Based on observation and interview the facility failed to ensure that each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident # 22) of 4 (Resident #9, Resident #22, Resident #43, and Resident #225) sampled Residents reviewed for dignity in a total sample size of 25. The facility failed to ensure S7 CNA did not stand while feeding Resident #22 during meal service. Findings: Review of Resident # 22's Clinical Record revealed an admit date of 10/19/2023 with diagnoses that included: Fracture of Unspecified part of the Neck of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing; Dementia; Anxiety; Protein Calorie Malnutrition; Vitamin deficiency; Hyperlipidemia; Depression; Psychotic Disorder with Delusions d/t know Psychological Condition; Delusions; Alzheimer's disease. Review of Resident # 22's Care Plan with a revision date of 04/17/2025 revealed a potential for Malnutrition with interventions that included in part . Resident to be fed meals per staff. Observation and interview on 04/29/2025 at 11:18 a.m. revealed S7 CNA standing while feeding Resident #22. S7 CNA confirmed that she should not have been standing while feeding Resident #22. Interview on 04/29/2025 at 1:01 p.m. with S2 DON confirmed that S7 CNA should not have been standing while feeding Resident # 22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure an allegation of physical abuse was reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 1 (#74) of 25 Sampled Residents. Findings: Review of the facility's undated policy on 04/30/2025 at 11:31 a.m. titled Abuse Prevention and Investigation read in part . Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. 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, and mental abuse including abuse facilitated or enabled through the use of technology. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. Review of the medical record for Resident # 74 revealed she was admitted to the facility on [DATE] and discharged from facility on 04/01/2025. Resident #74 had diagnoses that included in part . Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Hypertensive Heart Disease with Heart Failure, Chronic Obstructive Pulmonary Disease, and Cerebral Infarction, unspecified. Review of Resident #74's Quarterly MDS with an ARD of 02/24/25 revealed a BIMS score of 15, which indicated cognition was intact. Review of Resident #74's Departmental Progress Notes revealed in part . 03/25/2025 6:47 p.m. by S14 LPN: Resident #74 reported that she was sitting at the dining room table eating. Resident #11 was pushing a female resident in a wheelchair near Resident #74's chair. Resident #11 hit Resident #74's walker with the female resident's wheelchair. Resident #11 then began hitting Resident #74's walker with a closed fist striking her walker, and her arm several times. Resident #11 was removed from the area. Resident #74 was checked for injuries and bruising, none was noted. Interview on 04/30/2025 11:15 a.m. with S14 LPN revealed she immediately reported the resident to resident altercation that occurred on 03/25/2025 between Resident #11 and Resident #74 to S15 Former DON, and documented the incident on an incident form. Interview on 04/30/2025 11:32 a.m. with S1 Administrator revealed he was responsible for SIMS reporting at the facility. S1 Administrator revealed he recalled being made aware of the resident to resident altercation between Resident #11 and Resident #74. S1 Administrator confirmed he did not complete a SIMS report related to the resident to resident altercation on 03/25/2025. S1 Administrator stated he did not complete a SIMS report because he had been informed via email by an individual at the State Office program desk that facilities were not required to report SIMS for resident to resident altercations, if neglect was not identified, and there was no injury.

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #9) resident of 25 sampled residents. The facility failed to ensure Resident #9's care plan for Psychotropic drugs: Risperdal, Buspirone, and Trazodone was developed and/or initiated. Findings: Review of a facility's undated policy on 04/30/2025 at 1:18 p.m. titled, Care Plan-Comprehensive revealed the following in part . 11. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. Review of a facility's undated policy on 04/30/2025 at 1:18 p.m. titled, Care Plans-Preliminary revealed the following in part .A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident. The preliminary care plan consists of all nurse assessments, notes, face sheets, MARS, TARS, CNA care plans/flow sheets and Physician orders. Review of Resident #9's medical record revealed a re-admission date of 02/14/2024, with diagnoses that included in part . Rheumatoid Arthritis with Rheumatoid Factor; Bipolar Disorder; Major Depressive Disorder, Single Episode; Pain; and Anxiety Disorder. Review of Resident #9's Quarterly MDS with an ARD of 06/24/2025 revealed a BIMS score of 12, which indicated moderate cognitive impairment. Resident #9 received antipsychotic, antianxiety, and antidepressant medications. Review of Resident #9's 04/2025 physician orders revealed in part . 03/11/2025: Risperdone 0.5mg-give 1 tablet orally one time a day related to Bipolar Disorder. Target behaviors: increased agitation, complaints of feeling lonely and tearful. 03/12/2025: Risperdone 0.25mg-give 1 tablet by mouth one time a day. Target behaviors: yelling, isolation, paranoia related to Bipolar Disorder. 01/10/2025: Buspirone Hydrochloride (HCl) 15mg-give one tablet by mouth three times a day related to Anxiety Disorder. 09/03/2024: Trazodone Hydrochloride (HCl) 50mg-give one tablet orally at bedtime related to Major Depressive Disorder. Target behaviors: withdrawn, tearful, self-isolative. Review of Resident #9's care plan with a review date of 07/31/2025 revealed in part . Focus: Diagnosis: Depression. Prescribed Cymbalta 90mg. Target behaviors withdrawn, tearful, and self-isolative. Date initiated: 10/29/2024. Interventions: Administer anti-depressant medication as ordered; Assess for adverse side effects, document, and report. Date initiated: 10/29/2024. Further review revealed a care plan was not developed and/or initiated for Psychotropic drugs Risperdone 0.5mg, Risperdone 0.25mg, Buspirone HCl 15mg, and Trazodone HCl 50mg for Resident #9. In an interview and record review on 04/29/2025 at 11:58 a.m., S4 MDS LPN revealed she is responsible for developing and updating care plans. S4 MDS LPN confirmed she developed/initiated Resident #9's Psychotropic Drug care plan on 04/29/2025, which included the drugs Risperdone 0.5mg, Risperdone 0.25mg, Buspirone HCl 15mg, and Trazodone HCl 50mg. In an interview on 04/29/2025 at 1:52 p.m., S2 DON confirmed the Psychotropic drugs Risperdone 0.5mg, Risperdone 0.25mg, Buspirone HCl 15mg, and Trazodone HCl 50mg should have been developed and/or initiated on Resident #9's care plan prior to 04/29/2025, but had not.

Based on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality by failing to ensure Physician's Orders were implemented. The facility failed to ensure supplements were administered as ordered for 1 (Resident #22). Total sample 25. Findings: Review of Resident # 22's Clinical Record revealed an admit date of 10/19/2023 with diagnosis which included: Fracture of Unspecified part of the Neck of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing; Dementia; Anxiety; Protein Calorie Malnutrition; Vitamin Deficiency; Hyperlipidemia; Depression; Psychotic Disorder with Delusions d/t known Psychological Condition; Delusions; Alzheimer's Disease. Review of Resident # 22's Significant Change MDS with ARD of 03/02/2025 revealed a BIMS summary score not conducted due to Resident # 22 was rarely/never understood. Resident #22 required extensive assistance for bed mobility, transfers, eating, and toileting. Review of Resident # 22's Care Plan with a revision date of 04/17/2025 revealed in part .Provide and serve diet and supplements as ordered. Review of Resident # 22's 04/2025 Physician's Orders revealed in part . NSOT (No Salt on Tray) Diet, Regular Texture, Regular/Thin Consistency, ADD PBJ (Peanut Butter and Jelly) with all meals. Review of Resident # 22's Clinical Document titled Change in Diet dated for 03/07/2025 revealed in part . Add PBJ with all meals. Observation on 04/28/2025 at 11:35 a.m. revealed Resident #22 did not receive PBJ with lunch. Observation on 04/29/2025 at 11:18 a.m. revealed Resident #22 did not receive PBJ with lunch. Interview with S7 CNA revealed Resident # 22 had not received PBJ with meals on multiple occasions when S7 CNA assisted Resident # 22 with feeding. Interview with S16 DM on 04/29/2025 at 11:48 a.m. confirmed Resident #22's diet order and diet slip included PBJ with all meals dated 03/07/2025. S16 DM confirmed Resident # 22 should have received PBJ with all meals. Interview with S2 DON on 4/29/2025 at 11:59 a.m. confirmed Resident # 22 should have received a peanut butter and jelly sandwich with all meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident received adequate supervision to prevent incidents and accidents. The facility failed to ensure a resident received supervision while smoking for 1 (Resident #178) of 1 resident reviewed for smoking. Findings: Review of the facility's undated policy on 04/29/2025 at 10:20 a.m. titled Smoking Policy read in part . Residents who smoke will be assessed for safety awareness and for willingness and ability to follow the facility's safety rules for smoking upon admission, and thereafter as needed but at least quarterly. A standardized form will be used and incorporated into the care planning process. Residents who are assessed as not being able to smoke safely will not be allowed to smoke without supervision. If a resident exhibits dangerous behaviors with smoking paraphernalia such as smoking in non-designated areas, smoking in room, using lighter to start fire of any kind, giving or loaning lighter to other residents, the resident will be considered unsafe to maintain smoking paraphernalia and it will be maintained for them at the nurse's station or other specified location. Review of Resident #178's medical record revealed he was admitted to facility on 03/01/2024 and had diagnoses that included in part Generalized Anxiety Disorder, Chronic Obstructive Pulmonary Disease, End Stage Renal Disease, and Depression. Record review of Resident #178's Quarterly MDS with ARD of 03/12/2025 reveled Resident #178 had a BIMS of 15, and was a current tobacco user. Record review of Resident #178's Smoking Safety assessment dated [DATE] revealed Resident #178 was determined to be an unsafe smoker. Resident #178 did not demonstrate that he only smoked in designated areas. Resident #178 did not demonstrate that he would avoid giving cigarettes or smoking paraphernalia to other residents who may be unsafe, or lit cigarettes for them. Review of Resident #178's Care plan revealed description of: Unsafe Smoker. Requires supervision while smoking. Monitor for any safety issues and report immediately. Cigarettes and lighter kept at nurse's station. History of smoking in undesignated smoking areas. Interview on 04/29/2025 at 9:42 a.m. with Resident #178 revealed he was allowed to come out and smoke whenever he wanted, and was able to hold his cigarettes and lighter on himself. Observation on 04/29/2025 at 9:44 a.m. revealed Resident #178 was seated on a bench on the front smoking patio of the facility without staff present. Resident #178 was observed removing a pack of cigarettes and a lighter from his pocket, and lit a cigarette without difficulty. Observation on 04/29/2025 at 9:50 a.m. revealed Resident #178 got up from the bench and ambulated to the front door of the facility with his lit cigarette in hand, and then flicked the lit cigarette on the ground by the front door. Resident #178 did not distinguish or place the cigarette within the ash tray located on the patio. Observation on 04/29/2025 at 9:54 a.m. of the front patio area with S13 RN revealed she observed the lit cigarette that Resident #178 had thrown on the ground near the front door. Interview with S13 RN revealed Resident #178 was an unsafe smoker, and had been educated on placing cigarettes in the ashtray. S13 RN stated he often does what he wants to do. S13 RN stated Resident #178 was considered an unsafe smoker due to him smoking in his room, and places he was not supposed to. S13 RN revealed residents who are unsafe smokers were to be observed by staff when smoking, and go out at designated times. S13 RN stated she did not know Resident #178 was back from dialysis, and confirmed he should not have been outside smoking without supervision.

Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #4) of 1 sampled residents reviewed for respiratory care. The facility failed to ensure equipment was properly changed. Findings: Review of Resident 4's medical record revealed an admit date of 03/01/2017 with diagnosis that included in part .Chronic Obstructive Pulmonary Disease, Chronic Systolic (Congestive) Heart Failure and Shortness of Breath. Review of Resident #4's active Physician orders revealed the following: Oxygen at 2 Liters per nasal cannula PRN Shortness of Breath Desaturation and or Chest Pain as needed related to Chronic Obstructive Pulmonary Disease. Review of Resident #4's Care Plan with a Target date of 07/31/2025 revealed in part .At risk for respiratory distress related to diagnosis Chronic Obstructive Pulmonary Disease. Oxygen at 2 Liters per nasal cannula PRN Shortness of Breath Desaturation and or Chest Pain with interventions that included change oxygen mask/nebulizer tubing/mask every week and PRN nurse to sign and date bag. Observation and interview on 04/28/2025 at 9:19 a.m. revealed Resident #4's humidifier bottle on his oxygen concentrator had a date of 03/27 (no year was specified). Resident #4 stated he wore his oxygen at night. Observation on 04/29/2025 at 9:04 a.m. revealed Resident #4's humidifier bottle on his oxygen concentrator had a date of 03/27 (no year was specified). Observation and interview with S2 DON and S3 RN on 04/29/2025 at 9:10 a.m. in Resident #4's room revealed his humidifier bottle on his oxygen concentrator had a date of 03/27 (no year was specified). S2 DON confirmed the above date on Resident #4's humidifier bottle. S3 RN stated all oxygen equipment should be changed weekly. S2 DON confirmed Resident #4's humidifier bottle should have been changed weekly but had not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5%. The facility failed to: 1. Follow the manufacturer's instructions of Do Not Crush for a medication administered to Resident #23; and 2. Administer a medication as ordered for Resident #29. A total of 36 opportunities were observed for the 3 Residents (#1, #23, and #29) observed during medication administration, which included 2 medication errors for a medication error rate of 5.56%. Findings: Review of the facility's undated policy titled Medications- Administering on 04/30/2025 at 11:31 a.m. read in part . Medications shall be administered in a safe and timely manner, and as prescribed. The individual administering the medication must check the label 3 times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Resident #23 Observation on 04/29/2025 at 7:57 a.m. revealed S12 LPN performed medication administration for Resident#23. Observation revealed S12 LPN placed 3.5 tablets into medication cup for administration. S12 LPN confirmed count of 3.5 tablets. S12 LPN then crushed all medications, and administered the medications to Resident #23. Medications administered to Resident #23 at time of observation included in part . Slo-Mag 71.5-119mg OTC (Over the counter) 2 tablets. Observation on 04/29/2025 at 8:02 a.m. of the Slo Mag OTC bottle used for medication administration for Resident #23 read do not crush. S12 LPN reviewed the medication bottle used and revealed she was unaware the medication should not be crushed. S12 LPN confirmed medications labeled do not crush, should not be. Interview on 04/29/2025 at 10:05 a.m. with S2 DON confirmed medications labeled do not crush, should not be. Resident #29 Observation on 04/29/2025 at 7:54 a.m. revealed S12 LPN performed medication administration for Resident #29. Observation revealed S12 LPN placed 9.5 tablets into medication cup for administration. S12 LPN confirmed count of 9.5 tablets, and then administered the medications to Resident #29. Medications administered to Resident #29 at time of observation included in part . Spironolactone 25mg, 0.5 tablet. Record review revealed Resident #29 was admitted to the facility on [DATE] and had diagnoses that included in part . Hypertensive Heart Disease with Heart Failure, Aphasia Following CVA, and Hemiplegia and Hemiparesis following CVA affecting Right Dominant Side. Review of Resident #29's physician orders read in part . Spironolactone 25mg, 0.5 tablet by mouth daily. Start date 09/03/2024. End date 04/17/2025. Spironolactone 25mg, 1 tablet by mouth daily. Start date of 04/18/2025. Review of Resident #29's 04/2025 EMAR (Electronic Medication Record) revealed in part . Spironolactone 25mg, 0.5 tablet was documented as administered to Resident #29 from 04/01/2025- 04/17/2025. Spironolactone 25mg, 1 tablet was documented as administered to Resident #29 from 04/18/2025- 04/29/2025. Interview on 04/29/2025 at 2:23 p.m. with S12 LPN and observation of Resident #29's medication card on medication cart revealed Resident #29 had Spironolactone 25mg 0.5 tablets on medication cart. S12 LPN confirmed she administered the Spironolactone 25mg 0.5 tablet during medication administration this morning. S12 LPN reviewed Resident #29's current orders on EMAR, and confirmed Resident #29 should have been administered Spironolactone 25mg, 1 tablet. S12 LPN stated there was a change in the dosage of Spironolactone on 04/17/2025. S12 LPN stated the previous order was for Spironolactone 25mg, 0.5 tablet, but the physician increased the dose to 25mg to begin on 04/18/2025. S12 LPN stated when the order was changed, staff should have printed out the order and faxed it to the pharmacy, so that the new dosage could be delivered and placed on the medication cart. S12 LPN confirmed Resident #29 had not been administered Spironolactone 25mg since 04/18/2025, because the new dosage was not available at the facility.

Based on interview and record review, the facility failed to include the Medical Director or his designee and Director of Nursing in the Quality Assessment and Assurance (QAA) committee quarterly meeting, as required. The facility's total census was 73. Findings: Review of an undated facility policy titled, Quality Assessment and Assurance revealed the following in part .1. The Committee will be made up of, at a minimum, the Director of Nursing; the Medical Director or his designee, and at least three (3) other members of the facility staff, at least one of whom must be the administrator, owner, a board member or other individual in a leadership role; and the infection preventionist officer. Review of the facility's documented quarterly Quality Assurance (QA) meeting held on 04/24/2025 revealed S1 ADMIN and eight (8) other leadership personnel in attendance. There was no documentation of the Medical Director nor the Director of Nursing in attendance of the QA meeting held on 04/24/2025. In an interview on 04/30/2025 at 1:17 p.m., S1 ADMIN revealed S5 Corp RN was the designated interim facility DON on 04/24/2025. S1 ADMIN confirmed the Medical Director nor the interim DON, S5 Corp RN, were present at the last quarterly QA meeting held on 04/24/2025, but should have been.

Based on observation, interview, and record review 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 infection for 2 (Resident #7 and Resident #22) sampled residents by failing to: 1. Ensure staff wore PPE for Resident #7 who was on Enhanced Barrier Precautions; and 2. Ensure staff did not blow on Resident #22's food to cool it while feeding her. Findings: Resident #22 Review of Resident # 22's Clinical Record revealed an admit date of 10/19/2023 with diagnoses which included: Fracture of Unspecified part of the Neck of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing; Hypertensive Heart Disease without Heart Failure; Dementia; Anxiety; Protein Calorie Malnutrition; Vitamin deficiency; Hyperlipidemia; Overactive Bladder; Depression; Psychotic Disorder with Delusions d/t known Psychological Condition; Delusions; Alzheimer's Disease. Review of Resident # 22's Care Plan with a revision date of 04/17/2025 revealed a potential for Malnutrition with interventions that included in part . resident to be fed meals per staff. Observation on 04/18/2025 at 11:18 a.m. revealed S7 CNA had put food on Resident #22's spoon and then blew on it to cool it. S7 CNA then put the food in Resident #22's mouth. S7 CNA confirmed she should not have blown on Resident #22's food to cool it while feeding her. Interview on 04/29/2025 at 1:01 p.m. with S2 DON confirmed that S7 CNA should not have blown on Resident #22's food to cool it while feeding her. Resident #7 Review of a facility policy titled, Enhanced Barrier Precautions dated 01/2025 revealed the following in part .Enhanced Barrier Precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with an multidrug-resistant organisms (MDRO) as well as those at increased risk of MDRO acquisition (residents with wounds or indwelling medical devices). 48. High-contact resident care activities include: a. dressing; b. bathing; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use: central lines, urinary catheters, feeding tubes, tracheostomy tubes; h. wound care: any skin opening requiring a dressing. Review of Resident #7's medical record revealed a re-admission date of 12/08/2021, with diagnoses that included in part . Open Wound of Abdominal Wall, Unspecified Quadrant with Penetration into the Peritoneal Cavity, and Type 2 Diabetes Mellitus without Complications. Review of Resident #7's Quarterly and State Optional MDS with an ARD of 02/18/2025 revealed a BIMS score of 15, which indicated intact cognition. Resident #7 required total dependence with two person assist for transfers and extensive assistance with two person assist for bed mobility and toileting. Review of Resident #7's current physician orders revealed in part .08/15/2022 (start date): Enhanced Barrier Precautions related to Abdomen (ABD) wound. Review of Resident #7's care plan with an initiated date of 02/21/2025 revealed in part .Focus: Enhanced Barrier Precautions related to abdomen (ABD) wound. Intervention: Enhanced Barrier Precautions related to abdomen (ABD) wound. Maintain universal precautions when providing resident care. On 04/30/2025 at 10:00 a.m., observed S8 CNA and S9 CNA enter Resident #7's bedroom with the mechanical Hoyer lift and close the bedroom door. Observed the Enhanced Barrier Precaution signage taped to Resident #7's door in two different places for viewing. Observed the personal protective equipment (PPE) storage placed over the resident's door with disposable gowns and gloves in the storage caddy. Observed no evidence of gown usage by S8 CNA and S9 CNA upon entrance of the resident's room. In an interview on 04/30/2025 at 10:09 a.m., S8 CNA and S9 CNA both revealed they had provided a transfer from geri-chair to bed and a brief change for Resident #7. S8 CNA and S9 CNA both confirmed they only wore gloves during the transfer and brief change. S8 CNA and S9 CNA confirmed they were aware of the Enhanced Barrier Precaution signage on the resident's door and confirmed they should have worn a gown during Resident #7's transfer and brief change. In an interview on 04/30/2025 at 10:13 a.m., S2 DON revealed any resident on Enhanced Barrier Precautions required all the CNAs and nursing staff to wear gown and gloves during their transfer or brief change. S2 DON confirmed the CNAs should have worn a gown and gloves during the transfer and brief change of Resident #7, but did not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure residents were free of any significant medication errors for 1 (#29) of 3 (#1, #23, and #29) Residents observed during medication administration, by failing to administer Spironolactone (antihypertensive) medication as ordered. Review of the facility's undated policy titled Medications- Administering on 04/30/2025 at 11:31 a.m. read in part . Medications shall be administered in a safe and timely manner, and as prescribed. The individual administering the medication must check the label 3 times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Observation on 04/29/2025 at 7:54 a.m. revealed S12 LPN performed medication administration for Resident #29. Observation revealed S12 LPN placed 9.5 tablets into medication cup for administration. S12 LPN confirmed count of 9.5 tablets, and then administered the medications to Resident #29. Medications administered to Resident #29 at time of observation included in part . Spironolactone 25mg, 0.5 tablet. Record review revealed Resident #29 was admitted to the facility on [DATE] and had diagnoses that included in part . Hypertensive Heart Disease with Heart Failure, Aphasia Following CVA, and Hemiplegia and Hemiparesis following CVA affecting Right Dominant Side. Review of Resident #29's physician orders read in part . Spironolactone 25mg, 0.5 tablet by mouth daily. Start date 09/03/2024. End date 04/17/2025. Spironolactone 25mg, 1 tablet by mouth daily. Start date of 04/18/2025. Review of Resident #29's 04/2025 EMAR (Electronic Medication Record) revealed in part . Spironolactone 25mg, 0.5 tablet was documented as administered to Resident #29 from 04/01/2025- 04/17/2025. Spironolactone 25mg, 1 tablet was documented as administered to Resident #29 from 04/18/2025- 04/29/2025. Interview on 04/29/2025 at 2:23 p.m. with S12 LPN and observation of Resident #29's medication card on medication cart revealed Resident #29 had Spironolactone 25mg 0.5 tablets on medication cart. S12 LPN confirmed she administered the Spironolactone 25mg 0.5 tablet during medication administration this morning. S12 LPN reviewed Resident #29's current orders on EMAR, and confirmed Resident #29 should have been administered Spironolactone 25mg, 1 tablet. S12 LPN stated there was a change in the dosage of Spironolactone on 04/17/2025. S12 LPN stated the previous order was for Spironolactone 25mg, 0.5 tablet, but the physician increased the dose to 25mg to begin on 04/18/2025. S12 LPN stated when the order was changed, staff should have printed out the order and faxed it to the pharmacy, so that the new dosage could be delivered and placed on the medication cart. S12 LPN confirmed Resident #29 had not been administered Spironolactone 25mg since 04/18/2025, because the new dosage was not available at the facility, and the Resident's medication pack had Spironolactone 0.5 tablet in pack.

Based on interview and record review the facility failed to ensure residents received mail on Saturdays. This has the potential to affect all 73 residents residing in the facility. Findings: Review of an undated facility policy on 04/29/2025 at 11:45 a.m. titled, Resident Right to Privacy in Communication revealed the following in part .The facility will honor the resident's right to privacy in written communication including the right to: 1.Send and promptly receive mail that is unopened. 1. The social service designee, or another designated staff member, will ensure each resident receives any mail addressed to that particular resident promptly. On 04/28/2025 at 1:30 p.m., the Resident Council Meeting was conducted and revealed the residents did not receive mail on Saturdays. In an interview on 04/29/2025 at 10:09 a.m., S11 [NAME] Clerk stated her duty as [NAME] Clerk on Saturdays included gathering the facility mail from the mail box located outside the facility. S11 [NAME] Clerk stated she would then lock the facility mail in the medication room companied by the nurse on duty. S11 [NAME] Clerk stated that on Mondays she would notify S6 SSD and S10 BOM of the Saturday mail received. S11 [NAME] Clerk confirmed she does not distribute any facility mail on Saturdays and the mail would not be distributed until Monday by S6 SSD or S10 BOM. In an interview on 04/29/2025 at 10:20 a.m., S6 SSD revealed it is herself and S10 BOM who are responsible for distribution of the facility/resident mail and no other staff handle the facility mail. S6 SSD confirmed any Saturday mail that is received would be stored in a locked area until Monday when herself or S10 BOM are able to sort through the facility mail and distribute it to the residents. In an interview on 04/29/2025 at 10:50 a.m., S1 ADMIN revealed that the facility/resident mail is not distributed on Saturdays or the weekend. S1 ADMIN stated the facility mail received on Saturday would be stored in a safe place until Monday and S6 SSD and S10 BOM would distribute the Saturday mail on Monday. In an interview on 04/30/2025 at 9:47 a.m., Resident #43 revealed his daughter mailed him packages and letters often. Resident #43 stated that if he had received personal mail on a Saturday he would have to wait until Monday to receive it. Resident #43 stated he would like his mail delivered to him when the facility received it because he was aware of his resident rights and had his right mind. In an interview on 04/30/2025 at 10:35 a.m., S10 BOM revealed it is her duty and S6 SSD to sort and distribute facility/resident mail. S10 BOM stated on Mondays she would gather any Saturday mail received and sort through it. S10 BOM confirmed she was aware the resident's mail should be delivered as soon as the facility receives it including Saturdays, but was not. S10 BOM confirmed that since she has been in her role for two years as Business Office Manager, there never was a process for distribution of the resident mail on Saturdays.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure an injury of unknown source was reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 1 (#1) of 4 (#1, #2, #3, and #4) sampled residents reviewed for abuse. Findings: Review of the facility's undated policy on 11/04/2024 at 4:00 p.m. titled Abuse Prevention and Investigation read in part . The facility has implemented abuse prevention including 7 key components which are: Employee Screening, Training, Prevention, Identification, Investigations, Protection of residents during investigations, and Response and Reporting of incidents of suspected & actual abuse, according to current federal and state laws and regulations. 16. Reporting: a. All alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately, but not later than 2 hours after the allegation is made if the alleged violation involves abuse, or results in serious bodily injury OR within 24 hours if the alleged violation does not involve abuse and does not result in serious bodily injury to the administrator of the facility and to other officials including the state survey agency and adult protective services in accordance with state law through established procedures. 22. The appropriate State Agency will be notified per regulations for any abuse, suspected abuse, injury of unknown origin using the State- Mandated Protocol for Reporting. Review of the medical record for Resident #1 revealed she was admitted to the facility on [DATE] with diagnoses that included: Osteoporosis, Magnesium Deficiency, Displaced Fracture of Shaft of Left Clavicle (06/30/2021), Muscle Wasting and Atrophy, Dietary Calcium Deficiency, Generalized Muscle Weakness, Unspecified Dementia, Major Depressive Disorder, Anxiety, and Schizoaffective Disorder. Review of Resident #1's Quarterly MDS with an ARD of 08/14/2024 revealed a BIMS score of 99, which indicated the resident was not able to participate in interview. The MDS revealed Resident #1 was dependent on staff for eating, oral hygiene, toileting, showering/bathing, dressing, and personal hygiene. Review of Resident #1's Departmental Progress Notes revealed in part . 10/23/2024 10:31 a.m. by S3 Treatment Nurse: Informed by S5 CNA that Resident had skin tear to right elbow area measuring 5 cm x 2 cm, with small amount of bleeding noted. Cleansed with normal saline, triple antibiotic ointment applied, and covered. Bruising noted to right upper arm with blue and yellow discoloration. Facial grimaces noted upon assessing. S4 NP made aware, new orders given to x-ray right arm. 10/23/2024 2:03 p.m. by S3 Treatment Nurse: Portable x-ray obtained as ordered. Results of x-ray revealed right humerus fracture and osteopenia. S4 NP made aware of results, and ordered to send to orthopedist. Appointment scheduled for tomorrow at 9:30 a.m. RP also made aware of results and of appointment. Informed her that an investigation was on going as to what happened, she verbalized understanding. Interview on 11/04/2024 at 1:00 p.m. with S2 DON revealed on 10/23/2024 she was notified by S3 Treatment Nurse that Resident #1 obtained a skin tear to right upper arm with bruising. S2 DON stated S3 Treatment Nurse notified S4 NP, and S4 NP ordered an x-ray. S2 DON stated the X-ray resulted as a Right Humeral Fracture. S2 DON stated the facility began an investigation immediately due to injury of unknown origin and Resident #1 was not able to state the cause. S2 DON stated the facility ultimately could not determine how the injury occurred. Interview on 11/06/2024 at 3:40 p.m. with S1 Administrator revealed he was responsible for reporting incidents into the Statewide Incident Management System. S1 Administrator confirmed according to policy he should have reported the incident regarding Resident #1's injury of unknown origin, that resulted in a serious bodily injury, within 2 hours of becoming aware, but had not.

Based on interview and record review the facility failed to ensure that the resident's person centered plan of care for malnutrition was followed for 1 (#5) of 26 sampled residents by failing to: 1. Identify and report significant weight loss to Resident #5's physician and RP (Responsible Party), 2. Request an RD (Registered Dietician) consult, 3. Have RD assess Resident #5 at least annually, and 4. Perform a Weight Change Evaluation. Findings: Review of the facility's policy titled Weight Monitoring read in part .A weight loss of 5% in 30 days or less, will be considered significant regardless of resident's ideal body weight. Identification of why a resident is losing weight is important in determining what interventions to provide. All significant, unplanned weight losses will be reported to the physician, and the resident's responsible party as soon as is practical by the Nursing Department. Documentation of weight change review, physician notification, and responsible party notification will be documented in the medical record. Standardized assessment entitled Weight Change Evaluation may be used. Review of the facility's policy titled Registered Dietician- Consultant read in part .All residents will be assessed upon initial admission and at least annually thereafter. The RD will provide the Administrator and DM (Dietary Manager) with written, dated, and signed reports of each consultation visit. Review of Resident #5's Electronic Health Record revealed an admit date of 04/04/2012 with diagnoses that included in part . Generalized Muscle Weakness, Dysphagia, Unspecified Protein Calorie Malnutrition, Gastro Esophageal Reflux Disease, and Paraplegia. Review of Resident #5's Yearly MDS with ARD of 01/12/2024 revealed Resident had a BIMS of 15, and required set up assistance for eating. Review of Resident #5's Care Plan with target date of 04/22/2024 revealed in part .Resident #5 had Malnutrition. Interventions included: Ensure x1 carton everyday with breakfast. Provide diet as ordered. Monitor every shift for signs or symptoms of malnutrition, and notify MD promptly. Refer to RD for evaluation of current nutritional status. Review of Resident #5's Weight History Report revealed in part . On 11/06/2023, Resident #5 weighed 228.5 pounds. On 12/06/2023, Resident #5 weighed 216 pounds, which is a 12.5 pound (5.47 %) weight loss within 30 days, constituting a significant change. Review of Resident #5's Medical Record revealed no documentation of the significant weight loss being reported to his physician and RP, RD consult, RD assessment of the Resident at least annually, and no Weight Change Evaluation completed. Interview on 02/07/2024 at 8:33 a.m. with S1 DON revealed she was not able to find any current, or within the last year, RD evaluations for Resident #5. S1 DON stated when she reviewed weights monthly and significant weight loss was identified, she would contact the RD to perform an evaluation, and the Resident's physician and RP to determine if intervention is needed. Interview on 02/07/2024 at 9:13 a.m. with S1 DON confirmed she did not notify Resident #5's physician and RP, or RD and should have had Resident #5 evaluated by the RD when he had a 12.5 pound unplanned weight loss between November-December 2023. Interview on 02/07/2024 at 11:35 a.m. with S1 DON revealed she and S2 Tx Nurse were responsible for monitoring weights monthly to determine if there was significant weight changes for Residents. S1 DON stated S2 Tx Nurse was responsible for completing the Weight Change Evaluation, and notifying the DM that the RD would need to perform an evaluation on Resident. S1 DON confirmed this was not completed for Resident #5, but should have been. S1 DON confirmed the RD had not been notified of Resident #5's significant weight loss prior to 02/07/2024. Interview on 02/07/2024 at 11:40 a.m. with S3 DM revealed she did not recall being notified that Resident #5 had significant weight loss and needed to be evaluated by RD. Interview on 02/07/2024 at 11:49 a.m. with S2 Tx Nurse revealed she was responsible for reviewing weights monthly. S2 Tx Nurse stated Resident#5 had weight loss between November-December 2023. S2 Tx Nurse stated the computer system did not flag the weight loss as significant. S2 Tx Nurse stated she should have double checked the computer systems calculation, as she confirmed Resident #5's 5.47% weight loss within 30 days was significant. S2 Tx Nurse confirmed she failed to notify Resident #5's physician and RP, the RD, and complete a Weight Change Evaluation to determine if intervention was needed for the significant weight loss.

Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide oral care to dependent resident for 1 (Resident #61) of 26 sample size residents. Findings: Review of the facility policy titled: Activities of Daily Living (ADLs)revealed in part: Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's need and choices. Care and services will be provided for the following activities of daily living: 1. Oral care. Policy Explanation and Compliance Guidelines: 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of Resident #61's Annual MDS with an ARD of 11/14/2023 revealed a BIMS of 8 (moderately impaired cognition), with impairment of upper/lower extremity on one side, and required partial/moderate assistance with oral hygiene. Review of Resident #61's Care Plan revealed Resident #61 required limited assistance with ADLs and required assistance with oral care every day and as needed. The Care Plan further revealed that Resident #61 had left sided hemiplegia. Observation on 02/05/2024 at 2:00 p.m. and 4:00 p.m. revealed Resident #61 lying in bed with saliva drooling down the left side of his mouth onto his shirt. Resident #61 had white substances in the corners of his mouth with a foul smelling mouth odor. Observation of Resident #61 on 02/06/2024 at 10:30 a.m. revealed Resident #61 lying in bed with his mouth open, salvia drooling down the left side of his mouth onto his shirt. Resident #61 still had white substances in the corners of his mouth with a foul smelling mouth odor. Observation on 02/06/2024 at 11:00 a.m. of Resident # 61 accompanied by S1 DON revealed Resident #61 with saliva drooling down the left side of his face, under his neck and down unto his shirt. Resident #61 had white substances in the corners of his mouth with a foul smelling mouth odor. S1 DON at the time of the observation confirmed Resident #61 was in need of oral care and it should have been performed by the CNAs and wasn't.

Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #9) of 1 residents reviewed for respiratory care. The facility failed to ensure respiratory equipment was properly stored. Findings: Review of the facility policy titled Respiratory equipment-Infection Control Guidelines revealed in part . Medication Nebulizer/Continuous Aerosol Machines: Administration sets and tubing will be dated before using and will be changed at least weekly and whenever contamination is suspected. Equipment, administration sets, and tubing must be covered with plastic or clean towel when not in use. Observation on 02/05/24 at 11:03 a.m. revealed a nebulizer with aerosol mask and tubing attached open to air on top of a PTAC unit in Resident #9's room. Interview with Resident #9 at the time of observation revealed she received nebulizer treatments as needed. Observation on 02/06/2024 at 9:25 a.m. revealed Resident #9 seated on the side of her bed, rolling cigarettes. A nebulizer with aerosol mask and tubing attached, open to air, was observed on the top of the PTAC unit next to Resident #9's bed. Observation of Resident #9 on 02/06/2024 at 9:41 a.m. accompanied by S1 DON revealed the aerosol mask and tubing remained attached to a nebulizer open to air on top of Resident #9's PTAC unit. Interview with S1 DON at the time of observation revealed respiratory equipment should be dated and bagged when not in use and changed weekly. S1 DON confirmed Resident #9's aerosol mask and tubing had not been dated or stored properly and she could not tell the last time the setup had been changed.

Based on record review and interview, the facility failed to comply with the requirement of yearly in-service training for CNAs. The facility failed to provide documentation for the required 12 hours of training which included dementia management and abuse prevention trainings for 2 (S11 CNA and S13 CNA) of 5 (S9 CNA, S11 CNA, S12 CNA, S13 CNA, and S14 CNA) CNA personnel records reviewed. Findings: Review of S11 CNA's personnel record revealed a hire date of 08/10/2020 and no documentation that S11 CNA had received the required yearly 12 hours of dementia management and abuse prevention training since 12/22/2022. Review of S13 CNA's personnel record revealed a hire date of 09/18/2022 and no documentation that S13 CNA had received the required yearly dementia management training. Interview on 02/07/2024 at 2:30 p.m. with S7 Administrator revealed S11 CNA and S13 CNA were agency staff. S7 Administrator confirmed the facility had no documentation that S11 CNA had received the required 12 hours of yearly trainings which included dementia management and abuse prevention trainings. S7 Administrator confirmed the facility had no documentation that S13 CNA had received yearly Dementia Management training.

Based on observation and interview, the facility failed to ensure medications were stored and labeled properly in accordance with currently accepted professional principles on 1 (Hall A) of 2 (Hall A and Hall B) medication carts and 1 of 1 medication storage rooms. Findings: Review of the facility policy titled: Medications-Storage, revealed in part The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Observation on 02/07/2024 at 9:00 a.m. of the Hall A medication cart accompanied by S15 LPN revealed the second drawer of the medication cart contained 3 loose pills and the bottom drawer of the medication cart contained an opened 100ct box of 28G safety lancets with an expiration date of 02/01/2024. Findings confirmed with S15 LPN at the time of observation. S15 LPN revealed it was the responsibility of all nurses to ensure carts were kept clean and free of loose pills and to check dates on boxes. Observation on 02/07/2024 at 9:30 a.m. of the facility medication storage room revealed the following items on shelves for use: 5 (30ct) boxes of Ipratropium Bromide and Albuterol Sulfate inhalation 0.5mg/3mg solutions. Expiration dates noted as 11/2023 on 2 boxes, 07/2023 on 2 boxes, and 1 box expired on 05/2023. 1 (30ct) box of Ipratropium Bromide 0.02% inhalation solution with an expiration date of 01/2024. 1 (40ct) box of Guaifenesin Extended Release 600mg tablets with an expiration date of 01/2024. 4 Fluticasone Propionate & Salmetrol inhalation disk. Expiration dates noted as 04/2023 on 3 disk and 01/2023 on the other disk. 1 Symbicort 160/4.5 inhaler with an expiration date 06/2022. Interview on 02/07/2024 at 9:56 a.m. with S1 DON confirmed the medication room findings. S1 DON stated expired medications should have been removed from shelves and placed in the appropriate bins for disposal and had not been.

Based on observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu in regard to portion size to ensure nutritional adequacy of the meal for 28 residents that received mechanically altered diets prepared by the facility kitchen. Findings: Review of the facility's policy titled: Menu Planning read in part .Purpose: To assure that a variety of nutritious foods that meet the residents' needs are purchased, prepared and served to the residents. Policy: 1. Menus must be planned in advance and meet the nutritional needs of the residents in accordance with recommended dietary requirements. Review of the facility's policy titled: Use of Recipes read in part .Policy: Recipes are to be used when preparing menu items. Procedure: 1. Recipes (in appropriate portion sizes) for each set of cycles menus are provided and maintained in the facility. Review of the facility's approved 2023 Fall/Winter Menu revealed on 02/05/2024 the facility was on week 1, day 2. Pureed lunch menu, in part, consisted of a substitute meal: Pureed Chili -1 cup, mashed potatoes-1/2 cup, pureed carrots-1/3 cup, pureed brownie-1/4 cup, beverage of choice and water. Review of the facility's approved 2023 Fall/Winter Menu revealed on 02/06/2024 the facility was on week 1, day 3. The lunch menu consisted of in part .Pureed Fried Chicken- 3 ounces, ground fried chicken- 4 ounces, mashed potatoes- ½ cup, broccoli-1/3 cup, dinner roll, beverage of choice and water. Observation on 02/05/2024 at 11:46 a.m. revealed Resident #66 was served his lunch tray in the dining area. Resident #66's meal tray consisted of a single portion of mashed potatoes topped with single portion of chili, single portion of carrots, pudding cup and a beverage. Review of Resident #66's meal ticket on tray revealed resident was to be served double portions of mechanical soft chopped meats diet with thin liquids. Interview on 02/05/2024 11:50 a.m. with S10 LPN confirmed the tray served to Resident #66 was not double portioned. S10 LPN went to kitchen to get resident #66 a second portion. Interview on 02/05/2024 at 12:33 p.m. with S9 CNA revealed Resident #66's lunch tray did not appear to be served with double portions. Observation on 02/06/2024 at 11:15 a.m. revealed Resident #66 was served his lunch tray which consisted of pureed chicken with gravy that appeared to be the same amount of food as the Residents served with single portions. Interview on 02/06/2024 at 11:18 a.m. with S8 CNA revealed the lunch tray served to Resident #66 was a single serving. Observation on 02/06/2024 at 11:40 a.m. revealed S6 Dietary [NAME] serving lunch trays in the kitchen. S6 Dietary [NAME] revealed the scoop size used to serve pureed and chopped fried chicken were both 2 ounces per serving. S6 Dietary [NAME] confirmed she had placed (1) 2 ounce scoop per plate while serving. S6 Dietary [NAME] revealed she had not been trained on portion sizes in the facility. Interview on 02/06/2024 at 11:45 a.m. with S3 DM confirmed the scoop size used for pureed fried chicken was 2 ounces per serving and the recipe called for 4 ounces per serving. S3 DM confirmed the scoop size used for chopped fried chicken was 2 ounces per serving and the recipe called for 3 ounces per serving. S3 DM confirmed residents being served mechanically altered diets were not given the proper portion sizes for meats because the wrong scoop sizing was used.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that pureed foods were prepared by methods which conserved nutritional value for 5 (Resident #30, Resident #35, Resident #40, Resident #61 and Resident #119) of 5 Residents who were ordered and served pureed diets. Findings: Review of the facility's policy and procedure titled Use of Recipes read in part: Policy: Recipes are used when preparing menu items. Procedure: 3. Cooks are expected to use and follow the recipes provided. Review of the facility's approved 2023 Fall/Winter Menu Recipes read in part: Pureeing food can alter the taste, consistency and sometimes the volume of the food. Liquids should be added gradually and may need to increased or decreased slightly to ensure foods are served at a proper consistency. Cooking liquid, broth, or other suitable liquids may be used when pureeing food. Pureed chili with beans. Ingredients/Prep Method- Chilli with beans. Place prepared recipe portion(s) into blender or food processor. Add additional liquid/thickener/crackers as desired to reach a pudding-like consistency. Pureed chicken fried chicken. Ingredients/Prep Method- Chicken fried chicken and prepared cream gravy. Pureed broccoli florets. Ingredients/Prep Method- Broccoli. Broth or other suitable liquid may be used when pureeing this food. Mashed potatoes. Ingredients/Prep Method- Instant Complete Mashed Potatoes and Water. Prepare mashed potatoes according to package instructions. Resident #30 Review of Resident #30's EHR (Electronic Health Record) revealed he was admitted to facility on 01/10/2024 with diagnoses that included in part: Abnormal Weight Loss, Major Depressive Disorder, Anxiety Disorder, Dementia, and Protein-Calorie Malnutrition. Review of Resident #30's February 2024 physician's order revealed an order for NAS (no added salt) NCS (no concentrated sweet) Pureed diet with thin liquids, and mighty shakes. Resident #35 Review of Resident #35's EHR revealed he was admitted to facility on 06/08/2021 with diagnoses that included in part: Major Depressive Disorder, Metabolic Encephalopathy, Anxiety, and Dementia without behavioral disturbance. Review of Resident #35's February 2024 physician's order revealed an order for Pureed diet, Nectar thickened liquids, double portion with every meal, and mighty shakes. Resident #40 Review of Resident #40's EHR revealed she was admitted to facility on 04/12/2017 with diagnoses that included in part: Chronic Obstructive Pulmonary Disease and Protein-Calorie Malnutrition. Review of Resident #40's February 2024 physician's order revealed an order for Pureed thin liquids, mighty shake at breakfast, magic cup/ice cream by mouth three times per day with meals related to Malnutrition. Resident #61 Review of Resident #61's EHR revealed he was admitted to the facility on [DATE] with diagnoses that included in part: Hypertensive Heart Disease, Cerebral infarction, Dysphagia, Major Depressive Disorder, and Generalized Anxiety Disorder. Review of Resident #61's February 2024 physician's orders revealed an order for Pureed diet with nectar thick liquids with supervision provided at feeding table. Resident #119 Review of Resident #119's EHR revealed he was admitted to the facility on [DATE] with diagnoses that included in part: Displaced Sub Trochanteric Fracture of Right Femur, Unspecific Protein-Calorie Malnutrition, Dysphagia, and Unspecified Dementia. Review of Resident #119's February 2024 physician's orders revealed an order for Pureed diet. Observation on 02/05/2024 at 10:23 a.m. of S5 Dietary [NAME] preparing pureed chili in a blender. S5 Dietary [NAME] added an unmeasured amount of tap water to the chili, and an unmeasured amount of powered food thickener. Interview with S5 Dietary [NAME] during the observation stated she always used unmeasured water as an additive to puree foods. S5 Dietary [NAME] stated she used just enough water and thickener to the chili for a certain consistency. Interview on 02/05/2024 at 10:30 am. with S3 DM stated there is no certain method used to puree foods. S3 DM stated S5 Dietary Cook's method used was correct, and that milk and/or water was used, depending on the food. S3 DM stated thickener is added unmeasured depending on the food, since the consistency will vary. Telephone interview on 02/06/2024 at 9:37 a.m. with S4 RD stated pureed diets should be prepared according to the pureed meal recipe. S4 RD stated the pureed recipes are kept in the dietary department accessible to all dietary workers. S4 RD stated additives used to puree foods included broth, (food) liquids, juices, bread, and milk. S4 RD stated the use of water lowered the nutrient and vitamin values of the food(s), and should never be use as an additive in the preparation of pureed foods. S4 RD stated water is only used in the preparation of mashed potatoes, using the recommended amount on the package label. S4 RD stated thickener is added to pureed foods in order to give it a pudding-like consistency. S4 RD stated that all additives should be measured. Surveyor informed S4 RD of 02/05/2024 10:23 a.m. observation of pureed chili meal prep, prepared by S5 Dietary Cook. S4 RD confirmed the use of water lowered the nutritional value of the chili, and confirmed additives should always be measured, and staff should use the pureed meal recipes for guidance on food prep. Observation on 02/06/2024 at 11:10 a.m. revealed S6 Dietary [NAME] preparing pureed lunch meal trays. The meal included pureed chicken fried chicken, pureed broccoli, and mashed potatoes. Interview at the time of the observation with S6 Dietary [NAME] revealed she prepared the pureed foods at approximately 9:45 a.m. S6 Dietary [NAME] stated the chicken fried chicken was pureed with unmeasured tap water, broccoli with its juice, and mashed potatoes with unmeasured water. S6 Dietary [NAME] stated she always used water to puree foods unless it had its own juice. S6 Dietary [NAME] stated she was not familiar with using the puree recipes, nor had she ever used a puree recipe when preparing pureed foods. Interview on 02/06/2024 at 11:12 a.m. with S3 DM confirmed S6 Dietary [NAME] used unmeasured water and thickener to prepare the pureed chicken fried chicken. S3 DM confirmed that the approved puree recipes were not used in the preparation of pureed foods.

Based on observation, record review, and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to: 1) store dishes and utensils under sanitary conditions; 2) ensure food preparation equipment was clean. This deficient practice had the potential to affect the 64 residents that received meals prepared in the kitchen. Findings: Review of the facility's policy and procedure titled Cleaning Equipment/Wiping Cloths read in part: Policy: A detailed procedure for cleaning each piece of equipment should be maintained in the dietary department and reviewed periodically with the staff. 4. Sanitize all surfaces with a double-strength detergent, solution, and clean cloths used only for this purpose. 5. Allow to air dry. Can Opener and base: Proper sanitation and maintenance of the can opener is important to sanitary food preparation. The can opener must be thoroughly cleaned each work shift and, when necessary. Wash handle portion of the can opener in dish machine. Review of the facility's policy and procedure titled Sanitation read in part: The food service area and all equipment used in food preparation shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation 2. All utensils, counters, shelves and equipment shall be kept clean. 3. Electrical equipment (meat slicers, blenders, etc.) will be cleaned and sanitized according to the manufacturer's instructions. 4. Pots, bowls, lids, or other utensils that cannot be sanitized in the dish machine due to size or other factors will be sanitized using an approved sanitizing solution according to the instructions for use of the solution. General Cleaning Protocols: Cabinets and drawers: Clean cabinets and drawers on a weekly basis. 1. Use mild soap and water. Removable drawers should be removed and washed. Sanitize according to manufacturer's instructions, allow to air dry. Ingredient Bins: To prevent food contamination, ingredient bins must be kept clean and covered. Observation of the kitchen accompanied by S3 DM on 02/05/2024 at 9:29 a.m. revealed: 1. 3 tier plastic cart in the dishwashing area was noted to have dark black and brown substance caked in 4 corners on which 32 clean insulated plate covers and plate holders were stored. 2. 4 32 cups plastic storage containers of dry cereal of raisin bran, corn flakes, frosty flakes and cheerios stored in each bin were noted to have thick dark white film, with yellow gel like substances around the rims, and outside top of the bins. The outside side surface of each bin were sticky to touch, with cloudy light brownish color substance. 3. 3 drawer plastic storage container with clean serving utensils revealed: 1st drawer -12 scoop spoons with large amount of loose dark substance and a few bacon crumbs on the inside bottom surface of the storage container. 2nd drawer-10 dishers scoops, 1 large black plastic serving spoon with large amount of loose dark substance on the inside bottom surface of the storage container. 3rd drawer-cracked exposing the utensil inside- 2 long handle metal serving spoons, 1 Whisk, 1 potatoes masher, 3 long handle metal tongs, 2 long handle metal forks, 1 soup/gumbo latte server with dark red, brown, and black substance on the inside bottom surface of the storage container. 4. 6 gallon size pitchers located on a plastic movable cart were stored wet with one stacked inside another with red liquid dripping from the sides of the 2 pitchers stacked inside one another unto the bottom of the cart surface. 5. Microwave with yellow-type gel drippings on the top surface. 6. 2 slice toaster rusty on the top surface with bread crumbs on the top surface and a large amount of caked bread crumbs on the crumb plate. 7. Meat chopper on stationary stainless-steel table stored wet with water noted inside of the container. Interview with S3 DM on 02/05/2024 confirmed all of the above findings at the time during the observations. S3 DM stated that each dietary worker who was assigned to washing the dishes was responsible for ensuring that all of the cooking and eating utensils are stored washed/dried and stored properly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents' rights to be free from verbal abuse for 1 (Resident #1) of 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5 and Resident #6) sampled residents. The facility failed to protect Resident #1 from verbal abuse by staff. The facility implemented corrective actions which were completed prior to the State Agency's Investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility policy titled: Abuse Prevention and Investigation revealed the following in part . Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Observation on 05/15/2023 at 9:51 a.m. revealed Resident #1 rolling out of his bathroom in his wheelchair. Resident #1 had an unfriendly look on his face, and refused to talk or answer any questions. After several attempts, he finally said it's going good then turned his back. Observation on 05/17/2023 at 1:00 p.m. revealed Resident #1 sitting by the front door of the facility. Resident #1 refused to answer questions, and rolled away in his wheelchair. Review of Resident #1's EHR revealed an admit date of 04/27/2021, and diagnoses that included: Bipolar Disorder; Unspecified Dementia; Anxiety Disorder, unspecified; and Major Depressive Disorder, single episode, mild. Review of Resident #1's SM5 MDS with an ARD of 04/15/2023 revealed Resident #1 had a BIMS of 15 (Cognitively Intact). The MDS revealed Resident #1 had verbal behavior symptoms directed toward others and rejected care. Resident #1 was coded for Antidepressant medication. Review of Resident #1's Care Plan with target date of 07/31/2023 revealed the following in part . An update dated 03/12/2023 for: Behavior: Verbally aggressive behavior, Often non-compliant of medication, Refuses to allow staff to assist with personal hygiene care; Often becomes quickly agitated and curses at staff stating F--- you Calls staff very profane names; Will curse at other peers when spoken to; When offered medication resident often says I'm not taking that f---ing s-t. Goals included: Episodes of verbally aggressive behaviors will decrease by 50% this quarter. Interventions included: Talk in calm voice when behavior is disruptive; Refer to Social Services for evaluation; Remove from public area when behavior is disruptive and unacceptable; Reinforce unacceptability of verbal or physical abuse; Monitor and document target behaviors; Consult MD/PNP/Notify RP as needed; Do not argue with resident; Discuss options for appropriate channeling of anger; Schedule psychiatric visits as ordered; Administer behavior medications as ordered by physician; Do not challenge content of behaviors; and Transfer to Behavioral Clinic per PEC PNP r/t verbal aggressive behaviors. Review of Resident #1's 05/2023 MD orders revealed the following on part . Remeron 15 mg Soltab x 1 tab po q HS Dx: Depression target behaviors: Yelling and cursing at staff, refusing care, ordered on 12/22/2022. Review of Resident #1's nursing notes revealed the following in part On 03/12/2023 at 11:30 a.m., S2 LPN documented that Resident #1 was sitting in the dining room, a CNA (S3 CNA) asked Resident #1 what he would like to eat for lunch, he responded with just bring it here. CNA (S3 CNA) told kitchen staff to go ahead and just fix him a tray, CNA (S3 CNA) brought lunch tray to resident with only water and juice and he (Resident #1) started using foul language, Fu***** B****, you crackhead, you punk head a** B****, CNA (S3 CNA) then walked away from the resident, while she was walking away she also used foul language towards the resident. S2 LPN entered the dining room and heard Resident #1 still using foul language and repeating Fu** this, Fu** you, Fu** this place over and over. S2 LPN then approached resident and offered to take him out of the dining room, he refused and started using foul language again saying you can't make me leave this Fu****** dining room, Fu** you, S2 LPN walked away thinking it would help calm resident down. Resident #1 continued to use foul language. Resident #1 was removed from the dining room redirected at this time. Safety maintained. On 03/12/2023 at 12:30 p.m., police arrived to facility to begin a police report on incident that happened with staff today, officer took a copy of the witness statement and left the facility. He asked that when all of the facility's documentation/report was completed to give the police station a call for him to pick up a copy. On 03/13/2023 at 1:50 p.m., Resident #1's PNP was notified of Resident #1's behavior, and was to come that evening to see about a PEC. On 03/13/2023 at 8:00 p.m. Resident #1 was transferred to a behavioral hospital for an inpatient stay per ambulance. Review of Social Service documentation dated 03/13/2023 at 3:10 p.m. revealed the following: Spoke with Resident #1 today and asked him about the incident that happened over the weekend. Resident #1 stated when the aide (S3 CNA) brought him the tray of food, he did not want it and the aide went to go and get something else and he told her to bring it back. She (S3 CNA) brought the tray back and it did not have water or juice, and when she stated that someone else would get it for him, they started arguing. Resident #1 cursing a lot when talking to me (Social Worker) about it. Asked Resident #1 to not use that language while we were talking, but to no avail. Resident#1 left my office and went out into the hall. Review of S3 CNA's Witness Statement dated 03/12/2023 read as follows: I was told to ask Resident #1 what did he want for lunch, so when I did asked he was mad and started to fuss and curse me out calling me all kinds of punk a** b***h multiple times, and he kept on cursing me calling me a crack head b***h. Then after so many times of him cursing me I end up responding by saying I'm not that and said punk nig*a after cursing me out so many times. Review of S7 CNA's Witness Statement dated 03/12/2023 read as follows: I S7 CNA was in the kitchen waiting on the residents to finish eating lunch. S3 CNA asked Resident #1 what he wanted for lunch. Resident #1 stated bring it to me x2. S3 CNA went to the kitchen window and stated I guess he want lunch, because he not saying anything special. S3 CNA gave Resident #1 his lunch and walk away. Resident #1 stated I need some f***** water. S3 CNA stated someone give him some water because I'm not going to let him talk to me like that. Resident #1 began cursing towards S3 CNA. F*** you b**** you crackhead h*e. I, S7 CNA attempted to calm Resident #1 down stating Resident #1 stop talking like that, just calm down. Resident #1 continued stating f*** her. Review of S8 CNA's Witness Statement dated 03/12/2023 read as follows: S3 CNA asked Resident #1 what he wanted to eat and Resident #1 responded what the F*** you thin B****. S3 CNA forgot to give water and Kool-Aid so Resident #1 said B**** give me some water you crackhead B**** and just kept going calling out her name. Review of S6 CNA's Witness Statement dated 03/12/2023 read as follows: All staff was passing trays as usual when it came down to Resident #1's tray, S3 CNA ended up having it. S3 CNA brought Resident #1's tray but didn't bring nothing to drink. Resident #1 asked can I have some water and S3 CNA said somebody else can bring it because you have an attitude. S3 CNA and Resident #1 were kind of going back and forth arguing. Resident #1 called S3 CNA a name and she called him back. Review of the facility Employee Warning Report revealed S3 CNA was counseled on 03/12/2023 at 11:00 a.m. concerning verbal altercation with Resident #1 that included cursing/foul language. S3 CNA was suspended on 03/12/2023 with return date of 03/16/2023. Review of the 03/13/2023 facility investigation forms revealed all facility residents were interviewed concerning mistreatment by staff, witnessing any other residents being mistreated by staff and feeling safe in the facility. All residents were interviewed with no negative findings noted. Review of S3 CNA Counseling Form dated 03/16/2023 revealed the problem as Verbal altercation with resident that included cursing/foul language. The resolution included - 3 day suspension until investigation complete; training on abuse/neglect policies; and advised to remove self from situation when residents get aggressive/angry. Review of the facility's 03/2023 - 05/2023 monitoring tool revealed weekly monitoring was conducted on S3 CNA concerning any reports of abuse/mistreatment with negative findings, after her return to work on 03/16/2023. Review of the facility's 03/2023 - 05/2023 monitoring tool revealed weekly monitoring was conducted of residents (to include residents who were unable to verbalize abuse), and staff in the facility concerning any signs and/or reports of abuse with no negative findings. Review of the 03/12/2023 Facility Investigation of the incident involving Resident #1 and S3 CNA revealed in-services were started on 03/12/2023 and completed on 03/13/2023 concerning the facility's Abuse Prevention and Investigation Policy. All staff employed by the facility received training on the above policy. Telephone interview on 05/17/2023 at 8:00 a.m. with S2 LPN revealed she was the nurse on duty when the incident involving Resident #1 occurred. S2 LPN stated she did not witness the incident between Resident#1 and S3 CNA, but was told about it after the fact by S6 CNA. S2 LPN stated she was just walking into the dining room and was asked if she knew anything about what had happened. S2 LPN stated S6 CNA told her that S3 CNA brought a tray to Resident #1 and when she was walking away Resident #1 was cussing her. S2 LPN stated S6 CNA reported that she heard S3 CNA use ugly language concerning Resident #1 as she was walking away. S2 LPN stated the incident was quickly deescalated. S2 LPN stated she reported the incident immediately to S4 Previous DON. Interview on 05/17/2023 at 8:23 a.m. with S6 CNA revealed she witnessed the incident involving Resident #1. S6 CNA stated the CNAs were passing trays and everyone knew that Resident #1 liked to get water on his tray. S6 CNA stated S3 CNA brought Resident #1 his tray without water, and he said something to her. S6 CNA stated that S3 CNA told Resident #1 that she was not bringing him nothing because he had an attitude. S6 CNA stated another CNA brought Resident #1 some water. S6 CNA stated Resident #1 and S3 CNA were cussing each other. S6 CNA stated a nurse removed Resident #1 out of the dining room. Telephone interview on 05/07/2023 at 10:05 a.m. with S4 Previous DON revealed she was notified immediately about the 03/12/2023 incident between Resident #1 and S3 CNA by S2 LPN, and began the investigation process. Telephone interview on 05/17/2023 at 11:30 a.m. with S3 CNA concerning the incident with Resident #1, revealed she was working in the dining room and a kitchen worker asked her to see what Resident #1 wanted to eat because he usually wanted to be served something different. S3 CNA stated that she asked Resident #1 while S6 CNA was whispering something in Resident #1's ear and he started cursing her. S3 CNA stated she got him his tray and sat down. Resident #1 continued cursing her. S3 CNA stated she called Resident #1 a punk and that she did not curse him. S3 CNA stated she was sent home by S2 LPN, who had received instructions from S1 Administrator. Interview on 05/17/2023 at 1:00 p.m. with S1 Administrator revealed that the monitoring tool was part of the facility's QAPI on the 03/12/2023 incident involving Resident #1 and S3 CNA. S1 Administrator stated there had been no other incidents of abuse in the facility and monitoring was continuing. S1 Administrator stated no changes were required to the facility's Abuse policy. The facility implemented the following actions to correct the deficient practice: S3 CNA was suspended. Resident #1 was sent to a behavioral hospital on [DATE]. No further behavioral issues have been noted from Resident #1 since his return from the behavioral hospital. In-services were started immediately after the incident on 03/12/2023 and completed on 03/15/2023 concerning abuse until all staff were educated. All residents in the facility were interviewed on 03/13/2023 concerning abuse/mistreatment by staff, observations of mistreatment by staff and if they felt safe in the facility. Monitoring of residents who were unable to verbalize abuse was done weekly. Weekly monitoring started 03/12/2023 of staff and residents and remained in progress for complaints of abuse. Weekly monitoring started 03/16/2023 of S3 CNA concerning reports of abuse/mistreatment of resident in the facility. QA monitoring in place for reports of abuse. Abuse policy was reviewed with no updates needed. Facility correction date of 03/16/2023.

Based on record review and interview the facility failed to provide appropriate and sufficient services, treatment and care according to standards of professional practice for 1 (#54) of 2 (#16, #54) Residents that were reviewed for urinary catheter or UTI (urinary tract infection) out of a total of 23 sampled Residents. The facility failed to ensure Resident #54's Foley Catheter was removed as ordered by the physician. Findings: Review of Resident #54's Medical Record revealed an admit date of 09/01/2022 with diagnoses which included: Other Disorders of Urinary System, Abscess of Vulva and Sepsis due to Methicillin Susceptible Staphylococcus Aureus. Review of Resident #54's MDS with ARD of 11/11/2022 revealed a BIMS score of 7 (indicating severe cognitive impairment). Further review revealed Resident #57 had an indwelling catheter and occasionally incontinent of bowel. Review of Resident #54's Care Plan with a start date of 11/07/2022 revealed she returned from a recent hospitalization with a 16Fr/10cc Foley Catheter and to discontinue (remove) Foley on 11/11/2022 per Family Nurse Practitioner. Review of Resident #54's Physician's order dated 11/11/2022 revealed an order to discontinue Foley Catheter on 11/14/2022. Review of Resident #54's Progress notes dated 11/14/2022 at 10:48 a.m. read .Foley Catheter is in place and draining clear yellow urine to Genitourinary bag. Further review of progress notes dated 11/14/2022 at 11:25 p.m. read .Foley Catheter in place draining clear yellow urine. Review of Resident #54's Progress notes dated 11/15/2022 at 12:17 p.m. read .Foley Catheter D/C today using clean technique tolerated well Resident due to void in 6-8 hours will continue to monitor. Interview on 01/18/2023 at 10:47 a.m. with S1 DON and S3 LPN Treatment Nurse revealed Resident #54's Foley Catheter was not discontinued on 11/14/2022 as ordered by the physician. S3 LPN Treatment Nurse stated she was off on 11/14/2022 and when she returned to work on 11/15/2022 Resident #54's Foley Catheter was still in place. S1 DON confirmed Resident #54's Foley Catheter was not removed on 11/14/2022 as ordered and it should have been.

Based on observation, interview, and record review the Facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to care for resident's needs for 1 (Resident #14) of 23 Sampled Residents. Findings: Observation on 01/16/2023 at 3:50 p.m. revealed Resident #14 sitting in bed reading a book. Resident #14 stated she had sores to her lower stomach and right leg. She stated her skin was fragile and it would tear if rubbed across the sheets. Observation on 01/17/2023 at 8:37 a.m. of Resident #14's wound care with S3 LPN/Treatment Nurse revealed S3 LPN/Treatment Nurse sanitized her hands then put on a gown and gloves prior to providing wound care. Resident #14's abdominal wound was cleaned per MD order. S3 LPN/Treatment Nurse was observed not removing her gloves after cleaning the wound or prior to placing a new dressing on Resident #14's wound. Interview at this time with S3 LPN/Treatment confirmed she did not change gloves at any time during Resident #14's abdominal wound care. S3 LPN/Treatment Nurse stated she only changed gloves before performing care to a wound located on another part of a Resident's body. S3 LPN/Treatment Nurse put on fresh gloves and completed wound care to Resident #14's right lower leg. She did not change gloves during the entire wound care process to Resident #14's right lower leg. S3 LPN/Treatment Nurse confirmed this after completion of wound care. Review of the Resident #14's Face Sheet revealed an admit date of 12/08/2022 with the following diagnoses including: Unspecified Open Wound Abdominal Wall, Unspecified Quadrant with Penet Perit Cav; and Cutaneous Abscess. Review of the Resident #14's 01/2023 MD Orders revealed the following in part: 12/21/2022 - Cleanse abrasion to RLE with wound cleanser. Apply Muporicin and cover qod with dry dressing until healed 01/16/2023 - Cleanse wound to abdomen with wound cleanser, apply Adaptic to wound bed with Silver Alginate and cover prn til resolved. Review of the Resident's Quarterly MDS with ARD of 10/31/2022 revealed the following including: Section C - Cognitive Pattern - The Resident had a BIMS score of 15. Section M- Skin Condition - The Resident had other skin problems: lesions not ulcers, rashes, cuts; and skin tear(s). Review of the Resident #14's Care Plan with target date of 04/30/2023 for Open Lesion 7.5 cm x 29.00 cm x 0.00 cm RLQ wound to ABD Dx: Panniculitis Serosanguineous drainage No pain/infection noted MD/RP notified with a goal of Area will be healed his quarter. Interventions noted in part: Perform wound care as ordered. Review of the Facility Skin Program, Pressure Ulcers & Other Wounds Policy revealed in part: #21. Clean technique, using a no-touch method to avoid contaminating the wound is usually adequate for wound treatments. Clean technique and supplies will be used unless otherwise ordered. Interview on 01/17/2023 at 10:05 a.m. with S1 DON revealed that the Facility did not have a wound care procedure guide. She confirmed that the Treatment Nurse should be removing her gloves after cleaning the Resident's wound and putting on new ones before dressing the wound.

Based on interview and record review the facility failed to ensure that each Residents drug regimen remained free from unnecessary drugs by failing to 1) Discontinue medication as ordered by physician and 2) provide monitoring of target behaviors and potential side effects for the use of antidepressant medication for 1 Resident (#21) of 5(#21, #28, #50, #57, #58) sampled Residents for unnecessary medications in a total investigative sample of 23 Residents. Findings: Review of the Facility's Policy & Procedure titled Medications- Medication Regimen Review read in part: Upon completion of the MRR, the facility designee and/or physician, will respond to the recommendations in a timely manner. Review of Resident # 21's medical record revealed an admit date of 03/25/2009 with admitting diagnosis of Hypertensive Heart Disease with Heart Failure. Other diagnoses include in part: Unspecified Protein-Calorie Malnutrition, Schizoaffective Disorder, Cognitive Communication Deficit, Muscle Wasting and Atrophy, Constipation, Type2DM, Insomnia, Depression, History of Falls, Anxiety, and COPD. Review of Resident #21's Quarterly MDS with ARD of 12/28/2022 revealed BIMS score of 15, indicating the Resident was cognitively intact. Medications; Number of days Resident received medications received during 7 day lookback period- injectable medication received: insulin-1 day, Antipsychotic-5days, Antidepressant-7days, Antibiotic-7days, Opioid-3days. Review of Resident #21's Care Plan revealed she was at risk for behaviors with interventions of: Monitor and document target behaviors. The Resident was also at risk for depression with interventions that include in part: assess effectiveness of anti-depressant medication therapy, and monitor patterns of target behaviors and document. Review of a document titled Pharmaceutical Consultant Report dated 09/13/2022 revealed the pharmacist reviewed Resident # 21's drug regimen; he found items that must be addressed. The report read in part, Please evaluate the routine use of the following psychoactive medications and consider a dose reduction. If a dose reduction is not desired, please indicate below a rational for the continued use. This resident is prescribed the following psychoactive medications with corresponding start dates: Cymbalta 90 mg daily (03/2022), Trazadone 50 mg every night (03/2022), Risperdal 0.5 mg every night (06/2022), and Wellbutrin 150 mg every day (06/2022). Please evaluate the concurrent use of two or more antidepressants. The physician then responded by selecting yes for dose reduction, and wrote a new order to discontinue Wellbutrin. This report was signed by S1 DON on 09/15/2022. Review of a document titled Pharmaceutical Consultant Report, Director of Nursing Intervention Request dated 12/02/2022 revealed the pharmacist reviewed Resident # 21's drug regimen; he found items that must be addressed. The report read in part, Please review the following orders: Wellbutrin 150 mg every day. The above psychotropic medication does not have a target behavior identified for the use of the psychotropic medication and list on the physician orders. This report was signed by S1 DON on 12/10/2022 with a written note that read Worsening depression Review of Resident #21's Medication Administration Record (MAR) from September 2022- January 2023 revealed Resident continued to receive Wellbutrin 150 mg (milligrams) once daily after physician ordered this medication to be discontinued on 09/15/2022, and monitoring for target behaviors for the administration of Wellbutrin 150mg (milligrams) had not been completed. Interview on 01/18/2023 at 10:38 a.m. with S1 DON revealed the Physician Order for Wellbutrin 150 mg 1 tablet by mouth daily should have included a monitor for targeted behaviors in place and it did not. Interview further revealed that the physician order to discontinue Wellbutrin 150 mg on 09/15/2022 should have been followed and it had not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #57 Review of Resident #57's medical record revealed an admit date of 08/15/2022 with admitting diagnosis of Type 1 DM without complications. Other diagnosis include in part: Unspecified protein-calorie malnutrition, Major Depressive disorder, Insomnia, Hypertension, Unspecified abnormalities of gait and mobility, muscle weakness, anemia, polyneuropathy, anxiety disorder, dysphagia, COPD, paranoid schizophrenia, bipolar disorder, and restless leg syndrome. Review of the Quarterly MDS with ARD of 12/02/2022 revealed a BIMS score of 12. Further review revealed Resident #57 requires supervision, set up help only for bed mobility, transfer, dressing, eating, toileting, and personal hygiene. Review of Resident #57's Care Plan with a start date of 08/15/2022 revealed no documentation to address Resident leaving facility out on pass and not receiving his medications as ordered while out on pass. Review of Resident #57's January 2023 MAR revealed Resident did not receive at least 1 or more doses of medication as ordered due to being out on pass for the following dates: 01/02/2023, 01/03/2023, 01/04/2023, 01/05/2023, 01/07/2023, 01/08/2023, 01/09/2023, 01/10/2023, 01/16/2023, and 01/17/2023. Observations of Resident #57 on 01/16/2023 at 03:54 p.m. revealed Resident out of room, and out on pass. Observation on 01/17/2023 at 08:16 a.m. revealed Resident out of room. Resident left out on pass at 12:00 p.m. on this day. Interview on 01/18/2023 at 08:47 a.m. with S13 LPN revealed when Resident # 57 was out on pass, he was given his medication, and he administers the medication himself. She stated there is a form the facility used to document what medications are given to Resident when out on pass. This form is titled: Release of responsibility & medications for leave of absence or discharge and return She stated when the Resident returns staff performs a count of the medications and documents on the form what was returned. She stated the reason there are N's documented on Resident # 57's MAR was due to resident being out of the facility. Release of responsibility & medications for leave of absence or discharge and return documents for Resident # 57 were reviewed. There were only 2 of these titled documents dated 01/02/2023 and 01/08/2023 within Resident #57's medical record. S13 LPN confirmed there were no other Release of responsibility & medications for leave of absence or discharge and return forms within Resident #57's medical record and there should have been. Interview on 01/18/2023 at 11:50 a.m. with S1 DON revealed facility is aware Resident #57 signs out on pass frequently, but the facility had not identified any concerns regarding this. She confirmed Resident #57 was not care planned for going out on pass and should have been. Resident #44 Review of Resident #44's Medical Record revealed an admit date of 09/04/2021 with diagnoses which included: Unspecified Dementia, UTI, Dysphagia, Muscle Wasting and Atrophy upper arm, Left upper arm, Right Hand, and Left Hand. Difficulty in walking and Other Lack of Coordination. Review of the Quarterly MDS with ARD of 12/23/2022 revealed a BIMS score of 5 (indicating severe cognitive impairment). Further review revealed Resident #44 required extensive assistance of 1 person for bed mobility, dressing, toilet use and personal hygiene; limited assistance of 2 persons for transfers and 1 person assistance with eating. Review of Resident #44's Care Plan with a start date of 09/09/2021 revealed she was at risk for falls related to unsteady balance and required extensive assistance of transfers. There was no documentation of a pommel cushion for Resident #44. Observation and Interview on 01/17/2023 at 8:21 a.m. revealed Resident #44 in a high back wheelchair sitting on a pommel cushion. Resident nonverbal at this time. Interview on 01/17/2023 at 9:11 a.m. with S7 LPN revealed she did not know why Resident #44 had a pommel cushion in her wheelchair. Interview on 01/17/2023 at 9:21 a.m. with S8 CNA revealed Resident #44 had a Pommel cushion in her wheelchair because she slides out of it. S8 CNA stated she does not know how long Resident #44 has had the pommel cushion. Interview on 01/17/2023 at 9:25 a.m. with S9 CNA revealed documentation for the pommel cushion was in their smart charting via Kiosk. Observation with S9 CNA at this time of Resident #44's smart charting did not reveal documentation of a pommel cushion. Interview on 01/17/2023 at 9:35 a.m. with S10 PTA physical therapist assistant revealed therapy did not recommend the pommel cushion for Resident #44. S10 PTA stated it was a nursing measure due to Resident sliding out of her wheelchair. Interview on 01/17/2023 at 9:47 a.m. with S11 LPN/ MDS nurse confirmed Resident #44 did not have an order for a pommel cushion and the care plan did not reflect Resident was to have a pommel cushion in wheelchair to prevent sliding and it should. Based on observation, record review and interview, the facility failed to develop a comprehensive care plan for 2 (#44 and #57) sampled residents. The facility also failed to implement a comprehensive person centered care plan to meet a Resident's medical needs for 1 (#24) of 23 sampled residents reviewed for care plans. The facility failed to: 1. Ensure Resident #24's orders were followed to provide a nutritional supplement (magic cup) at lunch and supper, as ordered by the physician, 2. Ensure Resident #44 had a Comprehensive care plan in place to include the use of a pommel cushion, and 3. Ensure Residents #57 had a Comprehensive Care Plan to address the resident leaving the facility and not receiving his medications as ordered. Findings: Resident #24 Review of Resident #24's medical record revealed she was admitted to the facility on [DATE]. Resident #24's diagnoses included: Subarachnoid bleed, Hypertension, Malnutrition, GERD, Dementia, Anxiety and Depression. Review of Resident #24's Quarterly MDS with an ARD of 10/21/2022 revealed the resident was assessed to need supervision of 1 person with eating. Further review of the MDS revealed the resident was assessed as having a BIMS of 3 which indicated the resident had severe cognitive impairment. Review of Resident #24's weight logs revealed the following weights, which indicated the resident had a 7.59 % weight loss from 12/02/2022 to 01/05/2023: 08/04/2022 - 158.5 lbs. 09/07/2022 - 153 lbs. 10/06/2022 - 151.5 lbs. 11/04/2022 - 151.5 lbs. 12/02/2022 - 145 lbs. 01/05/2023 - 134 lbs. 01/13/2023 - 132 lbs. Review of January 2023 Physician's orders revealed an order dated 01/06/2023 for Magic cup with lunch and supper. Interview with S5 CNA on 01/17/23 at 08:21 a.m. revealed the resident had eaten 75% of her breakfast. S5 CNA revealed she works with the resident on the 7:00 a.m. to 3:00 p.m. shift and assists the resident with her breakfast and lunch meals. S5 CNA confirmed the resident had not received any supplements with lunch meals. Observation on 01/17/23 at 11:15 a.m. of the resident eating her lunch tray revealed no magic cup was placed on her tray. Interview with S6 CNA at 11:20 a.m. revealed Resident #24 did not receive a magic cup supplement with her meal tray. S6 CNA revealed all supplements come from dietary and should have been on the cart. Interview with S2 DM on 01/17/23 at 01:35 p.m. revealed she had a list of residents that received a magic cup posted in view for staff to look at when filling residents' meal trays. S2 DM observed the list posted and confirmed Resident #24 was not on the list. S2 DM then checked the meal card and confirmed that the magic cup was on the meal card but Resident #24 had not been added to the list. S2 DM revealed she should have updated the list on 01/06/2023 when the magic cup was added to the orders. S2 DM confirmed the magic cup was listed on the meal ticket, but the dietary staff were going by list that was posted. S2 DM revealed she did not how long Resident #24 had not received the magic cup supplement as ordered on 01/06/2023. Interview with S1 DON on 01/17/23 at 01:53 p.m. revealed Resident #24 had a 7.59 % weight loss from 12/2/2022 to 01/05/2023. S2 DON confirmed that she had ordered the magic cup on 01/06/2022 due to the weight loss. S2 DON also revealed she was not aware that dietary had not been providing the magic cup as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that a Resident's comprehensive care plan was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the Resident's needs for 1 (#57) of 23 sampled Residents. Findings: Review of Resident #57's medical record revealed an admit date of 08/15/2022 with an admitting diagnosis of Type 1 DM without complications. Other diagnoses include in part: Unspecified Protein-Calorie Malnutrition, Major Depressive Disorder, Insomnia, Hypertension, Unspecified Abnormalities of Gait and Mobility, Muscle Weakness, Anemia, Polyneuropathy, Anxiety Disorder, Dysphagia, COPD, Paranoid Schizophrenia, Bipolar Disorder, and Restless Leg Syndrome. Review of the Quarterly MDS with ARD of 12/02/2022 revealed a BIMS score of 12 indicating the resident was cognitively intact. Further review revealed Resident #57 required supervision only for bed mobility, transferring, dressing, eating, toileting, and personal hygiene. Review of Resident #57's Care Plan with a start date of 08/15/2022 revealed no documentation to address Resident leaving facility out on pass and not receiving his medications as ordered while out on pass. Review of Resident # 57's January 2023 Physician Orders revealed the following: May go out on pass with medications. Review of Resident #57's January 2023 MAR revealed Resident did not receive at least 1 or more doses of medication as ordered due to being out on pass for the following dates: 01/02/2023, 01/03/2023, 01/04/2023, 01/05/2023, 01/07/2023, 01/08/2023, 01/09/2023, 01/10/2023, 01/16/2023, and 01/17/2023. Review of Resident #57's nurses' notes revealed the resident had been admitted to the hospital on [DATE] due to uncontrolled diabetes. Interview on 01/18/2023 at 11:50 a.m. with S1 DON revealed facility was aware Resident #57 signed out on pass frequently, but the facility had not identified any concerns regarding this. She confirmed Resident #57 was not care planned for going out on pass and should have been. S1 DON acknowledged Resident #57 had been admitted to the hospital in January 2023 for uncontrolled diabetes. S1 DON further confirmed the facility had not had an interdisciplinary team meeting to discuss Resident #57's needs for going out on pass and receiving medications as ordered.

Based on observation, record review, and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to: 1) properly log temperatures daily for 4 of 4 Refrigeration units. 2) Failing to report or perform corrective action for temperatures documented as out of range on the Kitchen Refrigerator Temperature Log. 3) Ensure food stored was dated with an open date after opening 4) Ensure dry food was stored properly 5) Ensure expired food was disposed of. This deficient practice had the potential to affect the 69 Residents that received meals prepared in the kitchen. Findings: Review of the Facility's Policy & Procedure titled Temperature Control of Equipment read in part: Refrigeration units and dish machines are to be checked for proper working temperature and the amounts recorded on the appropriate log. This is to ensure safe and effective operation of the equipment. The temperature is checked daily on arrival to insure that the unit did not stop working overnight. The [NAME] will record the temperature of the refrigeration unit on the Temperature Monitoring Form. They are to put their initials in the Date Column. As per the Temperature Monitoring Form, if the temperature is not within the correct ranges the supervisor of the administrator is to be informed immediately. Observation of kitchen on 01/16/2023 at 9:05 a.m. accompanied by S2 Dietary Manager revealed: 1) Review of the kitchen's refrigeration units temperature logs did not include daily recorded temperatures for logs labeled as; Kitchen Refrigerator 2022/2023, Kitchen Freezer 2022/2023, Big Freezer (Kitchen) 2022/2023, and Store Room Freezer 2022/2023. 2) Review of the kitchen's refrigeration units temperature logs revealed temperatures out of range, with no corrective action taken for the following dates: 08/29/2022, 09/06/2022, 09/14/2022, 09/21/2022, 09/27/2022, 10/11/2022, 11/29/2022, and 12/21/2022. 3) 2 opened containers of seasoning within the food prep area without an open date labeled on the containers. 4) 1 large opened box of fettucine noodles within the dry food storage area without an open date labeled on box. 5) 185 packages of gold fish crackers within the dry food storage area with expiration date of 01/08/2023. Interview on 01/16/2023 at the time of the observations accompanied by S2 Dietary Manager, confirmed the above findings.

Based on record review and interview the facility failed to follow infection control practices to prevent the development and transmission of COVID-19, as outlined by the facility's policy. The facility failed to ensure 1 (S4 CNA) of 78 staff received, at a minimum, one dose of the COVID-19 vaccine or obtained a qualifying exemption prior to providing care or services to the residents resulting in a staff vaccination rate of less than 100%. This deficient practice had the potential to affect the 69 residents who resided in the facility. Findings: Review of facility's policy titled Employee COVID-19 Vaccinations policy revealed, in part: 4. The facility will ensure that all staff (except for staff who have pending requests for, or who have been granted exemptions to the vaccination requirements, or staff for whom COVID-19 vaccination must be temporarily delayed, as per CDC recommendations, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the facility and/or its residents. Review of the facility's COVID-19 Staff Vaccination Status for Providers revealed S4 CNA was documented as partially vaccinated. In an interview on 01/16/2023 at 3 p.m., S1 DON reported S4 CNA was hired on 12/27/2022, did not have an exemption to the COVID-19 vaccination pending or granted, and had not yet received any doses of a COVID-19 vaccine. In an interview on 01/17/2023 at 9:10 a.m., S1 DON provided S4 CNA's COVID-19 Vaccination Record Card which revealed S4 CNA received her first dose of COVID-19 vaccine on 01/16/2023. S1 DON reported S4 CNA received her first dose of a multi-dose COVID-19 vaccine on the evening of 01/16/2023. In an interview on 01/17/2023 at 10:19 a.m., S4 CNA confirmed she began working for the facility a couple of days after Christmas. S4 CNA reported she went through orientation for the first three days of employment and then began working the floor with residents. S4 CNA confirmed she received her first COVID-19 vaccine last night and had trouble finding one prior to last night. In an interview on 01/18/2023 at 1:45 p.m., S1 DON acknowledged S4 CNA was hired on 12/27/2022 and provided care and services to residents without having received at least one dose of the COVID-19 vaccine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect a Resident's right to be free from verbal abuse by a CNA for 1 (#1) of 5 (#1, #2, #3, #4 and #5) sampled residents reviewed for abuse Findings Review of the Facility's Policy titled Abuse Prevention and Investigation read in part: Policy Interpretation and Implementation; 1. Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. 18. If an alleged violation or crime is verified, the facility will implement a corrective action plan and will evaluate its effectiveness. The QAA committee will monitor the reporting and investigation of all allegations and ensure that corrective action is implemented as necessary. Review of Resident #1's medical record revealed he was admitted to the facility on [DATE] with Admitting Diagnoses of Type 1 Diabetes, Bipolar, Schizophrenia, Major Depressive Disorder, COPD, and Polyneuropathy. Review of the admission MDS (Minimum Data Set) with an ARD (Assessment Resident Date) of 08/24/2022 revealed Resident #1 had a BIMS (Brief Interview for Mental Status) of 15 (cognitively intact), with adequate hearing and vision, and exhibited no physical and verbal behavioral symptoms. Observation on 11/02/2022 at 1:10 p.m. revealed Resident #1 lying in bed fully dressed, and watching television. Interview with Resident #1 at the time of the above observation revealed he was admitted to the Facility in 08/2022. Resident #1 stated he has a problem with swallowing his saliva. Resident #1 stated after eating breakfast one morning, he was not able to hold his saliva so he went into the bathroom in the Staff's Lounge near the dining room. Resident #1 stated on his way out of the bathroom, S3 CNA was in the hall and stated to him Don't use our bathroom. Resident #1 replied I was told to use it by S6 CNA if I couldn't make it to my room. Resident #1 stated that S3 CNA replied Shut the hell up and go to your mother f . room and be quiet. Resident #1 stated that since his admission, S3 CNA had never been assigned to provide care to him. Review of the Facility's Investigative Report revealed the incident occurred on 09/30/2022, staff and Residents' statements, and a local law enforcement statement written by S1 Nursing Facility Administrator. This statement read in part . S3 CNA and Resident #1 verbal only argument and it was reported that S3 CNA told Resident #1 to shut up. The Investigative Report revealed on 09/30/2022, 10 Residents were interviewed and the questions were asked if S3 CNA had ever been disrespectful, yelled at, and or threatened them. The Investigative Report revealed that an in-service, monitoring, counseling, and write-up/suspension were corrective actions taken by the Facility. Interview on 11/02/2022 at 2:32 p.m. with S4 LPN revealed he was on duty and witnessed a verbal altercation that occurred between Resident #1 and S3 CNA. S4 LPN stated that Resident #1 and S3 CNA were shouting at each other, and he heard both say shut up. Telephone interview on 11/02/2022 at 2:52 p.m. with S5 LPN revealed on 09/30/2022, her medication cart was located at the entrance of the dining room, and Resident #1 walked passed her (S5 LPN) and S4 LPN, and went into the Staff Lounge. S5 LPN stated Resident #1 at no time stated that he needed assistance and/or was feeling ill. S5 LPN stated Resident #1 exited the bathroom as S3 CNA was passing. S3 CNA stated to Resident #1 you know you are not supposed to go in there, and Resident #1 responded you don't even know what was going on. S5 LPN stated Resident #1 and S3 CNA were arguing back and forth with one another exchanging words and S3 CNA stated to Resident #1 shut up. Interview on 11/03/2022 at 9:30 a.m. with S2 DON revealed that S3 CNA was still employed at the facility part-time, and had last worked on 11//01/2022. S2 DON stated that S3 CNA was the facility's women's whirlpool CNA. S2 DON stated an investigation was conducted by S1 NFA with assistance from her (S2 DON). S2 DON stated 2 Nurses, 1 CNA and 10 Residents were interviewed on 09/30/2022. S2 DON stated the 10 Residents were randomly selected because S3 CNA was the facility's whirlpool CNA. S2 DON confirmed on 09/30/2022 after learning of the incident, S3 CNA was counseled, in-serviced on Abuse and suspended for 2 days. Interview on 11/03/2022 at 10:45 a.m. with S1 NFA confirmed that S3 CNA admitted that she did in fact tell Resident #1 to shut-up, and S3 CNA telling Resident #1 to shut-up was clearly a form of verbal abuse. S1 NFA stated as a result of the allegation being substantiated, S3 CNA was suspended for 2 days (10/01/2022 & 10/02/2022), and returned to work on 10/03/2022. Interview on 11/03/2022 at 12:33 p.m., with S2 DON confirmed that on 10/03/2022, the incident was discussed in the Facility's Daily Quality Assurance meeting and the Facility has no documented Quality Assurance Action Plan as it relates to the verbal abuse that occurred on 09/30/2022. She further confirmed that it is not part of the Facility's Quality Improvement Plan, because it was just an isolated incident and no further action was needed. Interview on 11/03/2022 at 12:58 p.m. with S1 NFA confirmed that he monitored Abuse within the Facility weekly; however, he did not have adequate documentation of his method of monitoring. S1 NFA revealed he had no documentation to support what Residents he interviewed along with their responses. S1 NFA stated he interviewed Resident #4 who was the Facility's Council President weekly about anything that was happening with the Resident population and/or any abuse and/or mistreating of Resident(s). S1 NFA stated that he reported the verbal abuse to the local law enforcement agency. Review of a statement by law enforcement revealed no physical abuse occurred; however, verbal abuse did occur between S3 CNA and Resident #1. Review of facility documentation revealed that facility staff were trained on abuse and in-serviced after the incident 09/30/2022. There was no documentation to ascertain adequate monitoring was in place.