**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure services were provided to meet professional standards of practice for 2 (Resident #1 and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. The facility failed to ensure:1. A fall mat was in place as ordered and care planned for Resident #1, and2. Physician's orders for increasing water flush for Resident #3, who received feeding and hydration via PEG (Percutaneous Endoscopic Gastrostomy), was followed. Findings:Resident #1Review of Resident #1's electronic medical record revealed an admit date of 06/06/2025 with diagnoses that included in part: Encephalopathy, Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure, Generalized Anxiety Disorder, Alcohol Abuse Uncomplicated, and Major Depressive Disorder Recurrent with Psychotic Symptoms. Review of Resident #1's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/18/2025 revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 3, which indicated Severe Cognitive Impairment. Resident #1 was dependent on staff for all self-care and transfers. Review of Resident #1's Active Physician Orders revealed an order initiated 07/22/2025 for Fall Mat every shift. Review of Resident #1's Care Plan revealed the resident was at risk for falls related to impaired mobility with an intervention that read in part. 07/18/2025 resident found on floor by bed. Fall Mat initiated. On 07/28/2025 at 11:25 a.m., observation revealed that a fall mat was not in place in Resident #1's room.On 07/28/2025 at 11:45 a.m., S3ADON acknowledged Resident #1 did not have a fall mat at his bedside and confirmed he should have. Resident #3Record Review revealed Resident #3 was admitted to the facility on [DATE], and had the following diagnoses in part. Aphasia following Cerebral Infarction, Unspecified Protein-Calorie Malnutrition, and Encounter for Attention to Gastrostomy.Record Review of Resident #3's annual MDS with ARD of 07/16/2025 BIMS score was not assessed due to resident condition. Resident #3 was dependent on staff for Eating, and all ADL (Activities for Daily Living) care. Resident #3 had a feeding tube. Record Review of Resident #3's Departmental Progress Notes read in part.07/29/2025 1:36 p.m. S1DON documented: RD (Registered Dietician) seen Resident #3 yesterday (07/28/2025) and made recommendations for increasing free water flush to 40ml/hr.07/29/2025 11:00 p.m. S4LPN documented: Peg tube placement verified, patent and intact. No residual noted. Has formula isosource at 35ml/hour and Water at 30ml/hour in progress to peg per pump.Record Review of Resident #3's 07/2025 active physician orders read in part.Enteral Feed every shift isosource at 35ml/hr with 40ml/hr water flushes per e-pump. Start date: 07/29/2025Observation on 07/30/2025 at 8:35 a.m. of Resident #3 revealed she received feeding and hydration per PEG tube via pump. The tube feeding bag was labeled isosource and was programmed at 35ml/hr. The water flush was programmed at 30ml/hr. Observation on 07/30/2025 at 11:11 a.m. Resident #3 revealed she received feeding and hydration per PEG tube via pump. The tube feeding bag was labeled isosource programmed at 35ml/hr. The water flush was programmed at 30ml/hr. Observation on 07/30/2025 at 12:25 p.m. of Resident #3 and Interview with S2LPN confirmed Resident #3's water flush should be set at 40ml/hr, but was set at 30ml/hr. S2LPN stated the RD recommended an increase for Resident #3's water flush and confirmed the settings should have been changed when the order was put in on 07/29/2025, but had not. Interview on 07/30/2025 at 12:30 p.m. with S1DON revealed the facility had a standing order from the Medical Director to follow RD recommendations for all Residents who receive tube feedings. S1DON stated on 07/29/2025 the RD increased Resident #3's water flush to 40ml/hr from 30/hr, and confirmed that when the order was put in, nursing staff should have increased the water flush settings. S1DON confirmed nursing staff should have checked pump settings on 07/29/2025 night shift, and 07/30/2025 morning shift to ensure Resident #3 received the correct feeding and water flushes, but had not.

Based on record review and interview, the facility failed to ensure services were provided to meet professional standards of practice by failing to ensure a resident's Medical Director was notified of Registered Dietician recommendation in a timely manner for 1 (#2) of 6 (#1, #2,#3, #4,#5, and #6) sampled residents. Findings: Review of the facility's undated policy titled Weights read in part The Registered Dietician will complete the dietician recommendations and or/dietician noted at her discretion. The notes will be given to the DON for nursing staff to send to the physician for review and follow-up. Review of Resident #2's medical record revealed an admit date of 02/06/2025 with diagnoses that included in part .Supraventricular Tachycardia, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Cardiac Pacemaker, Aphasia following Cerebrovascular Disease and Chronic Atrial Fibrillation. Review of Resident #2's 03/2025 Physician Orders read in part . 02/06/2025 -Isosource hn at 50cc/hr per pump with water flushes at 30 cc/hr per feeding pump. Review of Registered Dietician note dated 02/18/2025 read in part Recommendations: 1. Change tube feeding to Jevity 1.2 @50cc/hr with 47cc/hr of free H20. This will provide 1440 kcal, 2096cc free H2o and 67 grams of protein. 2. To meet protein goals: 30 cc liquid protein per peg twice daily. Interview on 06/11/2025 at 2:55 p.m. with S1 ADON revealed that once the registered dietician makes recommendations they are sent to the MD for approval via fax or phone. S1 ADON stated the recommendations are kept in a box in the nurses' station and a follow up fax/calls are made until the MD responds. S1 ADON stated the facility did not get a response in regards to the Registered Dietician recommendations for Resident #2 until 03/05/2025, after Resident #2 had passed away in the hospital. Interview on 06/11/2025 at 1:33 p.m. with Resident #2's medical director stated that he could not recall receiving the registered dietician recommendation for Resident #2, but that didn't mean he didn't receive them. Interview on 06/11/2025 at 3:46 p.m. with S1 ADON confirmed that the registered dietician's recommendation to change tube feeding from Isosource hn at 50cc/hr with 30cc/hr H2o flush to Jevity 1.2 at 50cc/hr with 47cc/hr of free H2O dated 02/18/2025 and add 30 cc liquid protein per peg twice daily were faxed over to Resident #2's medical director's office on 02/18/2025. S1 ADON confirmed the facility failed to follow up via telephone after not receiving correspondence from the medical director until 03/05/2025, but should have.

Based on record review and interview the facility failed to ensure a resident's right to formulate an advanced directive was properly reflected in the resident's medical record for 1 (#38) of 1 resident reviewed for advance directives. The facility failed to ensure all medical records consistently reflected the resident's wishes to be a DNR (Do Not Resuscitate) code status. Findings: Review of the facility's policy dated 01/15/2025 titled, Advance Directives read in part . Policy statement: Advance Directives will be respected in accordance with state law and facility policy. 8. The plan of care for each resident will be consistent with his or her documented treatment preference and/or advance directives. Review of Resident #68's medical record revealed an admit date of 12/02/2024 with diagnoses that included: Cerebrovascular Disease, Dysphagia following Cerebral Infarction, Generalized Anxiety Disorder, Bipolar Disorder, and Chronic Systolic Heart Failure. Review of Resident #68's electronic record dashboard/orders revealed the resident was a Full Code status. Review of Resident #68's 03/2025 physician's orders revealed the code status as DNR. Review for Resident #68's care plan with the next review date of 06/24/2025 revealed the code status as DNR. Interview on 03/26/2025 at 10:40 a.m., with S11 LPN revealed she would look at the resident's dashboard/orders in their electronic record to determine their advance directive during a code. Interview on 03/26/2025 at 11:00 a.m., with S2 DON revealed the staff should look at the dashboard/orders of the resident's chart and determine their code status. S2 DON confirmed that Resident #68's electronic record and care plan had inconsistent data regarding advance directives and should be updated to reflect the corrected code status of DNR, but was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents identified with Mental Disorder and/or Intellectual Disability had an accurately completed PASARR (Pre-admission Screening and Resident Review) Level I and/or Level II for 1(#23) resident of 2(#23 and #26) residents reviewed for PASARR screening. Findings: Review of the facility's undated policy titled, PASARR Policy read in part .If during the residents stay, their condition warrants having an inpatient psychiatric hospitalization or becomes diagnosed with a serious mental illness, a Level 2 screening should be done. Review of Resident #23's medical record revealed an admit date of 02/18/2022 with diagnoses read in part Benign Neoplasm of Stomach , Chronic Kidney Disease, and Bipolar Disorder, Current Episode Severe with Psychotic Features (01/19/2023). Review of Resident #23's medical record revealed a Level 1 pre-screening was provided for Resident #23 prior to admission on [DATE], which indicated a Level 2 screening is not necessary due to no diagnoses of mental illness. Review of Resident #23's medical record revealed a psychiatric evaluation completed on 01/03/2023, which indicated Resident #23 has persistent symptoms of depression and delusions with diagnostic impression of Bipolar Disorder. Review of Resident #23's electronic record revealed a diagnosis of Bipolar disorder with a start date of 01/19/2023. Interview on 03/26/2025 at 09:50 a.m. with S2 DON revealed if a resident is admitted to the facility with a Level 1 PASARR and they received a new serious mental illness that a Level 2 screening would be required. S2 DON revealed Resident #23 was admitted with a Level 1 without any mental condition and received a diagnosis of Bipolar Disorder after being admitted to the facility. S2 DON confirmed that a Level 2 screening should have been completed for Resident #23 after the mental illness diagnosis, but had not been done.

Based on observation, interview and record review, the facility failed to implement a comprehensive person-centered care plan to meet the needs of 3 ( #34, #36, and #37) residents of 34 sampled residents. The facility failed to ensure Resident #34's and Resident #36's fall interventions were implemented, and failed to ensure 2 person physical assistance was used for bed mobility and toileting for Resident #37. Findings: Review of an undated facility policy titled, Care Plans Comprehensive read the following part .1. The interdisciplinary team will develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, dietary and psychosocial needs and maximize the resident's highest level of functioning. Resident #34 Review of Resident #34's medical record revealed an admission date of 06/17/2024, with diagnoses that included in part .Chronic Kidney Disease, Stage 4 (Severe), Atrial Fibrillation, Pulmonary Fibrosis, and History of Falling. Review of Resident #34's admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/16/2024 revealed a BIMS (Brief Interview of Mental Status) score of 13, which indicated intact cognition. Resident #34 had a history of falls in the last month and required limited assistance with one person physical assistance for bed mobility, transfers, and toilet use. Review of Resident #34's physician orders revealed an order for a fall mat on the floor next to her bed per the family's request every 12 hours with a start date of 12/04/2024. Review of Resident #34's care plan revealed in part .Focus: Risk for falls related to history of falls. Interventions: fall mat on the floor next to bed per the family's request with an initial date of 12/05/2024. On 03/24/2025 at 9:39 a.m., observed Resident #34 in the bed with the right side of the bed against the wall. No fall mat observed on the left side of the bed. On 03/25/2025 at 9:05 a.m., observed Resident #34 asleep in the bed with no fall mat on the bedside floor. On 03/26/2025 at 8:54 a.m., observed Resident #34 in the bed with no fall mat on the bedside floor. In an interview and record review on 03/26/2025 at 2:31 p.m., S12 LPN revealed that Resident #34 should have had a fall mat at the bedside per the physician's orders. S12 LPN confirmed that Resident #34 did not have a fall mat on the floor at her bedside and should have. In an interview and record review on 03/26/2025 at 2:58 p.m., S2 DON revealed that Resident #34 had active physician's orders started on 12/04/2024 for a fall mat next to her bed. S2 DON revealed Resident #34's fall risk care plan had a fall intervention to place a fall mat at the resident's bedside. S2 DON confirmed Resident #34 should have had a fall mat on the floor next to her bed, but did not. Resident #36 Review of Resident #36's medical record revealed an admission date of 02/14/2025, with diagnoses that included in part .Paroxysmal Atrial Fibrillation, Personal History of Transient Ischemic Attack (TIA), Cerebral Infarction Without Residual Deficits, and Seizures. Review of Resident #36's admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/20/2025 revealed a BIMS (Brief Interview of Mental Status) score of 14, which indicated intact cognition. Resident #36 had two or more falls since admission to the facility and required total dependence with two person physical assistance for bed mobility, transfers, and toilet use. Review of Resident #36's care plan revealed in part .Focus: Risk for falls characterized by history of fall/injury, and multiple risk factors related to unsteady gait. Interventions: Fall mat to the resident's bedside with an initial date of 02/18/2025. On 03/24/2025 at 10:55 a.m., observed Resident #36 in the bed with a black fall mat propped up against the wall, which was located behind the resident's bed. On 03/25/2025 at 2:14 p.m., observed Resident #36 asleep in the bed with a black fall mat propped up against the wall, which was located behind the resident's bed. On 03/26/2025 at 8:40 a.m., observed Resident #36 sitting on the side of her bed with a black fall mat propped up against the wall, which was located behind the resident's bed. In an interview and record review on 03/26/2025 at 10:04 a.m., S2 DON revealed Resident #36 had a fall on 02/16/2025 and the fall risk intervention was to place a fall mat at the resident's bedside. S2 DON confirmed that Resident #36's fall mat should not be propped up against the wall located behind the resident's bed. S2 DON confirmed Resident #36's fall mat should be placed on the left of the bedside floor, but was not. Resident #37 Review of Resident 37's's medical records revealed an admit date of 04/21/2020 with diagnoses that included: Malignant Neoplasm of Upper Lobe, Left Bronchus or Lung; Neoplastic (Malignant) related Fatigue, Spinal Stenosis, Chronic Systolic (Congestive) Heart Failure, and Chronic Pain. Review of Resident #37's care plan with a revision date of 12/5/2024 revealed Resident #37 required extensive assistance with bed mobility and toileting and requires 2-person physical assist using a lift with transfers. Review of Resident #37's Quarterly MDS with ARD of 10/16/2024 revealed a BIMS of 14, which indicated intact cognition. Resident #37 was dependent on staff with bed mobility and required 2 person physical assist. Review of a facility report dated 10/19/2024 revealed in part Resident #37 rolled on her side to be cleaned and rolled out of the bed. No injuries observed. Interview on 03/27/2025 at 12:05 p.m. with Resident #37 revealed 1 one CNA staff rolled her over in bed to provide incontinent care and the resident fell/rolled out of the bed. Several unsuccessful attempts to contact S10 CNA. Interview on 03/27/2025 at 12:19 p.m. with S2 DON, revealed that on 10/19/2024, S10 CNA reported that Resident #37 fell/rolled out of bed when she provided incontinent care alone. Interview on 03/27/2025 at 1:50 p.m. with S2 DON revealed that Resident #37's current care plan required 2 person physical assistance with bed mobility and toileting. S2 DON confirmed S10 CNA provided bed mobility and toileting on 10/19/2024 alone and confirmed S10 CNA failed to follow Resident #37's plan of care at the time of her fall.

Based on observation, record review, and interview, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for 1 (#68) of 1 resident reviewed for pressure ulcers. The facility failed to ensure: 1. gloves used during wound care were not contaminated by the bedside table; and 2. gloves were removed and hands were sanitized after cleaning Resident #68's wound. Findings: Review of the facility's undated policy titled Wound Treatment Management read in part .Policy: To promote wound healing of various types of wounds . to provide evidence based treatments in accordance with current standards of practice and physicians orders. 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. Review of Resident #68's medical records revealed an admit date of 12/02/2024 with diagnoses that include: Pressure Ulcer of Sacral Region, Stage 3, Cerebrovascular Disease, Dysphagia following Cerebral Infarction, Generalized Anxiety Disorder, Bipolar Disorder, and Chronic Systolic Heart Failure. Review of Resident #68's 03/2025 Physician Orders read in part . 03/25/2025 -Stage 3 Pressure ulcer to sacrum - Clean with wound cleanser, apply Santyl and apply collagen dressing, cover with silicone bordered foam dressing, change daily and as needed due to soiling or dislodgment. Observation of wound care for Resident #68 on 03/25/2025 at 9:16 a.m. revealed S17 Treatment nurse removing the gloves from her clean field and placing them on Resident #68's beside table on top of a banana and his belongings. S17 Treatment nurse was observed removing the gloves from the bedside table, donning the gloves, and providing wound care to Resident #68's sacrum pressure ulcer. S17 Treatment Nurse was observed cleaning the wound with a 4x4, discarded soiled 4x4, obtained a new 4x4 from the clean field and cleansed the wound with soiled gloves without discarding gloves and cleansing hands. Interview on 03/25/2025 at 3:35 p.m., S17 Treatment Nurse was notified by this surveyor that she placed clean gloves on the unclean bedside table on top of Resident #68's belongings prior to using them for wound care, and failed to remove soiled gloves and sanitize hands prior to obtaining supplies from the clean field and cleansing the wound. S17 Treatment Nurse confirmed the above findings.

Based on record review, observation, and interviews, the facility failed to administer a resident's enteral flush per the physician orders for 1(Resident #68) of 1 residents investigated for enteral feedings. Findings: Review of the facility's policy titled, Enteral Nutritional Therapy dated 04/05/2012, read in part Purpose: to provide hydration through a tube inserted into the stomach. If a feeding pump had been ordered .d. Adjust flow rate as prescribed. Review of Resident #68 medical records revealed an admit date of 12/02/2024 with diagnoses that include: Cerebrovascular Disease, Dysphagia following Cerebral Infarction, Generalized Anxiety Disorder, Bipolar Disorder, and Chronic Systolic Heart Failure. Review of Resident #68's 03/2025 physician orders revealed an order was started on 02/18/2025 for Glucerna 1.5 cal at 60cc/hour with 35cc/hour H2O flushes, per pump. Review of Resident #68's care plan with the next review date of 06/02/2025 read in part I require tube feeding related to Dysphagia secondary to Cerebrovascular Accident. Interventions: Glucerna 1.5 cal at 60cc/hour/pump with 35cc/hour/pump water flush. Observation on 03/24/2025 at 1:25 p.m. revealed Resident #68's tube feeding of Glucerna 1.5 cal at 60cc/hour with 30cc/hour water flush. Observation on 03/25/2025 at 2:15 p.m. revealed Resident #68's tube feeding of Glucerna 1.5 cal at 60cc/hour with 30cc/hour water flush. Interview on 03/25/2025 at 2:30 p.m. with S3 ADON revealed Resident #68's water flush was set incorrectly at 30 cc/hour and should have been set as ordered at 35cc/hour, but was not.

Based on record review, observations and interviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure oxygen was administered as ordered by the physician for 1 (#47) of 1 residents reviewed for respiratory care. Findings: Review of the facility's undated policy titled, Oxygen Concentrator revealed the following in part .Policy: The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators. Policy Explanation and Compliance Guidelines: 2. Oxygen is administered under orders of the attending physician, except in the case of an emergency. 4. Use of Concentrator: a. The nurse shall verify physician's orders for the rate of flow and route of administration of oxygen (mask, nasal cannula etc.). Review of Resident #47's medical record revealed an admission date of 02/14/2024 with diagnoses that included in part, Cerebrovascular Disease; Shortness of Breath; Anxiety Disorder; Aphagia; Anorexia; and Dysphagia. Review of 03/2025 physician orders for Resident #47 revealed O2 (oxygen) at 2 liters per minute via nasal cannula, continuously every day and night shift for shortness of breath with an order date of 02/25/2025. Review of the Significant Change Minimum Data Set (MDS) with an ARD (Assessment Reference Date) dated 05/28/2025 revealed the resident has a Brief Interview for Mental Status (BIMS) score of 01, which indicated severe cognitive impairment. Resident #47 was dependent on staff with activities of daily living and required oxygen therapy. Review of Resident #47's care plan revealed in part .Shortness of breath related to disease process receiving hospice services, decreased energy, and fatigue. Interventions: Oxygen as ordered. Observation on 03/24/2025 at 12:10 p.m. revealed Resident #47 lying in bed awake with oxygen in progress at 3 liters/minute via nasal cannula per oxygen concentrator. Resident #47 stated she wears oxygen via nasal cannula continuously. Observation on 03/25/2025 at 9:22 a.m. revealed Resident #47 lying in bed with oxygen in progress at 3 liters/minute via nasal cannula. Interview on 03/25/2025 at 10:58 a.m., S11 LPN stated Resident #47 required continuous oxygen at 2 liters per minute via nasal cannula. S11 LPN stated oxygen concentration settings are reviewed under physician orders at each shift. Observation at this time accompanied with S11 LPN revealed Resident #47 lying in bed with oxygen in progress at 3 liters per minute via nasal cannula. S11 LPN confirmed Resident #47's oxygen concentrator was set at 3 liters per minute via nasal cannula and should have been set at 2 liters per minute via nasal cannula according to the physician's order but was not. Interview on 03/25/2025 at 11:03 a.m., S2 DON stated a physician's order is required to titrate oxygen settings. S2 DON confirmed resident #47's oxygen was ordered for 2 liters per minute via nasal cannula and should not have been set at 3 liters per nasal cannula.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services that assure the accurate administering of all drugs to meet the needs of each resident by failing to maintain accurate and complete documentation of controlled substances. Findings: Review of an undated facility policy on 03/27/2025 at 7:05 p.m. titled Drug Administration: Nursing Department Procedures read in part . b. Charting of medications shall be kept current and shall be completed as soon as administration is completed. Observation on 03/25/2025 at 8:48 a.m. of Cart B on Hall Y with S11 LPN revealed she had just completed morning medication pass for all resident's on Hall Y. Observation revealed narcotics were stored within a separate compartment of the cart and had a separate lock with key held by nurse. There was a narcotic log binder stored within the bottom drawer of cart. Record Review of the narcotic record log at time of the above observation for Resident # 37's Gabapentin 300mg capsules revealed a total of 18 capsules documented, with a last entry date of 03/24/2025. Observation of Resident #37's Gabapentin 300mg medication blister pack revealed there were 17 capsules remaining in the pack. Record Review of Resident #37's Morphine 30mg tablet narcotic record log revealed a total of 2 tablets documented, with a last entry date of 03/24/2025. Observation of Resident #37's Morphine 30mg medication blister pack revealed there was 1 tablet remaining in pack. S11 LPN reviewed the narcotic record log sheets and blister packs and stated she forgot to sign out the medications on the log sheet when she administered the medications to Resident #37 this morning. Record Review of Resident #2's narcotic record log for Gabapentin 300mg capsules revealed a total of 44 capsules documented, with a last entry date of 03/24/2025. Observation of Resident #2's Gabapentin 300mg medication blister pack revealed there was 43 capsules remaining in the pack. Interview on 03/25/2025 at 9:08 a.m. with S11 LPN confirmed when she administered Resident #37 and Resident #2's medications this morning, she should have signed them out on the narcotic record log sheet and updated the log with the correct amount remaining in medication packs. S11 LPN confirmed the above medication counts for Resident #37 and Resident #2 were incorrect, and should not be. Interview on 03/25/2025 at 5:00 p.m. with S2 DON confirmed all controlled medications are to be signed off on the narcotic record log sheet as soon as it was administered by the nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #68 Review of Resident #68's medical records revealed an admit date of 12/02/2024, with diagnoses that included: Cerebrovascular Disease, Dysphagia following Cerebral Infarction, Generalized Anxiety Disorder, Bipolar Disorder, and Chronic Systolic Heart Failure. Review of Resident #68's Care plan with review date of 06/04/2025 revealed Resident #68's transfer status required a lift with 2-person physical assist, and extensive assistance with bed mobility. Review of Resident #68's Quarterly MDS with an ARD of 03/05/2025, revealed a BIMS of 14, indicating intact cognition, and the resident's chair/bed-to-chair transfer status as dependent on staff to complete the activity. Observation on 03/25/2025 at 2:25 p.m., revealed S6 CNA transferred Resident #68 from the bed to his wheelchair, without another staff member present, and without the use of a mechanical lift. Interview on 03/25/2025 at 2:57 p.m. with S3 ADON, revealed Resident #68's transfer status is 2-person lift according to his care plan. S3 ADON revealed that all staff should access a resident's transfer status prior to transfer by looking at the residents' POC in the kiosk on the hall. S3 ADON confirmed mechanical lift was documented in Resident #68's POC for transfer status. Interview on 03/25/2025 at 3:02 p.m. with S9 CNA revealed she was able to determine a resident's transfer status by the presence of a leaf on his or her door, and if there was a lifter pad underneath the resident. S9 CNA stated that she transferred Resident #68 by herself, and did not use a lift when she transferred Resident #68 by herself. S9 CNA stated she had transferred other residents with a lift, by herself at times, if she was unable to find staff to help. Interview on 03/25/2025 at 3:08 p.m. with Resident #68 revealed he was transferred by 1 staff member, without a lift, from the bed to the wheelchair. Resident #68 was unable to tell the surveyor which CNAs transferred him without the lift. He stated that when he was first admitted , a lift was used during transfers; however 2 person assistance with a lift had not been used in a while. Resident #68 was unable to say exactly how long the lift and 2 person assist had not been used for transfers. Interview on 03/26/2025 at 9:25 a.m. with S7 CNA revealed she has been trained to look in the kiosk for transfer status, but stated she was unaware that Resident #68 was a 2-person assist with lift. S7 CNA revealed if she were to call a nurse to come assist her, they would come help, but she does not always call for help. Interview on 03/26/2025 at 9:30 a.m. with S8 CNA revealed she had been trained to look in the kiosk to determine a resident's transfer status. S8 CNA stated she did not believe Resident #68 was a 2-person assist. S8 CNA stated there are times that she had to get residents up alone with the lifts, because there was no one else on the halls. Interview on 03/26/2025 at 9:40 a.m. with S6 CNA revealed she transferred Resident #68 by herself without a lift because she was unaware that he required a lift. S6 CNA stated she could find the residents transfer status on the kiosk located on the hall to determine transfer status, but did not look at the Kiosk for Resident #68's transfer status. Interview on 03/26/2025 at 5:10 p.m. with S2 DON, revealed that when a resident's POC was entered into the electronic system, it then fired to the kiosk located on the halls for the CNAs to view. S2 DON stated that staff were to look at the kiosk prior to caring for residents to determine their transfer status. S2 DON confirmed that Resident #68 was care planned as a 2-person lift, and should not have been transferred without another staff member present and without the use of a lift. An interview on 03/27/2025 at 3:06 p.m. with S20 CNA, revealed she has been trained by the facility that all residents who require a bed lift for transfers should always have 2 CNAs operating the lift. S20 CNA stated she has transferred lift residents by herself often because other CNAs were busy, and residents were ready to go to bed and don't want to wait. S20 CNA stated she recently transferred Resident #11 on 03/25/2025 by herself on Hall Y on the 2:00 p.m. to 10:00 p.m. shift. The Immediate Jeopardy was removed on 03/28/2025 at 6:04 p.m. as confirmed by onsite verification through observations, interviews and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to survey exit that included the following: The facility identified 4 instances of abuse/neglect in the facility: 1. Staff to Resident verbal and emotional abuse on 02/16/2025, when S4 CNA verbally and emotionally abused Resident #15; 2. Resident to Resident abuse on 02/21/2025, when Resident #25 physically abused Resident #51; 3. Resident to Resident abuse on 03/08/2025, when Resident #25 physically abused Resident #6; and 4. Neglect, when S6 CNA neglected Resident #68. These instances have the ability to affect all residents that reside in the facility. The facility implemented the following actions to remove the immediacy: On 03/27/2025 S4 CNA was placed on administrative leave pending thorough investigation. On 03/27/2025 at 5:56 p.m. all current staff in the facility were in-serviced on the facility's Abuse and Neglect Policy and Procedure. On 03/27/2025 Monitoring tool initiated for S5 CNA Supervisor or designee to complete the lift protocol monitoring tool 4 times a week for 4 weeks, then twice per week for 2 weeks to ensure compliance with lift protocol and mechanical lifts for residents who require 2 person transfer. On 03/27/2025 Monitoring tool initiated for every 15 minute and every 30 minute checks for Resident #6, Resident #15, Resident #25, and Resident #51, and shall be turned into S2 DON daily for review. On 03/27/2025 S2 DON completed a monitoring tool to ensure all allegations for abuse and neglect were properly and thoroughly investigated. The daily monitoring tool was to include any allegation of abuse and neglect was reported to S2 DON and S1 Administrator, and SIMS reporting was completed. Monitoring to be completed daily for 30days, then 3 times weekly for 2 weeks to ensure compliance is sustained. On 03/27/2025 monitoring tool initiated for review of the nurses notes from the prior day in the weekly morning stand up meeting with IDT team. Any findings/allegations shall be reported to S1 Administrator immediately. On 03/28/2025 at 6:00 a.m. all on coming staff was in-serviced on the facility's Abuse and Neglect Policy and Procedure. On 03/28/2025 at 2:00 p.m. there was a mandatory all staff meeting on the facility's Abuse and Neglect Policy and Procedure which addressed the required components to include reporting protocols and 2 hour timeline in which to report alleged incidents into SIMS. Staff member who had not received in-service would be required to receive in-service prior to beginning their scheduled shift. On 03/28/2025 S6 CNA was in serviced on the policy and procedure for patients requiring mechanical lift. Return demonstration for S6 CNA was required. Visual return demonstration was observed by S2 DON. Resident #68 was discharged home on [DATE] at 2:30p.m. On 03/28/2025 Interviews were conducted with Resident #15, Resident #6, Resident #25, and Resident #51 to ensure freedom of abuse/neglect. Resident #15 shall continue to be on every 30 minute checks indefinitely. Resident #6 was placed on every 30 minute checks indefinitely. Resident #25 had every 15 minutes checks for 24 hours, then every 30 minute checks indefinitely. Resident #51 was placed on every 30 minute checks for two weeks. Resident #68 was discharged from the facility on 03/27/2025 at 2:30 p.m. On 03/28/2025 Resident #25's psychiatrist was informed of resident's behaviors. No new orders were given. The above allegations and monitoring was added to the facility's QAPI, and shall be discussed monthly for the next 3 months. Facility completion date 03/28/2025. Based on interview, observation, and record review the facility failed to ensure residents' rights to be free from verbal abuse and psychosocial harm by staff (Resident #15), resident to resident physical abuse (Resident #51 and #6); and protect a resident's right to be free from neglect (Resident #68), for 4 (Residents #6, #15, #51, and #68) of 4 residents (#6, #15, #51, and #68) reviewed for abuse and neglect. This deficient practice resulted in an Immediate Jeopardy situation for Resident #15 on 02/16/2025, when S4 CNA yelled at Resident #15 You stupid piece of sh*t. You're going to do what I say, and you're going to get in bed! Resident #15, who is cognitively intact, stated the incident hurt her feelings, made her cry, and she was fearful of S4 CNA. The Immediate Jeopardy continued on 02/21/2025 at approximately 3:28 p.m., when Resident #25 hit Resident #51 in the face with a box of cookies. Resident #51 stated this made her mad. The Immediate Jeopardy continued on 03/08/2025 at approximately 4:20 p.m., when Resident #25 (who exhibited aggressive and angry behavior on day of the incident), pulled Resident #6's hair. The Immediate Jeopardy continued on 03/25/2025 at 2:25 p.m., when S6 CNA was observed to willfully transfer Resident #68 without the required 2 person physical assist with mechanical lift; although she was knowledgeable that 2 person assist with mechanical lift was required of Care. The deficient practice has the likelihood to affect all other residents who reside in the facility. S1 Administrator was notified of the deficient practice at the Immediate Jeopardy level on 03/27/2025 at 5:56 p.m. Findings: Review of a facility policy on 03/26/2025 at 12:39 p.m., titled Abuse Prevention, with revision date of 03/21/2012, read in part . Each resident shall remain free from harm. Abuse - the ill treatment or disregard of an individual, whether purposeful, or due to carelessness, inattentiveness or omission of the perpetrator Emotional Abuse - any threatening behavior or statement directed to a person including, but not limited to ridicule, gestures that subject the person to humiliation or degradation, threatening motions or noises intended to startle or frighten the person. Physical Injury - an act that physically hurts or damages an individual's body where damage is inflicted by external force. Neglect - failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. An intentional act of omission by an employee which denies the standard of care and treatment due to an individual as required by law, rules, regulations, policies, procedures, guidelines or care plans. Physical Abuse - any physical motion of action, e.g. hitting, spitting, slapping, punching, kicking, pinching, directed toward the individual . Threat- any condition or situation that could cause or result in severe, temporary or permanent injury or harm to the mental or physical condition of individuals or their death. Verbal Abuse - use of oral, written, or gestured language by which abuse occurs. Includes: Name calling, swearing., taunting, and using derogatory terms to describe persons with disabilities. Psychological Abuse - includes: humiliation, harassment, threats of punishment or deprivation, sexual coercion, and intimidation. If alleged abuse occurs staff will: Take immediate action to protect the individual(s) involved including removal of the alleged abuser. Ensure that any health or psychological needs of the resident are provided for. Notify the DON immediately. Review of a facility policy on 03/25/2025 at 4:16 p.m., titled Abuse and Neglect-Clinical Protocol, with revision date of 01/01/2025, read in part . Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, neglect, misappropriation of property or financial abuse, involuntary seclusion, and mental abuse including abuse facilitated or enabled through the use of technology. Neglect, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of a facility policy on 03/26/2025 at 1:30 p.m. titled Resident Rights with revision date of 12/2021, read in part . Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence; be treated with respect, kindness, and dignity; and to be free from abuse and neglect. Resident #15 Review of Resident #15's medical record revealed she was admitted to the facility on [DATE]. Resident #15 had diagnoses that included in part . Chronic Pain Syndrome, Major Depressive Disorder, Anxiety Disorder, Parkinson's Disease, Spinal Stenosis, and Other Lack of Coordination. Review of Resident #15's Quarterly MDS with ARD of 01/08/2025, revealed a BIMS score of 15 (cognition intact). Resident #15 had range of motion impairment on both sides, and was dependent on staff for toileting, showering/bathing, and dressing. Review of Resident #15's care plan with an initiation date of 12/18/2024, revealed Resident #15 had a problem of impaired physical mobility related to Parkinson's disease. Interventions included in part . 2 person assist, transfer with mechanical lift. Interview of Resident #37 during the Resident Council meeting on 03/24/2025 at 1:32 p.m., revealed Resident # 37 stated that S4 CNA made Resident #15 stay in bed, and refused to get Resident #15 up, per Resident #15's request. S4 CNA then yelled at Resident #15. Interview on 03/24/2025 at 3:05 p.m. with Resident #15, revealed on 02/16/2025 she was seated in her wheelchair in her room, and S4 CNA came into her room to put her to bed. Resident #15 said she stated to S4 CNA that she did not want to go to bed, and that S4 CNA then became upset. Resident #15 stated S4 CNA came at me, and I saw her pull a girl's hair once, so I was afraid of her. Resident #15 stated S4 CNA used an ugly tone with her, and she directly reported the incident and how she was afraid of S4 CNA to S1 Administrator on 02/17/2025. Resident #15 reported S1 Administrator asked her if she was afraid of S4 CNA, to which she replied yes. Resident #15 revealed S1 Administrator stated she would take care of the situation, and that S4 CNA would not provide care to her anymore. Resident #15 stated S1 Administrator moved S4 CNA from Hall Y to Hall Z, and S4 CNA had not provided care to her since. Interview on 03/25/2025 at 10:30 a.m. with S5 CNA Supervisor, revealed S2 DON moved S4 CNA from Hall Y to Hall Z last month, but she was unsure why. S5 CNA Supervisor revealed she was unaware of any incident between S4 CNA and Resident #15. S5 CNA Supervisor revealed she was aware that Resident #37 had informed S2 DON that she did not like the way S4 CNA spoke to residents, so she assumed that was why S2 DON moved S4 CNA to a different hall. Interview on 03/25/2025 at 11:30 a.m. with S1 Administrator revealed last month (02/2025), Resident #15 had reported that she was upset that S4 CNA put her back to bed when she (Resident# 15) did not want to go to bed. S1 Administrator stated Resident #15 reported this as a grievance to S2 DON. S1 Administrator revealed Resident #15 had never at any point in time informed her that she was afraid of S4 CNA, and denied Resident #15 reporting any abuse allegations to her. S1 Administrator revealed S2 DON moved S4 CNA's halls due to Resident #15 not wanting S4 CNA to care for her again. Review of a grievance form dated 02/17/2025, revealed Resident #15 filed a written grievance with S2 DON that read in part . Resident #15 stated S4 CNA put her to bed yesterday, although she was not ready to go to bed. She stated she did not care for S4 CNA due to her loud tone of voice. Action taken to resolve concern: In-service done. Statements received. S4 CNA reassigned to accommodate Resident #15 preference. Telephone interview on 03/25/2025 at 3:56 p.m. with S4 CNA revealed on 02/16/2025, she was paged to the nurses station by S13 LPN, and S13 LPN asked her to put Resident #15 to bed, because Resident #15 was not feeling well. S4 CNA stated Resident #15 stated she did not want to go to bed, but she and S15 CNA convinced Resident #15, and they transferred her 2 person assist with mechanical lift to bed. Interview on 03/26/2025 at 3:10 p.m. with Resident #37 (BIMS score of 15-indicating cognition intact), revealed she was fearful of S4 CNA. Resident #37 began to cry and revealed she was fearful because S4 CNA screamed and cursed at Resident #15. Resident #37 revealed on 02/16/2025, she could hear S4 CNA screaming at Resident #15 from the nursing station, so she went down the hall to Resident #15's room and witnessed S4 CNA yelling and cursing at Resident #15. Observation and Interview on 03/26/2025 at 3:20 p.m. with Resident #15 revealed, Resident #37 and a visitor were in the room Resident #15 stated S4 CNA yelled at her and said You stupid piece of sh*t, you're going to do what I say, and you're going to get in that bed! Resident #37 stated at that time that she heard S4 CNA yell at Resident #15 and say, You stupid piece of sh*t, you're going do what I say, and you're going to get in that bed! Resident #15 began to cry during the interview, and stated yes that is exactly what S4 CNA said to me! I don't like to use profanity, she hurt my feelings. The visitor stated that he has heard S4 CNA tell other residents on several occasions to Shut up and get in your room! Interview on 03/27/2025 at 8:43 a.m. with Resident #15 revealed she informed S1 Administrator of her exact concerns with S4 CNA, and reported to S1 Administrator that S4 CNA yelled and used profanity at her, made her go to bed, and grabbed her ankle and arm. Resident #15 stated S1 Administrator revealed she would take care of things. Resident #15 stated S4 CNA made me afraid and I just want to forget the whole incident, because it made me question if I made the right choice in moving here. Resident #15 stated she has often thought about going home since the incident with S4 CNA. Resident #51 Review of Resident #51's medical record, revealed Resident #51 was admitted to facility on 03/27/2024. Resident #51 had diagnoses that included in part . Bipolar Disorder, Paranoid Schizophrenia, Chronic Kidney Disease, Pain, and Major Depressive Disorder. Review of Resident #51's Annual MDS with an ARD of 12/18/2024 revealed a BIMS score of 15 (cognition intact). Review of Resident #51's Departmental Progress Notes revealed in part . On 02/21/2025 at 3:28 p.m., S16 LPN documented: CNA reported that Resident #25 hit Resident #51 in the face with a box a cookies. Neuro started, and Resident to Resident altercation in progress. Resident #51's husband made aware of altercation. Interview on 03/27/2025 at 8:32 a.m. with Resident #51, revealed sometime last month (unknown date), Resident #25 came into the dining room acting mad, and hit her in the face with a box of cookies. Resident #51 stated that made me mad and upset me, but she did not hurt me. She's just mean! Telephone interview on 03/28/2025 at 11:53 a.m. with Resident #51's RP confirmed the facility had called him last month to inform him another Resident had hit Resident #51 with a box of cookies. Interview with S16 LPN was unsuccessful. Interview on 03/27/2025 at 11:00 a.m. with S2 DON, revealed she was not aware of the resident to resident altercation between Resident #25 and Resident #51 on 02/21/2025. Resident #6 Review of Resident #6's medical record, revealed Resident #6 was admitted to facility on 10/14/2024. Resident #6 had diagnoses that included in part . Depression, Type 2 Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease. Review of Resident #6's Quarterly MDS with an ARD of 01/22/2025, revealed a BIMS score of 6 (severe cognitive impairment). Review of Resident #6's Departmental Progress Notes revealed in part . On 03/08/2025 at 4:39 p.m., S12 LPN documented: Resident #25 had a disagreement with Resident #6, and pulled Resident #6's hair. Telephone interview on 03/26/2025 at 12:31 p.m. with S14 CNA, revealed she worked the 2:00 p.m. - 10:00 p.m. shift on 03/08/2025 on Hall Y. S14 CNA stated she was working in another resident's room, and Resident #46's RP came to the room to tell her that Resident #25 and Resident #6 were fighting. S14 CNA stated that she did not witness the incident, but Resident #46's RP did, and she immediately reported the incident to S12 LPN. Resident #25 Review of Resident #25's medical record revealed Resident #25 was admitted to the facility on [DATE]. Resident #25 had diagnoses that included in part . Traumatic Subarachnoid Hemorrhage, General Anxiety Disorder, Bipolar Disorder, Depression, and Anxiety. Review of Resident #25's Quarterly MDS with an ARD 02/20/2025, revealed a BIMS score of 00 (severe cognitive impairment). Review of Resident #25's Care Plan with a problem initiation date of 12/24/2024, revealed in part . Potential for verbally aggressive behaviors due to a history of delusions and verbal aggression secondary to Bipolar disorder; Depressed Severe, with psychotic features; Depression; Anxiety Disorder. Interventions: 02/21/2025, Resident got into an altercation with another resident. S2 DON contacted psychiatrist, a medication review was done, and medication adjustment was ordered. Psychiatrist made aware of resident being manic. Review of Resident #25's Departmental Progress Notes revealed in part . On 02/21/2025 at 3:37 p.m., S16 LPN documented: CNA reported that Resident #25 hit Resident #51 in the face with a box a cookies. Resident to Resident altercation in progress. Resident #51's husband made aware of altercation. On 03/08/2025 at 4:39 p.m., S12 LPN documented: Resident #25 had a disagreement with Resident #6, and pulled Resident #6's hair. Interview on 03/25/2025 at 10:30 a.m. with S5 CNA Supervisor, revealed last month Resident #25 had aggressive behaviors. S5 CNA Supervisor stated there was an incident between Resident #25 and Resident #6 one day last month (date unknown). Resident #25 became mad and aggressive, and pulled her best friend's hair (Resident #6). S5 CNA Supervisor stated Resident #6 became very upset and told Resident #25 What's the matter with you? Don't do that! and went to her room crying. Interview on 03/25/2025 at 2:36 p.m. with S1 Administrator and S2 DON, confirmed last month Resident #25 had pulled Resident #6's hair. S2 DON stated she did not see this incident as resident to resident abuse, so the facility had not performed an abuse investigation. S1 Administrator confirmed the facility had not reported the resident to resident abuse to SIMS. S1 Administrator stated she was not aware of the details of situation, so she would have to look into it. Interview on 03/26/2025 at 3:50 p.m. revealed Resident #50 (BIMS score of 15 indicating cognition intact), stated on 03/08/2025, Resident #25 attempted to hit him right before she hit Resident #6. Resident #50 stated he told Resident #25 Don't hit me, and she left him alone and he went to his room. During interview Resident #46's RP revealed he visited daily, and stated on 03/08/2025 he saw Resident #25 hit Resident #6 in the head, and he went and told a CNA what was going on.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that all alleged violations involving verbal, sexual, physical,and/or mental abuse, are reported immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involved abuse, or not later than 24 hours if the events that cause the allegation do not involve abuse in accordance with State law through established procedures, for 3 (#6, # 15, and #51) of 3 (#6, # 15, #51) residents reviewed for abuse. This deficient practice resulted in an Immediate Jeopardy situation on 02/16/2025, when S4 CNA yelled and cursed Resident #15, and made her go to bed; on 02/21/2025 at approximately 3:28 p.m., when Resident #25 hit Resident #51 in the face with a box of cookies; and on 03/08/2025 at approximately 4:20 p.m., when Resident #25 pulled Resident #6's hair. The facility failed to report the above staff to resident verbal abuse, and resident to resident abuse, to the State Agency. The deficient practice has the likelihood to affect all other residents who reside in the facility. S1 Administrator was notified of the deficient practice at the Immediate Jeopardy level on 03/27/2025 at 5:56 p.m. Findings: Resident #15 Review of Resident #15's medical record revealed she was admitted to the facility on [DATE]. Resident #15 had diagnoses that included in part . Chronic Pain Syndrome, Major Depressive Disorder, Anxiety Disorder, Parkinson's Disease, Spinal Stenosis, and Other Lack of Coordination. Review of Resident #15's Quarterly MDS with ARD of 01/08/2025, revealed a BIMS score of 15 (cognition intact). Resident #15 had range of motion impairment on both sides, and was dependent on staff for toileting, showering/bathing, and dressing. Review of Resident #15's care plan with an initiation date of 12/18/2024, revealed Resident #15 had a problem of impaired physical mobility related to Parkinson's disease. Interventions included in part . 2 person assist, transfer with mechanical lift. Interview of Resident #37 during the Resident Council meeting on 03/24/2025 at 1:32 p.m., revealed. Resident # 37 stated that S4 CNA made Resident #15 stay in bed and refused to get Resident #15 up, per Resident #15's request. S4 CNA then yelled at Resident #15. Interview on 03/24/2025 at 3:05 p.m. with Resident #15, revealed on 02/16/2025 she was seated in her wheelchair in her room, and S4 CNA came into her room to put her to bed. Resident #15 said she stated to S4 CNA that she did not want to go to bed, and that S4 CNA then became upset. Resident #15 stated S4 CNA came at me, and I saw her pull a girl's hair once, so I was afraid of her. Resident #15 stated S4 CNA used an ugly tone with her. Resident #15 stated she directly reported the incident, and how she was afraid of S4 CNA to S1 Administrator on 02/17/2025. Resident #15 reported S1 Administrator asked her if she was afraid of S4 CNA, to which she replied yes. Resident #15 revealed S1 Administrator stated she would take care of the situation, and that S4 CNA would not provide care to her anymore. Resident #15 stated S1 Administrator moved S4 CNA from Hall Y to Hall Z, and S4 CNA had not provided care to her since. Review of Resident #15's medical record revealed no evidence that the alleged staff to resident abuse of Resident #15 by S4 CNA had been reported to the State Agency. Interview on 03/25/2025 at 11:30 a.m. with S1 Administrator, revealed last month Resident #15 reported that she was upset that S4 CNA put her back to bed when she (Resident# 15) did not want to go to bed. S1 Administrator stated Resident #15 reported this as a grievance to S2 DON. S1 Administrator revealed Resident #15 had never at any point in time informed her that she was afraid of S4 CNA, and denied Resident #15 reporting any abuse allegations to her. S1 Administrator revealed S2 DON moved S4 CNA to another hall due to Resident #15 not wanting S4 CNA to care for her again. Interview on 03/25/2025 at 2:36 p.m. with S1 Administrator and S2 DON confirmed there was no SIMS or facility incident report related to the allegations. S1 Administrator stated that the facility had completed a written grievance; however, S1 Administrator was unable to state how the facility addressed Resident #15's grievance. Telephone interview on 03/25/2025 at 3:56 p.m. with S4 CNA, revealed she was paged to the nurses station by S13 LPN on 02/16/2025, and S13 LPN asked her to put Resident #15 to bed, because Resident #15 was not feeling well. S4 CNA stated Resident #15 stated she did not want to go to bed, but she and S15 CNA convinced Resident #15, and they transferred her 2 person assist with a mechanical lift to bed. Interview on 03/26/2025 at 3:10 p.m. with Resident #37 (BIMS score of 15-indicating cognition intact), revealed she was fearful of S4 CNA. Resident #37 began to cry and revealed she was fearful because S4 CNA screamed and cursed at Resident #15. Resident #37 revealed on 02/16/2025, she heard S4 CNA screaming at Resident #15 from the nursing station, so she went down the hall to Resident #15's room, and witnessed S4 CNA yelling and cursing at Resident #15. Observation and Interview on 03/26/2025 at 3:20 p.m. with Resident #15 and Resident #37 revealed Resident #15 stated S4 CNA yelled at her on 02/16/2025, and said You stupid piece of sh*t, you're going to do what I say, and you're going to get in that bed! Resident #37 stated at that time that she heard S4 CNA yell at Resident #15 and say, You stupid piece of sh*t, you're going do what I say, and you're going to get in that bed! Resident #15 began to cry during the interview, and stated yes that is exactly what S4 CNA said to me! I don't like to use profanity, she hurt my feelings. Interview on 03/27/2025 at 8:43 a.m. with Resident #15, revealed she informed S1 Administrator of her exact concerns with S4 CNA, and reported to S1 Administrator that S4 CNA yelled and used profanity at her, made her go to bed, and grabbed her ankle and arm. Resident #15 stated S1 Administrator revealed she would take care of things. Resident #15 stated S4 CNA made me afraid and I just want to forget the whole incident, because it made me question if I made the right choice in moving here. Resident #15 stated she has often thought about going home since the incident with S4 CNA. Resident #25 Review of Resident #25's medical record revealed Resident #25 was admitted to the facility on [DATE]. Resident #25 had diagnoses that included in part . Traumatic Subarachnoid Hemorrhage, General Anxiety Disorder, Bipolar Disorder, Weakness, Generalized Muscle Weakness, Depression, and Anxiety. Review of Resident #25's Quarterly MDS with an ARD 02/20/2025, revealed Resident #25 had a BIMS score of 00 (severe cognitive impairment). Review of Resident #25's Care Plan with a problem initiation date of 12/24/2024, revealed in part . Potential for verbally aggressive behaviors due to a history of delusions and verbal aggression secondary to Bipolar disorder; Depressed Severe, with psychotic features; Depression; Anxiety Disorder. Interventions: 02/21/2025, Resident got into an altercation with another resident. S2 DON contacted psychiatrist, a medication review was done, and medication adjustment was ordered. Psychiatrist made aware of resident being manic. Review of Resident #25's Departmental Progress Notes revealed in part . On 02/21/2025 at 3:37 p.m., S16 LPN documented: CNA reported that Resident #25 hit Resident #51 in the face with a box a cookies. Resident to Resident altercation in progress. Resident #51's husband made aware of altercation. On 03/08/2025 at 4:39 p.m., S12 LPN documented: Resident #25 had a disagreement with Resident #6, and pulled Resident #6's hair. Interview on 03/25/2025 at 10:30 a.m. with S5 CNA Supervisor, revealed there was an incident between Resident #25 and Resident #6 one day last month (date unknown). Resident #25 became mad and aggressive, and pulled Resident #6's hair. S5 CNA Supervisor stated Resident #6 became very upset and told Resident #25 What's the matter with you? Don't do that! and went to her room crying. Interview on 03/25/2025 at 2:36 p.m. with S1 Administrator and S2 DON, confirmed last month Resident #25 pulled Resident #6's hair. S2 DON stated she did not see this incident as resident to resident abuse, and confirmed the facility had not reported the resident to resident abuse to the State Agency. Resident #51 Review of Resident #51's medical record, revealed Resident #51 was admitted to facility on 03/27/2024. Resident #51 had diagnoses that included in part . Bipolar Disorder, Paranoid Schizophrenia, Chronic Kidney Disease, Pain, and Major Depressive Disorder. Review of Resident #51's Annual MDS with an ARD of 12/18/2024 revealed a BIMS score of 15 (cognition intact). Review of Resident #51's Departmental Progress Notes revealed in part . On 02/21/2025 at 3:28 p.m., S16 LPN documented: CNA reported that Resident #25 hit Resident #51 in the face with a box a cookies. Resident to Resident altercation in progress. Resident #51's husband made aware of altercation. Interview on 03/27/2025 at 8:32 a.m. with Resident #51, revealed sometime last month (unknown date), Resident #25 came into the dining room acting mad, and hit her in the face with a box of cookies. Resident #51 stated that made me mad and upset me, but she did not hurt me. She's just mean! Telephone interview on 03/28/2025 at 11:53 a.m. with Resident #51's RP confirmed the facility had called him last month to inform him another Resident had hit Resident #51 with a box of cookies. S16 LPN was unavailable for interview at time of survey. Interview on 03/27/2025 at 11:00 a.m. with S2 DON, revealed the incident was not reported to the State Agency because she was not aware of the resident to resident altercation between Resident #25 and Resident #51 on 02/21/2025. Resident #6 Review of Resident #6's medical record, revealed Resident #6 was admitted to facility on 10/14/2024. Resident #6 had diagnoses that included in part . Depression, Type 2 Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease. Review of Resident #6's Quarterly MDS with an ARD of 01/22/2025, revealed a BIMS score of 6 (severe cognitive impairment). Review of Resident #6's Departmental Progress Notes revealed in part . On 03/08/2025 at 4:39 p.m., S12 LPN documented: Resident #25 had a disagreement with Resident #6, and pulled Resident #6's hair. Telephone interview on 03/26/2025 at 12:31 p.m. with S14 CNA, revealed she worked the 2:00 p.m. - 10:00 p.m. shift on 03/08/2025 on Hall Y. S14 CNA stated she was working in another resident's room, and Resident #46's RP came to the room to tell her that Resident #25 and Resident #6 were fighting. S14 CNA stated that she did not witness the incident, but Resident #46's RP did, and she immediately reported the incident to S12 LPN. Interview on 03/24/2025 at 1:04 p.m. with S1 Administrator confirmed the facility had no reportable incidents, and no submission to the State Agency since last survey on 06/12/2024. The Immediate Jeopardy was removed on 03/28/2025 at 6:04 p.m. as confirmed by onsite verification through observations, interviews and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to survey exit that included the following: The facility identified 4 instances of abuse/neglect in the facility: 1. Staff to Resident verbal and emotional abuse on 02/16/2025, when S4 CNA verbally and emotionally abused Resident #15; 2. Resident to Resident abuse on 02/21/2025, when Resident #25 physically abused Resident #51; 3. Resident to Resident abuse on 03/08/2025, when Resident #25 physically abused Resident #6; and These instances have the ability to affect all residents that reside in the facility. The facility implemented the following actions to remove the immediacy: On 03/27/2025 at 5:56 p.m. all current staff in the facility were in-serviced on the facility's Abuse and Neglect Policy and Procedure. On 03/27/2025 S2 DON completed a monitoring tool to ensure all allegations for abuse and neglect were properly and thoroughly investigated. The daily monitoring tool was to include any allegation of abuse and neglect was reported to S2 DON and S1 Administrator, and SIMS reporting was completed. Monitoring to be completed daily for 30days, then 3 times weekly for 2 weeks to ensure compliance is sustained. On 03/28/2025 at 6:00 a.m. all on coming staff was in-serviced on the facility's Abuse and Neglect Policy and Procedure. On 03/28/2025 at 2:00 p.m. there was a mandatory all staff meeting on the facility's Abuse and Neglect Policy and Procedure which addressed the required components to include reporting protocols and 2 hour timeline in which to report alleged incidents into SIMS. Staff member who had not received in-service would be required to receive in-service prior to beginning their scheduled shift. The above allegations and monitoring was added to the facility's QAPI, and shall be discussed monthly for the next 3 months. Facility completion date 03/28/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure allegations of verbal, physical, and/or mental abuse, were thoroughly investigated for 3 (Resident #6, Resident # 15, and Resident #51) of 3 (Resident #6, Resident # 15, and Resident #51) residents reviewed for abuse. This deficient practice resulted in an Immediate Jeopardy situation for Resident #15 on 02/16/2025, when S4 CNA yelled at Resident #15 You stupid piece of sh*t. You're going to do what I say, and you're going to get in bed! Resident #15, who is cognitively intact, stated the incident hurt her feelings, made her cry, and she was fearful of S4 CNA. The Immediate Jeopardy continued on 02/21/2025 at approximately 3:28 p.m., when Resident #25 hit Resident #51 in the face with a box of cookies. Resident #51 stated this made her mad. The Immediate Jeopardy continued on 03/08/2025 at approximately 4:20 p.m., when Resident #25 (who exhibited aggressive and angry behavior on day of incident), pulled Resident #6's hair. S1 Administrator was notified of the deficient practice at the Immediate Jeopardy level on 03/27/2025 at 5:56 p.m. Findings: Review of a facility policy on 03/26/2025 at 12:39 p.m. titled Abuse Prevention with revision date of 03/21/2012 read in part . Each resident shall remain free from harm. Should an employee and/or resident report suspected abuse the following should occur: The incident will be immediately reported to the charge nurse. The charge nurse will immediately contact the Director of Nursing. The charge nurse will then complete an incident report. The DON and/or Administrator will conduct an investigation per policy and federal/state guidelines. Investigation: The Administrator with the assistance of the DON and in their absence the ADON, and Social Services will begin the investigation process for all incidents that require investigation as soon as the following situations are identified: Abuse - the ill treatment or disregard of an individual, whether purposeful, or due to carelessness, inattentiveness or omission of the perpetrator. May also include domestic, institutional, self-abuse and self-neglect. Emotional Abuse - any threatening behavior or statement directed to a person including, but not limited to ridicule, gestures that subject the person to humiliation or degradation, threatening motions or noises intended to startle or frighten the person. Physical Injury - an act that physically hurts or damages an individual's body where damage is inflicted by external force. Neglect - failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. An intentional act of omission by an employee which denies the standard of care and treatment due to an individual as required by law, rules, regulations, policies, procedures, guidelines or care plans. Physical Abuse - any physical motion of action, e.g. hitting, spitting, slapping, punching, kicking, pinching, directed toward the individual. It included use of corporal punishment as well as the use of restrictive, intrusive procedure to control inappropriate behavior for purposes of punishment or correction. Threat- any condition or situation that could cause or result in severe, temporary or permanent injury or harm to the mental or physical condition of individuals or their death. Verbal Abuse - use of oral, written, or gestured language by which abuse occurs. Includes: Name calling, swearing., taunting, and using derogatory terms to describe persons with disabilities. Psychological Abuse - includes: humiliation, harassment, threats of punishment or deprivation, sexual coercion, and intimidation. If alleged abuse occurs staff will: Take immediate action to protect the individual(s) involved including removal of the alleged abuser. Ensure that any health or psychological needs of the resident are provided for. Notify the DON immediately. Resident #15 Review of Resident #15's medical record revealed she was admitted to the facility on [DATE]. Resident #15 had diagnoses that included in part . Chronic Pain Syndrome, Major Depressive Disorder, Anxiety Disorder, Parkinson's Disease, Spinal Stenosis, and Other Lack of Coordination. Review of Resident #15's Quarterly MDS with ARD of 01/08/2025, revealed a BIMS score of 15 (cognition intact). Resident #15 had range of motion impairment on both sides, and was dependent on staff for toileting, showering/bathing, and dressing. Review of Resident #15's care plan with an initiation date of 12/18/2024, revealed Resident #15 had a problem of impaired physical mobility related to Parkinson's disease. Interventions included in part . 2 person assist, transfer with mechanical lift. Interview on 03/24/2025 at 3:05 p.m. with Resident #15, revealed on 02/16/2025 she was seated in her wheelchair in her room, and S4 CNA came into her room to put her to bed. Resident #15 said she stated to S4 CNA that she did not want to go to bed, and that S4 CNA then became upset. Resident #15 stated S4 CNA came at me, and I saw her pull a girl's hair once, so I was afraid of her. Resident #15 stated S4 CNA used an ugly tone with her, and she directly reported the incident and how she was afraid of S4 CNA to S1 Administrator on 02/17/2025. Resident #15 reported S1 Administrator asked her if she was afraid of S4 CNA, to which she replied yes. Resident #15 revealed S1 Administrator stated she would take care of the situation, and that S4 CNA would not provide care to her anymore. Resident #15 stated S1 Administrator moved S4 CNA from Hall Y to Hall Z, and had not provided care to her since. Interview on 03/25/2025 at 11:30 a.m. with S1 Administrator, revealed last month (02/2025), Resident #15 reported that she was upset that S4 CNA put her back to bed when she (Resident# 15) did not want to go to bed. S1 Administrator stated Resident #15 reported this as a grievance to S2 DON. S1 Administrator revealed Resident #15 had never at any point in time informed her that she was afraid of S4 CNA, and denied Resident #15 reporting any abuse allegations to her. S1 Administrator revealed S2 DON moved S4 CNA's halls due to Resident #15 not wanting S4 CNA to care for her again. Interview on 03/25/2025 at 2:36 p.m. with S1 Administrator and S2 DON confirmed the facility had not investigated staff to resident verbal and emotional abuse that occurred for Resident #15 by S4 CNA on 02/16/2025, because they did not consider the incident as an abuse allegation, and so they did not investigate it as such. S2 DON confirmed the facility had not performed monitoring of S4 CNA, and had not interviewed any other resident following Resident #15's allegations of verbal abuse by S4 CNA. Telephone interview on 03/25/2025 at 3:56 p.m. with S4 CNA revealed on 02/16/2025, she was paged to the nurses station by S13 LPN, and S13 LPN asked her to put Resident #15 to bed, because Resident #15 was not feeling well. S4 CNA stated Resident #15 stated she did not want to go to bed, but she and S15 CNA convinced Resident #15, and they transferred her 2 person assist with mechanical lift to bed. Observation and Interview on 03/26/2025 at 3:20 p.m. with Resident #15 and Resident #37 revealed Resident #15 stated S4 CNA yelled at her on 02/16/2025, and said You stupid piece of sh*t, you're going to do what I say, and you're going to get in that bed! Resident #37 stated at that time that she heard S4 CNA yell at Resident #15 and say, You stupid piece of sh*t, you're going do what I say, and you're going to get in that bed! Resident #15 began to cry during the interview, and stated yes that is exactly what S4 CNA said to me! I don't like to use profanity, she hurt my feelings. Interview on 03/27/2025 at 8:43 a.m. with Resident #15 revealed she informed S1 Administrator of her exact concerns with S4 CNA, and reported to S1 Administrator that S4 CNA yelled and used profanity at her, made her go to bed, and grabbed her ankle and arm. Resident #15 stated S1 Administrator revealed she would take care of things. Resident #15 stated S4 CNA made me afraid and I just want to forget the whole incident, because it made me question if I made the right choice in moving here. Resident #15 stated she has often thought about going home since the incident with S4 CNA. Resident #51 Review of Resident #51's medical record, revealed Resident #51 was admitted to facility on 03/27/2024. Resident #51 had diagnoses that included in part . Bipolar Disorder, Paranoid Schizophrenia, Chronic Kidney Disease, Pain, and Major Depressive Disorder. Review of Resident #51's Annual MDS with an ARD of 12/18/2024 revealed a BIMS score of 15 (cognition intact). Review of Resident #51's Departmental Progress Notes revealed in part . On 02/21/2025 at 3:28 p.m., S16 LPN documented: CNA reported that Resident #25 hit Resident #51 in the face with a box a cookies. Resident to Resident altercation in progress. Resident #51's husband made aware of altercation. Interview on 03/27/2025 at 8:32 a.m. with Resident #51, revealed sometime last month (unknown date), Resident #25 came into the dining room acting mad, and hit her in the face with a box of cookies. Resident #51 stated that made me mad and upset me, but she did not hurt me. She's just mean! Telephone interview on 03/28/2025 at 11:53 a.m. with Resident #51's RP, confirmed the facility had called him last month to inform him another Resident had hit Resident #51 with a box of cookies. Interview on 03/27/2025 at 11:00 a.m. with S2 DON revealed she was aware of an incident between Resident #25 and Resident #51 that occurred sometime last month. S2 DON stated she was told by staff that Resident #25 and Resident #51 was arguing over a cookie, but was not informed of Resident #25 hitting Resident #51. S2 DON confirmed she did not further investigate the resident to resident abuse on 02/21/2025 when Resident #25 hit Resident #51 in the face with a box of cookies, but should have. Resident #6 Review of Resident #6's medical record, revealed Resident #6 was admitted to facility on 10/14/2024. Resident #6 had diagnoses that included in part . Depression, Type 2 Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease. Review of Resident #6's Quarterly MDS with an ARD of 01/22/2025, revealed a BIMS score of 6 (severe cognitive impairment). Review of Resident #6's Departmental Progress Notes revealed in part . On 03/08/2025 at 4:39 p.m., S12 LPN documented: Resident #25 had a disagreement with Resident #6, and pulled Resident #6's hair. Interview on 03/25/2025 at 2:36 p.m. with S1 Administrator and S2 DON confirmed last month (02/2025), Resident #25 pulled Resident #6's hair. S2 DON stated she did not see this incident as resident to resident abuse, so the facility had not performed an abuse investigation. Telephone interview on 03/26/2025 at 12:31 p.m. with S14 CNA, revealed she worked the 2:00 p.m. - 10:00 p.m. shift on 03/08/2025 on Hall Y. S14 CNA stated she was working in another resident's room, and Resident #46's RP came to the room to tell her that Resident #25 and Resident #6 were fighting. S14 CNA stated that she did not witness the incident, but Resident #46's RP did, and she immediately reported the incident to S12 LPN. Interview on 03/26/2025 at 12:53 p.m. with S2 DON revealed on 03/08/2025 she spoke to S12 LPN about the documented disagreement between Resident #25 and Resident #6. S2 DON stated S12 LPN informed her that she observed the two residents playing in each other's hair. S2 DON confirmed she did not interview any other staff, and that no one had reported a physical altercation between Resident #25 and Resident #6 to her, so she did not investigate further, but should have. The Immediate Jeopardy was removed on 03/28/2025 at 6:04 p.m. after it was verified through observation, interview and record review that the facility submitted and implemented a Plan of Removal that included the following: The facility identified 3 instances of abuse/neglect in the facility: 1. Staff to Resident verbal and emotional abuse on 02/16/2025, when S4 CNA verbally and emotionally abused Resident #15; 2. Resident to Resident abuse on 02/21/2025, when Resident #25 physically abused Resident #51; 3. Resident to Resident abuse on 03/08/2025, when Resident #25 physically abused Resident #6. These instances have the ability to affect all residents that reside in the facility. The facility implemented the following actions to remove the immediacy: On 03/27/2025 at 5:56 p.m. all current staff in the facility were in-serviced on the facility's Abuse and Neglect Policy and Procedure. On 03/27/2025 S2 DON completed a monitoring tool to ensure all allegations for abuse and neglect were properly and thoroughly investigated. The daily monitoring tool was to include any allegation of abuse and neglect was reported to S2 DON and S1 Administrator, and SIMS reporting was completed. Monitoring to be completed daily for 30days, then 3 times weekly for 2 weeks to ensure compliance is sustained. On 03/27/2025 monitoring tool initiated for review of the nurses notes from the prior day in the weekly morning stand up meeting with IDT team. Any findings/allegations shall be reported to S1 Administrator immediately. On 03/28/2025 at 2:00 p.m. there was a mandatory all staff meeting to discuss Abuse and Neglect Policy and Procedure, Lifting protocols, and the facility's Use of Mechanical Lift. In-service included monitoring for a reporting resident to resident abuse, staff to resident abuse, and neglect. In addition, reporting and investigation requirements of all alleged incidents of abuse and neglect. The facility shall thoroughly investigate any and all allegations of abuse and neglect to prevent the likelihood of further incidents of abuse and neglect. The above allegations and monitoring was added to the facility's QAPI, and shall be discussed monthly for the next 3 months. Facility completion date 03/28/2025.

Based on observations and interviews, the facility failed to provide drinks consistent with resident preferences. The facility failed to ensure staff, in Hall X dining room, provided water to 10 residents with their meal during lunchtime. Findings: Observation on 03/24/2025 at 11:11 a.m. revealed staff serving resident lunch trays in Hall X dining room with only juice observed on the lunch tray. No water was observed on the lunch trays or offered to the 10 residents prior to receiving their lunch trays. Interview on 03/24/2025 at 11:12 a.m. with S5 CNA Supervisor revealed that the residents were given juice and milk with their lunch tray, but were not served/offered water with their meal. Observation on 03/25/2025 11:30 a.m. in Hall X dining room revealed the 10 residents were served only milk and juice with their lunch tray and were not offered or provided water. Interview on 03/25/2025 at 2:32 p.m. S5 CNA Supervisor revealed the kitchen does not send water on resident's meal trays and only send juice and Kool-Aid. S5 CNA Supervisor stated only if a resident were to request water with their meal, staff would go get it for them.

Based on record review and interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 5 (Resident #6, Resident # 15, Resident #25, Resident #51, and Resident #68) of 34 Sampled Residents. The facility failed to: 1. Protect and ensure Resident #15 was free from verbal abuse and psychosocial harm by S4 CNA; 2. Ensure Resident #51 and Resident #6 were free from resident to resident physical abuse by Resident #25; 3. Ensure Resident #68 was free from neglect by S6 CNA; 4. Have an effective system in place to ensure all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegation was made for Resident #6, Resident # 15, and Resident #51; and 5. Have an effective system in place to ensure allegations of abuse and neglect were thoroughly investigated for Resident #6, Resident # 15, Resident #51, and Resident #68. This deficient practice resulted in an Immediate Jeopardy situation for Resident #15 on 02/16/2025, when S4 CNA yelled at Resident #15 You stupid piece of sh*t. You're going to do what I say, and you're going to get in bed! Resident #15, who is cognitively intact, stated the incident hurt her feelings, made her cry, and she was fearful of S4 CNA. The Immediate Jeopardy continued on 02/21/2025 at approximately 3:28 p.m., when Resident #25 hit Resident #51 in the face with a box of cookies. Resident #51 stated this made her mad. The Immediate Jeopardy continued on 03/08/2025 at approximately 4:20 p.m., when Resident #25 (who exhibited aggressive and angry behavior on day of the incident), pulled Resident #6's hair. The Immediate Jeopardy continued on 03/25/2025 at 2:25 p.m., when S6 CNA was observed to willfully transfer Resident #68 without the required 2 person physical assist with mechanical lift; although she was knowledgeable that 2 person assist with mechanical lift was required of Care. The deficient practice has the likelihood to affect all other residents who reside in the facility. S1 Administrator was notified of the deficient practice at the Immediate Jeopardy level on 03/27/2025 at 5:56 p.m. Findings: Cross reference F600, F609, and F610. Review of a facility policy on 03/26/2025 at 12:39 p.m., titled Abuse Prevention, with revision date of 03/21/2012, read in part . Each resident shall remain free from harm. Abuse - the ill treatment or disregard of an individual, whether purposeful, or due to carelessness, inattentiveness or omission of the perpetrator Emotional Abuse - any threatening behavior or statement directed to a person including, but not limited to ridicule, gestures that subject the person to humiliation or degradation, threatening motions or noises intended to startle or frighten the person. Physical Injury - an act that physically hurts or damages an individual's body where damage is inflicted by external force. Neglect - failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. An intentional act of omission by an employee which denies the standard of care and treatment due to an individual as required by law, rules, regulations, policies, procedures, guidelines or care plans. Physical Abuse - any physical motion of action, e.g. hitting, spitting, slapping, punching, kicking, pinching, directed toward the individual . Threat- any condition or situation that could cause or result in severe, temporary or permanent injury or harm to the mental or physical condition of individuals or their death. Verbal Abuse - use of oral, written, or gestured language by which abuse occurs. Includes: Name calling, swearing., taunting, and using derogatory terms to describe persons with disabilities. Psychological Abuse - includes: humiliation, harassment, threats of punishment or deprivation, sexual coercion, and intimidation. If alleged abuse occurs staff will: Take immediate action to protect the individual(s) involved including removal of the alleged abuser. Ensure that any health or psychological needs of the resident are provided for. Notify the DON immediately. Review of a facility policy on 03/25/2025 at 4:16 p.m., titled Abuse and Neglect-Clinical Protocol, with revision date of 01/01/2025, read in part . Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, neglect, misappropriation of property or financial abuse, involuntary seclusion, and mental abuse including abuse facilitated or enabled through the use of technology. Neglect, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of a facility policy on 03/26/2025 at 1:30 p.m. titled Resident Rights with revision date of 12/2021, read in part . Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence; be treated with respect, kindness, and dignity; and to be free from abuse and neglect. Interview on 03/24/2025 at 1:04 p.m. with S1 Administrator confirmed the facility had no reportable incidents, and no submission to the State Agency since last survey on 06/12/2024. Interview on 03/25/2025 at 2:36 p.m. with S1 Administrator and S2 DON confirmed the facility had not investigated staff to resident verbal and emotional abuse that occurred for Resident #15 by S4 CNA on 02/16/2025, because they did not consider the incident as an abuse allegation, and so they did not investigate it as such. S2 DON confirmed the facility had not performed monitoring of S4 CNA, and had not interviewed any other resident following Resident #15's allegations of verbal abuse by S4 CNA. Interview on 03/25/2025 at 2:36 p.m. with S1 Administrator and S2 DON, confirmed last month (02/2025), Resident #25 pulled Resident #6's hair. S2 DON stated she did not see this incident as resident to resident abuse, and confirmed the facility had not reported the resident to resident abuse to the State Agency. Interview on 03/25/2025 at 2:57 p.m. with S3 ADON, revealed Resident #68's transfer status is 2-person lift according to his care plan. S3 ADON revealed that all staff should access a resident's transfer status prior to transfer by looking at the residents' POC in the kiosk on the hall. S3 ADON confirmed mechanical lift was documented in Resident #68's POC for transfer status. Interview on 03/26/2025 at 5:10 p.m. with S2 DON, revealed that when a resident's POC was entered into the electronic system, it then fired to the kiosk located on the halls for the CNAs to view. S2 DON stated that staff were to look at the kiosk prior to caring for residents to determine their transfer status. S2 DON confirmed that Resident #68 was care planned as a 2-person lift, and should not have been transferred without another staff member present and without the use of a lift. Interview on 03/27/2025 at 11:00 a.m. with S2 DON revealed she was aware of an incident between Resident #25 and Resident #51 that occurred sometime last month. S2 DON stated she was told by staff that Resident #25 and Resident #51 was arguing over a cookie, but was not informed of Resident #25 hitting Resident #51. S2 DON confirmed she did not further investigate the documented resident to resident abuse on 02/21/2025 when Resident #25 hit Resident #51 in the face with a box of cookies, but should have. S2 DON revealed the incident was not reported to the State Agency because she was not aware of the resident to resident altercation between Resident #25 and Resident #51 on 02/21/2025. The Immediate Jeopardy was removed on 03/28/2025 at 6:04 p.m. after it was verified through observation, interview and record review that the facility submitted and implemented a Plan of Removal that included the following: The facility identified 4 instances of abuse/neglect in the facility: 1. Staff to Resident verbal and emotional abuse on 02/16/2025, when S4 CNA verbally and emotionally abused Resident #15; 2. Resident to Resident abuse on 02/21/2025, when Resident #25 physically abused Resident #51; 3. Resident to Resident abuse on 03/08/2025, when Resident #25 physically abused Resident #6; and 4. Neglect, when S6 CNA neglected Resident #68. These instances have the ability to affect all residents that reside in the facility. The facility implemented the following actions to remove the immediacy: On 03/27/2025 in-service was completed with all current staff on shift for abuse and neglect policy and procedure, lifting protocol, and what constitutes abuse and neglect. On 03/27/2025 S4 CNA was placed on administrative leave pending thorough investigation. On 03/27/2025 S6 CNA was in services on proper lifting techniques with proper return demonstration completed. On 03/27/2025 S2 DON completed a monitoring tool to ensure all allegations for abuse and neglect were properly and thoroughly investigated. The daily monitoring tool was to include any allegation of abuse and neglect was reported to S2 DON and S1 Administrator, and SIMS reporting was completed. Monitoring to be completed daily for 30days, then 3 times weekly for 2 weeks to ensure compliance is sustained. On 03/27/2025 Administrative oversight was provided to S1 Administrator and S2 DON by the regional administrator. The regional administrator shall thoroughly investigate all allegations of abuse and neglect to prevent the likelihood of further incidents of abuse. Regional administrator will monitor S1 Administrator weekly by direct observation and onsite oversight weekly for 30 days. On 03/28/2025 at 2:00 p.m. there was a mandatory all staff meeting to discuss Abuse and Neglect Policy and procedure, reportable incidents, lifting protocols, and use of lifters. In-service also included monitoring for and reporting resident to resident abuse, staff to resident abuse, and neglect. The facility shall thoroughly investigate any and all allegations of abuse and neglect to prevent the likelihood of further incidents of abuse. Any staff member not in serviced will be in serviced prior to the beginning of their shift. On 03/28/2025 a monitoring tool was initiated for nurse's notes to be reviewed daily for any alleged cases of abuse and neglect to be investigated as necessary. All alleged cases will be brought to S2 DON and S1 Administrator's attention and investigation and reporting are to be done immediately. On 03/28/2025 the above allegations and monitoring was added to the facility's QAPI, and shall be discussed monthly for the next 3 months. Facility completion date 03/28/2025.

Based on observation, interview, and record review, the facility failed to ensure a resident received services in the facility with reasonable accommodation of needs for 1 (#3) of 2 (#2 and #3) sampled residents reviewed for call bell placement. The facility failed to ensure Resident #3 had a call bell in reach in order to call for assistance. Findings: A review of Facility's undated policy on 06/11/2024 titled Call Bell/Light Policy, read in part . 2. The call bell must be within reach of the resident. If the resident constantly moves the call bell out of reach, it will be care planned. Review of Resident #3's medical record revealed an admit date of 03/27/2023, with diagnoses that included Cerebral Infarction due to thrombosis of right vertebral artery, CVA, Seizure Disorder, and HTN. Review of Resident #3's Minimum Data Set (MDS) with an ARD of 05/08/2024, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 8, indicating cognitive impairment. The MDS revealed Resident #3 was dependent on staff for oral hygiene, showering, bathing, and dressing. Review of Resident #3's Care Plan with review date of 08/07/2024, revealed assistance is required for all ADL's. Observation on 06/10/2024 at 9:05 a.m., revealed Resident #3 lying in bed with the call bell draped over a plug-in receptacle box on the wall behind Resident #3. Interview on 06/10/2024 at 9:10 a.m. with S2 LPN revealed Resident #3 is able to use the call bell to make her needs known. Observation on 06/10/2024 at 11:23 a.m. revealed Resident #3 lying in bed with the call bell draped over a plug-in receptacle box on the wall behind Resident #3. Observation on 06/10/2024 at 1:09 p.m. revealed Resident #3 lying in bed with the call bell draped over a plug-in receptacle box on the wall behind Resident #3. Interview with S2 LPN at that time confirmed the call bell was out of reach, and then placed the call bell next to Resident #3. Resident #3 then activated the call bell per S2 LPN's request. Interview on 06/11/2024 at 10:20 a.m. with S1 DON, revealed Resident #3 is able to use a call bell if she needs assistance. S1 DON stated that call bells should be in reach for any resident that is able to use a call bell.

Based on observation, interview, and record review the facility failed to ensure that a resident received adequate supervision and assistive devices to prevent incidents and accidents. The facility failed to ensure a resident wore a smoker's apron to prevent accidents while smoking for 1 (Resident #17) of 1 residents reviewed for smoking. Findings: Review of the facility's policy titled Safe Smoking Assessment read in part .The purpose of the Safe Smoking Assessment is to determine the individual's ability and willingness to comply with facility rules and regulations governing smoking. Appropriate care planning should be developed following the assessment. Review of Resident #17's medical record revealed she was admitted to facility on 08/03/2023 and had diagnoses that included in part Anxiety Disorder, Cerebral Infarction, Epilepsy, Parkinson's Disease, Major Depressive Disorder, and Type 2 Diabetes Mellitus. Record review of Resident #17's Quarterly MDS with ARD of 11/01/2023 reveled Resident #17 had a BIMS of 12. Record review of Resident #17's Safe Smoking Evaluation dated 01/11/2024 and completed by S3 LPN revealed Resident #17 required a fire resistant smoking apron while smoking. Review of Resident #17's Care plan revealed description for Safe Smoking with an intervention of Resident wears a fire resistant smoking apron while smoking due to frequently dropping cigarettes. Observation on 01/22/2024 at 10:30 a.m. revealed Resident #17 seated in a wheelchair on the smoking patio of the facility. Resident #17 was observed wearing a smoking apron and a lit cigarette was noted on the ground next to the wheelchair. Interview with Resident #17 at the time of observation revealed Resident #17 had dropped the cigarette. Resident #17 stated she was able to smoke whenever she wanted, but had to wear an apron. Interview on 01/23/2024 at 9:24 a.m. with S1 Laundry revealed she had noticed burn holes in Resident #17's clothing from smoking approximately 1 month ago. S1 Laundry stated she had notified the nurse about the holes and was aware Resident #17 now had to wear an apron while smoking. Observation on 01/23/2024 at 3:48p.m. revealed Resident #17 was outside smoking without wearing a smokers apron. Interview at time of observation with Resident #17 revealed she had come out for a smoke with the other residents. Resident #17 was observed with a lit cigarette in her left hand, and ashes were falling to ground near her leg. Interview on 01/23/2024 at 3:55 p.m. with S2 LPN revealed Resident #17 was to wear a smokers apron at all times while smoking. S2 LPN accompanied surveyor to smoking patio and confirmed Resident #17 was outside smoking without a smoker's apron, and should have been wearing one. Interview on 01/24/2024 at 9:52 a.m. with S3 LPN revealed she had completed a smoking evaluation on Resident #17 on 01/11/2024 due to staff witnessing burn holes in clothing, and Resident #17 dropping cigarettes. S3 LPN confirmed Resident #17 was to wear a smoker's apron at all times while smoking for safety, and staff was to ensure Resident #17 was compliant.

Based on interview and record review the facility failed to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments for 1 (#3) of 7 (#1, 2, 3, 4, 5, 6, and 7) sampled residents. The facility failed to ensure Resident #3 who had an iodine allergy was not served and consumed a meal tray that contained shellfish. Findings: Review of the facility policy titled: Meal Supervision and Assistance revealed in part . The resident will be prepared for a well-balanced meal in a calm environment, location of his/her preference and with adequate supervision and assistance to prevent accidents, provide adequate nutrition, and assure an enjoyable event. This includes: Identifying hazards and risk Evaluating and analyzing hazards and risk Review of Resident #3's clinical record revealed an admit date of 08/03/2023 with diagnosis that included: Anxiety Disorder, Epilepsy, Bradycardia, Macular Degeneration, Essential Hypertension, Parkinson's Disease, and Type II Diabetes Mellitus. Review of Resident #3's Quarterly MDS with ARD of 11/01/2023 revealed Resident #3 required setup or cleanup assistance with meals and had a BIMS score of 12 (which indicated moderately impaired cognition). Review of Resident #3's November 2023 nurses notes revealed in part . 11/19/2023 4:40 a.m. Resident reported to the night nurse, S4 LPN, that she ate shrimps Friday night for supper (11/17/2023) and she started feeling bad. This morning she reports she still wasn't feeling well. Resident had an allergy to iodine. Offered resident to go to ER dept for evaluation but resident refused x 2. Will ask again before shift change. Interview on 11/29/2023 at 2:30 p.m. with Resident #3 revealed after returning from pass on 11/17/2023 she received a lunch tray with what looked like tater tots. Resident #3 stated after eating two she realized they were shrimp. Resident #3 stated she did not experience a reaction. Resident #3 stated she notified the facility of her iodine allergy when she was admitted and had not eaten shellfish in 60 or more years. Review of the facility menu for November week 2, Friday lunch revealed: Fried popcorn shrimp, french fries, coleslaw, wheat dinner roll, margarine, and diced peaches. Review of Resident #3's dietary meal ticket revealed allergies were listed as shellfish. Review of 11/17/2023 facility staffing assignments revealed S7 CNA was assigned to Resident #3 for the 6:00 a.m. to 2:00 p.m. shift Interview on 11/29/2023 at 2:50 p.m. with S3 Dietary Manager revealed she had completed Resident #3's admission dietary assessment. S3 Dietary Manager stated residents with iodine allergies should not receive fish, shrimp or shellfish. S3 Dietary Manager stated she was not aware Resident #3 received shrimp on 11/17/2023 and Resident #3 should not have. Telephone interview on 11/29/2023 at 4:15 p.m. with S7 CNA revealed she did not remember serving Resident #3 shrimp on 11/17/2023. S7 CNA stated food allergies were listed on meal tickets. S7 CNA stated she was not sure what a shellfish allergy meant. Telephone interview on 11/17/2023 at 4:00 p.m. with S6 LPN revealed she was assigned to Resident #3 from 6:00 a.m. to 6:00 p.m. on 11/17/2023 and 11/18/2023. S6 LPN stated she was not aware of Resident #3 receiving shrimp on 11/17/2023. Interview on 11/30/2023 at 9:45 a.m. with S7 CNA stated meal tickets were checked with each tray before passing out. S7 CNA stated she had been trained to check meal tickets, for name, room number, and allergies on orientation. S7 CNA confirmed that before yesterday she was not sure what a shellfish allergy meant. Interview on 11/30/2023 at 10:08 a.m. with S5 CNA Supervisor, revealed meal tickets were supposed to be checked at every meal for residents name, diet and allergies. S5 CNA Supervisor stated in orientation CNA's are told to check meal tickets and if anything is incorrect on the tray to report it to the nurse. S5 CNA Supervisor stated she is not sure if other CNA's know what a shellfish allergy means because it's just assumed that people know. S5 CNA Supervisor confirmed Resident #3 should not have been served a tray with shrimp. Interview on 11/30/2023 at 11:05 a.m. with S2 DON revealed education on shellfish allergies should be part of CNA orientation and was not. S2 DON stated she assumed everyone knew what a shellfish allergy meant. S2 DON confirmed that checking slips for food allergies on meal trays is part of identifying food hazards and risk.

Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections by failing to ensure staff changed gloves and performed hand hygiene after touching contaminated areas during wound care for 1 (#6) of 1 residents observed for wound care. Findings: Review of the Facility's Wound care policy read in part . Purpose: The Purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Steps in the Procedure: 4. Put on exam glove. Loosen tape and remove old dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves. 11. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with antiseptic or soap and water. Review of Resident #6's 11/2023 Physician Orders read in part: 11/03/2023 -Stage 2 Pressure injury to right buttocks. Cleanse with wound cleanser, pat dry, apply honey alginate, and cover with a dressing daily until resolved. An observation of wound care for Resident #6 on 11/29/2023 at 2:47 p.m. revealed S1 Treatment Nurse removed old dressing to right buttocks wound, discarded dressing, then reached over the clean field without removing the soiled gloves or sanitizing hands. S1 Treatment Nurse then removed a 4x4 gauze and wound cleanser with soiled gloves attempting to cleanse the wound. An interview on 11/29/2023 at 2:55 p.m., S1 Treatment Nurse was notified by this surveyor that she failed to remove soiled gloves and sanitize hands prior to obtaining supplies from the clean field and attempting to cleanse wound. S1 Treatment Nurse confirmed that she should have removed the soiled gloves and sanitized her hands after removing the soiled dressing from Resident #6's right buttocks wound, but did not.

Based on record review, and interview the facility failed to ensure a residents received treatment and care in accordance with professional standards of practice, for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. The facility failed to: 1. Ensure that medication was prescribed by a physician prior to being administered; and 2. Ensure Resident #1 received medications as ordered by the physician. Findings: Review of Resident #1's EHR revealed an admit date of 08/14/2017 with a readmission date of 05/05/2023, with diagnoses which included: Sepsis, unspecified organism, Pneumonia, unspecified organism, Acute Kidney Failure, unspecified, Other neuromuscular dysfunction of bladder, and Muscle wasting and atrophy. Review of Resident #1's Physician's Orders revealed the following: Apply Silvadene cream to burn areas on right chest area and right upper back area every day bid until resolved. (08/24/2023). Hydrocodone 10 mg -Acetaminophen 325 mg tablet by mouth prn q 4 hrs. prn pain (08/28/2023. Probiotic 15 billion cell capsule by mouth 3x/day for 7 days (08/28/2023- 09/03/2023). Clindamycin 300 mg capsule by mouth 3x/day for 7 days (08/28/2023- 09/03/2023). Review of the Care Plan with a review date of 09/20/2023 for Resident #1 revealed altered skin integrity- Resident stated she spilled coffee on herself, interventions included: burned area to right chest area and upper back area, apply Silvadene cream bid daily until resolved; Clindamycin 300 mg po tid x 7 days for burns; Probiotic po tid x 7 days. Review of Resident #1's SC MDS with an ARD of 06/27/2023 revealed Resident #1 had a BIMS score of 11 (indicating moderately impaired cognition). Resident #1 required extensive 2 person assistance with bed mobility, transfer, locomotion on/off unit, and toilet use, one person assist with dressing, eating, personal hygiene, and bathing. Resident #1's balance was not steady, she was only able to stabilize with staff assistance. Resident #1 had impaired ROM to upper or lower extremities. Resident #1 used a wheel chair. Review of Resident #1's MAR's for 08/2023 and 09/2023 revealed Clindamycin 300 mg capsule by mouth 3x/day, scheduled for: 9:00 a.m., 3:00 p.m. & 9:00 p.m. for 7 days was ordered to be administered: 08/28/2023- 09/03/2023. The initial dose of Clindamycin was administered on 08/28/2023 at 9:00 p.m. and the last dose was documented as being administered on 09/02/2023 at 9:00 p.m. The medication was not completed as per physician orders. Probiotic 15 billion cell capsule by mouth 3x/day, scheduled for: 9:00 a.m., 3:00 p.m. & 9:00 p.m. for 7 days was ordered to be administered: 08/28/2023- 09/03/2023. The initial dose of Probiotic was administered on 08/28/2023 at 9:00 p.m. and the last dose was documented as being administered on 09/02/2023 at 9:00 p.m. The medications were documented as administered: 1 dose on 1 day, and 3 doses for 5 days for a total of 16 dosages of each medications. Interview on 09/20/2023 at 9:30 a.m., with S2 LPN stated at approximately 12:00 p.m. on 08/24/2023, she applied Silvadene to Resident#1s's right chest and right upper back area, immediately after assessing the Resident. S2 LPN stated she applied the Silvadene as nursing measure. S2 LPN stated she called Resident #1's phsyician on 08/24/2023 at approximately at 2:00 p.m., and received an order for Silvadene. Interview on 09/20/2023 at 2:15 p.m. with S1 DON confirmed both medications were administered for only 5 days and should have been 7 days. S1 DON confirmed Resident#1 should have been administered a total of 21 dosages of both medications and was only administered 16 dosages of each. Interview on 09/20/2023 at 3:50 p.m. with S2 LPN confirmed she had no order for the Silvadene prior to applying it on Resident #1 on 08/24/2023 at approximately 12:00 p.m. S2 LPN confirmed the Silvadene she used at 12:00 p.m. had been a discontinued medication for another resident (unable to recall who). S2 LPN stated she has since disposed of the Silvadene, and she should not have used it on Resident #1 on 08/24/2023. Interview on 09/20/2023 at 4:26 p.m. with S1 DON stated the facility had no standing orders for application of Silvadene to burns, nor is Silvadene stocked in the facility's first aid kit. S1 DON confirmed S2 LPN applied a medication (Silvadene) without a physician order. S1 DON confirmed S2 LPN should have contacted the resident's physician prior to applying the Silvadene but had not.

Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure Residents' assistive devices were maintained in good working condition for 2 (#26, and #34) of 31sampled Residents. Findings: Resident #26 Observation on 01/30/2023 11:14 a.m. revealed Resident #26 lying in bed with an electrical motorized wheelchair positioned next to his bed. The wheelchair was noted to have multiple tears on the right and left armrest, back pouch and back rest, and the left armrest was loose. Interview with Resident #26 at the time of the observation revealed he was unable able to walk so he used the wheelchair to move around his room and the facility. Observation on 01/31/2023 at 9:30 a.m. revealed Resident #26 lying in bed with an electrical motorized wheelchair positioned next to his bed. The wheelchair was noted to have multiple tears on the right and left armrest, back pouch and back rest, and the left armrest was loose. Interview on 01/31/2023 at 9:45 a.m. with S1 DON confirmed after inspecting the wheelchair for Resident #26, the wheelchair was in need of repairs. Resident #34 Observation on 01/30/2023 at 12:30 p.m. revealed Resident #34 lying in bed with a wheelchair positioned next to his bed. The wheelchair was noted to have multiple tears on the right and left armrests, and the left armrest was loose. Interview with Resident #34 at the time of the observation revealed he was unable to walk and he used the wheelchair to move around the facility. Observation on 01/31/2023 at 1:58 p.m. revealed Resident #34 lying in bed with a wheelchair positioned next to his bed. The wheelchair was noted to have multiple tears on the right and left armrests and the left armrest was loose. Interview on 01/31/2023 at 2:10 p.m. with S1 DON confirmed after inspecting the wheelchair for Resident#34, the wheelchair was in need of repairs and/or replacement. .

Based on observation, interview and record review the Facility failed to protect Residents from abuse, neglect, exploitation and misappropriation of their property by failing to screen Agency/Contract staff's background prior to allowing 2 of 2 unlicensed sampled (S6 Agency CNA and S7 Agency CNA) Agency/Contract staff to work in the Facility. This practice had the potential to affect all Residents in the Facility. Finding: Contract Staffing: Policy Interpretation and Implementation The contracted agency must adhere to federal and state guidelines when hiring their employees. The contracted agency is responsible for ensuring their staff have completed and passed criminal background checks, OIG, sexual offender check, and have the appropriate licensing and certifications. Observation on 02/01/2023 at 10:30 revealed S6 Agency CNA and S7 Agency CNA's performing Resident care. Record review of S6 Agency CNA and S7 Agency CNA personnel file revealed no documentation of a criminal background check. Interview on 02/01/2023 at 11:20 a.m. with S1 DON confirmed the contracting agency performed criminal history background checks on their employees and the facility had not requested or seen documentation from the contracted agency for S6 Agency CNA and S7 Agency CNA's criminal history background checks prior to them starting employment and she should have. S1 DON stated she did not check the criminal backgrounds because she had only been employed at the facility since 11/22 and that's how they did background checks in the past and she just followed the process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #53 Based on observation, interview and record review the facility failed to develop/implement a person-centered care plan for 2 Residents (#8 and #53) to include an indwelling Foley Catheter for Resident (#8) and appropriate nursing interventions for Resident (#53) with a new onset of seizures and an anticonvulsant medication. Total sample size was 31. Findings: Review of Resident #53's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included: Schizophrenia Unspecified, Anxiety Disorder, Unspecified Conversion Disorder with Seizures or Convulsions, Displaced Fracture of Lateral end of Right Clavicle and Pain Unspecified. Review of Resident #53's Quarterly MDS with an ARD of 12/14/2022 revealed the Resident had a BIMS score of 2 (which indicated severe cognitive impairment). The MDS revealed the Resident was coded as requiring 1 person for: transfers, bed mobility, dressing and eating, toilet use, personal hygiene and bathing. Record review of Physician orders dated 12/14/2022 for Resident #53 revealed Conversion Disorder with Seizures or Convulsions Phenytoin Sodium extended 100 MG capsule (Anticonvulsant) oral Q8HRS every day Review of Resident #53's Care Plan with a start date of 12/08/2022 revealed: New onset of Seizure with interventions to send to the emergency room for evaluation of seizure activity and right eye hematoma (actions from a fall that occurred on 12/07/2022). Phenytoin Sodium extended 100 MG capsule oral Q8HRS every day. Interview on 01/31/2023 at 3:07 p.m. with S8 LPN/MDS Coordinator confirmed Resident #53 had no documented interventions for her new onset of seizures or for medication Phenytoin Sodium (Anticonvulsant) other than a past occurrence of sending Resident to the emergency room for evaluation of seizure activity and right eye hematoma due to a fall. Interview on 01/31/2023 at 3:15 p.m. with S1 DON confirmed Resident #53 did not have a Care Plan for the medication Phenytoin Sodium (Anticonvulsant) or appropriate nursing interventions for new onset of seizure diagnosis and she should have. Review of the Facility's Policy titled Catheter Care, Urinary read in part . Purpose- The purpose of this procedure is to prevent catheter-associated urinary tract infection. Preparation 1. Review the resident's care plan to assess for any special needs for residents. Resident #8 Review of Resident #8's EHR (Electronic Health Record) revealed she was admitted to the facility on [DATE] with Admitting Diagnoses of Neuromuscular Dysfunction of Bladder Unspecific, Personal History of Urinary Tract Infection, Gastro-Esophageal Reflux, Mild Protein-Calorie malnutrition, Vitamin Deficiency Unspecified, and Insomnia Unspecified. Review of the January 2023 Physician orders: Furosemide 20 mg po 8 a.m. every day Change Catheter monthly and prn specify the size 16 French. Turn and reposition every 2 hours. Ensure resident is turned every 2 hours and document if non- compliant. Stage 4 Sacrum area, clean with normal saline, pat dry, apply collagen with Calcium alginate and dress every day until healed. Review of Resident #8's Quarterly Minimum Data Set with an Assessment Reference Date of 11/09/2022 a BIMS score (Brief Interview for Mental Status) of 05 (severely cognitively impaired) and requires two person assist with bed mobility, transfers, bathing, and toileting. Resident #8 was incontinent of bowel and bladder with a Urinary Catheter. Review of Resident #8's Care Plan revealed the Foley Catheter had not been addressed. Observation on 01/30/2023 at 10:41a.m., revealed Resident #8 lying bed positioned on her back. Resident #8 had a Foley catheter to gravity drainage with white sediments noted in the genitourinary tubing. Observation on 01/31/2023 at 10:12 a.m., revealed Resident #8 in bed position on her left side with a Foley catheter to gravity drainage with white sediments noted in the genitourinary tubing. Interview on 02/01/2023 at 2:50 p.m. with S1 DON and reviewing Resident #8's Care Plan confirmed that Resident #8's Care Plan did not address Foley catheter and should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure 2 (Resident #8 and #45) of 8 Residents, who were incontinent and required indwelling catheterization, received appropriate treatment to prevent urinary tract infections. Findings: Review of the Facility's Policy titled Catheter Care, Urinary read in part: Purpose- The purpose of this procedure is to prevent catheter-associated urinary tract infection. Maintaining Unobstructed Urine Flow 1. Check the Resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. Changing Catheters 2. Ensure that the catheter remains secured with a large leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh). Resident #8 Review of Resident #8's EHR (Electronic Health Record) revealed she was admitted to the facility on [DATE] with Admitting Diagnoses of Neuromuscular Dysfunction of Bladder Unspecific, Personal History of Urinary Tract Infection, Gastro-Esophageal Reflux, Mild Protein-Calorie malnutrition, Vitamin Deficiency Unspecified, and Insomnia Unspecified. Review of the January 2023 Physician orders revealed: Furosemide 20 mg po 8 a.m. every day, Change Catheter monthly and prn specify the size 16 French. Turn and reposition every 2 hours. Ensure resident is turned every 2 hours and document if non- compliant. Stage 4 Sacrum area, clean with normal saline, pat dry, apply collagen with Calcium alginate and dress every day until healed. Review of Resident #8's Quarterly Minimum Data Set with an Assessment Reference Date of 11/09/2022 revealed a BIMS (Brief Interview for Mental Status) of 05 (severely cognitively impaired) and requires two person assist with bed mobility, transfers, bathing, and toileting. Resident #8 was incontinent of bowel and bladder with a Urinary Catheter. Observation on 01/30/2023 at 10:41a.m., revealed Resident #8 in bed positioned on her back. Resident #8 had a Foley catheter to gravity drainage with white sediments noted in the genitourinary tubing. Resident #8 had an incontinent brief, and the Foley catheter tubing coming out of the right side of her brief and was on her right thigh unsecured. Observation on 01/31/2023 at 10:12 a.m., revealed Resident #8 in bed positioned on her left side with a Foley catheter to gravity drainage with white sediments noted in the genitourinary tubing. Resident #8 had an incontinent brief and the Foley catheter tubing coming out of the left side of her brief and was on her left thigh unsecured. Observation on 01/31/2023 at 2:20 p.m. accompanied by S1DON revealed that Resident #8 had Neurogenic Bladder and had frequent Urinary Tract Infection. S1 DON stated Resident #8 was not currently being treated for Urinary Tract Infection. S1 DON confirmed at the time of the observation that Resident #8's Foley catheter tubing was not secured with a leg strap and should have been. Resident #45 Review of Resident #45's EHR revealed she was admitted to the facility on [DATE] with admitting Diagnoses of Type II Diabetes Mellitus with Hyperglycemia, Severe Morbid (severe), Unspecified Dementia, Bipolar Disorder Unspecified, Major Depressive Disorder, Single episode, Primary Insomnia, Restless Leg Syndrome, Unspecified Systolic (Congestive Heart Failure), Venous Insufficiency (Chronic Peripheral), Chronic Obstructive Pulmonary Disease (COPD), Cellulitis, Overactive Bladder, Granulomatous Mastitis, Right Breast, Long term (current) use of anticoagulants, and Gastro-Esophageal Disease. Review of the January 2023 Physician orders revealed: Clean Foley catheter with soap and water q shift- 01/10/2023. Change Catheter monthly on 19th specify the size 16 Fr. (French) /5 ml (milliliters). Review of Resident # 45's Care Plan revealed: Indwelling catheter due to end of life care secondary to end stage heart disease. Goal- Symptoms will be resolved with target date of 04/19/2023. Interventions- Catheter care every shift, Change catheter every month on the 19th, teach about factors that affect urinary control, encourage adequate fluid intake, and Vesicare 10 mg (milligram) by mouth every day. Review of Resident #45's Significant Change Minimum Data Set with an Assessment Reference Date of 11/09/2022 revealed a BIMS (Brief Interview for Mental Status) of 01(severely cognitively impaired). She required two persons physical assist with bed mobility, toilet use, bathing and one person assist with eating and impairment on both sides. Observation on 01/30/2023 at 9:56 a.m. revealed Resident #45 in bed positioned on her left side with a Foley catheter to gravity drainage with white sediments noted in the genitourinary tubing. Resident #45 had an incontinent brief with the Foley catheter tubing coming out of the left side of her brief and was on her left thigh unsecured. Observation on 01/31/2023 at 10:20 a.m. revealed Activities of Daily Living's care was being performed by S9 CNA assisted by S10 CNA. Resident #45's Foley catheter tubing was noted to be positioned under her left thigh as she was being turned to her left side. The Foley catheter was not secured to Resident #45's thigh. Observation on 02/01/2023 at 10:30 a.m. accompannied by S1 DON revealed Resident #45's Activities of Daily Living's care was being performed by S6 Agency CNA and S7 Agency CNA. Resident #45's Foley catheter tubing was dangling to the left side over her left thigh and was not secured. S1 DON confirmed at the time of observation that Resident #45's Foley catheter tubing was not secured with a leg strap and should have been.

Based on observation, interview, and record review the Facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 3 (Resident #14, Resident #37 and Resident #157) of 31 sampled Residents. Findings: Resident #14 Review of Resident #14's medical record revealed an admit date of 01/22/2021 with the following diagnoses in part .Type 2 Diabetes Mellitus, Anxiety, Bipolar Disorder, Cerebral Vascular Accident, Anemia, Chronic Pain, Dyspnea, Urinary Tract Infection, and Overactive Bladder. Review of Resident #14's February 2023 Physician Orders revealed the following in part . 10/25/2022-Monitor fluid intake every meal and chart. Review of Resident #14's Care Plan revealed in part . Potential for fluid volume deficit related to daily use of diuretic. Onset date of 02/11/2021. Goal and Target date of 03/29/2023. Interventions of: observe, document, report to MD as needed signs and symptoms of dehydration, decreased urinary output, poor skin turgor, dry mucus membranes, confusion, hypotension, tachycardia, headache, fatigue, dizziness, fever, thirst, weight loss. Monitor intake and output. Potential for skin breakdown. Onset date of 02/11/2021. Goal and Target date of 03/29/2023. Interventions of: Provide diet as ordered. Record food intake percentage at each meal. Report decline in intake to physician. Offer food substitutes if resident refuses to eat. Review of Resident #14's December 2022 and January 2023 Meal and Fluid Intake Records revealed Resident #14 did not have meal intake percentages recorded every day as care planned, and did not have fluid intake recorded every meal as care planned and ordered by physician. Interview on 02/01/2023 at 08:20 a.m. with S1 DON revealed a review of Resident #14's meal and fluid intake records. S1 DON confirmed Resident #14's meal and fluid intake records did not have daily meal and fluid intakes recorded as ordered and care planned, and it should have been. Resident #37 Review of Resident #37's medical record revealed an admit date of 04/21/2020 with the following diagnoses in part . Hematuria, Dysuria, Depression, Anxiety, Chronic Pain, Urinary Tract Infection, and Diverticulitis. Review of Resident #37's February 2023 Physician Orders revealed the following in part . 10/25/2022-Monitor fluid intake every meal and chart. Review of Resident #37's Care Plan revealed in part . Nutrition/Weight Loss- the Resident will consume 75% of at least 3 meals every day for 90 days. Onset date of 05/03/2020. Goal and Target date of 02/16/2023. Interventions of: provide diet as ordered, monitor intake at all meals, offer alternate choices as needed, and alert registered dietician and MD to any decline in intake. Review of Resident #37's December 2022 and January 2023 Meal Intake Record, and January 2023 Fluid Intake Record revealed Resident #37 did not have meal intake percentages recorded every day as care planned, and did not have fluid intake recorded every meal as care planned and ordered by physician. Interview on 02/01/2023 at 08:20 a.m. with S1 DON revealed a review of Resident #37's meal and fluid intake records. S1 DON confirmed Resident #37's meal and fluid intake records did not have daily meal and fluid intakes recorded as ordered and care planned, and it should have been. Resident #157 Observation on 01/30/2023 at 9:27 a.m. revealed Resident #157 resting quietly. He had tube feeding pumps in his room, but did not have a feeding in progress. Observation on 01/30/2023 at 4:37 p.m. revealed Resident #157 had no tube feeding in progress. Observation on 01/31/2023 at 9:00 a.m. revealed Resident #157 asleep in bed. There was no tube feeding in progress though there was tube feeding pumps in his room. Observation on 01/31/2023 at 9:16 a.m. revealed S3 LPN/Treatment Nurse preparing to perform PEG tube care on Resident #157. Interview at time of this observation revealed S3 LPN/Treatment Nurse stated the Resident did not receive tube feedings. She further revealed Resident #157 was on hospice and the Facility was just providing comfort care. Review of Resident #157's Face Sheet revealed an admit date of 01/17/2023 with the following diagnoses in part .Secondary Malignant Neoplasm of the Brain; Malignant Neoplasm of upper lobe, left bronchus; and Cerebral Infarction, unspecified. Review of Resident #157's 01/2023 MD Orders revealed the following in part: 01/17/2023 - Osmolite 1.2 @ 40 ml/hr with 60 ml flush q 4 hours H2O. 01/17/2023 - Flush G-Tube with 60 cc of water before and after medication administration unless continuous 01/17/2023 - May use HiCal until Osmolite arrives 01/17/2023 - NPO 01/17/2023 - Admit to Hope Hospice - Dx: Metastatic disease to brain with vasogenic edema Review of Resident #157's Baseline Care Plan revealed a Dietary Orders for Tube Feeding of Osmolite per PEG. Review of Resident #157's 01/17/2023 - 01/31/2023 Nurse Notes revealed Resident #157 was admitted into the Facility with HiCal at 40 cc/hr continuous with 60 cc H2O q 4 hours. There was no documentation that Resident #157's tube feeding had been stopped. Interview on 01/31/2023 at 12:58 p.m. with S2 ADON confirmed there was not an order to d/c Resident #157's tube feeding. She stated an Agency nurse put the order on the e-MAR but failed to write a Doctor's order to d/c Resident #157's tube feeding and she should have. Interview on 01/31/2023 at 1:30 p.m. with S2 ADON revealed she had called Resident #157's Hospice provider concerning his tube feeding. She stated she wrote the following order dated 01/31/2023: Ok to discontinue tube feeding effective 01/19/2023. Family notified 01/31/2023.