Based on observations, interviews, and record reviews, the facility failed to ensure a notice of employees' rights against retaliation for reporting crimes against residents was posted in a conspicuous location. Findings: Review of the United States Social Security Act Title XI, Part A, Section 1150B(d)(3) dated 08/14/1935 and amended on 09/26/2024 revealed, in part, each long-term care facility shall post conspicuously in an appropriate location a sign specifying the rights of employees against retaliation for reporting crimes against residents of the facility. Further review revealed, such sign shall include a statement that an employee may file a complaint against a long-term care facility that violates the provisions against retaliation with respect to the manner of filing such a complaint. Observation of the facility's employee common areas on 05/19/2025 at 1:00PM revealed no conspicuous signage related to employees' rights against retaliation for reporting suspected crimes. In an interview on 05/20/2025 at 2:10PM, S10Licensed Practical Nurse indicated there was no signage displayed for staff members indicating employees' rights against retaliation for reporting suspected crimes. In an interview on 05/20/2025 at 3:33PM, S2Director of Nursing (DON) indicated the facility could not provide any evidence a sign was posted in a conspicuous location regarding.employees' rights against retaliation for reporting suspected crimes. S2DON further indicated she had never seen a sign posted with the above mentioned information on it. In an interview on 05/21/2025 at 12:30PM, S3Registered Nurse/Treatment Nurse indicated she had not observed signage related to employees' rights and the prohibition and prevention of retaliation for reporting suspected crimes. In an interview on 05/21/2025 at 1:35PM, S1Administrator indicated the facility could not provide any evidence a sign was posted in a conspicuous location regarding employees' rights against retaliation for reporting suspected crimes as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a care plan was developed for a resident to decrease the risk of skin tear injuries for 1 (Resident #43) of 2 (Resident #6, Resident #43) sampled residents investigated for accidents. Findings: Review of Resident #43's medical record revealed, in part, Resident #43 was admitted to the facility on [DATE] with diagnoses which included, in part, laceration to the left forearm, muscle weakness, lack of coordination, vision problems, and vascular dementia. Review of Resident #43's May 2025 physician's orders revealed, in part, an order to administer Plavix (a medication used to prevent blood clots and increases the risk of bleeding) 75 milligrams (mg) one tablet by mouth daily. Review of the facility's incident and accident log dated February 2025 through May 2025 revealed, in part, the following incidents involving Resident #43: - 02/20/2025 at 5:00AM: injury incident (skin tear); - 03/08/2025 at 12:00AM: injury incident (skin tear); - 03/19/2025 at 5:30AM: injury incident (skin tear); - 04/04/2025 at 4:45AM: injury incident (skin tear); and, - 04/04/2025 at 12:00AM: injury incident (skin tear). Review of Resident #43's care plan revealed no documented evidence and the facility did not present any documented evidence Resident #43 had a care plan developed to address safety prevention measures to prevent accidents resulting in skin tear injuries. There was no documented evidence and the facility could not provide any documented evidence Resident #43's plan of care included interventions for the prevention of skin tear injuries. In an interview on 05/21/2025 at 12:30PM, S3Registered Nurse/Treatment Nurse (RN/TN) confirmed Resident #43's above mentioned skin tear injuries. S3RN/TN further indicated the facility could not provide any documented evidence a care plan was developed for Resident #43 to address risk factors and interventions to keep Resident #43 safe from injuries and should have been. In an interview on 05/21/2025 at 1:35PM, S1Administrator was presented with the above mentioned findings and could offer no explanation for the reason as to why Resident #43's plan of care did not include prevention interventions for skin tear injuries. th

Based on interviews and record reviews, the facility failed to ensure a resident with a urinary tract infection (UTI) received antibiotic medication as ordered for 1 (Resident #50) of 1 (Resident #50) sampled resident investigated for UTIs. Findings: Review of the facility's Administering Medication policy and procedure, dated 08/2020 revealed, in part, medications should be administered as ordered. Review of the facility's Emergency Drug Kit inventory form dated 05/19/2025 revealed, in part, 6 doses of Sulfamethoxazole/Trimethoprim (a medication used to treat bacterial infections) 800/160 milligrams (mg) oral tablets available for resident use. Review of Resident #50's medical record revealed, in part, Resident #50 was diagnosed with a UTI on 05/13/2025. Review of Resident #50's May 2025 physician's orders revealed, in part, an order dated 05/13/2025 to administer Resident #50 one tablet of Sulfamethoxazole/Trimethoprim 800/160 mg by mouth twice daily for 7 days for treatment of a UTI. Further review revealed the medication should have been started on 05/14/2025 at 8:00AM. Review of Resident #50's May 2025 electronic Medication Administration Record (eMAR) revealed, in part, Resident #50 was not administered one Sulfamethoxazole Trimethoprim 800-160 mg oral tablet on 05/14/2025 at 8:00AM as ordered. In an interview on 05/19/2025 at 2:20PM, S7Licensed Practical Nurse (LPN) indicated the above mentioned medication was available in the facility's Emergency Drug Kit and should have been administered to a resident if the medication was due and not available from the pharmacy. In an interview on 05/20/25 08:31AM, S9LPN indicated if an ordered medication had not been received from pharmacy to administer when the medication was due, the nurse should chart the medication as not available. S9LPN further indicated she did not know what medications were available to administer in the facility's Emergency Drug Kit. In an interview on 05/20/2025 at 3:33PM, S2Director of Nursing (DON) indicated a resident that had a medication due that had not been delivered by pharmacy, but was available in the Emergency Drug Kit, the medication should have been administered from the Emergency Drug Kit. In an interview on 05/21/2025 at 12:30PM, S3Registered Nurse/Treatment Nurse (RN/TN) confirmed Resident #50 should have received his morning dose of Sulfamethoxazole Trimethoprim on 05/14/2025 as ordered. RN/TN further indicated the above mentioned medication was available in the facility's Emergency Drug Kit and should have been administered to Resident #50 on 05/14/2025. In an interview on 05/21/2025 at 1:35PM, S1Administrator was presented with the above mentioned findings and could off no explanation as to why Resident #50 was not administered a medication as ordered if that medication was available in the facility's Emergency Drug Kit for use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident's electronic Medication Administration Record (eMAR) was accurately documented for 1 (Resident #58) of 5 (Resident #31, Resident #42, Resident #43, Resident #51, Resident #58) sampled residents reviewed for accurate medical record documentation for medication administration. Findings: Review of the facility's Administering Medication policy and procedure, dated 08/2020, revealed, in part, medications should be administered as ordered. Review of Resident #58's medical record revealed, in part, Resident #58 was admitted to the facility on [DATE] with diagnoses of, in part, Parkinson's disease (a progressive brain disorder which affects the body's movements) with anxiety. Review of Resident #58's May 2025 physician's orders revealed, in part, an order for Sinemet (a medication used to treat Parkinson's disease) 25-100 mg 1 tablet by mouth three times a day. Review of Resident #58's May's 2025's eMAR revealed, in part, Resident #58's Sinemet 25-100 mg 1 tablet by mouth was not documented as being administered at 10:00PM on the following dates: 05/05/2025 and 05/09/2025. In a telephone interview on 05/21/2025 at 1:07PM, S7LPN indicated she administered Resident #58's Sinement on 05/05/2025 and 05/09/2025 and failed to document administration of the Sinement on the eMAR as required. In an interview on 05/21/2025 at 1:30PM, S1Administrator indicated Resident #58's Sinemet medication was not documented as being administered as ordered on 05/05/2025 and 05/09/2025, and should have been documented.

Based on observations, interviews, and record reviews, the facility failed to ensure a multi-dose bottle of wound cleanser was handled per Infection Control Guidelines between use on residents for 2 (Resident #18, Resident #42) of 2 (Resident #18, Resident #42) sampled residents observed during wound care. Findings: Review of the Center for Disease Control's Infection Control Assessment and Response (ICAR) Tool for General Infection Prevention and Control (IPC) Across Settings Module 8 Wound Care Facilitator Guide, dated 01/27/2023 revealed, in part, multi-dose topical wound care medications, such as sprays, should be dedicated to an individual resident, whenever possible. Further review revealed dedicated containers should have been properly labeled and stored in a manner to prevent cross-contamination or use on another patient/resident. Further review revealed if it was not possible to dedicate an entire tube or container of wound care cream or ointment to an individual patient/resident, then a small amount of medication should have been allocated for single-resident use prior to the procedure. Further review revealed the remainder of the multi-dose container should have been properly stored in a dedicated clean area. Further review revealed containers entering resident care areas should have been dedicated for single-resident use or discarded after use. Observation on 05/20/2025 at 10:29AM revealed S3Registered Nurse/Treatment Nurse (RN/TN) held a bottle of wound cleanser approximately 0.5 inch (in) to 1 in away from Resident #42's left shin wound and then proceeded to spray the wound cleanser directly on Resident #42's left shin wound four times. Further observation revealed after finishing Resident #42's left shin wound care, S3RN/TN walked out the room and placed the bottle of wound cleanser directly on top of her treatment cart, and then placed the bottle of wound cleanser into the bottom draw of her treatment cart without disinfecting the bottle or putting the bottle into a bag/container to prevent cross contamination. Observation on 05/20/2025 at 10:40AM revealed S3RN/TN removed the wound cleanser bottle used in the above mentioned observation without disinfecting the bottle and then entered Resident #18's room. S3RN/TN then proceeded to spray the wound cleanser 0.5 in to 1 in from Resident #18's left first metatarsophalangeal joint (joint at the bottom of the big toe) wound and then sprayed the wound cleanser directly on Resident #18's left first metatarsophalangeal joint wound two times. Further observation revealed after finishing Resident #18's left first metatarsophalangeal joint wound care, S3RN/TN walked out the room and placed the bottle of wound cleanser directly on top of her treatment cart, and then placed the bottle of wound cleanser into the bottom draw of her treatment cart without disinfecting the bottle or putting the bottle into a bag/container to prevent cross contamination. In an interview on 05/20/2025 at 10:48AM, S3RN/TN confirmed she had used the same bottle of wound cleanser to perform both Resident #18 and Resident #42's wound care. S3RN/TN acknowledged she had sprayed wound cleanser directly from the bottle onto Resident #42 and Resident #18's wounds and then put the bottle of wound cleanser back into the treatment cart without sanitizing between resident uses. In an interview on 05/20/2025 at 11:33AM, S2Director of Nursing indicated S3RN/TN should not have sprayed the wound cleanser directly onto the Resident #18 and Resident #42's wounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to: 1. Ensure medications were available for administration for 1 (Resident #58) of 5 (Resident #31, Resident #42, Resident #43, Resident #51, Resident #58) residents reviewed for medication administration; and, 2. Ensure an accurate and/or complete controlled medication reconciliation for 1 (Medication Cart a) of 2 (Medication Cart a, Medication Cart b) medication carts reviewed. Findings: 1. Review of the facility's Administering Medication policy and procedure, dated 08/2020, revealed, in part, medications should be administered as ordered. Review of Resident #58's medical record revealed, in part, Resident #58 was admitted to the facility on [DATE] with a diagnoses of, in part, dementia, unspecified Psychosis (a disorder characterized by a distorted perception of reality), Parkinson's disease (a progressive brain disorder which affects the body's movements) with anxiety. Review of Resident #58's physician's orders revealed, in part, an order for Klonopin (a medication used to treat anxiety) 0.5 milligrams (mg) administer 1 tablet by mouth two times a day. Review of Resident #58's Nursing Administration Notes dated 05/16/2025, 05/17/2025, 05/18/2025 and 05/19/2025 revealed, in part, Resident #58's Klonopin (medication used for anxiety) 0.5 milligrams (mg) was not available for use from the pharmacy. Review of Resident #58's Nursing Administration Note dated 05/20/2025 revealed, in part, Resident #58 did not receive Klonopin as ordered because the medication was not received from pharmacy. Review of Resident #58's May's 2025's e-Medication Administration Record (e-MAR) revealed, in part, Resident #58's Klonopin 0.5 mg by mouth was not available to be administered on the following dates: 05/16/2025- 6:00 AM and 6:00 PM; 05/17/2025-6:00 AM and 6:00PM; 05/18/2025-6:00 AM and 6:00 PM; and, 05/19/2025-6:00 AM. In an interview on 05/19/2025 at 2:16PM, S9Licensed Practical Nurse (LPN) indicated that Resident #58's Klonopin was unavailable since 05/16/2025. In an interview on 05/21/2025 at 11:48PM, S3Registered Nurse (RN)/Treatment Nurse indicated Resident #58's Klonopin was not administered as ordered for the above mentioned dates due to the medication not being received from the pharmacy. In an interview on 05/21/2025 at 1:30PM, S1Administrator confirmed that she was aware of Resident #58's Klonopin medication not being available for the above dates, and should have been. 2. Review of the facility's Administering Controlled Substances policy and procedure, dated 07/2020, revealed, in part, staff members receiving controlled substances should verify the amount of medication received, sign their name, date, time, and amount of medication received on the first line of the resident's narcotic record. Further review revealed staff coming on duty counts the number of pills in the container, and if the pill count is the same, both staff complete the narcotic count form. Review of the facility's undated Controlled Drug Inventory form revealed, in part, at each shift change, the oncoming and off going nurses were to count the number of controlled drug packages/cards in the control box and verify that number listed under total number on hand. Further review revealed a nurse should sign and have another nurse witness, verifying the amount received and/or on hand. Review of Resident #36's Controlled Substance Count Sheet revealed, in part, no date and time the controlled substance was received, the amount distributed was inaccurate, amount on hand was not completed, and no nurse's signatures verifying the received controlled substance count was correct for the following medications: - temazepam (a medication used to treat anxiety and insomnia) 15 milligrams (mg); - lorazepam (a medication used to treat anxiety and insomnia) 2mg/milliliter (mL); and, - morphine (a medication used to treat pain) 20 mg/mL. Review of Resident #18's Controlled Substance Count Sheet revealed no date and time the controlled substance was received for the following medications: - lorazepam 2mg/mL; and, - morphine 20 mg/mL. There was no documented evidence and the facility did not present any documented evidence of having a complete and accurate record of receipt and disposition of all the above mentioned controlled medications for Resident #18 and Resident #36. Review of the facility's April/May 2025 Medication Cart a Controlled Drug Inventory revealed, in part, there was no signature that indicated the off going nurse had reconciled Medication Cart b's controlled substances with the oncoming nurse on: - 04/28/2025 for the 11:00PM shift change; and, - 04/30/2025 for the 3:00PM shift change. Further review revealed there was no signature that indicated the oncoming nurse had reconciled Medication Cart a's controlled substances with the off going nurse on 04/28/2025 for the 11:00PM shift change. Further review revealed inventory was not completed on: - 04/24/2025 for the 11:00PM shift change; - 04/25/2025 for the 7:00AM shift change; - 04/25/2025 for the 11:00PM shift change; - 04/28/2025 for the 11:00PM shift change; - 04/30/2025 for the 3:00PM shift change; and - 05/07/2025 for the 7:00PM shift change. There was no documented evidence and the facility did not present any documented evidence of having a record of receipt and disposition of all controlled drugs in Medication Cart a for the above mentioned dates and/or times. Review of the facility's April/May 2025 Medication Cart b Controlled Drug Inventory revealed, in part, no entry was completed for a controlled drug inventory reconciled by 2 nurses on: - 05/14/2025 for the 7:00AM-3:00PM shift; - 05/16/2025 for the 7:00AM-3:00PM shift; and, - 05/16/2025 for the 3:00PM-11:00PM shift; There was no documented evidence and the facility did not present any documented evidence of having a record of receipt and disposition of all controlled drugs in Medication Cart b for the above mentioned dates and/or times. In an interview on 05/20/2025 at 9:05AM, S10LPN indicated she completed the Controlled Drug Inventory form and signed for the end of her shift at the beginning of her shift and should not have. In an interview on 05/21/2025 at 12:30PM, S3Registered Nurse/Treatment Nurse (RN/TN) indicated the above mentioned controlled substance reconciliations were incomplete and/or inaccurate and should not have been. S3RN/TN further indicated controlled substance forms should have been complete and accurate with the correct dates, shifts, inventory amounts, and verified by 2 nurses' signatures. In an interview on 05/21/2025 at 1:35PM, S1Administrator was presented with the above mentioned findings and could offer no explanation as to why the controlled substance reconciliations were inaccurate and or incomplete.

Based on observation, interviews, and record reviews, the facility failed to ensure an expired medication was not available for resident use in 1 (Medication Cart b) of 2 (Medication Cart a, Medication Cart b) medication carts reviewed for expired medications. Findings: Review of the facility's Storage of Medications policy and procedure, dated 08/2020, revealed, in part, no discontinued, outdated, or deteriorated medications were to be used in this facility. Further review revealed all such medications were recycled or destroyed per facility policy. Review of Resident #52's May 2025 physician's orders revealed, in part, an order to administer Resident #52 one tablet of atorvastatin (a medication used to lower cholesterol) 20 milligrams (mg) by mouth daily. Observation on 05/20/2025 at 9:10AM of Medication Cart b revealed a bottle of Resident #52's atorvastatin 20 mg with a discard by date of 04/30/2025 and was available for Resident #52's use. In an interview on 05/20/2025 at 9:15AM, S10Licensed Practical Nurse indicated the above mentioned medication was expired and available for Resident #52's use and should not have been. In an interview on 05/20/2025 at 9:25AM, S2Director of Nursing confirmed the above mentioned medication was expired and available for Resident #52's use and should not have been.

Based on observation and interview, the facility failed to ensure: 1. Food was stored in a sanitary manner; and, 2. Food was thawed in an appropriate manner. Findings: 1. Observation of the facility's kitchen refrigerator on 05/18/2025 at 9:13AM revealed an opened half full box of uncooked bacon was stored on the shelf above seven and a half quarts of orange juice. Further observation of the facility's refrigerator revealed an opened and undated package of shredded cheddar cheese, an opened and undated package of multiple slices of American cheese, an opened and undated container of liquid eggs, an opened and undated container of sour cream, and an opened and undated gallon container of Italian dressing which was approximately one-eighth full. Further observation revealed an unlabeled, undated package (which was identified by S5Cook as crab cakes), an unlabeled, undated container (which was identified by S5Cook as peas), and an unlabeled, undated bag of cooked meat. In an interview on 05/18/2025 at 9:25AM, S5Cook indicated all food items in the facility's refrigerator should be labeled with an opened/prepared date and/or the contents of the bag/package/container. S5Cook further indicated meat items should not be stored above other food items. Observation on 05/18/2025 at 9:34AM revealed 14 undated individually wrapped sandwiches (turkey/mayonnaise, ham/mayonnaise, and peanut butter/jelly) present on a tray which did not allow temperature regulation. In an interview on 05/18/2025 at 9:36AM, S5Cook indicated the above mentioned sandwiches were prepared on the evening shift of 05/17/2025 for residents for lunch and dinner on 5/18/2025. S5Cook further indicated the above mentioned sandwiches were removed from the refrigerator around 5:00AM on 5/18/2025 for use on 5/18/2025. Observation on 05/18/2025 at 9:36AM revealed the temperature of a random turkey/mayonnaise sandwich from the above mentioned tray was 74 degrees Fahrenheit. Further observation revealed the temperature of a random ham/mayonnaise sandwich from the above mentioned tray was 71.5 degrees Fahrenheit. In an interview on 05/21/2025 at 12:37PM, S4Dietary Manager (DM) indicated the food in the facility's refrigerator should be labeled with an opened/prepared date and/or a description of the contents of the container. S4DM further indicated the above mentioned sandwiches should have been stored in the facility's refrigerator to keep them at an appropriate temperature.S4DM further indicated the bacon should not have been stored over other food items and should have stored on the bottom shelf. 2. Observation on 05/21/2025 at 12:40PM revealed 5 bags of raw chicken with holes in the bags, to allow the liquid in the sink to enter the bags, were submerged in standing water in the facility's sanitization sink. Further observation revealed the water was not running over the chicken. In an interview on 05/21/2025 at 12:42PM, S4DM confirmed S6Cook was defrosting the raw chicken in the facility's sanitization sink and should not have been. S4DM further indicated raw chicken should have been defrosted in the kitchen's refrigerator.

Deficiency Text Not Available

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record reviews, facility document review, and facility policy review it was determined that the facility failed to protect a resident's right to be free from physical abuse for 1(Resident #3) of 3 residents reviewed for abuse. Findings included: Review of the facility's policy titled, Identification of Types of Abuse, dated April 2023, revealed, in part, 3. Physical abuse is defined as hitting, slapping, punching, kicking, etc. Review of Resident #3's medical record revealed, in part, Resident #3 was admitted to the facility on [DATE] with a diagnosis of sequelae of Poliomyelitis and hemiplegia. Review of Resident #3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/30/2024 revealed, in part, Resident #3 had a Brief Interview of Mental Status (BIMS) of 7, indicating severe cognitive impairment; and she was dependent upon staff for activities of daily living (ADLs) such as transfers, toileting, personal hygiene, bathing, and mobility. Review of Resident #3's Care Plan, with a review date of 11/06/2024 revealed, in part: Resident #3 requires assistance with transfers, will be monitored for maintenance of current level of mobility, requires two person total assistance and requires a mechanical lift (initiated 02/01/2024). Review of Resident #2's progress note dated 11/04/2024 at 10:06AM, by S6Licensed Practical Nurse (S6LPN) revealed, in part, a resident to resident altercation occurred, in which Resident #2 was witnessed in the dining room, approaching, punching, and placing her hands on Resident #3's face; as a result of this resident to resident altercation, Resident #2 caused a scratch to Resident #3's chin, with a small amount of bleeding. Further review revealed Resident#3 was aware of what occurred during the altercation. Observation on 11/04/2024 at 1:40PM, revealed Resident #3 had a small superficial linear scratch with redness on her chin. In an interview on 11/04/2024 at 1:40PM, Resident #3 indicated she was hit in the face by Resident #2. In an interview on 11/04/2024 at 1:50PM, S6LPN indicated Resident #3 was the victim in a resident-to-resident altercation with Resident #2. S6LPN further indicated the witnessed altercation between Resident #2 and Resident #3 occurred in the dining room, during the residents' activity group session on the morning of 11/04/2024. S6LPN also indicated Resident #3 was punched in the face and then grabbed and scratched in the face by Resident #2. S6LPN also indicated Resident #3 was very upset after the altercation because she was attacked and she could not defend herself due to her diagnosis of hemiplegia and Poliomyelitis. S6LPN further indicated Resident #3 had a superficial scratch to the chin as a result of the altercation. In a telephone interview on 11/07/2024 at 2:30PM, S4Resident Activity Director (S4RAD) indicated she witnessed the altercation, which involved Resident #2 and Resident #3 that occurred on a few minutes past 10:00AM on 11/04/2024, during an activity group in the facility's dining room. S4RAD further indicated she was assisting another resident to the table, when Resident #2 went up to, and hit Resident #3 in the face. S4RAD further indicated Resident #2 pressed both of her thumbs in Resident #3's eyes, and scratched Resident #3 on her chin, which resulted in a small amount of blood. S4RAD indicated she could not stop Resident #2 before she physically attacked Resident #3 because she was not within arm's reach; and Resident #3 was unable to defend herself, due to her paralysis related to her diagnosis of hemiplegia and Poliomyelitis. S4RAD further indicated the witnessed altercation when Resident #2 hit Resident #3 was considered physical abuse. In an interview on 11/07/2024 at 2:45PM, S10Resident Activity Aide indicated the witnessed altercation when Resident #2 hit Resident #3 was considered physical abuse. In an interview on 11/07/2024 at 2:50PM, S2Director of Nursing indicated the witnessed altercation when Resident #2 hit Resident #3 was considered physical abuse. In an interview on 11/07/2024 at 3:00PM, S1Adminstrator indicated the witnessed altercation when Resident #2 hit Resident #3 was considered physical abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, facility document reviews, and facility policy review, it was determined that the facility failed to ensure an alleged incident of resident to resident abuse was reported immediately, but no later than 24 hours, to Health Standards Section (HSS) for 1 (Resident #2) of 3 sampled residents for abuse. Findings Included: Review of the facility's policy titled, Identification of Types of Abuse, dated 04/2023 revealed, in part, 3. Physical abuse is defined as hitting, slapping, punching, kicking, etc. Review of the facility's Policy for Reporting Abuse, Neglect, or Misappropriation of Resident and Their Property, dated 04/2023 revealed, in part, 7. Reporting - In accordance with guidelines, alleged, and validated violations shall be reported to the governing state agency. Review of Resident #2's medical record revealed, in part, Resident #2 was admitted to the facility on [DATE] with a diagnosis of unspecified dementia with mood disturbance. Review of Resident #2's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/27/2024 revealed, in part, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated Resident #2 had severe cognitive impairment. Review of Resident #2's Care Plan with a review date of 11/20/2024 revealed, in part: Problem: Behavior: Resident #2 had physically aggressive behavior. Episodes of physically aggressive behavior will not occur. Interventions: administer behavior medications as ordered by physician (initiated 04/21/2022); remove from public area when behavior is disruptive and unacceptable (initiated 04/21/2022); and notify physician if violence persists (initiated 04/21/2022). Review of Resident #2's progress note dated 11/04/2024 at 10:06AM, by S6Licensed Practical Nurse (S6LPN) revealed, in part, a resident to resident altercation occurred, in which Resident #2 was witnessed in the dining room, approaching, punching, and placing her hands on Resident #3's face; as a result of this resident to resident altercation, Resident #2 caused a scratch to Resident #3's chin, with a small amount of bleeding. Further review revealed Resident#3 was aware of what occurred during the altercation. In an interview on 11/04/2022 at 1:50PM, S6LPN indicated Resident #2 was involved in a resident-to-resident altercation with Resident #3, in which Resident #2 was the aggressor. S6LPN further indicated the witnessed altercation between Resident #2 and Resident #3 occurred in the dining room, during the residents' activity group session on the morning of 11/04/2024. S6LPN also indicated during the incident, Resident #2 placed herself in front of Resident #3 and hit Resident #3 in the face. S6LPN further indicated Resident #2 then proceeded to grab Resident #3's face and scratched Resident #3 on her chin. In a telephone interview on 11/07/2024 at 2:30PM, S4Resident Activity Director (S4RAD) indicated she witnessed the altercation, which involved Resident #2 and Resident #3 that occurred a few minutes past 10:00 AM on 11/04/2024, during activity group in the facility's dining room. S4RAD further indicated she was assisting another resident to the table, when Resident #2 went up to, and hit, Resident #3 in the face. S4RAD also indicated Resident #2 then pressed both of her thumbs in Resident #3's eyes, and scratched Resident #3 on her chin, which resulted in a small amount of blood. S4RAD further indicated the witnessed altercation when Resident #2 physically hit Resident #3 was considered physical abuse. In an interview on 11/06/2024 at 2:54PM, S1Administrator further indicated, in regards to the witnessed incident on 11/04/2024, which involved the altercation between Resident #2 and Resident #3. S1Administrator further indicated she did not report the incident because Resident #2 had a diagnosis of dementia and she did not consider the incident as abuse; and the incident did not result in serious bodily harm, or an injury of an unknown source. In an interview on 11/07/2024 at 2:45PM, S10Resident Activity Aide indicated the witnessed altercation between Resident #2 and Resident #3 was considered physical abuse. In an interview on 11/07/2024 at 2:50PM, S2Director of Nursing indicated the witnessed altercation between Resident #2 and Resident #3 was considered physical abuse. In an interview on 11/07/2024 at 3:00PM, S1Administrator indicated the witnessed altercation between Resident #2 and Resident #3 was considered physical abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident was free from verbal and mental abuse from S2Certified Nursing Assistant (CNA). This deficient practice was identified for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for abuse. Findings: Review of the facility's policy titled, Identification of Types of Abuse (Reviewed April 2023) revealed, in part, on page 1: 1. Verbal abuse is defined as oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents, employees or families that are within hearing distance regardless of their age, ability to comprehend or disability. 4. Mental abuse can be defined as, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Review of the admission MDS (Minimum Data Set) with an ARD (Assessment Resident Date) of 05/14/2024 revealed Resident #1 had a BIMS (Brief Interview for Mental Status) of 13 (cognitively intact), with adequate hearing and vision, and exhibited no physical and verbal behavioral symptoms. Review of Resident #1's medical record revealed he was admitted to the facility on [DATE] with diagnoses, in part, Aphasia. In an interview on 06/17/2024 at 8:25 a.m., S1Administrator indicated verbal and mental abuse was substantiated for Resident #1 by S2CNA. Review of the Statewide Incident Management System (SIMS) #170430 entered on 05/28/2024 at 3:18 p.m. revealed verbal and mental abuse was substantiated by the facility. Further review revealed the victim, Resident #1, was abused by S2CNA on 05/24/2024 who was terminated as a result of the facility investigation. Still further review revealed Resident #2 witnessed this incident. In an interview on 06/17/2024 at 1:10 p.m., Resident #2 indicated he heard S2CNA yell what the hell do think you are doing three times at Resident #1. In an interview on 06/18/2024 at 12:35 p.m., Resident #1 indicated S2CNA had yelled at him on 05/24/2024. In an interview on 06/18/2024 at 2:30 p.m., S1Administrator indicated the facility substantiated verbal and mental abuse of Resident #1 by S2CNA, and S2CNA was terminated. S1Adminstrator indicated mental abuse was substantiated because other residents also report the verbal abuse from S2CNA.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to assess a resident for self-administration of medications for 1 (Resident #32) of 3 (Resident #32, Resident #39, and Resident #60) residents investigated for accidents. Findings: Review of the facility's policy titled Self-Administration of Medication, with a review date of March 2024, revealed, in part, self-medication consent and release form must be obtained from resident and/or the responsible party. Director of Nursing will complete a self-medication assessment to ensure residents ability to self-medicate. An order must be obtained from resident's physician to keep medication in room. Resident #32 was admitted to the facility on [DATE] with diagnosis of, in part, Gastro Esophageal Reflux Disease. Review of Resident #32's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/03/2024 revealed, in part, Resident #32 had a Brief Interview for Mental Status score of 15, which indicated Resident #69 had intact cognition. Observation on 05/19/2024 at 10:12 a.m. revealed there were 6 disposable medicine cups on Resident #32's bedside table. The 6 disposable medicine cups contained different colored tablets. Resident #32 identified the different colored tablets as tums (a medication which treats heartburn, indigestion or an upset stomach caused by too much stomach acid.) Resident #32 stated she kept a bottle of tums in her dresser drawer and she kept some of the tums in disposable medicine cups at her bedside. Observation on 05/20/2024 at 9:12 a.m. revealed there were 6 disposable medicine cups on Resident #32's bedside table. The 6 disposable medicine cups contained different colored tablets. In an interview on 05/20/2024 at 9:22 a.m., S7Certified Nursing Assistant (CNA) confirmed Resident #32 had 6 disposable medicine cups on her bedside table with different colored tablets. S7CNA indicated Resident #32's granddaughter brought the tablets. Observation on 05/20/2024 at 12:05 p.m. revealed Resident #32 was in her bed and the 6 disposable medicine cups with different colored tablets were on Resident #32's bedside table. In an interview on 05/20/2024 at 12:07 p.m., S5Licensed Practical Nurse (LPN) indicated S7CNA notified her that Resident #32 had tums in her room. S5LPN indicated she was not aware Resident #32 self-administered tums. S5LPN further indicated Resident #32 did not have an order for tums. In an interview on 05/20/2024 at 12:10 p.m., S2Director of Nursing (DON) indicated Resident #32 was not assessed for self-administration of medications and indicated Resident #32 should not have medications at the bedside.

Based on observation, record review, and interviews, the facility failed to allow residents unrestricted visitation. This deficient practice was identified for 4 (Resident #30, Resident #44, Resident #62, and Resident #15) of 4 (Resident #30, Resident #44, Resident #62, and Resident #15) sampled residents reviewed for visitation. Findings: Observation on 05/19/2024 at 9:30 a.m. revealed a sign was posted on the door to the entrance of the residents' living area which read Visitation Hours 10:00 a.m. to 8:00 p.m. Review of the facility's Visitation Policy updated March 2024 revealed, in part, the intent of the policy was to maintain security, dignity, and the rights of all the residents of the facility. Further review of the policy revealed scheduling of visits can be arranged for the convenience of the family member so that bath time, therapy, meals and care shall not interfere with valuable visitation time and posted visitation is 10:00 a.m. through 8:00 p.m. to allow our residents maximum comfort and dignity in their home. Resident #30 In an interview on 05/20/2024 at 9:30 a.m., S6AgencyCertified Nursing Assistant (CNA) stated Resident #30 stayed in her room most of the time but she does go to the lobby for family visits. S6AgencyCNA further stated the facility required Resident #30's family to make an appointment to visit Resident #30 in the lobby of the facility. In an interview on 05/20/2024 at 11:40 a.m., Resident #30 confirmed her family had to make an appointment with the facility to visit her and further stated the visits were held in the lobby. In a Confidential Interview on 05/21/2024 at 9:56 a.m., the interviewee stated there had been several complaints from family members in regards to having to schedule appointments to visit residents and the limited visitation times. The interviewee further stated families and residents wish not to be interviewed in fear of retaliation. Resident #44 In an interview on 05/20/2024 at 10:30 a.m., Resident #44 indicated residents were not allowed to go out on pass or have visitors after the front office was closed. Resident #62 Observation on 05/21/2024 at 10:26 a.m. revealed a visitor in the lobby area waiting to visit Resident #62. In an interview on 05/21/2024 at 10:27 a.m., Resident #62's visitor stated the facility required an appointment be made at least 24 hours in advance and the visits are to be scheduled between the hours of 10:00 a.m. and 5:00 p.m. Resident #62's visitor stated the facility encourages the visitsors to visit in the lobby or outside with the reisdent. Resident #15 Observation on 05/21/2024 at 10:29 a.m. revealed 2 visitors visiting with Resident #15 in a room near the lobby. In an interview on 05/21/2024 at 10:30 a.m., Resident #15's daughter stated she was required to make an appointment to visit her mom. Resident #15's daughter stated she usually visited her mom on Mondays but when she attempted to make an appointment on-line all appointments allowed for Monday were full. Resident #15's daughter further stated there was an on-line system and facility required visits to be made between the hours of 10:00 a.m. and 5:00 p.m. In an interview on 05/21/2024 at 9:33 a.m., S1Administrator indicated the decision was made to set the facility's visiting hours from 10:00 a.m. to 8:00 p.m. for all residents except hospice residents. S1Administrator further indicated resident's family members are required to make appointments to visit between the hours of 10:00 a.m. to 8:00 p.m. because the facility feels these are times that would not interfere with resident care.

Based on observations and interview, the facility failed to: 1. Ensure food available for use was dated, labeled, stored and not left open to air; 2. Ensure food items were not placed directly on the freezer floor without a barrier; 3. Ensure expired food was discarded properly; and, 4. Ensure kitchen equipment and ceiling fans were clean. Findings: 1. Observation on 05/19/2024 at 9:10 a.m. of the walk-in cooler revealed, in part, the following: 1. An opened and undated box of homestyle chicken breast chunks; 2. An opened and undated 5.5 oz. opened fig preserve; 3. An opened and undated Ziploc bag of cubed cheese; 4. 2 opened and undated bags of celery stalks; 5. An undated 3lb bag of cubed cheese; 6. A Ziploc bag of sliced ham dated 05/16/2024 opened to air; and, 7. A Ziploc bag of sliced turkey dated 05/16/2024 opened to air In an interview on 05/19/2024 at 9:10 a.m., S4Dietary Supervisor (DS) confirmed all of the above items were found opened and undated. S4DS indicated food should have been dated and labeled when opened. 2. Observation on 05/19/2024 at 9:10 a.m. of the walk-in freezer revealed a 10 pound (lb.) roll of ground beef was on the freezer floor. The bottom shelf of the walk-in freezer was slanted which allowed the rolls of ground beef to roll off and on to the floor. In an interview on 05/19/2024 at 9:10 a.m., S4DS confirmed the10 lb. roll of ground meat on the floor in the walk-in freezer. S4DS indicated the bottom shelf was slanted which caused 10lb. roll of ground meat to roll on the floor. S4DS further indicated food should not be stored on the freezer floor. 3. Observation on 05/19/2024 at 9:10 a.m. revealed 1opened box of cinnamon rolls with an expiration date of 12/27/2023 in the walk-in freezer. Further observation revealed 1- Hershey's syrup chocolate flavor bottle with an expiration date of 11/23/2023 in the walk-in cooler. In an interview on 05/19/2024 at 9:10 a.m., S4DS indicated items in the walk-in freezer and cooler should be discarded when expired. 4. Observation on 05/19/2024 at 9:10 a.m. revealed 2 ceiling fans, in the food service area, with a buildup of an unidentified gray substance. Further observation of the kitchen area revealed a yellow mop bucket had a buildup of an unidentified black substance. In an interview on 05/19/2024 at 9:10 a.m., S4DS confirmed the ceiling fans in the kitchen area were used during the day and blew over food preparation areas. S4DS indicated the 2 ceiling fans should have been cleaned. S4DS further confirmed the yellow mop bucket was used to mop the kitchen area daily and indicated the yellow mop bucket should have been replaced.

Based on observation and interview, the facility failed to dispose of garbage and refuse properly. Findings: Observation on 05/19/2024 at 9:10 a.m. revealed the dumpster had a large crack in the lid. In an interview on 05/19/2024 at 9:10 a.m., S4DietarySupervior (DS) confirmed the above documented findings. S4DS indicated the dumpster lid had been cracked for approximately 3 months.

Based on record review, observation, and interview the facility failed to ensure nursing staffing data was posted daily at the beginning of each shift. Findings: Observation on 06/27/2023 at 9:30 a.m. revealed there was no nurse staffing posted daily which included the facility's name, date, census and total number and actual hours worked per shift for Registered Nurses (RN), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs) noted. Observation on 06/28/2023 at 9:45 a.m. revealed there was no nurse staffing posted daily which included the facility's name, date, census and total number and actual hours worked per shift for Registered Nurses (RN), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs) noted. Observation on 06/29/2023 at 9:50 a.m. revealed there was a daily nurse staffing posted on a bulletin board in the facility's dining room, and there was a gate blocking access for visitors and residents to see the nurse staff posting. Further observation of the facility's nurse staffing posting dated 06/29/2023 revealed the form was blank, and it did not include the resident census number, total number of, Licensed Practical Nurses, and Registered Nurses for each shift, and actual staffing hours worked per shift for Registered Nurses (RN), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs). In an interview on 06/29/2023 at 9:52 a.m., S1Executive Director stated she does not post nurse staffing information until the end of each day because she does not know who was coming into work or not.

Based on record reviews, observations and interviews, the facility failed to ensure expired medications were not administered or available for use for 2 (Medication Cart a and Medication Cart b) of 2 (Medication Cart a and Medication Cart b) medication carts and 1 (Medication Storage Room c) of 2 (Medication Storage Room c and Medication Storage Room d) medication storage rooms observed for expired medications. Findings: Review of the facility's Storage of Medications policy and procedure revealed, in part, outdated medications are not to be used in the facility. Observation on 06/28/2023 at 3:25 p.m. revealed Medication Cart a contained Resident #48's bottle of Clear Eyes (an eye drop that moisturizes the eye) with a manufacturer's expiration date of 03/2023. In an interview on 06/28/2023 at 3:33 p.m., S17Licensed Practical Nurse (LPN) confirmed Resident #48's Clear Eyes had an expiration date of 03/2023. S17LPN stated Resident #48's expired eye drops were administered to Resident #48, but the eye drops should not have been available for administration. Observation on 06/28/2023 at 3:37 p.m. revealed Medication Cart b contained Resident #18's tube of Santyl (an ointment that removes dead tissue and aides in wound healing) with an expiration date of 05/2023. In an interview on 06/28/2023 at 3:38 p.m., S8Treatment Registered Nurse confirmed Resident #18's tube of expired Santyl ointment was administered to Resident #18 during wound care. S8Treatment Registered Nurse further confirmed Resident #18's tube of Santyl ointment had an expiration date of 05/2023 and should not have been administered to Resident #18. Observation on 06/28/2023 at 3:41 p.m. revealed Medication Storage Room c contained Clear Eyes with a manufacturer's expiration date of 03/2023 available for resident use. In an interview on 06/28/2023 at 3:45 p.m., S2Diretcor of Nursing (DON) confirmed the expired Clear Eyes in the Medication Storage Room c should not have been available for use. In an interview on 06/28/2023 at 4:29 p.m., S2DON confirmed Resident #48's Clear Eyes was expired and should not have been used. S2DON also confirmed Resident #18's Santyl ointment was expired 05/2023 and should have been discarded. S2DON stated expired medications should not be available for use.

Based on record reviews, observations, and interviews the facility failed to provide a resident with the correct form of food to meet the resident's needs for 1 (Resident #53) of 3(Resident #4, Resident #18, and Resident #53) sampled residents reviewed for dining services. Findings: Review of Resident #53's MDS (Minimum Data Sheet) with an ARD (Assessment Reference Date) of 05/03/2023 a revealed, in part, Resident #53 was assessed malnutrition, and had weight loss without being on a physician-prescribed weight-loss regimen. Review of Resident #53's physician orders dated April 2023, May 2023, and June 2023 revealed, in part, regular diet with chopped meats. Review of Resident #53's care plan revealed, in part, Resident #53 was care planned for malnutrition. Further review revealed an intervention to include diet per physician's order. Observation on 06/27/2023 at 12:29 p.m., revealed Resident #53 was served a plate that had a whole fried chicken leg, sweet potato mash, and cooked green beans. Observation on 06/28/2023 at 12:36 p.m., revealed Resident #53 was served a plate of penne pasta with red sauce, 3 whole meatballs, 1 bread stick, steamed vegetables, salad, chicken noodle soup, and dessert. In an interview on 06/28/2023 at 2:25 p.m., S7Minimum Data Set Nurse stated Resident #53 was on a regular diet. In an interview on 06/29/2023 at 8:38 a.m., S11Certified Nursing Assistant stated Resident #53 was not on a special diet. In an interview on 06/29/2023 at 12:45 p.m., S3Food Service stated chopped meats would require fried chicken to be pulled off the bone by the kitchen staff and meatballs should be chopped by the kitchen staff. S3Food Service stated Resident #53 is on a regular diet and received a fried chicken leg on 06/27/2023 and whole meatballs on 06/28/2023 on her lunch tray. In an interview on 06/29/2023 at 12:47 p.m., S4Dietary Aide stated Resident #53 attempted to bite the meat off the bone during lunch on 06/27/2023 but was not able to eat it. In an interview on 06/29/2023 at 1:30 p.m., S2Director of Nursing (DON) confirmed Resident #53's diet order was a regular diet with chopped meats. S2DON confirmed fried chicken should have been pulled off the bone by the kitchen staff and meatballs should have been chopped by the kitchen staff before the meal was served to Resident #53.

Based on observation and interview, the facility failed to store food in a manner to prevent the possibility of food contamination. This deficient practice had the potential to effect the 63 residents who receive meals from the facility's kitchen according to the Resident Census and Condition Forms (CMS-672). Findings: Review of the facility's food storage policy dated August 2020 revealed, in part, raw meat is to be stored on the lowest shelf in the refrigerator. Further review revealed, juice shall be stored in a tightly seal, labeled, and dated container. Observation of the facility's cooler on 06/27/2023 at 8:10 a.m., revealed in part, a 15 pound (lb) box of sliced bacon open and placed on the middle shelf above a crate of eggs. Further observation revealed, a box of Gulf Shrimp placed on the middle shelf above a closed case of 75, 4 ounce (oz), Vital Cuisine brand Vanilla Mighty Shakes. Further review revealed, a pot with an unknown brown substance covered with a piece of saran wrap with no date present. Further observation revealed a half full, 46 fluid (fl) oz container of prune juice with no open date noted, and a one-fourth 46 fl oz container of apple juice with no open date noted. Observation of the facility's dry storage on 06/27/2023 at 8:10 a.m., revealed in part, a three-fourths full, 22 quart (qt), container of sugar with a handled scoop placed in sugar, and a one-half full, 22 qt, container of powdered sugar with a handled scooped placed in powdered sugar. Observation of the facility's cooler on 06/27/2023 at 8:50 a.m., revealed in part, a 15 lb box of sliced bacon open and placed on another middle shelf above an open case of Vital Cuisine brand Vanilla Mighty Shakes. Further observation revealed, a box of Gulf Shrimp on a shelf above a closed case of 75, 4 oz, Vital Cuisine brand Vanilla Mighty Shakes. Further review revealed, a container with an unknown brown substance covered with a piece of saran wrap with no date present. Further observation revealed a half full, 46 fl oz container of prune juice with no open date noted, and a one-fourth 46 fl oz container of apple juice with no open date noted. Observation of the facility's dry storage on 06/28/2023 at 8:50 a.m., revealed in part, a three-fourths full, 22 qt container of sugar with a handled scoop placed in sugar, and a one-half full, 22 qt container of powdered sugar with a handled scooped placed in powdered sugar. In an interview on 06/28/2023 at 11:50 a.m., S3FoodService stated raw bacon and shrimp should not have been stored above other food in facility's cooler. S3FoodService further stated juices should be dated when opened, and thrown away within two weeks of the open date. S3FoodService also stated the brown substance in the pot was gravy and the brown substance in the container was chocolate pudding. S3FoodService further stated the pot of gravy and the container of chocolate pudding should have be labeled with a date before being stored in the cooler. S3FoodService further stated that the handled scoops should not have been inside of the sugar or powdered sugar container.

Based on observation, interview, and record review the facility failed to ensure a functional call bell was available for 1 (Resident #47) of the 2 residents (Resident #18 and Resident #47) investigated for environmental issues. Findings: Review of Resident #47's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/08/2023 revealed, in part, resident had a Brief Interview for Mental Status (BIMS) score of 10 which indicated she was mildly cognitively impaired and that Resident #47 required extensive assistance with bed mobility and was totally dependent with transfers. Review of Resident #47's care plan revealed, in part, an intervention to remind Resident #47 to ask for assistance for all transfers. In an interview in Resident #47's room on 06/28/2023 at 8:55 a.m., Resident #47 stated that her call bell did not work. A test of Resident #47's call bell was conducted by surveyor on 06/28/2023 at 8:55 a.m. which revealed the call bell was not functioning and the indicator light did not illuminate on wall of Resident #47's room or outside of Resident #47's room above door. Observation on 06/28/2023 at 4:00 p.m., revealed Resident #47 lying in bed. Further observation of a call bell test revealed the call bell not functioning. Observation on 06/29/2023 at 9:00 a.m., revealed Resident #47 lying in bed. Further observation of a call bell test revealed the call bell not functioning. In an interview on 06/29/2023 at 9:30 a.m., S9Licensed Practical Nurse (LPN) stated Resident #47 knew how to use the call bell, and that Resident #47 was to use the call bell to reach staff for assistance. Observation on 06/29/2023 at 9:35 a.m., revealed S9LPN tested Resident #47's call bell, and found that call bell was not functioning. In an interview on 06/29/2023 at 9:41 a.m., S9LPN stated Resident #47's call bell was not functioning and should be functioning so that Resident #47 could call for assistance. Observation on 06/29/2023 at 9:55 a.m., revealed S2Director of Nursing (DON) tested Resident #47's call bell, and found that call bell was not functioning. In an interview on 06/29/2023 at 9:55 a.m., S2DON stated Resident #47's could use her call bell to call for assistance, and that Resident #47's call bell was not functioning and should be functioning so that Resident #47 could call for assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure residents were free from unnecessary physical restraint for 2 (Resident #40 and Resident #56) of 4 (Resident #9, Resident #29, Resident #40, and Resident #56) sampled residents reviewed for restraints. Findings: Review of the facility's Policy Governing Protocol in Decision to Utilize Restraints revealed, in part, physical restraints are to be used only for the safety of the resident. Further review revealed if restraints were necessary for the resident, a Physical Restraint Assessment should be completed. Review also revealed a consent which lists the risk factors and pros and cons of utilizing restraints must be signed by a family member/responsible party. The facility must also complete a review of the use of the restraint at least quarterly by the Interdisciplinary Team, the family member/responsible party and the physician in an attempt to reduce the use of the restraint. Review of the facility's Policy and Procedure on Use and Reductions of Restraints revealed, in part, the resident has the right to be free from clinical and physical restraints. Further review revealed prior to any use of any type of restraint, it will be assured that the facility consulted with the appropriate health professionals in the use of less restrictive support devices prior to the use of restraints, and the physician's order will include the diagnosis and symptoms which may benefit by the use of restraints. Review revealed there is evidence that the restraint will enable the resident to have greater functional independence. The policy also revealed the risks involved with restraint used will be documented to the resident and/or their responsible party for evaluation, and a consent from the resident and/or responsible party will be executed when restraints are elected. Further review revealed the facility agreed to use restraints only for specific periods as ordered by the attending physician to address a specific diagnosis and/or medical symptom, and restraints will also be removed at intervals. Review also revealed the restraint quarterly review would include, but not be limited to: a) completion of Medical Immobilization Evaluation, b) Side Rail Assessment, c) Physical Restraint Assessment, and d) Physical Restraint Reduction Assessment. Resident #40 Review of Resident #40's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/14/2023 revealed, in part, Resident #40 was documented to have a memory problem and moderately impaired decision making. Further review revealed Resident #40 utilized a walker as a mobility device. Review also revealed Resident #40 had diagnoses of non-traumatic brain dysfunction, non-Alzheimer's dementia, and apraxia (a condition where damage of the brain causes people to be unable to carry out everyday movements and gestures). Review of Resident #40's care plan revealed Resident #40 was care planned to require assistance with mobility with interventions to use a merry walker to aid in ambulation. Further review revealed Resident #40 was also care planned for the potential for falls due to Resident #40 being observed climbing out her merry walker with interventions for staff to frequently remind Resident #40 to remain seated and ask for assistance for all transfers. Review of Resident #40's June 2023 physician's orders revealed, in part, an order with a start date of 03/21/2022 for Resident #40 to use a merry walker to promote independent ambulation. Further review revealed no documented evidence, and the facility was unable to provide any documented evidence of a physician's order for restraints. Review of Resident #40's Consent for Emergency Use of Physical Restraints signed on 09/17/2021 revealed, in part, Resident #40's merry walker was not listed on the consent form. Further review revealed if standard use of restraints was anticipated, a new restraints consent would be executed. Review of Resident #40's Restraint Necessity Assessment, completed on 06/12/2023, revealed, in part, Resident #40's mental status was documented as intermittent confusion. Further review revealed Resident #40 lost balance with ambulation and had a history of falls. Review also revealed Resident #40's had severe cognitive loss and was unable to follow commands, could not comprehend her surroundings, and could not remember any assistive device, such as a walker. Review of Resident #40's Electronic Health Record and physical chart revealed no documented evidence and the facility was unable to present any documented evidence of a restraint consent for Resident #40's merry walker, a physician's order for the restraint use, the medical symptom that warranted the use of the restraints, or ongoing re-evaluation of the need for Resident #40's restraint. Observation on 06/27/2023 at 12:49 p.m. revealed Resident #40 seated in a merry walker with a cloth strap between her legs attached by a buckle to the plastic bar over her lap. Observation on 06/28/2023 at 8:41 a.m. revealed Resident #40 seated in a merry walker with a cloth strap between her legs attached by a buckle to the plastic bar over her lap. Observation on 06/28/2023 at 12:42 p.m. revealed Resident #40 seated in a merry walker with a cloth strap between her legs attached by a buckle to the plastic bar over her lap. Observation on 06/29/2023 at 9:20 a.m. revealed Resident #40 seated in a merry walker with a cloth strap between her legs attached by a buckle to the plastic bar over her lap. Observation further revealed S22Licensed Practical Nurse (LPN) instructed Resident #40 to unbuckle the strap between her legs. Observation revealed Resident #40 was unable to release buckled strap between her legs and get out of the merry walker. In an interview on 06/29/2023 at 9:21 a.m., S22LPN confirmed Resident #40 was not capable of removing the merry walker's buckled strap between her legs. S22LPN further confirmed Resident #40 was restricted from getting out of the merry walker because Resident #40 was unable to unbuckle the strap. In an interview on 06/29/2023 at 9:25 a.m., S2Director of Nursing (DON) confirmed Resident #40 was not able to remove the buckled strap on the merry walker. S2DON confirmed Resident #40's movement was restricted due to the buckled strap, and Resident #40 was unable to get out of the merry walker if she wished. In an interview on 06/29/2023 at 10:45 a.m., S1Executive Director stated a restraint was anything that restricted a resident's movement and was unable to be removed by the resident. In an interview on 06/29/2023 at 11:45 a.m., S15Physical Therapist stated Resident #40 was capable of walking independently with her merry walker and transferring herself independently. S15Physical Therapist confirmed Resident #40 being unable to unbuckle the strap between her legs on the merry walker restricted Resident #40 from getting out of her merry walker and transferring independently. In a telephone interview on 06/29/2023 at 12:59 p.m., Resident #40's guardian stated she had witnessed Resident #40 previously attempt to get out of the merry walker without unbuckling the strap. In an interview on 06/29/2023 at 1:40 p.m., S8Treatment Registered Nurse (TRN) stated Resident #40 could lift the plastic bar across her lap, but Resident #40 could not unbuckle the strap between her legs in order to get out of the merry walker. S8TRN stated Resident #40's merry walker was not considered a restraint. Observation on 06/29/2023 at 1:42 p.m. revealed S8TRN instructed Resident #40 to unbuckle the merry walker strap between her legs in order to transfer to her bed. Further observation revealed Resident #40 was unable to unbuckle the strap between her legs to get out of the merry walker. In an interview on 06/29/2023 at 1:46 p.m., S8TRN confirmed Resident #40 was unable to unbuckle the merry walker strap between her legs on command. S8TRN confirmed without being able to unbuckle the strap between her legs, Resident #40 was restricted from getting out of the merry walker. She further stated she had witnessed Resident #40 attempt to bring her leg over the strap between her legs in the past in order to attempt to climb out of the merry walker. Resident #56 Review of facility's policies on restraints, revealed, in part The facility agrees to use restraints only for specific periods as ordered by the attending physician to address a specific diagnosis and/or medical symptom. If standard use is anticipated, a new restraint consent will be executed. Types of restraints which may be utilized include: Seat belt - designed similarly to airplane seatbelts and may be installed on some wheelchairs by the manufacturer. If a resident can remove this device, it is not considered a restraint. Review of Resident #56 record revealed, in part, resident was admitted on [DATE] with diagnoses of Alzheimer's disease; lack of coordination; dementia with agitation. Review of the quarterly Minimum Data Set with an Assessment Review Date of 06/07/2023 revealed, in part, Resident #56 had a Brief Interview for Mental Status (BIMS) of 99 indicating resident chose not to answer the questions or gave a nonsensical response. Further review revealed, in part, there was no indication of a restraint being used at the time of the completion of the MDS. Review of Resident #56's Physician Orders for May and June 2023, revealed, in part, orders for SB (Seatbelt) in WC (Wheelchair). Unable to safely ambulate/transfer D/T (due to) severe cognitive impairment. Hx (History) of falls with injury. Monitor Q2H (every 2 hours) and PRN (as needed) with a start date of 03/02/2023. Review of Resident #56's Care Plan revealed, in part: -Care Plan Description: Seat Belt for safety/therapeutic treatment of pelvic fractures. Resident had fall that resulted in numerous pelvic fractures. Working with therapy. Therapy recommends removable seatbelt in wheelchair needed to assist with neutral pelvic alignment to aid healing of fracture as well as decrease pain. Monitor q2h when resident up in wheelchair. Start date 10/17/2023. Review date 09/06/2023. Interventions to assess for ability to reduce or discontinue use of safety device. Record review of Physician Progress Notes, revealed, in part: -11/01/2022: Orthopedist Progress Note indicated x-ray of pelvis shows fractures were healing and remain stable. Recommendations to continue physical therapy; weight bearing as tolerated (WBAT). -12/05/2022: Orthopedist Progress Note indicated x-ray shows fracture remains stable. Recommendations to continue WBAT, Range of Motion as tolerated (ROM AT). Use [NAME] at all times. -01/09/2023: Orthopedist Progress Note indicated x-ray of his pelvis shows fracture remains stable. No new fractures seen. Recommendations to WBAT with walker and ROM AT. -04/17/2023: Orthopedist Progress Note indicated x-ray shows fracture is stable. No new fractures seen. Recommendations to WBAT with walker. ROM as tolerated and follow-up with Ortho as needed. Record review of Restraint Necessity Assessments completed on 06/09/2023 revealed, in part, resident had a seatbelt while in wheelchair and was unable to safely ambulate/transfer due to severe cognitive impairment with a history of falls with injury. Record review found no consent for restraint. Observation on 06/27/23 at 10:33 a.m., Resident #56 was sitting in the hallway in his wheelchair with a seatbelt attached to the wheelchair and buckled across his lap. Observation on 06/28/2023 at 9:19 a.m., Resident #56 was sitting in the hallway in his wheelchair with a seatbelt attached to the wheelchair and buckled across his lap. Observation on 06/28/2023 at 3:30 p.m., Resident #56 was sitting in the hallway in his wheelchair with a seatbelt attached to the wheelchair and buckled across his lap. Observation on 06/29/2023 at 9:08 a.m., Resident #56 sitting in his wheelchair in the doorway of his room with a seatbelt attached to the wheelchair and buckled across his lap. In an interview on 06/29/2023 at 9:10 a.m., S12Certified Nursing Assistant (CNA) stated Resident #56 had a seatbelt in place because he was unsafe. Observation on 06/29/2023 at 9:12 a.m. Resident #56 was asked to remove his seatbelt and he looked down at his seatbelt, but did not unbuckle it. S12CNA tried again to get him to unbuckle the seatbelt. Once again, he looked down at the seatbelt but was unable to complete the task. Review of Resident #56 Physical Therapist Progress & Discharge Summary on 12/05/2022 revealed, in part, post discharge recommendations for staff to ambulate with resident around nursing station. Signed by S15PT (Physical Therapist). In an interview on 06/29/2023 at 12:30 p.m., S8Treatment Registered Nurse confirmed there was no documentation in Resident #56's care plan indicating the seatbelt was now being utilized for positioning. In an interview on 06/29/2023 at 1:45 p.m., S2Director of Nursing confirmed Resident #56 had a seatbelt in place while he was in the wheelchair without proper indication for use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident's medications were acquired and administered as ordered for 1(Resident #58) of 5 (Resident #47, Resident #50, Resident #51, Resident #53, and Resident #58) residents reviewed for unnecessary medications. Findings: Review of Resident #58's medical record revealed, in part, an admission date of [DATE] with diagnoses of, in part, Generalized Anxiety Disorder and Recurrent Major Depressive Disorder. Review of Resident #58's Minimum Data Set (MAR) with an Assessment Reference Date (ARD) [DATE] of, revealed, in part, Resident #58 had a Brief Interview of Mental Status(BIMS) score of 15, which indicated Resident #58 was cognitively intact. Review of Resident #58's [DATE] Physician Orders, in part, revealed an order with a start date of [DATE] that revealed Buspirone (a medication used to decrease anxiety) 5mg (milligrams) tablet, administer 1 tablet by mouth three times daily. Review of Resident #58's electronic medical administration record (eMAR) for February 2023, revealed, in part, Resident #58 received Buspirone 5 milligrams (mg) three times daily with no omissions. Further review revealed no documented evidence Resident #58 was administered Buspirone 10mg three times a day. Review of Resident #58's eMAR for [DATE], revealed, in part, Resident #58 received Buspirone 5 mg three times daily with no omissions. Further review revealed no documented evidence Resident #58 was administered Buspirone 10mg three times a day. Review of Resident #58's eMAR dated [DATE] revealed, in part, Resident #58 received Buspirone 5 mg three times daily with no omissions until [DATE], when Resident #58 was sent to the hospital. Further review revealed no documented evidence Resident #58 was administered Buspirone 10mg three times a day. In an interview on [DATE] at 9:35 a.m., Resident #58 stated she received medication for anxiety. Resident #58 stated she requested the physician increase her buspirone due to her daughter recently passing away. Resident #58 further stated every time she had seen the physician he had stated that her buspirone was increased but she when her buspirone was administered she was still receiving the same dosage Review of Resident #58's physician's progress note, dated [DATE] revealed, in part, Resident #58's physician discussed with nursing that Resident #58's daughter died unexpectedly and Resident #58 was distraught. Further review revealed, Resident #58's physician was sending a prescription for Ativan (a medication used to decrease anxiety) 0.5mg to be administered every 8 hours as needed. Review of Resident #58's physician's progress note dated, [DATE], revealed, in part, Resident #58's anxiety and depression had worsened over time. Review revealed, Resident #58 utilized 14 days of Ativan, but reported she was not doing well and she was very anxious. Review revealed Resident #58 was agreeable to an increase in her buspirone. Further review revealed Resident #58's physician's plan was to increase Resident #58's buspirone to 10mg three times a day. Review of Resident #58's physician's progress note dated [DATE] revealed, in part, Resident #58's plan for Resident #58's Major Depressive Disorder and Anxiety was buspirone 10mg three times a day. In an interview on [DATE] at 2:15 p.m., S2Director of Nursing (DON) stated she received Resident #58's physician progress notes after he makes rounds in the facility. S2DON stated she was responsible for reviewing his notes and ensuring his recommendation for Resident #58 were implemented and placed in to the computer. S2DON stated she acknowledged Resident #58's physician wrote an order to increase Resident #58's buspirone to 10mg three times a day on [DATE] in his progress note, it was not placed in the computer, and Resident #58 did not receive it. S2DON further stated Resident #58's buspirone should have been increased to 10mg three times daily on [DATE] when the progress note was written and it wasn't. In an interview on [DATE] at 2:32 p.m., Resident #58's physician acknowledged he wrote the physician's progress note on [DATE]. He stated he wrote the note to increase Resident #58's buspirone to 10mg three times a day due to the recent death of her daughter and Resident #58 having increased anxiety. Resident #58's physician stated when he rounded on [DATE] and he realized Resident #58's medication had never been increased. Resident #58's physician stated he notified the facility and rewrote the order to ensure Resident #58's Buspirone was increased to 10mg three times a day. In an interview on [DATE] at 3:39 p.m., S1Executive Director stated Resident #58 is a drug seeker, but that does not change the fact that Resident #58 did not receive her medication and she should have gotten her medication. S1Executive Director stated regardless if a physician order was written or not, the physician's progress note should have been acknowledged by someone at the facility and Resident #58 should have gotten her medication increased.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure staff performed hand hygiene while serving meal trays to residents who ate in their room. Findings: Review of the facility's Handwashing and Glove Use Policy and Procedure dated August 2020 revealed, in part, hands must be washed prior to beginning work, after using the restroom, when working with different food substances, and following contact with any unsanitary surface i.e. touching hair, sneezing, opening doors, etc. Further review revealed gloves may be used when working with food to avoid contact with hands, and gloves must be worn when touching any ready-to-eat food. When gloves are used, hand washing must occur per above procedure prior to putting on gloves and whenever gloves are changed. Gloves must be changed as often as hands need to be washed, and gloves may be used for one task only. Observation on 06/29/2023 at 11:55 a.m., S6Dietary Aide (DA) removed from a resident's room and placed the dirty tray on the nurse's station and took a clean tray into Resident #12's room, opened Resident #12's room's door, and placed a meal tray on Resident #12's table without performing hand hygiene. Observation on 06/28/2023 at 12:41 p.m., revealed S16Dietary Aide (DA) entered Resident #1's room and set up a table. S16DA touched Resident #1's bed remote to reposition Resident #1, and fixed Resident #1's bed sheets. S16DA then exited room [ROOM NUMBER]'s room and grabbed another tray without performing hand hygiene. S16DA then went into Resident #20's room and set down the meal tray on the table, and exited room and grabbed another tray without performing hand hygiene. S16DA then went into Resident #12's room and placed the meal tray on the table and exited room without performing hand hygiene to grab another tray. S16DA then she placed a new pair of gloves without washing her hands prior to placing the new gloves and grabbed a meal tray and went into Resident #366's room and placed the meal tray on table and exited Resident #366's room. S16DA went into Resident #13's room and placed the meal tray down on the table and exited the room then grabbed a new meal tray without performing hand hygiene. At no point during observation after S16's gloves being put on did S16DA remove her gloves or perform hand hygiene. In an interview on 06/29/2023 at 3:26 p.m., S2Director of Nursing stated that staff should be washing their hands before and after staff would provide assist with meal setup or repositioning a resident to eat. In an interview on 06/29/2023 at 3:54 p.m., S16Dietary Aide stated that she should have performed hand hygiene before and after passing meal trays, and she should have performed hand hygiene after passing out meal trays from Resident #20's room and Resident #12's room.