained of arm pain and she reported it to S4LPN. Phone interview attempt with S4LPN was unsuccessful. On 08/15/2023 at 4:44 p.m., a phone interview was conducted with S5LPN who stated that she worked on Monday 7/10/2023. S5LPN stated she was passing resident's medicine and resident stated to her that her arm was hurting. S5LPN stated that she did not assess the resident's arm and she did not notify the physician at that time. On 08/15/2023 at 5:03 p.m., an interview and review of Resident #2's record was conducted with S3LPN. She stated the resident complained of pain in her left arm on 07/06/2023 and 07/07/2023 on her shift. She further stated that Resident #2's complaint of pain was not typical of her. She stated that she did not assess the resident's arm or call the physician to report this change in her condition. S3LPN stated that she should have assessed the resident's arm and notified the physician on 07/06/2023. She stated that she did not report the resident's pain to the physician until 07/10/2023. An x-ray was done on 07/11/2023. The x-ray results found the resident had a fractured left arm. On 08/15/2023 at 05:18 p.m., an interview and review of Resident #2's record was conducted with S1DON and S2ADON. They both confirmed that the resident's report of pain began on 07/06/2023. They read the witness statements and confirmed that S10CNA reported to S4LPN that Resident #2 had a bruise and was complaining of pain in her left arm on 07/07/2023. They further confirmed that there was no evidence that the nurse reported this to the physician. S1DON confirmed that the resident continued to complain of arm pain with multiple staff observing and reporting a bruise to the nurse. S1DON stated that an x-ray was done on 07/11/2023, which revealed the resident had a fractured left arm. She stated that had the nurse notified the physician on 07/07/2023 after S10CNA reported the resident's condition, the resident could have received treatment for her broken arm sooner. S1DON confirmed the nurses failed to assess, document and report Resident#2's change in condition.

Based on record review and interview, the facility failed to ensure the agency CNAs (Certified Nursing Assistants) demonstrated competency in skills and techniques necessary to care for residents' needs, such as transfers described in the residents' plan of care for 2 out of 2 (S4CNA, S5CNA) agency personnel records reviewed. Findings: Review of S4CNA's personnel record revealed that she was an agency CNA. There was no date of hire noted in the CNA's personnel record. The CNA's personnel record had a CNA Skills Checklist that revealed, Check if you are experienced in the following . The document was dated 3/31/2023. There was a list of skills with check marks next to the skills that included have been trained and know how to properly use a lift. There was no evidence that the agency CNA had demonstrated those skills. Review of S5CNA's personnel record revealed that she was an agency CNA. There was no date of hire noted in the CNA's personnel record. The CNA's personnel record had a CNA Skills Checklist that revealed, Check if you are experienced in the following . The document was dated 12/21/2021. There was a list of skills with check marks next to the skills that included have been trained and know how to properly use a lift. There was no evidence that the agency CNA had demonstrated those skills. On 5/23/2023 at 1:05 p.m., an interview was conducted with S2ADON (Assistant Director of Nurses). S2ADON stated that the agency CNAs have their own skills checklist from the agency. S2ADON reviewed the skills checklist and confirmed that it did not provide evidence the CNAs demonstrated that they were competent in performing those skills. On 5/24/2023 at 8:17 a.m., an interview was conducted with S1DON (Director of Nurses). She reviewed the agency CNAs skills checklist and confirmed that it did not provide evidence the CNAs demonstrated that they were competent in performing those skills.

Based on record review and interview, the facility failed to provide evidence that ongoing monitoring or evaluations were being done to ensure the corrective actions put in place during an in-service for proper transfers with a mechanical lifter were implemented. The facility identified that 24 residents out of a census of 91 residents required a mechanical lifter for transfers. Findings: Review of the facility's in-service documents revealed that the nursing staff/CNAs (Certified Nursing Assistants) were in-serviced on transfers on 4/3/2023 and in-serviced on lifter use and transfers on 5/5/2023. There was no evidence that monitoring or evaluations were being done to ensure the nursing staff/CNAs were performing the transfers properly. On 5/23/2023 at 1:05 p.m., an interview was conducted with S2ADON and S3LPN (Licensed Practical Nurse). They stated the facility conducted several in-services on transfers and the use of the mechanical lifter. S2ADON and S3LPN stated they did not have any evidence of monitoring, QA (Quality Assurance), or audits to ensure the nursing staff/CNAs, employed or agency, were implementing the use of the mechanical lifter with 2 person assist for transfers for the residents that were assessed and care planned for them. On 5/24/2023 at 8:17 a.m., an interview was conducted with S1DON. S1DON confirmed that there was no evidence that monitoring and QA was being done to ensure the nursing staff/CNAs, employed or agency, were implementing the use of the mechanical lifter with 2 person assist for transfers for the residents assessed and care planned for them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and interview, the facility failed to protect residents from abuse for 1 resident (Resident #59) out of 1 residents investigated for abuse out of 23 sampled residents. Findings: Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program read in part: Residents have the right to be free from abuse, neglect .This includes but is not limited to freedom from . verbal, mental . or physical abuse 1. Protect residents from abuse, neglect . by anyone including but not necessarily limited to: a. facility staff; e. staff from other agencies . 4. Conduct employee background checks . Resident #59 was admitted to the facility on [DATE] with diagnoses in part: Dementia, Cognitive Communication Deficit, Depression, Anxiety, and Diabetes. Review of Resident #59's Plan of Care revealed Resident #59's daughter elected to have a monitoring device in her room while living at the facility. The system recorded visual and audio feed. Further review of Resident's Plan of Care revealed the Resident had a language barrier and communicated via Spanish. Review of Resident #59's most recent MDS (Minimum Data Set), dated 01/14/2023, revealed the Resident had a BIMS (Brief Interview for Mental Status) of 8 indicating moderately impaired cognition. On 02/27/2023 at 12:12 p.m., an interview was conducted with Resident #59's daughter who stated she watched video footage from her mother's room and heard one of the CNAs (Certified Nursing Assistant) tell her mom that if she pinched her, she would pinch her back. This incident happened within the last week. She was not sure of who the two CNAs were in the room, but had not seen either CNA since then. She further stated that she would notify the facility's administrator of the incident as she felt it was not appropriate even though her mother did not understand. Resident #59 was seated at the dining room table at this time. The Resident spoke Spanish with her daughter who then stated she did not feel that her mother was scared of the CNA or scared to be at the facility after the incident. A review of footage from the monitoring device in Resident #59's room revealed that on 2/21/2023 at 7:00 a.m., S8CNA and S9CNA were in the Resident's room providing ADL (Activities of Daily Living) care for the Resident. S8CNA was standing in front of the Resident as she sat on the bed, and S9CNA was standing on the right side of the Resident. S8CNA then bent down and was eye level with Resident #59. She then pointed in the Resident's face and said to her, Don't pinch me. I will pinch you back! in a chastising manner. Resident #59 did not respond. S8CNA and S9CNA then proceeded to transfer Resident #59 to the chair, and began removing linen from the Resident's bed. The video ended. On 02/28/2023 at 10:15 a.m., S1Administrator stated that she received and reviewed the video footage from Resident #59's daughter on 2/28/2023 and the 2 CNAs in Resident #59's room at the time of the incident were S8CNA (agency CNA) and S9CNA (staff CNA). She stated that S8CNA told the Resident that she would pinch her back. S2DON (Director of Nursing) counselled the staff CNA about reporting what the other CNA said to Resident #59. On 02/28/2023 at 10:22 a.m. an interview was conducted with S2DON (Director of Nursing). S2DON stated that the 2 CNAs who were seen on the video footage and provided care for Resident #59 were S8CNA, who was an agency CNA and S9CNA who was a staff CNA. The video footage from Resident #59's room was then reviewed with the S2DON. The time stamp on the video was 2/21/2023 at 7:00 a.m S8CNA and S9CNA were seen on the video providing care for Resident #59. As Resident #59 was sitting on the bed, S8CNA bent down, pointed at Resident #59's face and said to her, Don't pinch me. I will pinch you back! The video then ended. S2DON stated that it was inappropriate for S8CNA to point in Resident #59's face and to tell her that she would pinch her back. On 02/28/2023 at 1:52 p.m., a phone interview was conducted with S8CNA. S8CNA stated that on the morning of 02/21/2023, she and S9CNA were changing Resident #59 and as they were about to transfer her to the chair, Resident #59 pinched her really hard on her leg. S8CNA stated she moved her arm from under the Resident's arm, and she pointed at her in her face and told her not to pinch her and she would pinch her back. She further stated that she did that because Resident #59 speaks Spanish and she wanted her to understand that it wasn't okay for her to pinch her. S8CNA stated that she knew she should have refrained from pointing in her face and telling Resident #59 that she would pinch her back.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interviews, the facility failed to ensure staff report alleged staff-to-resident verbal abuse to the administrator for 1 resident (#59) out of a total of 23 sampled residents. Findings: Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating read in part: . 1. If resident abuse, neglect . is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law . Resident #59 was admitted to the facility on [DATE] with diagnoses in part: Dementia, Cognitive Communication Deficit, Depression, Anxiety, and Diabetes. On 02/27/2023 at 12:12 p.m., an interview was conducted with Resident #59's daughter who stated she watched video footage from her mother's room and heard one of the CNAs (Certified Nursing Assistant) tell her mom that if she pinched her, she would pinch her back. This incident happened within the last week. She was not sure of who the two CNAs were in the room, but has not seen either CNA since then. She further stated that she would notify the facility's administrator of the incident as she felt it was not appropriate even though her mother did not understand. Resident #59 was seated at the dining room table at this time. The Resident spoke Spanish with her daughter who then stated she did not feel that her mother was scared of the CNA or scared to be at the facility after the incident. A review of footage from the monitoring device in Resident #59's room revealed that on 2/21/2023 at 7:00 a.m., S8CNA and S9CNA were in the Resident's room providing ADL (Activities of Daily Living) care for the Resident. S8CNA was standing in front of the Resident as she sat on the bed, and S9CNA was standing on the right side of the Resident. S8CNA then bent down and was eye level with Resident #59. She then pointed in the Resident's face and said to her, Don't pinch me. I will pinch you back! in a chastising manner. Resident #59 did not respond. S8CNA and S9CNA then proceeded to transfer Resident #59 to the chair, and began removing linen from the Resident's bed. The video ended. On 02/28/2023 at 10:15 a.m., S1Administrator stated that she received and reviewed the video footage from Resident #59's daughter on 2/28/2023 and the 2 CNAs in Resident #59's room at the time of the incident were S8CNA (agency CNA) and S9CNA (staff CNA). She stated that S8CNA told the Resident that she would pinch her back. S2DON (Director of Nursing) counseled the staff CNA about reporting what S8CNA said to Resident #59. On 02/28/2023 at 10:22 a.m., an interview was conducted with S2DON (Director of Nursing). S2DON stated that she reviewed video footage from Resident #59's room that revealed S8CNA (Certified Nursing Assistant) and S9CNA provided care for Resident #59 on the morning of 02/21/2023. Both S8CNA and S9CNA were in the Resident's room when S8CNA pointed in Resident #59's face and told the Resident I will pinch you back! S2DON stated that she spoke with S9CNA over the phone on 2/28/2023. S9CNA stated that she did not report S8CNA because she didn't feel S8CNA meant any harm when S8CNA told Resident #59 that she would pinch her back. S2DON further stated that S9CNA should have reported S8CNA at the time of the incident. On 02/28/2023 at 1:52 p.m., a phone interview was conducted with S8CNA. S8CNA stated that on the morning of 02/21/2023, she and S9CNA were changing Resident #59 and as they were about to transfer her to the chair, Resident #59 pinched her really hard on her leg. S8CNA stated she moved her arm from under the Resident's arm, and she pointed at her in her face and told her not to pinch her and she would pinch her back. She further stated that she did that because Resident #59 speaks Spanish and she wanted her to understand that it wasn't okay for her to pinch her. S8CNA stated that she knew she should have refrained from pointing in her face and telling Resident #59 that she would pinch her back.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that respiratory equipment was properly stored and labeled with the date and time for 1 Resident (#32) out of 23 sampled residents. Findings: Review of the facility's policy titled Oxygen Administration read in part: 11. If Oxygen is ordered as needed or not in use, place appropriate device (i.e. mask, nasal cannula, and/or nasal catheter) and tubing in a secure device for keeping clean. Resident #32 was admitted to the facility on [DATE] with diagnoses including: Obstructive Sleep Apnea, Shortness of Breath, COPD (Chronic Obstructive Pulmonary Disease), and Type 2 Diabetes. Review of Resident #32's current Physician's Orders revealed an order for Oxygen 2 Liters, Nasal Cannula for Diagnosis of COPD. Review of Resident #32's Medication Administration Record revealed he received Oxygen daily. On 02/27/2023 at 10:07 a.m., an observation was made of Resident #32's room. Oxygen tubing was on the resident's bed, with droplets inside of the line. A CPAP (Continuous Positive Airway Pressure) mask was also observed in the Resident's room. The mask was hanging on an end table by the straps of the mask. The mask was not in a bag. On 02/28/2023 at 8:00 a.m., a second observation was made of Resident #32's room. The Resident was not in his room at this time. Oxygen tubing connected to a nasal cannula was hanging on the oxygen concentrator and not in a bag. The tubing was not labeled with the date or the time. A CPAP mask was hanging on the end table by the straps and not in a bag. On 02/28/2023 at 8:10 a.m., an interview and observation was conducted in Resident #32's room with S7LPN. The Resident's oxygen tubing extension was on the floor and the nasal cannula portion was hanging on the humidifier bottle that was attached to the oxygen concentrator. S7LPN stated that Resident #59 uses oxygen daily, and when oxygen tubing is not in use, it is to be put in a bag. She further stated that although the Resident can remove his oxygen himself, it is not expected for him to put the oxygen tubing in a bag, and the nurses should put it in a bag. S7LPN also confirmed that the oxygen tubing was not labeled with the date or time that it was changed and it should be labeled with the date and time. Resident #59's CPAP mask was then observed hanging by the straps from an end table. She stated that the Resident uses the mask every night, and it should also be in a bag when it is not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #29 Review of the facility's policy titled Nutrition (Impaired)/ Unplanned Weight Loss-Clinical Protocol read in part: 1. the nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparison over time. 4. The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. Resident #29 was admitted to the facility on [DATE] with diagnoses including: Malignant Neoplasm of Rectum, Colostomy Status, Schizoaffective Disorder, and Generalized Anxiety. Review of Resident #29's Plan of Care revealed Resident #29 was at risk for malnutrition with interventions to consult a dietitian PRN (as needed) and monitor for weight loss. Review of Resident #29's Electronic Medical Record revealed the following weights: 1/18/23 222.1 lbs. (pounds) 2/13/23 209.2 lbs. 2/20/23 191.0 lbs. The Resident's current weight on 2/28/2023 was 185.2 lbs. Review of Resident #29's percentage of meals eaten from January 2023 to March 2023 revealed the Resident's meal intake ranged from 0-25% eaten to 75-100% eaten. On 2/27/2023 at 12:20 p.m., Resident #29 was observed in his room. His lunch tray was at bedside untouched. He stated that he did not feel like eating and sometimes he does not have an appetite. On 2/28/2023 at 8:30 a.m., a second observation was made of Resident #29. Resident #29 did not eat breakfast. He stated that he would eat later but would drink a soda. On 2/28/2023 at 1:00 p.m., a third observation was made of Resident #29. Resident #29 was sleeping and did not eat his lunch. He stated that he was okay and did not want to eat. On 3/1/2023 at 8:52 a.m., a fourth observation was made of Resident #29. Resident #29 stated that he does not really have an appetite and does not feel like eating. He stated he has not had an appetite lately because eating sometimes upsets his stomach and he just wants to stay in bed. On 03/01/2023 at 11:35 a.m., an interview was conducted with S6LPN (Licensed Practical Nurse). S6LPN stated that she monitored the residents' weights. She stated that Resident #29 was diagnosed with cancer in October of 2022 and had weight loss at the time. Resident #29's weights from 1/18/2023 and 2/13/2023 and his Registered Dietitian notes were reviewed with S6LPN. She confirmed that there were no reccommendations or notes from the Registered Dietitian on 02/12/2023 or 02/21/2023 when she came to the facility. She also confirmed that the Resident had a significant weight loss because his weight decreased from 222.1 lbs. to 209.2 lbs in one month. S6LPN stated the Registered Dietitian was not available and was not notified of the significant weight loss. S6LPN stated that a weight variance sheet should have been completed, and they should have notified the physician of the significant weight loss. S6LPN stated that she should have notified the physician of the significant weight loss so that an intervention or order could have been obtained to prevent further weight loss. On 3/1/2023 at 11:48 a.m., a phone interview was conducted with S4RD. S4RD stated that she was out of the facility the week of 2/13/2023 to 2/18/2023, and was not aware of the Resident's significant weight loss from January 2023 to February 2023. She was also not sure of why there was no documentation from her for the Resident since December of 2022. She further stated that she did not notice the weight loss or received a weight variance sheet from the facility when she came to the facility on 2/21/2023. S4RD stated that the weight loss and decrease in appetite were changes for Resident #29. She confirmed that the weight loss should have been addressed when the weight was taken on 2/13/2023. Resident #24 Resident #24 was admitted to the facility on [DATE] with diagnosis of Dysphagia, Legal Blindness, Deaf, Malnutrition, Slow Transit Constipation, Anemia, Chronic Kidney Disease, Diabetes, and Vitamin Deficiency. Record review of Resident #24's Dietary Manager Quarterly Assessment revealed the following, 01/2023 there was no quarterly dietary manager's assessment on this date. 10/4/22 Quarterly Assessment. Resident on Mechanical Soft Diet. He complained about his diet. Resident on nectar thick liquids. Consumed 100% of meals. 07/12/22 Quarterly Assessment. Resident on regular diet. He consumes 100 % of meals. On 03/01/23 at 10:22 a.m., S1Administrator confirmed the Dietary Manager failed to assess Resident #24 on 01/2023. She stated the Dietary Manager should assess the Residents quarterly and document in the computer. Resident #53 Resident #53 was admitted to the facility on [DATE]. Her Diagnosis were Spastic Hemiplegia, Cerebral Palsy, Anxiety, Bipolar, Major Depression, Profound intellectual Disability, Gastritis, Slow Transit Constipation, Anemia, and Epilepsy. Record review of Resident #24's Dietary Manager Quarterly Assessment revealed the following, 2/28/23 there was no dietary manager quarterly assessment on this date. 11/30/22 there was no dietary manager quarterly assessment on this date. 09/27/22 Pureed Regular. Compliant with diet. Consumes 50-100% of all meals. Resident on honey thick liquids. On 03/01/23 at 10:40 a.m., Review of Resident record with S2 DON confirmed the last assessment by the Dietary Manager was on 9/27/2022. S3DON stated the Dietary Manager failed to assess the resident on 11/30/22 and 2/28/2023. S3DON stated the Dietary Manager was to assess the resident quarterly. Resident #74 Resident #74 was admitted to the facility on [DATE] with diagnosis of, schizoaffective disorder, Dementia, Constipation, Glaucoma, Moderate Protein Malnutrition, Delirium, Cognitive Communication Deficit, and Legal Blindness. Record review of Resident #24's Dietary Manager Quarterly Assessment revealed the following, 01/17/2023 Resident on a regular diet. Complaints with diet. Consumed 75-100% of meals. Weight was 93.8 pounds. 10/25/2022 there was no quarterly dietary manager's assessment. 08/2/2022 Resident on a regular diet. Consumed 50-100% of meals. Weighed108.8 pounds. On 03/01/2023 at 11:26 a.m., S2DON confirmed the dietary manager failed to assess Resident #74 quarterly on 10/25/2022. She stated the Dietary manager was to assess the resident quarterly. Based on observation, record review and interview, the facility failed to maintain acceptable parameters of nutritional status, by failing to ensure the RD (Registered Dietitian) and DM (Dietary Manager) conducted nutritional assessments for 5 (#24, #29, #37, #53, #74) out of 6 (#21, #24, #29, #37, #53, #74) and failing to implement interventions when significant weight loss occured for 1 resident (#29) out 6 (#21, #24, #29, #37, #53, #74) residents investigated for nutrition out of a total sample of 23 residents. Findings: Resident #37. Review of the resident's clinical record revealed that the resident was admitted to the facility on [DATE]. The resident's diagnoses included Cerebral Infarction, Major Depressive Disorder, and Muscle Wasting and Atrophy. On 02/27/2023 at 10:02 am, the resident was observed in his room. He stated that he was eating and had a good appetite. The resident stated that he does not why he was losing weight. Review of the resident's weight log revealed that the resident weighed 127.6 pounds on 10/24/2022 and weighed 119 pounds on 11/16/2022. The resident lost 8.6 pounds, which was a 6.74 % significant weight loss. Further review of the resident's weight log revealed the resident continued to lose weight. The resident weighed 114 pounds on 2/15/2023. The resident lost 13.6 pounds, which was a 10.74% significant weight loss since 10/24/2022. There was no evidence that the RD conducted a nutritional assessment on the resident between 10/24/2022 to 03/01/2023. Review of the resident's care plan revealed that it addressed that the resident was at risk for weight loss. Interventions included RD to evaluate and make diet change recommendations . Review of the resident's mini nutrition note dated 01/19/2023 at 3:46 pm revealed, W (weight) 116 lb (pound) . Weight loss greater than 3kg (kilograms) (6.6 lbs) in the last 3 months . There was no evidence the RD evaluated or conducted a nutritional assessment. On 03/01/2023 at 11:30 am, an interview was conducted with S10LPN (Licensed Practical Nurse). S10LPN stated she was not aware of the resident's weight loss. S10LPN reviewed the resident's clinical record and confirmed the resident was having weight loss. S10LPN confirmed that there was no evidence the RD (Registered Dietitian) was informed concerning the resident's weight loss or that the RD conducted a nutritional assessment on the resident for his weight loss. On 03/01/2023 at 11:30 am, an interview was conducted with S11LPN. S11LPN stated that she monitored the resident's weight and noticed that the resident was losing like a pound a week. S11LPN reviewed the resident's electronic clinical record and the physical clinical record and confirmed that there was no evidence the RD had conducted a nutritional assessment on the resident since 07/06/2022. On 03/01/2023 at 11:55 am, an interview was conducted with S2DON (Director of Nurses). S2DON confirmed the resident had weight loss. S2DON confirmed there was no evidence the RD conducted a nutritional assessment on the resident since 07/06/2022. On 03/01/2023 at 12:05 pm, an interview was conducted with S6LPN. S6LPN stated that she was responsible for monitoring the weights and keeping track of the weight variances. She stated that she did not have a RD recommendation and confirmed that there was no evidence the RD conducted a nutritional assessment on the resident since 07/06/2022. On 03/01/2023 at 12:18 pm, a telephone interview was conducted with S4RD. S4RD stated that she was not aware of the resident's weight loss and could not remember when the last the nutritional assessment was conducted on the resident.

Based on observations, record review and interviews, the facility failed to 1. ensure the kitchens air conditioning vents were clean and sanitary, the sanitizer and water temperature in the 3 part sink and dishwasher were appropriate for sanitization, and documented for each meal; and 2. ensure the food temperatures were obtained on the serving line for each meal. This had the potential to affect the 88 residents that consumed food from the kitchen. Findings: 1. Record review of the facilities policy titled, Dishwasher/Three Compartment Sink read in part, The purpose of the policy is to provide guidelines sanitizing testing procedures for the dishwasher and the three-compartment sink .1. Routinely check the product levels on the dishwasher and the three part sinks and record every shift. 2. Dishwasher: .Dip test strip in rinse water solution. The concentration should be 100 ppm (Parts per million) .Perform sanitizer test and temperature on dishwasher before breakfast, lunch and dinner. 3 Three Compartment Sink: Sink 3 is the sanitize station and contains clean warm water (75 Degrees) and sanitizer .200 ppm. 4. Record testing results on the Dishwasher/Three Compartment Sink Log. On 02/27/23 at 08:37 a.m., a tour of the kitchen was conducted. During the tour, an observation of the kitchen revealed in the right corner there was a closet with the Air Conditioning Intake and output vent. The intake vent at knee level was covered with a light brown greasy film covered by lint. The top of the closet had 2 output vents. One vent was covered with a light brown greasy film covered by lint. The second vent had a black thick substance in the center of the vent. The vent over the food preparation area was observed with a yellow cotton like substance caught in the vent. Observation of the 3 part sinks, revealed #1 sink was filled with soapy water, #2 was empty and #3 was filled with clear water. At this time S13Cook Helper checked Sink #3 with litmus paper and confirmed the litmus did not change colors (Indicating there was no Sanitizer in the sink). She confirmed this was the dish water from breakfast. S13Cook Helper stated she did not know how to test the sanitizer in sink #3 or what the litmus was supposed to read. On 2/27/2023 at 9:00 a.m., an observation of the Dish Machine Temperature Log posted next to the Dish washing machine revealed from 2/23/2023 to present (2/27/2023) There was no documentation for the litmus test results and water temperature. On 02/27/23 at 11:22 a.m., S14Cook Helper confirmed the staff that wash dishes in the three part sinks (1Wash, 2Rinse, 3Sanitize) were to ensure #3 sinks water was to be at least 75 Degrees and the sanitizing solution was to be tested with a Litmus paper to read 50-200 parts per million. She stated the staff were to check the dish washer and 3 part sinks temperature and sanitizer litmus prior to washing for every meal. She confirmed she did not log the results for the 3 part sinks. She stated she only logged the temperature and litmus test for the Dishwasher. On 02/27/23 at 2:00 p.m., S12Cook confirmed the staff did not document the water temperature for the 3 part sink. She stated the staff only documented the temperature and litmus test for the dishwasher. On 02/27/23 at 2:15 p.m., S1Administrator confirmed there was no log for the 3 part sink. She also confirmed the staff did not document the Dishwasher water temperatures and Litmus test from 2/22/23 to present date (2/27/2023). She stated the Staff should log the water temperatures and Litmus test results on this log sheet for each meal. She stated there was no Log sheet for the 3 part sink. On 03/01/23 at 9:48 a.m., S1Administrator confirmed the Kitchens Air Conditioning intake and output vents were not sanitary. 2. Review of policy titled, Food Temperature Policy read in part, The purpose of the policy is to provide guidelines for taking food temperatures and recording .Policy Statement 1 .Nursing Home to routinely check and record the food temperatures prior to serving. 2. Food temperatures should be taken at least 30 minutes prior to serving. 3. All foods on the line must be a minimum 145 degrees . On 02/27/2023 at 11:05 a.m., observation revealed S12Cook checking the food temperatures on the serving line. On 01/27/2023 at 12:20 p.m., review of the Food Temperature Log binder with S12Cook confirmed the food temperatures were checked on the serving line on the following dates 01/01/2023, 01/02/2023, 01/03/2023, 01/04/2023, 01/05/2023, 01/06/2023, 01/15/2023, 01/16/2023, 01/17/2023, 01/21/2023. S12Cook stated she did not log the food temperatures for each meal served in the Food Temperature log book as required by the facility. On 02/27/2023 at 2:15 p.m., S1Administrator confirmed the kitchen staff were to check the food temperatures on the serving line 30 minutes prior to serving meals and document the findings in the Food Temperature Log Binder.