Based on interview and record review the facility failed to ensure an allegation of staff to resident sexual abuse and resident to resident physical abuse was reported to the State Survey Agency immediately, but not later than 2 hours after the staff to resident sexual abuse and resident to resident physical abuse was discovered, for 2 (Resident #1 and Resident #2) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents. Findings:Review of an undated facility policy titled “Abuse Prevention and Prohibition” revealed in part . “An alleged violation of abuse…will be reported immediately, but not later than: Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury - to the mandated state agency per reporting criteria within guidelines of notification of an alleged abuse.” Resident #1 Review of Resident #1's medical record revealed an admission date of 04/08/2025, a discharge date of 09/25/2025, with diagnoses that included in part…Intellectual Disabilities, Schizoaffective Disorder; Anxiety Disorder; Major Depressive Disorder, Single episode; Pain; Hypertensive Heart Disease with Heart Failure; and Atrial Fibrillation. Review of Resident #1's Quarterly Minimum Data Set (MDS) with an ARD of 07/15/2025 revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate impaired cognition. Resident #1 was independent with eating and required supervision with toileting and personal hygiene. Interview on 09/26/2025 at 11:50 a.m. with S2 DON revealed that she was notified on 09/22/2025 at approximately 10:00 a.m. that there had been an allegation that Resident #1 was sexually abused at a movie theatre outing by an unnamed facility staff member. S2 DON stated she immediately notified S1 ADM of the allegations of staff-to-resident sexual abuse. In an interview on 09/30/2025 at 11:50 a.m., S1 ADM revealed he did not think the allegation of staff-to-resident sexual abuse involving Resident #1 on 09/22/2025 needed to be reported or opened in the Statewide Incident Management System (SIMS). S1 ADM revealed that this allegation of sexual abuse was not reported. Resident #2 Review of Resident #2's medical record revealed an admission date of 03/05/2025, with diagnoses that included in part…Cerebral Infarction due to Embolism of Right Cerebellar Artery; Displaced Fracture of Upper End of Left Humerus; Diabetes; Hemiplegia and Hemiparesis following a Cerebral Infarction affecting Left Dominant Side; and Schizoaffective Disorder. Review of Resident #2's Quarterly Minimum Data Set (MDS) with an ARD of 07/01/2025 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. Resident #2 was dependent or required substantial/ maximum assistance with activities of daily living (ADLS). On 09/30/2025 at 11:05 a.m., an interview with S2 DON revealed she was made aware of the alleged resident to resident abuse involving Resident #2 that occurred on 09/21/2025. S2 DON stated she was responsible for SIMS reporting but required administrative approval before entering an incident, which she did not receive from S1 Administrator. S2 DON confirmed that the alleged abuse was not reported into the SIMS, but should have been. On 09/30/2025 at 11:45 a.m., an interview with S1 Administrator confirmed he was aware of the alleged resident to resident abuse involving Resident #2 on 09/21/2025, but chose not to initiate a SIMS report, due to he felt it was not warranted.

Based on record review and interview, the facility failed to ensure services were provided to meet professional standards of practice by failing to ensure a residents received a prescribed antibiotic in a timely manner for 1 (#2) of 3 (#1, #2, and #3) sampled residents. Findings:Review of Resident #2's medical record revealed an admit date of 03/10/2025 with diagnoses that included: Other Chronic Osteomyelitis, Left ankle and foot, Cerebral Infarction, Unspecified Hemiplegia and Hemiparesis, Persona; History of Urinary Tract Infection, Unspecified Mood Affective Disorder, Epilepsy, Paranoid Schizophrenia, and Major Depressive Disorder. Review of Resident #2's medical record revealed a progress notes dated 06/23/2025 by the facility Nurse Practitioner read in part. New order noted for urinalysis with culture and sensitivity for dysuria and altered mental status. Review of Resident #2's medical records revealed an unloaded urinalysis dated 06/26/2025 with a hand written note at the bottom that read Cefdinir 300 mg BID. Review of Resident #2's 06/2025 Physician Orders read in part.Order input on 06/27/2025 with a start date of 06/28/2025 at 8:00 a.m. Cefdinir Oral Capsule Give 300 mg by mouth two times a day for UTI for 7 Days. Discontinue date of 06/28/2025. Order input on 06/28/2025 with a start date of 06/28/2025 at 4:00 p.m. Macrobid Oral Capsule 100 MG Give 100 mg by mouth two times a day related to Personal history of UTI for 7 Days. Completed on 07/05/2025. Review of Resident #2's progress noted date 06/28/2025 at 11:22 a.m. read in part. Resident states she is allergic to Cefdinir, it makes me itch. MD notified. No new orders at this time. Review of Resident #2's progress noted date 06/28/2025 at 11:34 a.m. 6/28/2025 11:34 a.m. read in part.New order for Macrobid 100mg by mouth , twice daily for 7 days. Discontinue Cefidinir. This surveyor was unable to reach the nurse that put in the order on for Cefdinir 300mg by mouth twice a day for 7 days on 06/27/2025 during the survey via telephone. An interview on 08/18/2025 at 2:50 p.m., with S1 ADON stated that once a preliminary lab result comes back, the Nurse practitioner is notified for further guidance. S1 ADON stated the lab sends the results to the facility through there Electronic Medical Record (EMR) system immediately after they are resulted. S1 ADON stated the Urinalysis with culture and sensitivity that was collected on 06/26/2025 sent the preliminary report to their EMR on 06/26/2025 at 2:25 p.m. S1 ADON stated an order was put in by staff on 06/27/2025 with a start date of 06/28/2025 at 8:00 a.m. for Cefdinir 300mg, twice daily for 7 days. S1 ADON confirmed Resident #2 should have received the antibiotic medication on 06/26/2025 from the facility emergency kit on the day it was ordered, but had not.

Based on observations, interviews, and record review, the facility failed to ensure a resident received enteral feedings as ordered by the physician for 1 (#3) of 3 (#1, #2, and #3) sampled residents. Findings:Review of the Facility's undated policy titled Enteral Feeding Therapy (Tube Feeding) Policy and Procedure read in part.Purpose: to provide liquid nourishment through a tube, inserted into the stomach. Policy: All enteral tube feedings shall have care according to physician orders. Review of Resident #3's medical record revealed and admit date of 09/28/2021 with a readmission date of 07/10/2024 with diagnoses that included: Cerebral Palsy, Aphasia, Mild Protein Calorie Malnutrition, Gastrostomy Status, Dysphagia, Type 2 Diabetes Mellitus, and Bipolar Disorder. Review of Resident #3's admission MDS with an ARD of 07/22/2025 revealed a BIMS of 2, which indicated severely impaired cognition. Review of Resident #3's Care Plan with a review date of 11/02/2025 read in part. I require a PEG tube for adequate nutritional intake related to my dysphagia. Administer my tube feeding as ordered by my physician. Review of Resident #3's current Physician Orders revealed the following, in part: 07/10/2024 -Glucerna 1.5 at 60ml/hr via pump from 7:00 p.m. to 7:00 a.m. 02/28/2025- H20 Flush at 250ml/Q4h via pump from 7:00 p.m. to 7:00 a.m. 09/13/2024-Glucena 1.5 give carton bolus daily at 12:00 p.m. and at 4:00 p.m.; then flush with 100ml of water.07/10/2024- Flush with 100ml of water after bolus feeding. 04/28/2025- PRN-Glucerna 1.5 carton bolus every 24 hours if asks for extra feeding. Observation and interview on 08/18/2025 at 9:38 a.m., accompanied with S2 LPN revealed a bag of peg tube feeding Glucerna dated 08/18/2025 and timed 12:00 a.m. with 1000ml of feeding in the bag and 1000ml of H2O hanging on a feeding pole in Resident #3's bedroom. The peg tube feeding was not connected to Resident #3 and the feeding pump was turned off. S2 LPN stated that she came on shift at 6:00 a.m. today and had not been in Resident #3's room. S2 LPN stated that during her shift Resident #3 gets 2 bolus feedings and receives continuous tube feedings overnight. An interview on 08/18/2025 at 9:53 a.m. with S3 LPN stated she worked on Resident #3's hall last night. S3 LPN stated she went into Resident #3's room between 7:15 p.m. -7:30 p.m. last night but cannot recall if a peg feeding was hanging at the time. S3 LPN stated she gave Resident #3 a bolus feeding at 3:00 a.m. and stated she hung the Glucerna and H2O with tubing on the pole at around 3:00 a.m. S3 LPN confirmed she read the physician orders but may have missed the order for continuous feeding to be administered overnight for Resident #3. S3 LPN denied Resident #3 had refused any feedings. An interview on 08/18/2025 at 3:10 p.m. with S4 DON revealed that Resident #3 should have received the ordered continuous feeding of Glucerna the night of 08/17/2025, but had not.

Based on a record review and interview, the facility failed to provide care and services that met professional standards of quality by failing to ensure that a resident's medical record reflected whether Physician's Orders were implemented or refused. The facility failed to document whether wound care was or was not provided for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) residents reviewed for skin and pressure ulcers. Review of facility undated policy titled, Skin/Wound Documentation Policy and Procedure, revealed in part. Skin and wounds will be documented upon admission, readmission, weekly, and as needed. The facility shall follow the practitioner's orders for treatment of the pressure ulcer (injury). With each dressing change, or at least weekly, the pressure ulcer (injury) wound shall be assessed and documented. Pressure ulcer (injury) documentation should include, in part.date and time of initial and subsequent treatments. Review of Resident #3's medical record revealed an admit date of 03/10/2025 with the following diagnoses in part. Chronic Osteomyelitis Left Ankle and Foot, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Dysarthria following Cerebral Infarction, Epilepsy, Peripheral Vascular Disease, Presence of Vascular Implants and Grafts, Cellulitis of Left Lower Limb, and history of Venous Thrombus and Embolism. Record Review of Resident #3's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/10/2025 revealed Resident #3 had a BIMS score of 15, which indicated intact cognition. Resident #3 had documented 1 unhealed, unstageable pressure ulcer. Record review of Resident #3's Active Physician Orders read in part. Order Date 07/10/2025- Treatment #1: Stage 4 Left Lateral Foot: Cleanse with wound cleanser, pat dry, apply collagen with silver to wound bed, cover with calcium alginate, cover with dry dressing daily until healed. Record review of Resident #3's care plan with initiation date of 03/13/2025, revealed Resident #3 had an unstageable pressure ulcer to her left lateral foot with interventions that included in part. Provide treatment as ordered by physician. On 07/21/2025 at 2:32 p.m., review of Resident #3's Treatment Administration Record (TAR) revealed no documentation of treatment provided and/or refused for Stage 4 Left Lateral Foot on 07/16/2025 and 07/17/2025. During an interview on 07/22/2025 at 12:57 p.m., with S3LPN and S8RN, Resident #3's 07/2025 TAR was reviewed. S3LPN confirmed Resident #3 did not have any wound care documentation for 07/16/2025 and 07/17/2025, and should have. S3LPN and S8RN confirmed that if Resident #3 had refused care on those dates, refusal should have been documented on Resident #3's TAR and was not.

Based on observation, interview, and record review, the facility failed to ensure residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain personal hygiene for 1 (Resident #3) of 3(Resident #1, Resident #2, Resident #3) residents reviewed for Activities of Daily Living (ADL) care. The facility failed to ensure a Bath/Shower was provided for Resident #3.A review of facility undated policy titled, Quality of Care Policy and Procedure, read in part. It is the policy of our company that each resident receives the necessary care to attain or maintain the highest practicable physical, mental and psychological well-being, in accordance with the resident's comprehensive assessment and plan of care.Review of Resident #3's medical record revealed an admit date of 03/10/2025 with the following diagnoses in part. Chronic Osteomyelitis Left Ankle and Foot, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Dysarthria following Cerebral Infarction, Epilepsy, Peripheral Vascular Disease, Presence of Vascular Implants and Grafts, Cellulitis of Left Lower Limb, Dependence of Wheelchair, Generalized Anxiety Disorder, and history of Venous Thrombus and Embolism.Review of Resident #3's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/10/2025 revealed Resident #3 had a BIMS score of 15, which indicated intact cognition. Resident #3 had 1 documented unhealed, unstageable pressure ulcer. Resident #3 required moderate assistance for shower/bathing and dependent for all transfers.Review of Resident #3's care plan with initiation date of 03/13/2025, revealed Resident #3 required assistance for all Activities of Daily Living (ADLs) with interventions that included in part. assist resident in bathing, hygiene, and grooming task.Review of Resident #3's electronic health record-facility task titled Bathing/Shower Scheduled (Three times weekly) Specify days:(Monday, Wednesday, Friday OR Tuesday, Thursday, Saturday) with a lookback period of 30 days, revealed Resident #3 had 3 documented baths in the past 30 days.During an interview on 07/22/2025 at 8:45 a.m. Resident #3 revealed she had not received a bath in two weeks and would like a bath daily.During an interview on 07/22/2025 at 9:10 a.m., with S5CNA revealed the facility's bath schedules are determined by gender. S5CNA revealed women were bathed every Tuesday, Thursday, Saturday and men were bathed every Monday, Wednesday, and Friday. S5CNA revealed residents' baths/showers were documented in the resident's electronic chart and/or facility whirlpool binder. Review of whirlpool binder with S5CNA for month of 07/2025, revealed Resident #3 had a bath refusal on 07/12/2025. S5CNA reviewed Resident #3's electronic medical record which revealed Resident #3's last documented bath was on 07/09/2025.During interview on 07/22/2025 at 1:12 p.m. review of Refusal binder with S2DON, revealed Resident #3 refused a bath on 07/12/2025 and 07/15/2025. S2DON acknowledged Resident #3 did not receive a bath within the past 2 weeks, and the Resident's medical record did not contain documented baths and/or all refusals as required.During interview on 07/22/2025 at 1:30 p.m. with S4Corporate revealed he developed the Refusal binder to track and trend cause of refusals and reviewed the binder weekly. S4Corporate verbalized Resident #3 was overlooked by him during this process, and he had not addressed Resident #3's bath refusals.During interview on 07/23/2025 at 9:40 a.m. S6CNA revealed Resident #3 did not refuse care.During interview on 07/23/2025 at 9:43 a.m. S7CNA revealed Resident #3 did not refuse care.

Based on observation and interview the facility failed to maintain housekeeping and maintenance services necessary to maintain a sanitary and orderly interior. This deficient practice had the potential to affect the 124 resident's that resided at the facility. Findings:Observation on 07/21/2025 at 11:45 a.m. of Resident #2's room (Room B) revealed the floor had hair and a dark brown substance near the bed area. The wall near Resident #2's bed had a moderate amount of a splattered substance that was tan and pink in color. The window blinds in the room had broken pieces and was in disrepair.Observation on 07/21/2025 at 11:49 a.m. of Room A area revealed a large puddle of yellow liquid on the floor. The area smelled of urine. Interview with S4Corporate at time of observation confirmed the floor was unsanitary and was in need of cleaning.Observation on 07/21/2025 at 11:56 a.m. of Hall A, near Room C revealed a ceiling tile with a moderate sized amount of mold. Interview with S10HK at time of observation revealed the ceiling had been leaking, for at least a few weeks, and she had reported it to S9Maintenance. Interview with S9Maintenance at time of observation confirmed the ceiling tile was in need of replacement.Observation on 07/22/2025 at 9:04 a.m. of Room B revealed the wall near Resident #2's bed had a moderate amount of a splattered substance that was tan and pink in color. The window blinds in the room had broken pieces and was in disrepair.Observation on 07/23/2025 at 1:47 p.m. of Room B revealed the splattered substance on the wall next to Resident #2's bed remained and his blinds had broken pieces. Interview with Resident #2 revealed the splattered substance and broken blinds had been in this manner for quite some time. Resident #2 voiced he would like his wall cleaned and blinds replaced. Interview on 07/23/2025 at 1:49 p.m. with S1ADMIN confirmed Resident #2's wall was in need of cleaning, and the window blinds were in disrepair and needed replacement.

Based on observation, interview, and record review, the facility failed to ensure a resident received reasonable accommodation of needs for 2 (#3 and #4) of 4 (#1, #2, #3, and #4) sampled residents. The facility failed to ensure Resident #3 and Resident #4 had an appropriate call light and that it was within reach to call for assistance. Findings: Review of the Facility's undated policy titled Call light, Use of Policy and Procedure read in part . Policy: To respond promptly to residents call for assistance. Procedure: 13. Have the resident demonstrate the use of the call light to be sure he/she understands your instructions. 15. Be sure the call lights are placed on the bed at all times, never on the floor or bedside stand. Resident #3 Review of Resident #3 's medical record revealed an admit date of 03/28/2025 with diagnoses that included in part: Spondylolisthesis, Neuromuscular Dysfunction of Bladder, Pseudoarthrosis after Fusion, Major Depressive Disorder, Hemiplegia, and Personal History of Urinary Tract Infection. Review of Resident #3's Minimum Data Set (MDS) with an ARD of 04/08/2025 revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Resident #3 was totally dependent upon staff and required physical assistance for all activities of daily living. Observation and interview on 06/23/2025 at 11:44 a.m. revealed Resident #3 lying in bed with the call bell out of reach, on the bedside table away from the bed. Resident #3 stated she was paralyzed after a neck surgery and was unable to reach the call bell. Resident #3 stated she had very little use of her fingers and was unable to lift her arms. Resident #3 stated that if the call bell is not placed near her fingers she is unable to call for help. Resident #3 stated she has to yell for help or ask for her roommate to notify staff if her call bell is not within reach. Telephone interview on 06/23/2025 at 1:41 p.m. with Resident #3's Responsible Party revealed that during visits the call bell was not consistently within reach and was typically on the other side of the room. Interview on 06/24/2025 at 8:15 a.m. with Resident #3 stated that the call bell was not within reach for most of the night and she had to yell for help. Observation on 06/24/2025 at 08:40 a.m. with S1 DON revealed that after many attempts of moving the call bell to different places on the bed, Resident #3 was physically incapable of using the call bell. Interview on 06/24/2025 at 8:50 a.m. with S1 DON confirmed that Resident #3 was physically incapable of using the call bell. Resident #4 Review of Resident #4 's medical record revealed an admit date of 04/28/2020 and a re-entry date of 06/05/2025 with diagnoses that included in part: Paroxysmal Atrial Fibrillation; Acute and Chronic Respiratory Failure with Hypoxia; Hypertensive Heart Disease with Heart Failure; Mild Protein-Calorie Malnutrition; Schizoaffective Disorder; Bipolar Type; Major Depressive Disorder; Generalized Anxiety Disorder; and Peripheral Vascular Disease. Review of Resident #4's Minimum Data Set (MDS) with an ARD of 06/08/2025 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Resident #4 was dependent or required substantial/ maximum assistance with activities of daily living. Observation and interview on 06/23/2025 at 11:50 a.m. revealed Resident #4 lying in bed with call bell attached to the light over Resident #4's bed, out of reach. Resident #4 stated he hollers for assistance due to call light not being accessible. Observation on 06/23/2025 at 12:55 p.m. Resident #4 observed sitting up in bed, receiving feeding assistance from staff. Call bell remains inaccessible, clipped to the light over Resident #4's bed. Interview on 06/24/2025 at 8:12 a.m. S3 LPN confirmed Resident #4's call light was not within reach. S3 LPN also confirmed Resident #4 was unable to utilize the call bell due to physical inability. Interview on 06/24/2025 at 8:50 a.m. with S1 DON confirmed Resident #4 was unable to use call bell to call for assistance due to physical inability. S1 DON stated she would order resident an adaptive call light he would be able to utilize.

Based on observation, record review and interview, the facility failed to ensure 1 (Resident #3) of 2 ( Resident #3 and Resident #4) sampled residents received the necessary treatment and services to prevent and promote the healing of pressure ulcers by failing to perform hand hygiene during treatment of a pressure ulcer. Findings: Review of Resident #3 's medical record revealed an admit date of 03/28/2025 with diagnoses that included in part: Spondylolisthesis, Neuromuscular Dysfunction of Bladder, Major Depressive Disorder, Hemiplegia, and Personal History of Urinary Tract Infection. Review of Resident #3's Minimum Data Set (MDS) with an ARD of 04/08/2025 revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Resident #3 was totally dependent on staff and required physical assistance for all activities of daily living. Review of Resident #3's 06/2025 Physician Orders read in part . Treatment #1- Unstageable Pressure Ulcer to left buttocks. Cleanse with wound cleanser, pat dry, apply medihoney to wound bed, followed by calcium alginate with silver, and cover with a dry dressing. Treatment #2- Unstageable Pressure Ulcer to right buttocks Cleanse with wound cleanser, pat dry, apply medihoney to wound bed, followed by calcium alginate with silver, and cover with a dry dressing Treatment #3 Deep Tissue Injury to right heel. Cleanse with wound cleanser, pat dry, cover with betadine soaked gauze, andd cover with a dry dressing. Treatment #4 Deep Tissue Injury to left heel. Cleanse with wound cleanser, pat dry, cover with betadine soaked gauze, and cover with a dry dressing. Treatment #5- Unstageable Pressure Ulcer to sacrum. Cleanse with wound cleanser, pat dry, apply medihoney to wound bed, followed by calcium alginate with silver, and cover with a dry dressing. Observation of Resident #3's wound care on 06/24/25 at 10:15 a.m. with S2 Treatment Nurse revealed hand hygiene with alcohol based hand rub or washing of hands was not performed when gloves were changed, or between performance of wound care for each of Resident #3's (5) pressure ulcers. Interview on 06/24/2025 at 10:38 a.m. with S2 Treatment Nurse confirmed she did not perform hand hygiene during wound care of Resident #3's 5 pressure ulcers. S2 Treatment Nurse stated that it was her understanding that you should only sanitize hands between residents, or if hands were visibly soiled. Interview on 06/25/2025 at 1:29 p.m. with S1 DON confirmed S2 Treatment Nurse should have performed hand hygiene when changing gloves, and between wound care of each wound, 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 each resident was free of medication errors for 1 (#4) of 4 residents reviewed. The facility failed to ensure medications were administered to Resident #4 as ordered by the physician. Findings: Review of Resident #4 's medical record revealed an admit date of 04/28/2020 and a re-entry date of 06/05/2025 with diagnoses that included in part: Paroxysmal Atrial Fibrillation; Acute and Chronic Respiratory Failure with Hypoxia; Hypertensive Heart Disease with Heart Failure; Mild Protein-Calorie Malnutrition; Schizoaffective Disorder; Bipolar Type; Major Depressive Disorder; Generalized Anxiety Disorder; and Peripheral Vascular Disease. Review of Resident #4's Minimum Data Set (MDS) with an ARD of 06/08/2025 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Resident #4 was dependent or required substantial/ maximum assistance with activities of daily living. Review of Resident #4's hospital discharge paperwork dated for 06/05/2025 revealed in part .This is the list of medications for you to take upon discharge. Be sure to follow this list and do not take any meds not on this list. Updated medication list included: 1. Amiodarone HCL 400mg oral every morning 2. Bisacodyl 5mg oral every morning 3. Divalproex DR 500mg oral every morning 4. Divalproex DR 1000mg oral at bedtime 5. Ipratropium/Albuterol Sulfate 3ml nebulization three times a day 6. Invega ER 6mg oral at bedtime 7. [NAME] 1% topical one application every morning Review of Resident #4's Physician Orders and Medication Administration Record (MAR) for June 2025 revealed in part . Medication Amiodarone HCL 400mg was not initiated on return from hospitalization. On 06/25/2025 at 11:49 a.m. Interview with S4 Nurse Practitioner confirmed Resident #4 is not currently taking medication Amiodarone as listed on hospital discharge paperwork and should be. S4 Nurse Practitioner confirmed medication was overlooked when Resident #4 returned from the hospital. S4 Nurse Practitioner stated Resident #4 has not had any adverse reactions related to the medication error. On 06/25/2025 at 12:10 p.m. Interview with S1 DON confirmed Resident #4 is not currently taking mediation Amiodarone as listed on the hospital discharge paperwork and should be.

Based on observation, record review, and interview the facility failed to provide care and services that meet professional standards of quality, by failing to: 1. Perform weights as ordered for 3 (#3, #4, and #R1) of 6 (#1, #2, #3, #4, #R1, and #R2) residents reviewed for weights; and 2. Input orders for wound care for 1 (#4) of 3 (#2, #3, and #4) residents reviewed for wound care. Findings: 1. Resident #3 Review of the Facility's undated policy titled Weight Evaluation Policy and Procedure read in part .Purpose: To review, monitor, and maintain the resident weight. Procedure: 1. Weights are to be completed and documented in PCC chart for resident. 3. The following residents will be weighed weekly for 4 weeks until stable unless otherwise prescribed by the physician. D. 5% loss or gain in less than 31 days. Review of Resident #3 's medical record revealed an admit date of 03/28/2025 with diagnoses that included in part: Spondylolisthesis, Neuromuscular Dysfunction of Bladder, Pseudoarthrosis after Fusion, Major Depressive Disorder, Hemiplegia, and Personal History of Urinary Tract Infection. Review of Resident #3's weights revealed the following: 05/12/2025-109.2 lbs 04/28/2025-111.3 lbs 04/14/2025- 109.3 lbs 04/07/2025-114.9 lbs 04/01/2025-119.0 lbs 03/31/2025-119.6 lbs Review of Resident #3's Registered Dietician note dated 05/16/2025 read in part . Significant weight loss noted: -5.0% change over 30 days. Recommend: Continue weekly weights. Interview on 06/24/2025 at12:49 p.m. with S1 DON revealed Resident #3's weight, as of 06/24/2025 was 113 lbs. S1 DON stated Resident #3 was weighed on 05/12/2025 and was not weighed again until 06/24/2025. S1 DON confirmed Resident #3 should have been weighed weekly due to 5% weight loss over 30 days, but had not been. Resident #R1 Review of Resident #R1's medical record revealed an admit date of 02/06/2024 with diagnoses that included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non dominant side, Post Traumatic Seizures, Schizoaffective Disorder, Major Depressive Disorder, Dysphagia following Cerebral Infarction, and Unspecified Protein Calorie Malnutrition. Review of Resident #R1's care plan with a target date of 07/19/2025 read in part . I have lost weight recently. 05/17/2024 I revoke hospice. I will start weekly weights. Interventions: weigh me as appropriate. Review of Resident #3's weights revealed the following: 06/24/2025 145.8 lbs 05/05/2025 158.2 lbs 03/25/2025 152.6 lbs 01/28/2025 159.4 lbs 11/5/2024 161.8 lbs Interview on 06/25/2025 at 3:00 p.m. with S1 DON revealed Resident #R1 was not weighed during the month of 04/2025 and was not weighed weekly as care-planned, but should had been. Resident # 4 Review of Resident #4 's medical record revealed an original admit date of 04/28/2020 and a re-entry date of 06/05/2025 with diagnoses that included in part: Paroxysmal Atrial Fibrillation; Acute and Chronic Respiratory Failure with Hypoxia; Hypertensive Heart Disease with Heart Failure; Mild Protein-Calorie Malnutrition; Schizoaffective Disorder; Bipolar Type; Major Depressive Disorder; Generalized Anxiety Disorder; and Peripheral Vascular Disease. Review of Resident #4's medical records revealed the following weights: 06/24/2025- 124.0 lbs 05/06/2025- 128.6 lbs 04/29/2025- 129.8 lbs 04/01/2025- 130.6 lbs 02/24/2025- 144.0 lbs 01/07/2025- 155.2 lbs Review of Resident #4's Registered Dietician notes dated 03/03/2025 read in part . Significant weight loss noted: -11.2 lbs weight loss noted x 30 days (-7.2 %). Recommend: Monitor weight weekly due to significant weight loss noted. Review of Resident #4's Registered Dietician notes dated 04/22/2025 read in part . Significant weight loss noted: -14.3 % x 6 months. Recommend: Monitor weight weekly due to significant weight loss noted. Interview on 06/24/2025 at12:49 p.m. with S1 DON revealed that Resident #4 has a weight today of 124 lbs. S1 DON stated that Resident #4 has not had weights obtained since 5/06/2025 prior to today. S1 DON confirmed that Resident #4 should have been weighed weekly due to significant weight loss, but had not been. Observation on 06/23/2025 at 11:50 a.m. revealed bandages to Resident #4's right and left forearm. Review of Physician Orders revealed no active treatment for wounds to bilateral arms. Interview on 06/23/2025 at 01:00 p.m. with S2 Treatment Nurse revealed Resident #4 had a skin tear to his left forearm that occurred on 06/05/2025. S2 Treatment nurse was unsure when skin tear to right forearm occurred. S2 Treatment Nurse confirmed Resident #4 should have a Physician Order for all active wounds and did not. Interview on 06/23/2025 at 01:10 p.m. with S1 DON confirmed Resident #4 should have a Physician Order for all active wounds and did not.

Based on interviews, and record reviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards and practices. The facility failed to ensure: 1. A wound care order was documented for Resident #3 when received by facility; 2. Documentation on the Treatment Administration Report (TAR) was accurate for Resident #3; and 3. Wound care was documented for Resident #3. Findings: Interview with S5 ADON on 02/26/2025 at 11:25 a.m. revealed Resident #3 had a fall with a wound to his right elbow on 02/21/2025. S5 ADON confirmed there should have been an order for wound care for Resident #3, but there was not. Interview with S2 DON on 02/26/2025 at 2:07 p.m., revealed she was not at the facility on 02/21/2025, and was notified by S10 RN via telephone that Resident #3 had fallen and had a wound to his right elbow. S10 RN notified the provider on 02/21/2025 at 11:38 p.m., and was given an order for wound care. S2 DON stated on 02/25/2025 she realized the order for wound care had not been documented or entered. S2 DON stated she performed wound care for Resident #3 on 02/25/2025; however, she did not document it. S2 stated she entered the order for wound care on 02/26/2025, with a start date of 02/23/2025. S2 DON confirmed the order for wound care was not documented or entered when the order was given on 02/21/2025, but should have been. S2 DON stated that she initialed that wound care was performed on 02/23/2025 and 02/24/2025. Review of Resident #3's 02/2025 MAR revealed wound care was initialed by S2 DON as being done on 02/23/2025 and 02/24/2025. Interview with S2 DON on 02/26/2025 at 2:07 p.m. confirmed that she initialed that wound care was performed on 02/23/2025 and 02/24/2025. During interview on 02/27/2025 at 12:35 p.m., S2 DON confirmed she documented wound care was provided on Resident #3's TAR on 02/23/2025 and 02/24/2025. S2 DON stated that did not provide wound care to Resident #3's right elbow on 02/23/2025 and 02/24/2025; however, initialed on those dates because she knew wound care had been provided, and the nurse did not initial. S2 DON confirmed this documentation in Resident #3's record on 02/23/2-25 and 02/24/2025 was not accurate. S2 DON confirmed she did provide wound care to Resident #3 on 02/25/2025, but did not document the wound care. She confirmed the wound care should have been documented.

Observation on 01/26/2025 at 3:08 p.m. revealed cracks and tears to the arm pads, exposing the material of Resident #39's wheelchair. Observation on 01/27/2025 at 10:37 a.m. of Resident #39 awake sitting up in wheelchair propelling himself down the hall. Observation of both of the arm pads of Resident #39's wheelchair cracked and torn. Interview at this time with Resident #39 revealed that the arms of his wheelchair had been like this for about 2 years now. Interview on 01/27/2025 at 10:42 a.m. with S15 CNA revealed she had worked since 09/2024 and reported that Resident #39's arms of his wheelchair have been cracked and torn since she had started working here but had not reported it. Interview with 01/27/2025 at 10:44 a.m. with S16 Maintenance revealed that he was not aware of Resident #39's wheelchair was in disrepair. S16 Maintenance confirmed that Resident #39's wheelchair was in disrepair and should have been reported to him. Based on observation, interview, and record review the facility failed to maintain a clean, safe, comfortable and homelike environment by failing to ensure the cleanliness and good repair of patient care equipment for 2 (Resident #52 and Resident #39) of 40 total sampled residents. Findings: Review of the facility's undated policy titled Reusable Medical Devices Cleaning Policy and Procedure read in part . Purpose: To keep reusable medical devices clean and prevent transmission of infection. Policy: Reusable medical devices will be cleaned after each resident use to prevent spread of infection. Procedure: 1. All surface areas of the machine will be cleaned with disinfectant wipe according to manufacture recommendations. Equipment and Supplies: 7. Any reusable medical device Resident #52 Observation on 01/26/2025 at 10:30 a.m. revealed Resident #52's wheelchair cushion was soiled with a large amount of brown substance. Observation on 01/27/2025 at 09:41 a.m. revealed Resident #52's wheelchair and black wheelchair cushion was visibly dirty. Observation on 01/28/2025 at 10:23 a.m. revealed Resident #52 sitting in his wheelchair with visible brown dried substances to the black cushion and side of Resident #52's wheelchair. Interview with S13 CNA on 01/28/2025 at 10:29 a.m. revealed that Resident #52's wheelchair was dirty with a dried brown substance and should have been cleansed before use. Interview with S12 LPN on 01/28/2025 at 10:35 a.m. revealed that Resident #52's wheelchair and cushion was dirty and needed to be cleaned, but had not been. Interview with S14 Housekeeping Supervisor on 01/28/2025 at 4:00 p.m. revealed CNAs were responsible for cleaning resident wheelchairs. Interview with S3 ADON on 01/28/2025 at 4:09 p.m. revealed that it is everyone's job to clean the resident wheelchairs, if staff observe that wheelchairs are visibly soiled that the wheelchairs are to be cleaned with disinfectant wipes. S3 ADON stated she was unsure of a scheduled day for cleaning resident wheelchairs and stated housekeeping was ultimately responsible for keeping up with resident wheelchairs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to transmit/encode a Discharge MDS (Minimum Data Set) Assessment accurately for 1 (Resident #100) of 1 sampled resident reviewed for resident assessments. The total sample size was 40 residents. Findings: Review of Resident #100's clinical record revealed an admit date of 11/18/2024 with diagnoses that included Bipolar Disorder, current episode mixed, Severe without Psychotic Features, Sepsis, unspecified organism, Type 2 Diabetes Mellitus, Major Depressive Disorder, unspecified Mood (Affective) Disorder, Anxiety Disorder and Essential (Primary) Hypertension. Review of Resident #100's Discharge summary dated [DATE] read in part . Resident #100 requested to transfer to sister facility. Resident #100 only stayed at facility one night and wanted to leave AMA. Resident #100 decided she would prefer to be transferred to another nursing home and her spouse agreed. Resident #100 was transported by staff with her medications and all of her belongings. Signed by S19 SSD. Review of the facility's MDS transmission report revealed an ARD (Assessment Reference Date) of 11/19/2024 was encoded as an unplanned (facility initiated) discharge. Interview on 01/28/2025 at 2:27 p.m. with S18 MDS revealed she had input data incorrectly for Resident #100's Discharge MDS Assessment as an unplanned facility-initiated discharge. S18 MDS reported that Resident #100's Discharge MDS should have been input as a planned resident-initiated discharge because the Resident #100 requested to leave facility and go to another specific nursing home. Interview on 01/28/2025 at 2:30 p.m. with S3 ADON confirmed Resident #100's MDS transmission report should have been encoded as a resident-initiated discharge instead of a facility-initiated discharge. S3 ADON confirmed Resident #100's MDS assessment transmission report was completed incorrectly on 11/19/2024.

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 as ordered. The facility failed to ensure the correct tube feeding was administered at a continuous rate for 1 (#67) of 1 residents reviewed for tube feeding. Total sample size was 40. Findings: Review of the Facility's undated Policy titled Enteral Nutritional Therapy, (Tube Feeding) Policy and Procedure revealed in part .All enteral tube feedings shall have care according to physician orders. Review of Resident #67's medical record revealed an admission date of 10/14/2022 with a re-entry date of 05/07/2024 with diagnoses that included in part .Cerebral infarction unspecified; Schizoaffective Disorder, Bipolar type; Type 2 Diabetes Mellitus; Dysphagia following Cerebral Infarction; Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side; Paranoid Schizophrenia; Unspecified Dementia. Review of Resident #67's Annual MDS with an ARD of 01/19/2025 revealed a BIMS summary score not conducted due to Resident #67 is rarely/never understood. Resident #67 required substantial/maximal assistance for transfers and personal hygiene. Resident #67 has parenteral feeding and a PEG tube. Review of Resident #67's Care Plan with a Target date of 02/06/2025 revealed in part .I am NPO (Nothing by Mouth). I have a PEG tube. Interventions included: 06/10/2024-Registered Dietician recommendation to change enteral feeding to continuous. Glucerna 1.5 at 55 ml/hr (milliliters per hour) and water at 45 ml/hr. Review of Resident #67's 01/2025 Physician's Orders revealed in part .enteral feed-Glucerna 1.5 continuous at 55 ml/hr; enteral feed-Enteral Water Continuous: 45 ml/hr per PEG via pump. Review of Resident #67's Progress notes revealed a nursing progress note dated 01/20/2025 revealed in part . Resident lying in bed, PEG running continuous feeding at 55 ml/hr with flush of 45 ml/hr. Observation of Resident #67 on 01/26/2025 at 10:29 a.m. revealed a bottle of Jevity 1.5 with about 600 mls (milliliters) inside hanging on pole, next to Resident #67. Tube feeding turned off, and detached from resident. Observation of Resident #67 on 01/26/2025 at 12:21 p.m. revealed a bottle of Jevity 1.5 with about 600 mls inside hanging on pole, next to Resident #67. Tube feeding turned off, and detached from resident. Observation of Resident #67 on 01/26/2025 at 2:04 p.m. revealed a bottle of Jevity 1.5 with about 600 mls inside hanging on pole, next to Resident #67. Tube feeding turned off, and detached from resident. Interview with S4 LPN on 01/26/2025 at 2:07 p.m. revealed Resident #67 gets Glucerna 1.5 for tube feeding at a continuous rate. S4 LPN stated she hung the last bottle of Glucerna 1.5 on Friday evening. S4 LPN confirmed the Jevity 1.5 was the incorrect formula administered and the tube feeding was to be continuous and had not. Interview with S2 Interim DON accompanied with S3 ADON on 01/26/2025 at 2:30 p.m. confirmed the above findings.

Based on observation, interview, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary service to maintain good nutrition for 1 (Resident #52) resident reviewed during dining services in a total of 40 sampled residents. The facility failed to provide assistance during meal time to Resident #52. Findings: Review of the Facility's undated Policy titled Meal- Time Assistance Policy and Procedure revealed in part . Policy: All residents who require assistance with meals will be provided assistance. Purpose: To ensure residents receive adequate nutrition. Procedure: 1. Assistance will be provided to residents as needed. Review of Resident #52's clinical record revealed an admit date of 08/15/2023 with diagnoses which included in part . Huntington's disease, contracture-right hand, drug induced subacute dyskinesia, and deficiency of other vitamins. Review of Resident #52's Quarterly MDS with an ARD of 11/19/2024 revealed a BIMS was not conducted: resident rarely/never understood. Resident had modified independence. Resident used a wheelchair. Resident required setup or clean-up assistance with eating; partial/moderate assistance with oral hygiene, lower body dressing and personal hygiene; supervision or touching assistance with toileting hygiene, showering/bathing, upper body dressing; substantial/maximal assistance with putting on/taking off footwear. Review of Resident #52's Care Plan dated 12/2/2024 revealed in part . I am at risk for weight loss with interventions to include . I need my meals served as ordered by my physician. I require staff assistance for all ADL's with interventions to include . help me with my tray setup and I require assistance with feeding. Review of Resident #52's 01/2025 Physician's Orders revealed in part . Regular diet, Regular texture, Regular Fluid consistency; Double portions and seated at the assist table to be fed with a start date of 11/7/2023. Observation in the Dining Hall on 01/26/2025 at 11:59 a.m. revealed Resident #52 eating lunch that consisted of baked ham, veggie blend, scalloped potatoes and a brownie for dessert. Resident #52 dropped large amounts of food in his lap and his arm shook as he attempted to place potatoes in his mouth. Resident #52 was not being assisted with meal by staff. Observation of Resident #52's meal ticket read to assist with meals. Interview with S10 CNA on 01/26/2025 at 12:09 p.m. revealed that Resident #52 feeds himself and normally eats all of his food except a few bites. S10 CNA stated that Resident #52 does not sit at the Assistance table. Observation in the Dining Hall for lunch on 01/27/2025 at 11:38 a.m. revealed Resident #52 was seated at the table designated for feeding/assistance with meals. Lunch consisted of chicken fried chicken, creamy white gravy, buttered mashed potatoes, parslied carrots, dinner roll with butter and cake. Food items were removed from serving tray and were placed in front of Resident #52 and a staff member walked away. Resident #52 was observed picking up a large chicken patty and ate it using his hands without assistance from staff. Resident #52 was observed eating with no assistance for 20 minutes. Resident #52 consumed 80% of his meal. A significant amount of food was observed in Resident #52's lap and on his bib. Resident #52 was observed struggling to reach for his cake and this surveyor inquired if he would like assistance. Resident #52 nodded and stated yeah. This surveyor notified staff. Interview with S11 CNA on 01/27/2025 at 11:59 a.m. revealed Resident #52 was to be assisted with meals and was not. Interview with S3 ADON on 01/27/2025 at 12:04 p.m. confirmed that Resident #52 should have been assisted with his meal, but was not.

Based on interview and record review, the facility failed to ensure staff followed a resident's person centered plan of care, by failing to use 2-person physical assistance when transferring a resident from wheelchair to bed for 1 (Resident #55) of 3 (Resident #55, Resident #79, and Resident #251) residents reviewed for accidents. Findings: Review of the facility's undated policy titled Transfer Activities Policy and Procedure on 01/28/2025 revealed in part . Purpose: To transfer the resident from bed to chair or toilet safely. Procedure: 1. Obtain assistance of another individual if necessary, for safe transfer. Review of Resident 55's medical records revealed an admit date of 04/28/2020 with diagnoses that included: Hypertensive Heart disease with Heart Failure, Schizoaffective Disorder, Major Depressive Disorder, and Peripheral Vascular Disease. Review of Resident #55's Quarterly MDS with an ARD of 09/17/2024 revealed a BIMS score of 14, indicative of intact cognition. Resident #55 required 2-person physical assist for bed mobility and transfers. Resident #55 had range of motion impairment for bilateral upper and lower extremities and required a wheelchair device for mobility. Review of Resident #55's Care Plan with a Target date of 04/06/2025 revealed in part . Resident #55 is at risk for falls related to a history of unsteady balance, seizure activity and cognitive deficits. Interventions included in part . Assess for any injuries with any fall and Hoyer Lift Transfer (11/27/2024). Review of a facility report dated 11/27/2024 revealed in part S5 CNA was putting Resident #55 into the bed and he pulled against her, which caused him to hit his head leaving a superficial laceration with moderate amount of blood. Resident #55 was seen by the facility MD who was visiting at the time with new orders to continue neuro checks. Resident #55 had complaints of pain and Tylenol was given. Resident #55 stated he hit his head while getting into bed. Interview on 01/27/2025 at 2:17 p.m. with S5 CNA revealed Resident#55 was a 2-person assist with hoyer lift. S5 CNA revealed on 11/27/2024 she transferred Resident #55 by herself without a hoyer lift after calling for help from fellow staff, but no one came. S5 CNA stated during the transfer Resident #55 tensed, jerked backwards, and hit his head on the wooden headboard that caused a cut to the back of his head and it began bleeding. S5 CNA stated she immediately notified the nurse on duty and the MD was called. Interview on 01/28/2025 at 08:38 a.m. with Resident #55 stated he recalled a staff member transferred him and he cut on his head on his headboard. Resident #55 stated the laceration did not require a bandage. Interview on 01/28/2025 at 1:45 p.m. with the facility MD revealed he made a visit on Resident #55 on the day of the incident. The facility MD revealed Resident #55's laceration to his head was superficial and he did not feel as though wound care was necessary as the bleeding had already stopped. The facility MD stated at the time Resident #55's neuro exam was normal and he did not feel as though he needed to be sent out to the hospital for further testing. The facility MD stated he ordered staff to continue neuro checks on Resident #55 and to notify him for any changes in his condition. Interview on 01/28/2025 at 1:05 p.m. with S3 ADON revealed Resident #55's transfer status prior to the incident on 11/27/2024 was 2-person physical assist. S3 ADON revealed on 11/27/2024 Resident #55 was being put back to bed by S5 CAN, and he pulled against her, and hit his head. S3 ADON stated Resident #55 was assessed, the MD was notified, and neuro checks were initiated. She revealed all CNA and nursing staff were in-serviced on transfers. Interview on 01/28/2025 at 1:25 p.m. with S2 Interim DON revealed that she started as interim DON in the facility 2 days ago. S2 Interim DON reviewed the investigation of the incident that occurred on 11/27/2024 and stated that due to poor communication, Resident #55 was transferred by 1 staff member resulting in a superficial laceration to his head after hitting his headboard. S2 Interim DON confirmed that Resident #55 should have been transferred by 2 staff members at the time of the incident, but was not.

Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 2 (Resident #67 and Resident #81) of 4 sampled Residents reviewed for respiratory care. The facility failed to ensure equipment was properly labeled and stored. Total sample size was 40. Findings: Resident #81 Review of Resident #81's medical record revealed an admit date of 04/12/2023 with diagnoses that included in part .Chronic Obstructive Pulmonary Disease, Asthma, Respiratory Infection, Pneumonia in Diseases Classified Elsewhere and Dementia. Review of Resident #81's active Physician orders revealed the following order with a start date of 08/23/2024: Administer Oxygen at 2 Liters per minute via nasal cannula as needed for Shortness of Breath. Review of Resident #81's Care Plan with a Target date of 02/04/2025 revealed in part .I have Asthma, Chronic Obstructive Pulmonary Disease or Chronic Lung Disease with interventions that included in part .I need Oxygen when I have a respiratory crisis, administer nebulizer treatments as ordered. Observation on 01/26/2025 at 11:00 a.m. of Resident #81's nasal cannula revealed it lying on top of an oxygen concentrator uncovered and undated. Interview on 01/26/2024 at 11:17 am with Resident #81 revealed he had his oxygen on the previous night and that morning. Interview on 01/26/2025 at 11:48 a.m. with S9 LPN revealed Resident #81 used his oxygen as needed. S9 LPN confirmed resident #81's nasal cannula was uncovered and undated and it should have been. Resident #67 Review of Resident #67's medical record revealed an admission date of 10/14/2022 with a re-entry date of 05/07/2024 with diagnoses that included in part .Cerebral infarction unspecified; Schizoaffective Disorder, Bipolar type; Type 2 Diabetes Mellitus; Acute Bronchiolitis; Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side; Paranoid Schizophrenia; and Unspecified Dementia. Review of Resident #67's Annual MDS with an ARD of 01/19/2025 revealed a BIMS summary score was not conducted due to Resident #67 is rarely/never understood. Review of Resident #67's 01/2025 physician orders revealed in part .12/14/2024: Ipratropium-Albuterol Solution-1 vial inhale orally every 4 hours as needed; Airway Inhalation Treatment. Review of Resident #67's Care Plan with a target date of 02/06/2025 revealed in part . I am on a Respiratory Therapy Program. Interventions: Administer my nebulizer treatments as ordered by my physician. Watch me for any side effects and effectiveness of medication. Observation of Resident #67 on 01/26/2025 at 10:29 a.m. revealed a nebulizer concentrator and respiratory suction uncovered and undated. Observation of Resident #67 on 01/26/2025 at 12:21 p.m. revealed nebulizer concentrator and respiratory suction uncovered and undated. Observation of Resident #67 on 01/26/2025 at 2:04 p.m. revealed nebulizer concentrator and respiratory suction uncovered and undated. Interview with S4 LPN on 01/26/2025 at 2:07 p.m. confirmed the nebulizer and respiratory suction should have been covered and dated, but had not.

Based on record review and interview the facility failed to ensure there was sufficient nursing staff available at all times to provide nursing and related services to meet the resident's needs and safety in a manner that promotes each residents rights, physical, mental and psychosocial well-being. The facility failed to ensure there was sufficient staff on Saturday 09/28/2024, to provide care and services for residents residing in the facility. The facility census was 96. Findings: Review of the Payroll Based Journal (PBJ) staffing data submission for fiscal year 2024, Quarter 4 revealed in part .one star staffing rating (triggered), and excessively low weekend staffing (triggered). Review of a Staffing Pattern Reporting Form for 07/01/2024 - 09/30/2024 revealed in part . On 09/28/2024, the facility's census was 110 residents. Minimum staffing hours required for that day was 258.5 hours; however, the total number of nursing hours provided on 09/28/2024 was 256.5. Interview on 01/28/2025 at 4:56 p.m. with S2 Interim DON, confirmed the facility did not provide sufficient nursing staff hours on 09/28/2024. S2 Interim DON confirmed the facility was 2 hours short of the minimum required hours to meet the residents' needs and safety.

Based on interview and record review the facility failed to ensure services were provided according to the residents plan of care for 2 (#33 and #91) out of a sample of 40 residents. The facility failed to follow the following physician's orders for monthly labs for Resident #33 and failed to ensure wound care was provided for Resident #91 as ordered. Findings: Review of the facility's undated policy titled Lab/Diagnostic Monitoring Log Policy and Procedure on 01/28/2025 read in part Purpose: To ensure all labs and diagnostics are completed and followed up on for all residents as ordered by the physician. Procedure: All nurses are responsible for: 1. Making sure labs/diagnostics are being performed. Resident #33 Review of Resident #33's medical records revealed an admit date of 01/10/2023 with diagnoses that included: Type 2 Diabetes Mellitus, Cerebellar Stroke Syndrome, Unspecified Convulsions, Generalized Anxiety Disorder and Conversion Disorder with seizures or Convulsions. Review of Resident #33's 01/2025 Physician's Order read in part 11/07/2023-Trileptal Oral Tablet 150 MG (Oxcarbazepine) Give 1 tablet by mouth 2 times a day. 11/07/2023-Trileptal Oral Tablet 300 MG (Oxcarbazepine) Give 1 tablet by mouth 2 times to equal 450 mg twice daily. 11/07/2023-Trileptal level every month (Jan, Feb, Mar, Apr, May, Jun, Jul, Aug, Sep, Oct, Nov, Dec) Review of Resident #33's Care plan with a review date of 03/23/2025 read in part .I am at risk for injury related to a seizure disorder. Interventions: obtain my lab work as ordered. Review of Resident #33's medical record revealed missing Trileptal lab results for 02/2024, 04/2024, 06/2024, and 07/2024. Interview on 01/28/2025 at 9:40 a.m. with S2 Interim DON confirmed that Resident #33's Trileptal levels for 02/2024, 04/2024, 06/2024, and 07/2024 were not drawn, but should have been. Review of Resident #91's Medical Record revealed an admission date of 05/22/2024 with diagnoses that included Type 2 Diabetes Mellitus, Encounter for Surgical Aftercare following Surgery on the Skin and Subcutaneous Tissue, Vitamin D Deficiency and Essential (Primary) Hypertension. Review of Resident #91's Physician's Orders for 01/2025 revealed the following order dated 01/16/2025: Cleanse with NS or wound cleanser, pat dry, monitor surgical openings for signs of infection, cover with dry dressing, secure with tape daily until resolved every day shift for post-surgical incision. Review of Residents #91's TAR for 01/2025 revealed documentation of wound care treatment dated 01/25/2025 initialed by S9 LPN coded 9 = other/See Progress Notes: Resident #91 out to IOP (Intensive Outpatient Program) Review of Resident #91's Progress Note by S9 LPN dated 01/25/2025 at 12:56 p.m. read in part . Resident is alert, skin warm/dry, respirations even/unlabored. Left for IOP today at 8:30 a.m. Wounds are being dressed per wound care nurse. Review of Resident's Quarterly MDS with an ARD of 01/07/2025 revealed a BIMS score of 13, indicative of intact cognition. Review of Resident #91's Care Plan with a Target date of 03/05/2025 revealed resident with impaired skin integrity related to surgical wound to back. Interventions initiated on 01/13/2025 included in part . I need wound care as ordered by my physician. Observation in Resident #91's room on 01/26/2025 at 10:50 a.m. of S7 LPN treatment nurse performing wound care treatment to Resident #91's lower back. At this time of observation revealed Resident #91's dressing dated 01/24/2025. S7 LPN revealed the dressing must not have been changed yesterday due to Resident #91's orders are for his wound care dressings are to be changed daily. Interview at this time with Resident #91 revealed that his wound care dressing was not done yesterday (Saturday, 01/25/2025) because he had went out for his appointment. Interview in Resident #91's room on 01/26/2025 at 11:05 a.m. with S9 LPN reported Resident #91 had went to IOP yesterday on 01/25/2025 and came back about 1:45 p.m. S9 LPN revealed that she had not done Resident #91's wound care treatment because she thought the treatment nurse did his treatment. S9 LPN revealed that she was not aware of Resident #91's treatment was not done on 01/25/2025. Telephone interview on 01/27/2025 at 04:30 p.m. with S6 RN revealed she had worked on 01/25/2025. S6 RN reported Resident #91 was not in the facility while she was working and had not done his treatment that day. S6 RN revealed that she reported to S8 LPN that she had not performed wound care treatment to Resident #91 because he had went out to IOP and had still not returned from IOP at the end of her shift. Interview on 01/27/2025 at 4:41 p.m. with S8 LPN revealed that she had worked on 01/25/2025 and had helped S6 RN chart on Resident 91's TAR that treatment was not performed due to Resident #91 was out of facility to IOP. S8 LPN reported that she had not performed Resident #91's treatment when he returned from IOP. S8 LPN further revealed that she had not reported to S9 LPN that Resident #91's treatment was not done that day and should have done so. Interview on 01/27/2025 at 4:45 p.m. with S3 ADON stated the treatment nurse, S7 LPN had called in on 01/25/2025 and the prn S6 RN was called in to work to replace treatment nurse. S3 ADON reported the nursing staff should have communicated with each other and reported to Resident #91's nurse in order to have his wound care treatment done when he returned from IOP and did not. Interview on 01/28/2025 at 2:15 p.m. with S3 ADON confirmed Resident #91's wound care treatment was not performed as ordered for 01/25/2025 and should have been done.

Based on interview and record review, the facility failed to ensure an allegation of resident to resident abuse was reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Findings: An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than: Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. Resident #1 Review of Resident #1's medical record revealed an admission date of 08/16/2024, with diagnoses that included: Cerebral Infarction, Chronic Kidney Disease, Schizoaffective Disorder, Aneurism of Unspecified Site, Personal History of Traumatic Brain Injury, Major Depressive Disorder, and Anxiety Disorder. Review of Resident #1's admission MDS with an ARD of 08/26/2024, revealed a BIMS was not conducted as Resident #1 was rarely/never understood, and had moderately impaired cognitive skills for daily decision making. Review of Resident #1's Care Plan with a Target date of 11/18/2024, revealed in part . I reside in the secure care unit related to wandering behaviors, and difficult redirection. Interventions: Approach me positively and in a calm, accepting manor. Monitor and document my behavior. Provide diversional activities for me. Staff is aware of my wandering/elopement behavior. Resident #2 Review of Resident #2's medical record revealed an admit date of 08/10/2023, with diagnoses that included: Schizoaffective Disorder Bipolar Type, Anxiety Disorders Unspecified, Extrapyramidal and Movement Disorder, and Drug Induced Subacute Dyskinesia. Review of Resident #2's Quarterly MDS with an ARD of 08/06/2024, revealed a BIMS score of 15, indicating intact cognition. Review of Resident #2's Care Plan with a Target date of 11/09/2024, revealed in part . I display physically and verbally aggressive behavior. I have history of pacing/wandering, delusions, and refusal of care. Interventions: Administer my behavior medications as ordered by my physician. Identify causes for my behavior and reduce factors that may provoke me. Place me in area where observation is possible - Secure Unit. Interview on 10/24/2024 at 2:53 p.m. with S1 DON, revealed on 09/18/2024 at approximately 3:00 p.m., S5 CNA reported she heard a noise coming from Resident #2's room. S5 CNA reported Resident #1 was on the floor, and Resident #2 was kicking him in the side of chest area with bare feet. S1 DON revealed Resident #2, who was lucid, and could say what he did and did not do, admitted to punching and kicking Resident #1. S1 DON reported she did not complete a SIMS report for the incident.

Based on interview and record review, the facility failed to ensure an allegation of staff to resident physical abuse was reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Findings: Review of the facility's policy on 03/14/2024 at 4:20 p.m. titled Abuse Prevention and Prohibition revision 4.0 dated 01/27/2023 read in part . An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury . The facility administrator or designee shall report or cause a report to be made to the mandated state agency per reporting criteria within guidelines of notification of an alleged abuse. Review of Resident #1's Quarterly MDS with an ARD of 01/16/2024 revealed a BIMS score of 13, indicating intact cognition. Interview on 03/13/2024 at 2:53 p.m. with Resident #1 revealed he was abused about 2 weeks ago (could not recall date) at approximately 7:00 p.m. Resident #1 reported a CNA hit him with a fan on his back and head, and then took him to a shower room and hit him with a plastic hanger on the buttocks, penis, head, and back. Resident #1 reported she called him white trash, white honkey and a mother f*****. Resident #1 stated he reported it to the nurse (could not recall name) on duty that evening, and to S1 ADM the following morning. Interview on 03/14/2024 at 3:15 p.m. with S1 ADM revealed she was notified of the allegation of staff to resident physical abuse reported by Resident #1 on 02/26/2024, by either S3 DON, or S4 SSD. S1 ADM stated she was told the alleged incident occurred on 02/25/2024 during the day shift. S1 ADM reported Resident #1 informed her during an interview that S5 CNA had hit him on the back of the head with a fan, and with a plastic coat hanger in his groin. Interview on 03/18/2024 at 2:49 p.m. with S1 ADM and S2 Regional ADM, confirmed the allegation of staff to resident physical abuse was not entered into the Statewide Incident Management System (SIMS), but should have been.

Based on interview and record review, the facility failed to have evidence that an allegation of staff to resident physical abuse was thoroughly investigated for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents. Findings: Review of the facility's policy on 03/14/2024 at 4:20 p.m. titled Abuse Prevention and Prohibition revision 4.0 dated 01/27/2023 read in part . Investigation: Administrator or designee will complete a thorough investigation. Interview employees who were working in resident's room during the time in question. Signed statements should be obtained from these employees. Interview the resident if they are cognitively able to answer questions. If the resident is not interviewable, interview the roommate. Resident family and friends may be questioned. A licensed professional nurse will examine the resident for signs of injury and notify the resident's physician of any injuries noted. Maintain a file in the administrator or designee office. This file must be kept private and confidential. Review of the facility's investigation documentation for Resident #1 on the allegation of staff to resident physical abuse revealed a body audit conducted on 02/26/2024, a statement from the nurse who conducted the body audit on 02/26/2024, safe surveys conducted on residents who resided on the same hall on 02/26/2024, and text message communication with S5 CNA on 02/26/2024. Review of Resident #1's Quarterly MDS with an ARD of 01/16/2024 revealed a BIMS score of 13, indicating intact cognition. Interview on 03/13/2024 at 2:53 p.m. with Resident #1 revealed he was abused about 2 weeks ago (could not recall date) at approximately 7:00 p.m. Resident #1 reported a CNA hit him with a fan on his back and head, and then took him to a shower room and hit him with a plastic hanger on the buttocks, penis, head, and back. Resident #1 reported she called him white trash, white honkey and a mother f*****. Resident #1 stated he reported it to the nurse (could not recall name) on duty that evening, and to S1 ADM the following morning. Interview on 03/14/2024 at 3:15 p.m. with S1 ADM revealed she was notified of the allegation of staff to resident physical abuse reported by Resident #1 on 02/26/2024, by either S3 DON, or S4 SSD at approximately 8:10 a.m. S1 ADM stated she was told the incident occurred on 02/25/2024 during the day shift. S1 ADM reported Resident #1 informed her during an interview that S5 CNA had hit him on the back of the head with a fan, and with a plastic coat hanger in his groin. S1 ADM reported Resident #1's roommate was interviewed, who was cognitively intact, but she did not obtain a written statement. S1 ADM stated S5 CNA and S6 CNA stated during an interview, that Resident #1 was being rude and cursing; however, she did not obtain written statements. Interview on 03/18/2024 at 2:49 p.m. with S1 ADM, with S2 Regional ADM present, confirmed she did not have documentation that a thorough investigation was conducted, which included a timeline of the investigation, or signed statements from staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that each resident was treated with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #101) of 1 residents sampled for dignity. The facility failed to ensure Resident #101 was dressed in appropriate footwear. Findings: Review of the clinical record revealed Resident #101 was admitted to the facility on [DATE] with diagnosis that included: Hypertensive Heart Disease, Moderate Protein-Calorie Malnutrition, Anxiety Disorder, Hyperlipidemia, Obstructive and Reflux Uropathy, Chronic Pain Syndrome, and Major Depressive Disorder. Review of Resident #101's MDS Assessment with an ARD of 10/06/2023 revealed a BIMS score of 10, indicating moderate cognitive impairment. The MDS revealed Resident #101 required supervision for bed mobility, transfers, and toileting. Review of the Resident #101's care plan with a target date of 01/24/2024 revealed in part . I require staff assistance for all ADL's. Observation on 11/13/2023 at 11:00 a.m. revealed Resident #101 in the facility day area wearing one white and one black tennis shoe. A zip-tie was observed in place of laces on the black tennis shoe. Observation revealed the shoe on Resident #101's left foot was a white, right shoe. Interview with Resident #101 at that time revealed he was wearing two different shoes because someone had stolen his shoes. Resident #101 stated he wore mismatched shoes every day because that was all he had. Resident #101 reported the white, right shoe was hurting left his foot. Interview on 11/13/2023 at 11:07 a.m. with S24 CNA revealed Resident #101 always wore the mismatched shoes. S24 CNA stated that was the first she had heard about Resident #101 having missing or stolen shoes. Interview on 11/13/2023 at 11:20 a.m. with S25 CNA revealed he had worked at the facility for three weeks and the mismatched shoes were the only shoes he had seen Resident #101 wear. Observation on 11/13/2023 at 11:30 a.m. of Resident #101's closet accompanied by S26 RN and S25 CNA revealed a large clear garbage bag of personal belongings. S25 CNA removed a pair of tennis shoes as well as the match to Resident #101's white tennis shoe. Interview with S26 RN at the time of the above observation confirmed Resident #101 required supervision with dressing, had not been dressed appropriately and should have been. Interview on 11/15/2023 at 9:37 a.m. with S2 DON confirmed Resident #101 requires supervision with dressing. S2 DON stated whoever assisted Resident #101 with AM care and dressing should have reported the missing shoes and not put mismatched shoes on Resident #101.

Based on observation and interview, the facility failed to maintain a safe, clean, comfortable and homelike environment for 2 (Resident #45 and Resident #66) residents by failing to ensure the floor was in good repair for Room A; and by failing to ensure a residents clothes were stored properly off the floor. Total sample size was 37. Findings: Resident #45 Review of Resident #45's medical record revealed an admit date of 02/07/2019 with diagnoses which included: Schizoaffective Disorder, Anxiety Disorder, Major Depressive Disorder and Vascular Dementia Severe with other Behavioral Disturbance. Review of Resident #45's Annual MDS with an ARD of 01/19/2023 revealed a BIMS score of 99 (indicating resident was unable to complete the interview). The MDS revealed Resident #45 was always incontinent of bowel and bladder. Observation on 11/13/2023 at 9:23 a.m. revealed Resident #45 who resided in room A lying on the bed. At the foot of Resident #45's bed were several missing floor tiles. Observation on 11/14/2023 at 9:17 a.m. of Room A revealed several missing floor tiles at the foot of Resident #45's bed. Resident #45 was unable to state how long the floor tiles had been missing. Interview on 11/14/2023 at 9:31 a.m. with S15 RCNA revealed Resident #45 had a history of using the bathroom in the corner of his room, at the foot of his bed. S15 stated the tiles had to be taken up, but was unsure of how long they had been gone. Interview on 11/14/2023 at 9:33 with S16 Maintenance revealed the floor tiles in Room A had been missing for weeks. S16 Maintenance stated Resident #45 urinated on the floor which caused the floor tiles to loosen, so therefore had to be removed. S16 Maintenance stated he did not replace the missing floor tiles in Room A because he did not see what it was hurting. S16 Maintenance acknowledged the missing floor tiles in Room A were not homelike. Interview on 11/14/2023 at 11:06 a.m. with S1 ADM revealed she was unaware of Room A having had missing floor tiles. S1 Administrator confirmed it was not homelike for Resident #45 to have had missing floor tiles and they should have been replaced. Resident #66 Review of Resident #66's medical record revealed an admit date of 02/22/2017 with diagnoses which included: Unspecified Dementia with Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. Review of Resident #66's Quarterly MDS with an ARD of 07/11/23 revealed a BIMS score of 15 (indicating intact cognition). The MDS revealed no behaviors exhibited or rejection of care. Review of Resident #66's recent care plan revealed he had a diagnosis of Dementia and was at risk for cognitive impairment and behavior problems with interventions that included reality orientation as needed; Anticipate and meet the resident's needs. Observation on 11/13/2023 at 11:12 a.m. revealed several large black trash bags on the floor with clothes and shoes in them. Resident #66 stated the clothes and shoes on the floor and in the large black trash bags belonged to him. Observation and interview on 11/14/2023 at 10:01 a.m. accompanied by S2 DON and S12 SSD revealed Resident #66 in his bed. Resident #66's clothes and shoes were in large black trash bags sitting on the floor. On top of the large black trash bags were stained clothes and gnats were flying around them. S2 DON and S12 SSD confirmed Resident #66's clothes should not be on the floor in trash bags and they needed to be washed.

Based on interview and record review the facility failed to ensure their grievance policy and procedure was followed by failing to ensure prompt investigation of an allegation and to provide a written resolution of a resident's complaint/grievance for 1 (Resident #29) resident of 37 sampled residents. Findings: Facility's Grievance Policy read in part . Purpose: To ensure each resident grievance will be followed up by prompt efforts to resolve grievances that the resident may have, including those with respect to the behavior of other residents. Policy: All grievances will be investigated thoroughly, and appropriate corrective action take. Review of Resident #29's Quarterly MDS with an ARD of 07/08/2023 revealed resident had a BIMS score of 15 (indicating intact cognition). Resident #29's MDS revealed he is able to be understood and understand others. Resident #29 had clear speech and used distinct intelligible words. Review of a facility form titled Grievance/Complaint Report dated 09/28/2023 at 12:15 p.m. by S12 SSD read in part .Resident #29 stated that another Resident (Resident # 78), had banged on his door several times at night. The resolution part of the grievance/complaint form was left blank. Interview on 11/16/2023 at 10:15 a.m. with S1 Administrator revealed she did not document a resolution on the grievance/complaint report form of Resident #29's complaint, of Resident # 78 banging on his door. S1 Administrator confirmed she did not have any documentation addressing Resident #29's complaint of Resident #78 banging on his door and she should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a reportable incident was reported to the State Agency for 1 (#18) of 3 (#18, #108, #313) residents reviewed for incidents and accidents. The facility failed to report an incidence of resident to resident abuse. Findings: Review of the facility policy titled Abuse Prevention and Prohibition revealed in part . Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals. Abuse defined: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Resident abuse may include: 1. resident to resident abuse Physical Abuse may include an aggressive act, including inappropriate physical contact that is harmful or likely to cause injury or harm to a resident. Reporting/Response The facility employee or agent, who becomes aware of abuse or neglect, including injuries of unknown source or alleged misappropriation of resident property, shall immediately report the matter to the facility administrator or director of nurses. An alleged violation of abuse, neglect, exploitations, or mistreatment will be reported immediately, but no later than: Two hours if the alleged violation involves abuse or has resulted in a serious bodily injury The facility administrator or designee shall report or cause a report to be made to the mandated state agency per reporting criteria within guidelines of notification of an alleged abuse. Administrator or designee will have 5 working days from the initial report of abuse to complete SIMS report according to DHH guidelines. #18 Review of the clinical record revealed Resident #18 was admitted to the facility on [DATE], with diagnoses that included: COPD, Type II DM, Essential HTN, Primary Open Angle Glaucoma, Bipolar disorder, Human Immunodeficiency Disorder, Major Depressive Disorder, Chronic Atrial Fibrillation, and Atrial Flutter. Review of Resident #18's Quarterly MDS with an ARD of 10/09/2023 revealed Resident #18 had a BIMS of 14, indicating intact cognition. The MDS revealed Resident #18 required supervision for bed mobility, transfers, eating and toilet use and had no impairment in functional ROM to the upper and lower extremities. Resident #18 used a cane as mobility device. Review of Resident #18's CPOC revealed Resident #18 was at risk for bleeding due to anticoagulant therapy and had impaired vision related to a diagnosis of Glaucoma. Resident #18 was not care planned for aggressive verbal or physical behaviors towards others. #363 Review of the Resident #363's clinical record revealed an admission date of 01/28/2019 with diagnoses that included: Aphasia; Cerebral Edema; Human Immunodeficiency Disorder; Persistent Mood Disorder; Toxoplasmosis; Unspecified Dementia, unspecified severity, with other behavioral disturbance; Hyperlipidemia; Essential Hypertension; Unspecified Glaucoma; Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease affecting left non-dominant side. Review of Resident #363's Discharge Summary revealed he discharged from the facility to the community on 07/20/2023. Review of Resident #363's Quarterly MDS with an ARD of 07/07/2023 revealed Resident #363 had a BIMS of 15, indicating no cognitive impairment. The MDS revealed Resident #363 required the extensive assistance of 2 or more persons for bed mobility, transfers, dressing, toileting and personal hygiene. Resident #363 had ROM limitation to the upper and lower extremity on one side and utilized a wheelchair for mobility. Review of Resident #363's CPOC revealed in part The resident has behavior problems threatens to throw himself on the floor at risk for injury. I have episodes of verbal behavior as evidenced by being verbally abusive, verbally inappropriate to staff and peers, calling staff derogatory names and demanding staff use 2 briefs on him at night despite education on the risk associated with extra brief use. Demanding to be cared for first despite refusing to get up when staff first attempted to provide care for resident, not easily redirected. 05/28/2023-I was observed drinking vodka on facility grounds, when counseled on policy violation I became verbally aggressive 06/19/2023-I made contact with a resident Review of a facility incident reported documented by S10 LPN revealed that on 06/18/2023 at 9:40 p.m. staff overheard Resident #18 tell Resident #363 not to go outside of the facility. Resident #363 became angry and threw his wheelchair arm at Resident #18's face, unprovoked. Resident #18's eye was noted to be moderately bleeding. Pressure held until bleeding stopped. Resident #363 ordered to be sent to ED to be evaluated for PEC. Interview on 11/13/23 at 1:47 p.m. with Resident #18 revealed on the day of the incident another resident got mad and pulled the arm rest off a wheelchair and threw it across the room, striking him in the left eye. Resident #18 stated he was sent out to the emergency room and had a procedure done on his eye because of the incident. Review of an emergency department record with a service date of 06/18/2023 revealed Resident #18 presented to the emergency department for evaluation of a laceration to the face. An irregular, 1.5cm laceration was noted over patients left zygoma. Laceration extends through dermis, but does not appear to extend into deeper tissues. Bleeding controlled at time of initial examination. No visible foreign body noted. Wound closed with 3 sutures of 5-0 monocryl using simple uninterrupted technique. Telephone interview on 11/15/2023 at 11:58 a.m. with S10 LPN revealed she was the nurse on duty on 06/18/2023 and assigned to Resident #18 and Resident #363. S10 LPN stated approximately 30 minutes before the incident she saw both residents playing cards in the side dayroom. S10 LPN stated another nurse came and got her from down the hall and told her #363 had hit #18 with a piece of his wheelchair. S10 LPN stated she believed #363 was trying to go out the side door to smoke and was redirected by Resident #18, which made him mad. S10 LPN stated residents were separated, the DON and police were called and Resident #18 was sent to the ER. S10 LPN stated Resident #363 was taken to his room by staff until they could get him sent out to be PEC'd. Review of a physician consultation report dated 07/13/2023 revealed Resident #18 was seen by an ophthalmologist with findings that included a dislocated intraocular lens. Recommendations stated Resident #18 would need surgery to left eye on 08/08/2023. Interview on 11/15/2023 at 9:17 a.m. with S2 DON revealed Resident #18's eye surgery and appointments were due to the wheelchair incident. S2 DON stated Resident #18 began complaining of pain and vision changes in his left eye and was sent to an ophthalmologist who determined something was torn in the eye. Interview on 11/16/2023 at 4:17 a.m. with S1 Administrator revealed she was not Administrator at the time of the incident on 06/18/2023. S1 Administrator confirmed a SIMS report and investigation should have been completed regarding the incident between #18 and #363 and had not been.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person centered plan of care consistent with the resident rights, which included measurable objectives and timeframes to meet a resident's nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #55) of 37 sampled residents. The facility failed to include in Resident #55's care plan the need for staff assistance with ADLs. Findings: Review of Resident #55's medical record revealed an admit date of 02/13/2023 with diagnoses which included: Schizoaffective Disorder, Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Osteoarthritis, Neuropathy, and Glaucoma. Review of Resident #55's Quarterly MDS with an ARD of 09/13/2023 revealed a BIMS score of 14, indicating intact cognition. The MDS revealed Resident #55 required extensive 2+ person physical assistance with bed mobility, transfer, and toilet use; limited one person physical assistance with dressing and personal hygiene; and one person physical help in part of bathing activity. Review of Resident #55's care plan with a target date of 01/29/2024 revealed no focus/problem of needing assistance with ADLs with goals and interventions. Observation on 11/13/2023 at 12:08 p.m. revealed Resident #55 had facial hair that was growing in. Interview at that time with Resident #55 revealed he wanted his facial hair shaved/groomed. He reported the staff don't do it routinely. He stated it was not often enough because it was too long. Observation on 11/14/2023 at 9:33 a.m. revealed Resident #55 had facial hair that was growing in on the sides of his face. Interview at that time with Resident #55 revealed he wanted a mustache and a goatee but did not like hair on the side of his face. He reported the CNAs were aware of how he likes his facial hair. Observation on 11/14/2023 at 10:00 a.m. accompanied by S2 DON revealed Resident #55 had facial hair that was growing in on the sides of his face. S2 DON asked Resident #55 how he liked his facial hair and he reported he liked a mustache and a goatee and did not like hair on the side of his face. Interview with S2 DON at that time revealed she was not aware of the resident's preference. S2 DON asked the resident if he told the CNAs how he wanted his facial hair and he reported yes. S2 DON stated she could not say when the last time he was shaved judging by the length but she would get staff to provide care for him. Interview on 11/14/2023 at 10:02 a.m. with S2 DON revealed if they know a resident's preference for facial hair, it will be care planned. Interview on 11/14/2023 at 4:23 p.m. with S2 DON confirmed Resident #55 was not care planned for needing assistance with ADLs. S2 DON stated the care plan should have included Resident #55's need for assistance with ADLs and interventions for ADL care.

Based on interview and record review, the facility failed to revise a comprehensive person-centered care plan for 1 (Resident #78) of 37 sampled residents, by failing to reflect Resident #78 required increased supervision due to wandering behavior. Findings: Review of Resident #78's medical record revealed an admission date of 11/10/2022 with diagnoses that included in part .Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-dominant side; Traumatic Subdural Hemorrhage; Major Depressive Disorder Recurrent-Severe with Psychotic symptoms; Generalized Anxiety Disorder; Schizoaffective Disorder Bipolar Type, and Post Traumatic Seizures. Review of Resident #78's Quarterly MDS with an ARD of 05/31/2023 revealed a BIMS score of 99 (indicating unable to complete interview) The MDS revealed Resident #78 had verbal behavioral symptoms directed toward other (threatening others, screaming at others, cursing at others). The MDS revealed Resident #78 was coded as requiring 2 person assistance for bed mobility, transfers, and toilet use and 1 person assistance for eating, dressing, and personal hygiene. The MDS revealed Resident #78 used a wheelchair as a mobility device on and off unit. Review of Resident #78's care plan revealed in part .I am an elopement risk related to I am a wanderer with interventions that included to alert staff of my wandering behavior. I have the behaviors of throwing myself on the floor, rolling around on the floor, removing my clothes, and removing my linens with interventions that included frequent monitoring and redirect behaviors as needed. Interview on 11/13/2023 at 11:01 a.m. with Resident #29 who resided across the hall from Resident #78 stated Resident #78 banged on his door several times, and wandered into his room, and rolled his wheelchair against his bed. Interview on 11/14/2023 at 2:00 p.m. with S22 ADON revealed Resident #78 resided across the hall from Resident #29. S27 ADON stated Resident #78 did wander in and out of residents rooms and was not easily redirected. Interview on 11/16/2023 at 9:58 with S1 Administrator revealed Resident #78 would wander into any resident's room if the door was open and frequently had to be redirected by staff. Interview on 11/16/2023 at 1:21 p.m. with S2 DON revealed Resident #78 had wandering behavior and frequently had to be redirected from Resident #29's room. S2 DON stated Resident #78's supervision should have been increased to every 1 hour. Review of Resident #78's care plan at that time with S2 DON confirmed it was not revised to reflect increased supervision with 1 hour checks and it should have.

Resident #77 Review of the Resident #77's medical record revealed an admit date of 09/19/2023 with diagnoses which included: Pneumonitis, Hypertensive Heart Disease, Acute Respiratory Failure, Major Depressive Disorder, and Schizoaffective Disorder. Review of Resident #77's Quarterly MDS with an ARD of 09/22/2023 revealed a BIMS was not conducted as Resident #77 was rarely/never understood and had moderately impaired cognitive skills for daily decision making. The MDS revealed Resident #77 was totally dependent on 2+ persons physical assist for bathing, and required extensive 2+ persons physical assistance for dressing and personal hygiene. Review of Resident #77's care plan with a target date of 01/29/2024 revealed a problem of I require staff assistance for all ADLs. Interventions included in part: assist me with bathing, and assist me with hygiene and grooming tasks. Observation on 11/13/2023 at 10:08 a.m., and 11/14/2023 at 9:40 a.m. revealed Resident #77's fingernails were approximately 0.5 cm in length. Interview at those times with Resident #77 revealed he did not want his fingernails that long. Observation on 11/14/2023 at 10:02 a.m. accompanied by S2 DON revealed Resident #77's fingernails were approximately 0.5 cm in length. Interview at that time with S2 DON confirmed Resident #77's nails needed to be trimmed. Interview on 11/15/2023 at 11:33 a.m. with S3 CNA revealed he was Resident #77's CNA on 11/13/2023. S3 CNA reported he saw Resident #77's fingernails were long and he needed nail care. S3 CNA stated he did not have time to get to it. Resident #90 Review of Resident #90's medical record revealed an admit date of 08/21/2023 with diagnoses which included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Dysphagia, Aphasia, and Other Lack of Coordination. Review of Resident #90's Quarterly MDS with an ARD of 09/08/2023 revealed a BIMS was not conducted as Resident #90 was rarely/never understood and was coded as modified independence with cognitive skills for daily decision making. The MDS revealed Resident #90 required physical help with one person assist with bathing, and extensive one person physical assist with dressing and personal hygiene. Review of Resident #90's care plan with a target date of 02/11/2024 revealed a problem of I require staff assistance for all ADLs. Interventions included in part: assist me with bathing, and assist me with hygiene and grooming tasks. Observation on 11/13/2023 at 11:52 a.m. revealed Resident #90 had long fingernails with dark black debris under them. Observation on 11/14/2023 at 9:43 a.m. revealed Resident #90 had long fingernails, approximately 0.4 cm in length, with dark black debris under them. Observation on 11/14/2023 at 9:58 a.m. accompanied by S2 DON revealed Resident #90 had long fingernails, approximately 0.4 cm in length, with dark black debris under them. Interview with S2 DON at that time confirmed Resident #90's fingernails needed to be cleaned and trimmed. Interview on 11/15/2023 at 11:33 a.m. with S3 CNA revealed he was Resident #90's CNA on 11/13/2023. S3 CNA reported he saw Resident #90's fingernails were long and dirty and he needed nail care. S3 CNA stated he just did not have time to get to it. Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 (Resident #19, Resident #77, and Resident #90) of 5 (Resident #19, Resident #31, Resident #55, Resident #77, and Resident #90) residents investigated for activities of daily living out of a total sample of 37 residents. Findings: Review of the facility's policy titled Nail Care Policy and Procedure read in part . Policy: 1. To prevent infection. 2. To prevent irritation. 3. To prevent break in skin integrity. 4. To promote peripheral circulation. 5. To promote cleanliness. 6. To relieve pain. Procedure: 1. Care of fingernails and toenails is part of the bath. 2. Be certain the nails are clean. Resident #19 Review of Resident #19's medical record revealed an admit date of 01/01/2011 with diagnoses which included in part . Schizoaffective Disorder Depressive Type, Type 2 Diabetes Mellitus, Aphasia, Vascular Severe with other Behavioral Disturbance and Pain in Unspecified Joint. Review of Resident #19's Quarterly MDS with an ARD of 05/18/2023 revealed a BIMS score of 0 (indicating severe cognitive impairment). The MDS revealed Resident #19 required extensive assistance with personal hygiene and 1 person physical assistance with bathing. Review of Resident #19's care plan with a review date of 11/19/2023 revealed a diagnosis of Schizoaffective disorder with interventions that included to assist Resident #19 with some ADL's. Observation on 11/13/2023 at 11:12 a.m. revealed Resident #19 had long fingernails, approximately an inch long with a black substance under them and around the cuticles. Observation on 11/14/2023 at 9:40 a.m. revealed Resident #19 had long fingernails, approximately an inch long with a black substance under them and around the cuticles. Resident #19 unable to state when was the last time his fingernails had been clean and trimmed. Observation and interview on 11/14/2023 at 11:45 a.m. accompanied by S2 DON revealed Resident #19 sitting in a wheelchair in the dining room. Resident #19 had long fingernails, approximately an inch long with a black substance under them and around the cuticles. S2 DON stated the CNA's are responsible for cleaning and trimming resident's fingernails if they are not a Diabetic. S2 DON stated if a Resident is a Diabetic the treatment nurse is responsible for cleaning and trimming the resident's fingernails. S2 DON confirmed Resident #2 had long fingernails with a black substance under them and around the cuticles and he should not have.

**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 accidents and incidents for 1 (#363) of 3 (#18, #108, and #363) sampled residents for incidents and accidents. The facility failed to ensure Resident #363 received increased supervision after inflicting injury upon Resident #18. Findings: Review of the facility policy titled Abuse Prevention and Prohibition revealed in part . Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals. Abuse defined: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Resident abuse may include: 1. resident to resident abuse Physical Abuse may include an aggressive act, including inappropriate physical contact that is harmful or likely to cause injury or harm to a resident. #18 Review of the clinical record revealed Resident #18 admitted to the facility on [DATE], with diagnoses that included COPD, Type II DM, Essential HTN, GERD, Primary Open Angle Glaucoma, Bipolar disorder, Human Immunodeficiency Disorder, Major Depressive Disorder, Chronic Atrial Fibrillation, and Atrial Flutter. Review of Resident #18's Quarterly MDS with an ARD of 10/09/2023 revealed Resident #18 had a BIMS of 14, indicating no cognitive impairment, required supervision for bed mobility, transfers, eating and toilet use and had no impairment in functional ROM to the upper and lower extremities. Mobility device was noted as cane or crutch. Review of Resident #18's CPOC revealed Resident #18 was at risk for bleeding due to anticoagulant therapy and had impaired vision related to a diagnosis of Glaucoma. Resident #18 was not care planned for aggressive verbal or physical behaviors towards others. #363 Review of the Resident #363's clinical record revealed an admission date of 01/28/2019 with diagnoses that included Aphasia, Cerebral edema, Human Immunodeficiency Disorder, Persistent Mood Disorder, Toxoplasmosis, Unspecified Dementia, unspecified severity, with other behavioral disturbance, Hyperlipidemia, Essential Hypertension, Unspecified Glaucoma, Hemiplegia and Hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side. Continued record review revealed Resident #363 discharged from the facility to the community on 07/20/2023. Review of Resident #363's Quarterly MDS with an ARD of 07/07/2023 revealed Resident #363 had a BIMS of 15, indicating no cognitive impairment, required the extensive assistance of 2 or more persons for bed mobility, transfers, dressing, toileting and personal hygiene. Resident #363 also had ROM limitation to the upper and lower extremity on one side and utilized a wheelchair for mobility. Review of Resident #363's CPOC revealed in part The resident has behavior problems threatens to throw himself on the floor at risk for injury. Resident has a history of verbal behavior as evidenced by being verbally abusive, verbally inappropriate to staff and peers, calling staff derogatory names and demanding staff use 2 briefs on him at night despite education on the risk associated with extra brief use. Demanding to be cared for first despite refusing to get up when staff first attempted to provide care for resident, not easily redirected. 05/28/2023-I was observed drinking vodka on facility grounds, when counseled on policy violation I became verbally aggressive 06/19/2023-I made contact with a resident Review of a facility incident reported documented by S10 LPN revealed that on 06/18/2023 at 9:40 p.m. staff overheard Resident #18 tell Resident #363 not to go outside of the facility. Resident #363 became angry and threw his wheelchair arm at Resident #18's face, unprovoked. Resident #18's eye was noted to be moderately bleeding. Pressure held until bleeding stopped. Resident #363 ordered to be sent to ED to be evaluated for PEC. Review of resident statements regarding the incident revealed Resident #363 refused to give details of incident and began using vulgar language. Resident #18 stated that he told Resident #363 he could not go outside to smoke in the non designated smoking area. As resident #18 was telling Resident #363 not to go, Resident #363 took the arm of his wheelchair and threw it at Resident #18 and hit him in the left eye. Staff immediately intervened and separated residents. Interview on 11/13/23 at 1:47 p.m. with Resident #18 revealed during the incident another resident got mad and pulled the arm rest off a wheelchair and threw it across the room, striking him in the left eye. Resident #18 stated he was sent out to the emergency room and has had a procedure done on his eye because of the incident. Review of an emergency department record with a service date of 06/18/2023 revealed Resident #363 presented to the emergency department for dementia and combative behavior. The resident was discharged back to the facility on [DATE] at 5:53 a.m. Telephone interview on 11/15/2023 at 11:58 a.m. with S10 LPN revealed she was the nurse on duty on 06/18/2023 and assigned to Resident #18 and Resident #363. S10 LPN stated approximately 30 minutes before the incident she saw both residents playing cards in the side dayroom. S10 LPN stated another nurse came and got her from down the hall and told her #363 had hit #18 with a piece of his wheelchair. S10 LPN stated she believed #363 was trying to go out the side door to smoke and was redirected by Resident #18, which made him mad. S10 LPN stated #363 was very rude to staff, often caused issues, and had frequent outburst with staff and other residents. S10 LPN stated it had been several months since #363 had hit another resident. S10 LPN stated residents were separated, the DON and police were called and Resident #18 was sent to the ER. S10 LPN stated Resident #363 was taken to his room by staff until they could get him sent out to be PEC'd. S10 LPN stated they kept an eye on #363 by making sure he stayed in his room until he was transferred to the hospital but did not increase supervision. Telephone interview on 11/15/2023 at 12:24 p.m. with S13 LPN revealed on 06/18/2023 she and S14 LPN were walking into the side dayroom just as #363 threw a piece of his wheelchair at Resident #18. S13 LPN stated Resident #18 was standing when she entered the dayroom and appeared to be telling #363 that he had to wait to go out and smoke. S13 LPN stated she was aware #363 had occasional outburst of screaming and cursing at staff and residents but does not remember him hitting or throwing things. S13 LPN stated after the incident Resident #18 was assessed in the dayroom and Resident #363 taken to his room by staff. S13 LPN stated both residents were sent out to the hospital. Attempted telephone interview with S14 LPN on 11/15/2023 was unsuccessful. Review of a nurses' note dated 06/19/2023 at 6:54 a.m. and documented by S21 LPN revealed Resident #363 returned from the hospital with no new orders, did not want family notified, denied pain and had no behaviors. Telephone interview on 11/15/2023 at 1:39 p.m. with S21 LPN revealed she worked the 11p-7a shift on 06/18/2023 and Resident #363 returned to the facility before the end of her shift with no new orders. S21 LPN stated supervision was not increased because Resident #18 and Resident #363 had shook hands and made up. S21 LPN stated #363 was calm and cooperative and expressed understanding of why he was sent out when he returned. S21 LPN stated she was not sure if she notified the NP that #363 had not been PEC'd. Interview on 11/15/2023 at 11:22 a.m. with S19 CNA revealed Resident #363 did not exhibit behaviors unless someone made him mad. S19 CNA states Resident #18 and Resident #363 were on regular every 2 hours rounds but did most things for themselves Interview on 11/15/2023 at 11:33 a.m. with S18 LPN revealed #363 was rude to staff, refused medications and had a couple fights with other residents. S18 LPN stated the altercation when Resident #18 was hit with the wheelchair piece was the only incident between Resident #18 and Resident #363 that she knew of. S18 LPN stated Resident #18 usually kept to himself. Interview on 11/15/2023 at 11:37 a.m. with S17 LPN revealed #363 had good and bad days and was not always compliant with taking his medication. S17 LPN stated Resident #363 would get mad and throw things at other residents after the incident with Resident #18. S17 LPN stated Resident #18 could sometimes be difficult with staff but not with other residents. S17 LPN stated Resident #18 and Resident #363 were on regular rounding every two hours. Interview on 11/15/2023 at 2:45 p.m. with S20 LPN revealed she was the nurse assigned to Resident #363 when he transferred to a behavioral hospital on [DATE]. S20 LPN stated Resident #363 had no behaviors that day and was unusually quiet. S20 LPN stated Resident #363 was not on increased supervision on the morning he transferred to the behavioral hospital. Observation on 11/15/2023 at 2:50 p.m. revealed Resident #18 in the facility dining area conversing with other residents. An eye shield was noted covering Resident #18's left eye and the resident had a neck roll pillow in place. Resident #18 stated the day after the incident Resident #363 kept coming to his room and trying to apologize to him and he told him not to worry about it. Resident #18 stated his eye pain just wouldn't go away so the nurse made him an appointment with the eye doctor. Interview on 11/15/2023 at 4:35 p.m. with S2 DON revealed Resident #363 was not placed on increased supervision when he returned from the emergency department on 06/19/2023. S2 DON confirmed #363 could have hit another resident when he returned. S2 DON confirmed supervision should have been increased for Resident #363 and had not been. Telephone interview on 11/16/2023 at 8:49 a.m. with Resident #363's MHNP (Mental Health Nurse Practitioner) revealed she provided care to Resident #363 while a resident of the facility. The MHNP stated she wasn't sure if she had been notified that Resident #363 had not been PEC'd in the ED on 06/18/2023. The MHNP stated the nursing home didn't always let her know when residents don't get PEC'd. The MHNP stated the facility has problems with the ED not PECing residents if they're not acting out in the ED. The MHNP revealed supervision should have been increased when #363 returned to the facility without being PEC'd, especially after an incidence of violence towards someone else.

Based on observation and interview the facility failed to ensure that food was stored in accordance with professional standards for food service. The facility failed to ensure that expired/outdated items were not available for resident consumption. This deficient practice had the potential to affect all residents that received meals prepared by the kitchen. Findings: Initial tour of the kitchen on 11/13/2023 at 8:30 a.m. accompanied by S23 DM revealed the following items on cooler shelves for use: 1 opened case of 118 mL thickened orange juice containers with a use by date of 10/24/2023, 1 opened 48 count case of 4 oz. yogurt cups with a use by date of 11/07/2023, and 1 opened case of sugar free gelatin cups with a use by date of 11/01/2023. The above findings were confirmed with S23 DM at the time of observation.

Based on interview and record review, the facility failed to act promptly on grievances concerning issues of resident care and life in the facility reported by residents during a monthly Resident Council meeting for 1 (10/30/2023) of 3 (08/28/2023, 09/26/2023, and 10/30/2023) meetings reviewed. Findings: Review of the facility's policy titled Grievance Policy and Procedure read in part . Purpose: 1. To ensure each resident has the right to voice grievances with respect to treatment or care, that is, or fails to be furnished without discrimination or reprisal for voicing grievances. 2. To ensure each resident grievance will be followed up by prompt efforts to resolve grievance that the resident may have, including those with respect to the behavior of other residents. Policy: All grievances will be investigated thoroughly, and appropriate corrective action taken. Procedure: 1. The facility Administrator or designee will act as the Grievance Official. 6. Resident council or other resident meeting minutes are to be given to administration after completion of meeting. Review of Resident Council meeting minutes dated 10/30/2023 revealed in part . Discussion of New Business 1. Hall A night shift CNAs have been rude. When a resident turns light on he says the CNAs turn light off without asking what he needed. 2. CNAs being rude. 3. Residents say they do not get water and snacks at night. Interview on 11/14/2023 at 8:09 a.m. with S10 AD revealed if complaints are brought up by the residents in a Resident Council meeting, she reports it to S1 Administrator. S10 AD reported CNAs being rude and the call lights being turned off without residents being assisted were complaints from Hall A residents. S10 AD stated the complaints about not getting water and snacks at night were throughout the facility. S10 AD stated she gave S1 Administrator a copy of the minutes from the meeting and verbally reported the residents' complaints to her. Interview with on 11/14/2023 at 9:18 a.m. S1 Administrator revealed if grievances are brought up by residents in the Resident Council meetings, S10 AD brings them to her attention and she addresses them immediately. She stated she was not present for the 10/2023 meeting and no concerns were brought to her attention. S1 Administrator reported she has never received copies of minutes from S10 AD and she verbally tells her if the residents had concerns. S1 Administrator stated she was not aware residents in the Resident Council meeting on 10/30/2023 reported staff were being rude, turning off call lights without assisting them, and not passing water and snacks at night. S1 Administrator confirmed she should have been notified of the above stated grievances so they could have been addressed. Interview on 11/14/2023 at 3:48 p.m. with S1 Administrator and S10 AD regarding the residents' complaints from the Resident Council meeting on 10/30/2023 revealed S1 Administrator spoke to the S10 AD earlier today and S10 AD reported she put the minutes from the meeting on her desk and she does not recall seeing it. S10 AD stated S1 Administrator was not in her office when she brought her the copy of the minutes on 10/30/2023, so she did not tell her. S10 AD reported she usually brings a copy of the minutes and verbally tells S1 Administrator if there are concerns. S1 Administrator reported she only recalled seeing a copy from the 07/2023 meeting. S1 Administrator confirmed there was a breakdown in communication regarding the residents' concerns from the Resident Council meeting on 10/30/2023 resulting in residents' grievances not being addressed.

Resident #80 Review of Resident #80's medical record revealed an admit date of 09/14/2020 with diagnoses which included: Parkinson's Disease, Mild Protein-Calorie Malnutrition, Vascular Dementia, Iron Deficiency Anemia, Gastrostomy Status, and Dysphagia. Review of Resident #80's Annual MDS with an ARD of 08/04/2023 revealed a BIMS score of 14, indicating intact cognition. The MDS revealed Resident #80 required 2+ persons extensive physical assistance with bed mobility, transfer, and toilet use and required 1 person extensive physical assistance with eating. Review of Resident #80's care plan with a target date of 11/20/2023 revealed a problem of resident requires a PEG tube for adequate nutritional intake. Interventions included in part: watch me for changes that may indicate worsening of my condition and notify the physician and family, and watch for tolerance of formula. Review of Resident #80's 11/2023 physician orders revealed the following orders with a start date of 11/08/2023: Enteral Feed Order H2O at 40 mL/hr. continuous Enteral Feed Order Jevity 1.5 at 50 mL/hr. continuous Observation on 11/13/2023 at 9:10 a.m. revealed Resident #80's dual feeding pump was alarming with the message of Flush Error on the screen. There was no water remaining in H2O flush bag connected to the feeding pump. The pump was not running while alarming. Observation on 11/13/2023 at 11:19 a.m. revealed Resident #80's dual feeding pump was turned off. There was no tube feeding or H2O flush noted on the pump. Observation on 11/14/2023 at 10:33 a.m., and 11/14/2023 at 11:55 a.m. revealed Resident #80's dual feeding pump was alarming with the message clog in line downstream of pump on the screen. The pump was not running while it was alarming. A bag with approximately 700 mL of Peptamen at 40 mL/hr. dated 11/14/2023 at 3:00 a.m. and a bag with approximately 700 mL of H2O dated 11/14/2023 was connected to the pump. Observation on 11/14/2023 at 12:22 p.m. accompanied by S4 LPN revealed Resident #80's dual feeding pump was alarming with the message clog in line downstream of pump on the screen. The pump was not running while it was alarming. A bag with approximately 700 mL of Peptamen at 40 mL/hr. dated 11/14/2023 at 3:00 a.m. and a bag with approximately 700 mL of H2O dated 11/14/2023 was connected to the pump. Interview with S4 LPN at that time revealed the last time she was in the room was at approximately 10:30 a.m. and the pump was running. S4 LPN stated the machine usually alarms louder. S4 LPN reported the alarm might have been due to it detecting a little air in the line. Observation revealed S4 LPN disconnecting the feeding from Resident #80's PEG tube and getting air out of the tubing. S4 LPN then restarted the pump and the feeding was infusing at 40 mL/hr. S4 LPN reported she was unsure why the alarm was low. S4 LPN stated the feeding was set at 40 mL/hr. and the H2O was set at 200 mL every 4 hours. S4 LPN confirmed Resident #80 should not have gone since 10:33 a.m. without the feeding running. S4 LPN stated Resident #80's Jevity 1.5 was ordered for 50 mL/hr. and H2O was ordered for 40 mL/hr. S4 LPN confirmed the feeding on the pump was set incorrectly to give 40 mL/hr. and the H2O on the pump was set incorrectly to give 50 mL/hr. S4 LPN stated S2 DON told her Peptamen 1.5 was a substitute for Jevity 1.5. Interview on 11/14/2023 at 2:15 p.m. with S2 DON revealed if they had a problem with getting a certain feeding due to supply issues, they would call the dietitian to get a recommendation for a substitute and then call the NP or MD to get the approval. S2 DON reported once the NP or MD approved, the order is to be updated. S2 DON stated under additional instructions the order would say, may substitute with the name of the other feeding. S2 DON confirmed Resident #80 did not have an order to substitute Peptamen 1.5 for Jevity 1.5. Resident #90 Review of Resident #90's medical record revealed an admit date of 08/21/2023 with diagnoses which included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Dysphagia, Aphasia, and Other Lack of Coordination. Review of Resident #90's Quarterly MDS with an ARD of 09/08/2023 revealed a BIMS was not conducted as Resident #90 was rarely/never understood and was coded as modified independence with cognitive skills for daily decision making. The MDS revealed Resident #90 required supervision and setup help with eating. Review of Resident #90's care plan with a target date of 02/11/2024 revealed problems of I am at risk for dehydration related to dependence on staff for physical and nutritional needs and I have lost weight recently. Interventions included in part: encourage me to drink fluids as tolerated, provide me with diet as ordered, and monitor for changes in my condition that may warrant increased supervision/assistance with nutritional intake and notify MD. Review of Resident #90's physician orders for 09/2023, 10/2023, and 11/2023 revealed the following orders in part: 1. Mighty Shake with meals twice a day related to unspecified protein-calorie malnutrition Additional Directions: 4=100%; 3=75%; 2=50%; 1=25%; R=refused 2. House Supplement three times a day related to unspecified protein-calorie malnutrition Additional Directions: give 8 oz.; 4=100%; 3=75%; 2=50%; 1=25%; R=refused Review of Resident #90's Medication Administration Record (MAR) for 09/2023 and 10/2023 revealed Mighty Shake and House Supplement had no documentation of the percentages consumed by Resident #90 as ordered for the entire months of 09/2023 and 10/2023. Review of Resident #90's MAR for 11/2023 revealed Mighty Shake and House Supplement had no documentation of the percentages consumed by Resident #90 as ordered for 11/01/2023 and 11/02/2023. Interview on 11/15/2023 at 10:17 a.m. with S2 DON confirmed on the 09/2023 and 10/2023 MARs for the entire months and on the 11/2023 MAR for 11/01/2023 and 11/02/2023 the Mighty Shake and House Supplement did not have documentation of the percentages consumed by Resident #90 as ordered. S2 DON stated there was no way to know what percentages Resident #90 consumed for those days since it was not documented on the MARs. Based on observation, record review, and interview, the facility failed to ensure services were provided to meet professional standards of practice for 3 (Resident #70, Resident #80, and Resident #90) of 37 sampled residents. The facility failed to ensure: 1. A resident's peg tube was checked for placement and residual prior to beginning a feeding as ordered for Resident #70, 2. Physician's orders for peg tube feedings were followed for Resident #80, and 3. Physician's orders for documenting percentages of Mighty Shake and House Supplement were followed for Resident #90. Findings: Review of the facility's policy titled Enteral Nutritional Therapy, (Tube Feeding) Policy and Procedure revealed in part . Procedure: 1. Place resident in semi-Fowler's position, unless contraindicated. 2. Remove plug from end of feeding tube, check position of tube, and attach barrel of syringe to end of tubing. 3. Check position of tube by: a. Listening for breath sounds at end of tube or place end of tube in a glass of water below water level to be sure no bubbles appear from Nasogastric tube. b. Checking the length of tube for proper position for gastric or jejunostomy tubes. c. Placing stethoscope over stomach and instill a small amount of air into enteral feeding tube. Listen for air to enter the stomach. 4. Holding the barrel of the syringe at or below the level of the stomach, pour prescribed amount of water into the syringe. 5. Administer the amount of feeding to be given by holding the syringe 12 to 14 inches above the level of the stomach. 7. If a feeding pump has been ordered: a. Fill container with prescribed formula or use prefilled formula container. c. Expel air from tubing and connect tubing to feeding tube. d. Adjust rate of flow as prescribed. e. flush tubing with water as prescribed following feeding. To check residual stomach contents 1. Check physician's order to check gastric residual. 2. Insert feeding syringe into feeding tube and aspirate stomach contents, gently. 3. The amount of residual may determine the amount of current feeding. . Resident #70 Review of the medical record for Resident #70 revealed an admit date of 8/20/2018 with diagnoses that included in part .Aphasia, Unspecified Protein-Calorie Malnutrition, Gastrostomy Status, and Dysphagia. Review of Resident #70's Annual MDS with an ARD of 08/12/2023 revealed a BIMS score of 3, which indicated severe cognitive impairment, and revealed the resident was totally dependent on one person physical assist with eating. Review of Resident #70's care plan revealed she was care planned for requiring a peg tube for adequate nutritional status. Interventions listed stated to watch the resident for tolerance of formula and watch the resident for changes that may indicate worsening of my condition. Resident #70 was also care planned for being at risk for weight loss related to a history of malnutrition. Interventions listed included to administer peg tube feedings as ordered by the physician. Review of the physician's orders for Resident #70 revealed the following orders: 11/07/2023 order: Enteral feed every 4 hours related to dysphagia, oropharyngeal phase, Peptamen 1.5 (1 carton). 11/07/2023 order: Every 4 hours related to dysphagia, oropharyngeal phase; gastrostomy status; enteral water bolus 75ml before and after each bolus feeding. In an observation on 11/14/2023 at 11:50 a.m., S4 LPN was entering Resident #70's room to administer the resident's bolus feeding. S4 LPN removed the plug from Resident #70's peg tube and ran a long blue declogger down the resident's peg tube. S4 LPN pulled the declogger out of the peg tube and screwed a syringe to the peg tube and began pouring Peptamen 1.5 into the syringe. After completing the feeding, S4 LPN flushed it with water. In an interview on 11/14/2023 at 12:19 p.m., S4 LPN confirmed she did not check placement or residual before beginning Resident #70's bolus tube feeding and should have. In an interview on 11/14/2023 at 1:17 p.m., S2 DON confirmed S4 LPN should have checked placement and residual on Resident #70 prior to beginning the enteral feeding. S2 DON stated Resident #70 usually had some residual and if S4 LPN had checked for residual, she would have verified placement.

Based on record review and interview, the facility failed to ensure the facility had 8 consecutive hours per day of Registered Nurse (RN) coverage for 4 of 91 days reviewed for RN hours. Findings: Review of the facility's PBJ (Payroll Based Journal) Staffing Data Report for Fiscal Year Quarter 3 2023 (April 1-June 30) revealed no RN hours on 04/16/2023, 04/23/2023, 04/29/2023, and 04/30/2023. In an interview on 11/15/2023 at 3:46 p.m., S1 Administrator stated she could not confirm there was no RN coverage on the days reported in April 2023 because she was not employed by the facility at that time and was unable to obtain the information from the previous owner of the facility. S1 Administrator acknowledged the four days were reported by the old company as not having RN coverage. In an interview on 11/16/2023 at 8:10 a.m., S2 DON acknowledged she did work at the facility in April 2023 and confirmed there was no RN coverage on 04/16/2023, 04/23/2023, 04/29/2023, and 04/30/2023.

Based on record review and interview, the facility failed to complete an annual performance review of every nurse aide at least once every 12 months for 5 (S5 CNA, S6 CNA, S7 CNA, S8 CNA, and S9 CNA) of 5 CNA personnel records reviewed. Findings: Review of personnel records revealed the following: 1. S5 CNA-date of hire was on 08/31/2018. Further review failed to reveal evidence that an annual performance review had been completed in the past 12 months. 2. S6 CNA- date of hire was on 08/21/2015. Further review failed to reveal evidence that an annual performance review had been completed in the past 12 months. 3. S7 CNA-date of hire was on 10/02/2019. Further review failed to reveal evidence that an annual performance review had been completed in the past 12 months. 4. S8 CNA-date of hire was on 09/14/2017. Further review failed to reveal evidence that an annual performance review had been completed in the past 12 months. 5. S9 CNA-date of hire was on 08/01/2017. Further review failed to reveal evidence that an annual performance review had been completed in the past 12 months. In an interview on 11/15/2023 at 3:46 p.m. S11 HR confirmed annual performance reviews were not done within the last 12 months for S5 CNA, S6 CNA, S7 CNA, S8 CNA, and S9 CNA.

Based on observation and interview the facility failed to ensure garbage and refuse were disposed of properly. This deficient practice had the potential to affect all 119 residents who resided in the facility. Findings: Observation on 11/13/2023 at 9:00 a.m. of the facility dumpster area accompanied by S23 DM revealed there were three dumpsters. Two of the three dumpsters were observed to be overflowing with garbage bags with lids unable to be completely closed. One dumpster was observed to have bags of trash stacked on top of the partially closed lid. The above findings were confirmed with S23 DM at the time of observation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure resident's responsible party (RP) was notified of an unplanned discharge and a significant change in physical, mental, or psychosocial status for 2 (#1, #2) of 3 (#1, #2, #3) residents reviewed for notification of change. The facility failed to: 1. Notify Resident #1's RP of his unplanned discharge from the facility. 2. Notify Resident #2's RP of a significant change in her condition that required a transfer to the hospital. Findings: Review of the facility's policy titled, Change of Condition policy and procedure revealed in part: Purpose: to ensure that person's involved in the residents care are made of aware of any changes to the resident. Policy: Physicians, responsible family members or legal representatives shall be notified as soon as possible, or within 24 hours, of any changes in the resident's condition. Procedure: 1. The Charge nurse shall be responsible for notifying the attending physician and the resident's RP members or legal representatives when a change occurs in the resident's condition. 2. These changes shall include significant changes in physical, mental, or psychosocial status as well as any accident that results in injury. 3. The Charge nurse shall document this notification of the resident's medical record. 4. If unable to contact RP, the charge nurse shall document changes on the resident's medical record. The Nurse Manager shall follow through with attempts to contact RP and to document the changes. Resident #1 Review of Resident #1's Medical Record revealed an admission date of 12/16/2020 with an admitting principal diagnosis of HIV disease. Other diagnoses included AKF, Type 2 DM with DN, Cirrhosis of Liver, Chronic Viral Hepatitis C, Dementia, Psychoactive Substance Abuse, Seizures and Tobacco Use. Review of Resident #1's Quarterly MDS with an ARD of 06/14/2023 revealed a BIMS score of 9 (Moderate Cognitive Impairment). Resident #1 required limited assistance with 1 person assistance for bed mobility and toileting. Supervision for transfers and eating. Resident #1's ROM was without impairment to extremities and he used a wheelchair mobility device. Review of Resident #1's Care Plan with a Target date of 10/04/2023 revealed an ADL self-care performance deficit r/t confusion, dementia, impaired balance, and use of psychotropic medications. Goal: Remain free of psychotropic drug complications that include: movement disorder, discomfort, hypotension, gait disturbance, constipation/ impaction, and cognitive / behavioral impairment. Interventions included in part . to discuss with MD and family ongoing need for use of medication. Review of Grievance report for Resident #1 dated 09/01/2023 at 3:45 p.m. reported by S5 SSD revealed Resident's girlfriend came to visit on 09/01/2023 when she was informed that Resident #1 was not in the facility. S5 SSD reported the Resident #1's girlfriend called Resident #1's mother on a 3-way call to inform her that Resident #1 was not in facility. RP, Resident #1's mother was upset that she was not called and informed of situation. Follow-up: S1 ADM and S5 SSD spoke with Resident #1's mother and girlfriend, they were informed that bounty hunters came with arrest warrants to get Resident #1 and they took him to jail. Paperwork was given to the Resident #1's girlfriend and she stated she will bring paperwork to Resident #1's mother and they will take care of situation. Resolution: Family was notified of where Resident #1 was and given paperwork. Date of notification 09/01/2023. Review of Resident #1's Discharge Summary by S5 SSD dated 8/28/2023 revealed status at time of discharge: Awake, alert, oriented x 3 and cooperative with staff. Medications at discharge released to the Bounty Hunters. Discharge plan: Unplanned discharge. Review of Resident #1's Nurses Notes with S2 DON revealed no documentation of notifying the RP of Resident #1's discharge from the facility. Interview on 10/03/2023 at 12:15 p.m. with S2 DON revealed there was no documentation noted in regards to residents discharge from the facility and should have been. Interview on 10/03/2023 at 12:55 p.m. with S2 DON revealed she thought Resident #1's mother/ RP was aware of resident's discharge from the facility on 08/28/2023. S2 DON confirmed she was not aware that Resident #1's mother / RP was not notified, but should have been. Interview on 10/03/2023 at 2:30 p.m. with S1 ADM revealed Resident #1's girlfriend came on Friday, 09/01/2023, to visit with the resident, and that is when she and Resident #1's RP were informed Resident #1 was discharged from the facility on 08/28/2023. S1 ADM confirmed she should have notified Resident #1's mother/ RP of resident's unplanned discharge from the facility on 08/28/2023, but did not. Resident #2 Review of Resident #2's Medical Record revealed an admission date of 05/10/2023 with a readmission date of 09/14/2023 with diagnoses that included Schizophrenia, Bipolar Disorder, MDD, recurrent, Anxiety Disorder, Hereditary and Idiopathic Neuropathy. Review of Resident #2's Quarterly MDS with an ARD of 02/24/2023 revealed a BIMS score of 03 (severe cognitive impairment) Resident #2 had behaviors of wandering, and physical and verbal behaviors towards others. Review of Resident #2's Care Plan with a Target date of 11/01/2023 revealed Resident displayed physically aggressive behavior and had delusions. Interventions included in part .to encourage family/ RP to visit and to notify my MD/ RP of changes in behaviors. Review of Resident #2's Nurses Notes revealed no documentation for notification of Resident #2's transfer to the hospital to Resident #2's RP. Interview on 10/03/2023 at 12:35 p.m. with S4 LPN revealed Resident #2 was in the process of being PEC'd for her behaviors. Resident #2 had orders to be sent to hospital to be medically cleared before admission to a psychiatric facility. S4 LPN stated she had called Resident #2's daughter/RP, to notify her of Resident #2's transfer to hospital, but did not document the notification and confirmed she should have. Interview on 10/03/2023 at 12:55 p.m. with S2 DON revealed Resident #2 was transported by ambulance to hospital for PEC order on 09/25/2023. S2 DON confirmed Resident #2's RP was not notified of resident's transfer to the hospital on [DATE] and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice and the comprehensive person-centered plan of care for 1 (Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. The facility failed to have Hydrocodone-Acetaminophen (a narcotic analgesic) 10-325 mg available to administer PRN when Resident #4 required it for pain. Findings: Review of the facility's policy titled Medication Administration Policy and Procedure revealed in part . Policy The facility shall provide medications as ordered by the physician. 35. Each dose of medication administered shall be properly recorded in the resident's medical record. Review of Resident #4's Medical Record revealed an admit date of 11/02/2022 with diagnoses that included: Other Secondary Parkinsonism; Other Lack of Coordination; Other Abnormalities of Gait and Mobility; Chronic Pain Syndrome; Spinal Stenosis, Thoracic Region; and Hereditary Idiopathic Neuropathy. Review of Resident #4's Quarterly MDS with an ARD of 05/11/2023 revealed a BIMS score of 15, indicating intact cognition. Resident #4 was coded as independent in bed mobility, transfers, dressing, toilet use, personal hygiene; and required supervision with one person physical assist with eating and bathing. Review of Section J revealed Resident #4 received a scheduled pain medication regimen and PRN pain medication. Review of Resident #4's Care Plan with a Target Date of 10/16/2023 revealed a problem of chronic pain related to a diagnosis of spinal stenosis as well as neuropathy with the following interventions, in part . Administer analgesia as per orders. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Monitor/record/report to nurse resident complaints of pain or requests for pain treatment. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Review of a document titled Grievance/Complaint Report dated 07/25/2023 at 10:45 a.m. for Resident #4 revealed in part . Describe concern using factual terms: Resident #4 stated he did not get his pain medication for the weekend. Review of Resident #4's 06/2023 and 07/2023 Medication Administration Record (MAR) revealed an order for Hydrocodone-Acetaminophen Oral Tablet 10-325 mg give 1 tablet by mouth every 4 hours as needed for pain related to Chronic Pain Syndrome, and Spinal Stenosis, Thoracic Region with a start date of 05/24/2023. Review of Resident #4's 07/2023 MAR revealed Hydrocodone-Acetaminophen 10-325 mg was administered on 07/22/2023 at 11:54 a.m. and not administered again until 07/25/2023 at 9:18 a.m. Review of Resident #4's Narcotic Usage sheets for Hydrocodone-Acetaminophen (Norco) 10-325 mg revealed the following in part . Narcotic Usage sheets for 06/18/2023 - 06/25/2023, 06/26/2023 - 07/05/2023, and 07/05/2023 - 07/22/2023 revealed Resident #4 required Hydrocodone-Acetaminophen at least daily, and twice daily on most days. On 07/22/2023, the count for Hydrocodone-Acetaminophen 10-325 mg was 0 after it was signed out as administered at 2:00 p.m. 07/23/2023 and 07/24/2023 - no Narcotic Usage sheets were noted. On 07/25/2023, the medication card had a start count of 30 and was signed as administered at 10:53 a.m. Review of a fax sent by the facility to the pharmacy on 07/05/2023 revealed a prescription for Hydrocodone-Acetaminophen 10-325 mg written on 07/03/2023 by Resident #4's physician. A fax confirmation was received on 07/05/2023 at 11:31 a.m. Review of the facility's pharmacy Delivery RX (Prescription) Details list revealed Resident #4's Hydrocodone-Acetaminophen 10-325 mg was delivered on 07/24/2023 at 9:25 p.m. Review of Resident #4 Nurses' Progress Notes revealed in part . 07/25/2023 resident stopped this nurse in hallway stating that the nurses are pitiful, I can't get nothing I need around here. I asked him what he needed and he stated I need someone to give me my @#%* pain pill. I told him I could take care of that for him, the he whipped his wheelchair around and went to his room cursing saying Don't bother. I informed his nurse to offer him a pain pill if it is time. She verbalized understanding. Resident #4 was interviewed on 08/01/2023 at 8:35 a.m. and 08/02/2023 at 3:40 p.m. regarding whether he had pain on 07/23/2023 and 07/24/2023, and received his pain medication. However, during the interview on 08/02/2023 at 3:40 p.m., Resident #4 stated he did not want the interviews to be disclosed. Interview on 08/03/2023 at 8:22 a.m. with S1 DON revealed Resident #4 ran out of Hydrocodone-Acetaminophen on 07/22/2023 and the pharmacy delivered his prescription on 07/24/2023. S1 DON confirmed Resident #4 was out of the medication from when it was last administered on 07/22/2023 (11:54 a.m.), until it was delivered on 07/24/2023, but should not have been. S1 DON stated his pain medication should have been in the facility for as needed administration as ordered. Interview on 08/03/2023 at 8:43 a.m. with S1 DON revealed the nurses should have called the pharmacy when Resident #4 was low on the medication and had them deliver it to the facility before he ran out. Interview on 08/03/2023 at 1:42 p.m. with S3 LPN, while looking at Resident #4's 07/2023 MAR, revealed she was his nurse on 07/24/2023 for the 2:00 p.m. to 10:00 p.m. shift. S3 LPN reported he was out of Norco that day. S3 LPN stated Resident #4 was very upset that day and said This is some [NAME]---. S3 LPN reported Resident #4 takes Norco at least daily for pain.

Based on interview and record review, the facility failed to ensure medications were available to be administered as ordered for 1 (Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. The facility failed to have Hydrocodone-Acetaminophen (a narcotic analgesic) 10-325 mg available to administer PRN when Resident #4 required it for pain. Findings: Review of the facility's policy titled Medication Administration Policy and Procedure revealed in part . Policy The facility shall provide medications as ordered by the physician. Review of a facility document titled Orders, Monitoring Guidelines revealed in part . Areas to Monitor Daily 4. Clinical Dashboard a. Number of Active and On Hold Medication Schedules for Each Resident i. Review the current medication count of all active and on hold pharmacy category orders for each resident. ii. This information can assist with billing and pharmacy reviews. Review of Resident #4's Medical Record revealed an admit date of 11/02/2022, with diagnoses that included: Other Secondary Parkinsonism; Other Lack of Coordination; Other Abnormalities of Gait and Mobility; Chronic Pain Syndrome; Spinal Stenosis, Thoracic Region; and Hereditary Idiopathic Neuropathy. Review of Resident #4's Quarterly MDS with an ARD of 05/11/2023 revealed a BIMS score of 15, indicating intact cognition. Resident #4 was coded as independent in bed mobility, transfers, dressing, toilet use, personal hygiene; and required supervision with one person physical assist with eating and bathing. Review of Section J revealed Resident #4 received a scheduled pain medication regimen and PRN pain medication. Review of Resident #4's Care Plan with a Target Date of 10/16/2023, revealed a problem of chronic pain related to a diagnosis of spinal stenosis as well as neuropathy with the following interventions, in part . Administer analgesia as per orders. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Monitor/record/report to nurse resident complaints of pain or requests for pain treatment. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Review of a document titled Grievance/Complaint Report dated 07/25/2023 at 10:45 a.m. for Resident #4 revealed in part . Describe concern using factual terms: Resident #4 stated he did not get his pain medication for the weekend. Review of Resident #4's 06/2023 and 07/2023 Medication Administration Record (MAR) revealed an order for Hydrocodone-Acetaminophen Oral Tablet 10-325 mg, give 1 tablet by mouth every 4 hours as needed for pain related to Chronic Pain Syndrome, and Spinal Stenosis, Thoracic Region, with a start date of 05/24/2023. Review of Resident #4's 07/2023 MAR revealed Hydrocodone-Acetaminophen 10-325 mg was administered on 07/22/2023 at 11:54 a.m., and not administered again until 07/25/2023 at 9:18 a.m. Review of Resident #4's Narcotic Usage sheets for Hydrocodone-Acetaminophen (Norco) 10-325 mg revealed the following in part . Narcotic Usage sheets for 06/18/2023 - 06/25/2023, 06/26/2023 - 07/05/2023, and 07/05/2023 - 07/22/2023 revealed Resident #4 required Hydrocodone-Acetaminophen at least daily, and twice daily on most days. On 07/22/2023, the count for Hydrocodone-Acetaminophen 10-325 mg was 0 after it was signed out as administered at 2:00 p.m. 07/23/2023 and 07/24/2023 - no Narcotic Usage sheets were noted. On 07/25/2023, the medication card had a start count of 30 and was signed as administered at 10:53 a.m. Review of a fax sent by the facility to the pharmacy on 07/05/2023 revealed a prescription for Hydrocodone-Acetaminophen 10-325 mg that was written on 07/03/2023 by Resident #4's physician. A fax confirmation was received on 07/05/2023 at 11:31 a.m. Review of the facility's pharmacy Delivery RX (Prescription) Details list revealed Resident #4's Hydrocodone-Acetaminophen 10-325 mg was delivered on 07/24/2023 at 9:25 p.m. Resident #4 was interviewed on 08/01/2023 at 8:35 a.m. and 08/02/2023 at 3:40 p.m. regarding whether he had pain on 07/23/2023 and 07/24/2023, and received his pain medication. However, during the interview on 08/02/2023 at 3:40 p.m., Resident #4 stated he did not want the interviews to be disclosed. Interview on 08/02/2023 at 10:58 a.m. with S1 DON revealed she faxed a new prescription for Resident #4 for Hydrocodone-Acetaminophen 10-325 mg to the pharmacy on 07/05/2023. S1 DON stated the pharmacy filled and delivered the prescription 07/24/2023. S1 DON reported on 07/01/2023 the facility switched to a new pharmacy, which was why a new script was written. Interview on 08/03/2023 at 8:22 a.m. with S1 DON revealed Resident #4 ran out of Hydrocodone-Acetaminophen on 07/22/2023, and the pharmacy delivered his prescription on 07/24/2023. S1 DON confirmed Resident #4 was out of the medication from when it was last administered on 07/22/2023 (11:54 a.m.), until it was delivered on 07/24/2023, but should not have been. Interview on 08/03/2023 at 8:43 a.m. with S1 DON revealed the pharmacy delivered the medication on 07/24/2023 at 9:25 p.m. S1 DON stated the nurses should have called the pharmacy when Resident #4 was low on the medication and had them deliver it to the facility before he ran out. S1 DON reported the pharmacy had the script she faxed on 07/05/2023, and would have been able to deliver it. S1 DON stated the nurses were to notify the pharmacy when there was approximately a week of medications remaining on a card. Telephone interview on 08/03/2023 at 8:58 a.m. with S2 LPN revealed the correct time of administration of Hydrocodone-Acetaminophen to Resident #4 on 07/22/2023 was 11:54 a.m. as documented on the MAR; however, she confirmed she incorrectly documented the administration time as 2:00 p.m. on the Narcotic Usage sheet on 07/22/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to protect the residents' right to be free from physical abuse by residents Resident #30, Resident #27, Resident #22, and Resident #17, for 15 residents (#1, #4, #5, #6, #12, #14, #31, #35, #36 and #37) out of 37 residents (#1-37) sampled for resident abuse. Findings: Review of the Facility's Policy titled Abuse Investigation and Reporting read in part: Role of Administrator: 5. The Administrator will ensure that any further abuse, neglect exploitation or mistreatment is prevented. Review of the facility's investigations revealed the following residents were accused of physically abusing other residents: Resident #30, Resident #27, Resident #22, and Resident #17. 1. Resident #30 Review of the facility's investigations revealed resident #30 was accused of resident to resident physical abuse of Resident #1 on 04/11/2023, Resident #4 on 04/01/2023, Resident #5 on 04/25/2023, Resident #6 on 01/27/2023 and 03/08/2023, and Resident #35 on 10/27/2022. Review of Resident #30's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included in part .Schizophrenia, Dementia, Diabetes Mellitus and Hypothyroidism. Review of Resident #30's Discharge MDS with an ARD of 02/16/2023 revealed a BIMS of 03, indicating severe cognitive impairment. The MDS revealed Resident #30 exhibits behaviors that put Resident #30 at significant risk for physical illness or injury, and exhibits behaviors that put others at risk for physical injury. Resident #30 was coded to require no set-up or physical help from staff for transfers, and walk in room and corridor. Observation on 05/16/2023 at 11:07 a.m. revealed Resident #30 resided on the men's locked unit, and was observed sitting on the side of his bed with S10 CNA present as 1:1 supervision staff. Interview with Resident #30 at that time revealed Resident #30 stated he hit other residents a long time ago because they were picking on him. Interview with S9 LPN on 05/22/2023 at 9:25 a.m. revealed that Resident #30 was doing okay at the moment. S9 LPN stated on 05/19/2023, Resident #30 was sent to the ER for PEC, but the hospital refused to PEC. S9 LPN revealed that when the resident goes out of this environment, his mood changes and he becomes non-hostile, so the hospital sees a different picture of the resident than what he is doing at the facility. S9 LPN stated that Resident #30 also had behaviors throughout the weekend and was sent to the hospital again, but nothing was done. S9 LPN stated Resident #30 had attempted to attack residents, yelling at them and was placed 1:1 while he was having his behaviors. Interview on 05/23/2023 at 1:48 p.m. with S2 DON revealed the facility was not confident that Resident #30 was in the most appropriate environment, and the facility was seeking alternative placement. S2 DON stated the staff were acting to protect other residents by often redirecting Resident #30, and reporting to the Administration Resident #30's escalating behaviors. Psych gives orders for medications as needed. Review of Resident #30's medical record revealed he was placed on continuous 1:1 supervision after his return to the facility from a behavioral hospital stay dated 04/27/2023 to 05/12/2023. Resident #30 has had no further incidences of resident to resident abuse after 04/25/2023. Resident #1 Review of a facility investigative report dated 04/11/2023 revealed the following in part . Resident #30's hand made contact with the back of Resident #1's head. Protective Actions included counseling and a medication change per Psych for Resident #30. Safe surveys and in-service on abuse, neglect, and exploitation initiated. Resident #30 was counseled and had a medication change following this incident. Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included in part .Unspecified Dementia with Behavioral Disturbance, Impulse Disorder, Schizoaffective Disorder and Anxiety Disorder. Review of Resident #1's Quarterly MDS with an ARD of 03/20/2023 revealed a BIMS score of 99, indicating unable to complete interview. The MDS revealed Resident #1 exhibited no physical or verbal behaviors; and was independent with no setup or physical help from staff for transfers, and walk in room, walk in corridor. Observation on 05/16/2023 at 10:56 a.m. revealed Resident #1 ambulating independently on the men's secure unit. Resident #1 smiled and was in no distress. Interview with Resident #1 on the above date and time was unsuccessful. Resident #4 Review of a facility investigative report dated 04/01/2023 revealed Resident #30's hand made contact with Resident #4's abdomen after a verbal altercation. The report revealed staff immediately intervened. Resident #30 was observed with small amount of blood to his lower lip. Both residents were transferred to the hospital. Resident #30 was not admitted to the hospital and returned to the facility that same day. Review of Resident #4's medical record revealed Resident #4 was admitted to the facility on [DATE]. Diagnoses included in part . Alzheimer's disease, Anxiety Disorder, Bipolar Disorder, and Schizophrenia. Review of Resident #4's Quarterly MDS with an ARD of 02/07/2023 revealed a BIMS score of 15, indicating cognitively intact. The MDS revealed the following: Physical behavioral symptoms directed toward others occurred 1-3 days; exhibits behaviors that put resident at significant risk for physical illness or injury and exhibits behaviors that put others at risk for physical injury. Review of Resident #4's functional status revealed he required supervision, set-up help only for transfers, and walk in room and corridor. Observation on 05/23/2023 at 3:40 p.m. of Resident #4 revealed he was sitting outside smoking. Interview at that time revealed Resident #4 had just returned from a home pass, and he had a good time on pass, but was glad to be back home. Resident #5 Review of a facility investigative report dated 04/25/2023 Resident #30's hands suddenly made contact with the neck and body of Resident #5. The report revealed they were immediately separated with no injuries noted on Resident #5. Resident #30 was placed 1:1 supervision until psych orders arrive. NP and RPs contacted, safe surveys and in-services on abuse, neglect, and exploitation initiated. Resident #30 was on 1:1 supervision until PEC'd on 04/27/2023. Resident #30 returned to the facility on [DATE] and was placed on continuous 1:1 supervision. Review of Resident #5's medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnosis included in part .Unspecified Dementia with Psychotic Disturbance, Insomnia, Mild Cognitive Impairment and Depression. Review of Resident #5's Quarterly MDS with an ARD of 04/07/2023 revealed a BIMS score of 01, indicating severe cognitive impairment. The MDS revealed Resident #5 exhibited no physical or verbal behaviors; and required supervision with one person physical assistance for transfer, walk in room, and walk in corridor. Resident #6 Review of a facility investigative report dated 01/27/2023 revealed Resident #30's hand made contact with Resident #6's face. Resident #30 accused Resident #6 of talking about his mother before making contact. The residents were immediately separated and Resident #30 was placed on 1:1 supervision. Both residents denied pain or trauma. RPs, NP and Psych were notified and PEC was obtained for Resident #30. Resident #30 was on 1:1 supervision until PEC'd on 01/28/2023. Resident #30 returned to the facility on [DATE]. Review of a facility investigative report dated 03/08/2023 revealed Resident #30's hand made contact with Resident #6's face. The residents were immediately separated, and Resident #6 was assessed with no injuries noted. Resident #30 was placed 1:1 supervision until PEC to a behavioral center. Safe surveys and in-service on abuse, neglect and exploitation. Resident #30 was on 1:1 supervision until PEC'd on 03/08/2023. Resident #30 returned to the facility on [DATE]. Review of Resident #6's medical record revealed an admission date of 12/22/2022. Diagnoses included in part .Schizophrenia, Anxiety Disorder, Essential Hypertension, and Seizures. Review of Resident #6's Quarterly MDS with an ARD of 04/12/2023 revealed a BIMS score of 08, indicating moderate cognitive function. Resident #6's MDS revealed no physical or verbal behaviors were exhibited; and Resident #6 was independent for transfers and walk in room; and supervision with no setup or physical help from staff for walk in corridor. Observation on 05/16/2023 at 11:24 a.m. revealed Resident #6 walking independently in the hallway on the secured men's unit. Interview of Resident #6 on the above date and time revealed he has been in fights with other residents, and stated he wanted to move back to his family home with his mother. Resident #35 Review of a facility investigative report dated 10/27/2022 revealed Resident #35's hand made contact with the back of Resident #35's head. Resident #35 was placed on 1:1 supervision pending PEC. Resident #35 was assessed and noted to have no injuries. Safe surveys were done on cognitively intact residents with no findings. All staff was in-serviced on abuse, neglect, and exploitation as well as handling residents with challenging behaviors. Resident #30 was PEC'd on 10/27/2023. Resident #30 returned to the facility on [DATE]. Review of Resident #35's medical record revealed Resident #35 was admitted to the facility on [DATE]. Diagnoses included in part .Schizoaffective Disorder-Bipolar Type, Seizures, Wernicke's encephalopathy, Chronic Viral Hepatitis C, Alcohol Dependence, Personal History of Mental and Behavioral Disorders and Receptive-Expressive Language Disorder. Review of Resident #35's Quarterly MDS with an ARD of 04/13/2023 revealed a BIMS score of 03, indicating severe cognitive impairment. The MDS revealed Resident #35 exhibited no physical or verbal behaviors; and was independent with no setup or physical help from staff for transfers, walk in room and walk in corridor. Review of Resident #35's care plan with a target date of 06/06/2023 revealed in part . I have impaired cognition function, impaired thought processes. (10/27/2022 Res. to Res) Goal: I will attempt to make routine daily decisions with cues/supervision. Interventions reviewed and appropriate. 2. Resident #27 Review of the facility's investigation report revealed Resident #27 was accused of resident to resident abuse of Resident #14 on 05/06/2023 and Resident #12 on 05/09/2023. Review of Resident #27's medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included in part .Schizoaffective disorder-bipolar type, Type 2 Diabetes Mellitus, Epilepsy, Personal History of TIA and Cerebral Infarction without Residual Effects, Anxiety Disorder and Insomnia. Review of Resident #27's admission MDS with an ARD of 03/17/2023 revealed a BIMS of 08, indicating moderate cognitive function. Resident #27 was coded for verbal behaviors directed towards others, and other behavioral symptoms not directed towards others occurred 1 to 3 days; Yes was coded for overall presence of behavioral symptoms; and wandering and rejection of care occurred 1 to 3 days. The MDS revealed Resident #27 required supervision with transfers, walking in room, and walking in corridor. Review of Resident #27's care plan with a target date 06/26/2023 revealed: I had a physical altercation with another resident. Goal: I will not exhibit physical altercations towards other over the next review - Interventions: Notify my RP and MD of my behaviors, staff immediately intervened when the incident occurred. I have behavioral problem related to bipolar schizophrenia, resident has rejected care, has attempted to wander. - Goal: I will have fewer episodes of behavior by review date - Interventions reviewed and appropriate. Review of the Physicians Orders revealed the following in part . 1. Seroquel (an antipsychotic used to treat schizophrenia and bipolar disorder), 50 mg give 5 tablets at bedtime - Start Date 04/24/2023. 2. Seroquel 50 mg give 3 tablets daily - Start Date 04/25/2023 Review of Resident #27's Progress Notes dated 05/06/2023 and documented by S5 LPN read as followed in part . 05/06/2023 at 5:30 a.m. - Resident #27 was found by S4 CNA standing over Resident #14 hitting/fighting with her. S4 CNA removed Resident #27 from her room and escorted her into the dayroom. When asked Resident #27 why she hit her roommate, this resident states I didn't hit nobody she took my man. 05/06/2023 at 11:27 a.m. - NP ordered to increase Seroquel by 50 mg BID. If resident starts hitting again send to hospital. Review of the MAR for 05/2023 revealed the order on 05/06/2023 at 11:27 a.m. to increase Seroquel by 50 mg BID, was never transcribed and; therefore, was never administered to Resident #27. Review of Resident #27's medical record revealed there was no documentation that Resident #27 exhibited behaviors on 05/07/2023 and 05/08/2023. Review of Resident #27's progress notes dated 05/09/2023 documented by S3 LPN read as follows: 05/09/2023 at 3:25 a.m. - Resident #27 was walking from her room and down the hallway stating she wanted to get out of this jail. S4 CNA documented that she tried redirecting Resident #27 . S4 CNA documented Resident #27 had been slamming doors all night. Resident #27 pushed open the bathroom door and hit resident #12 in the face, resulting in a laceration to the forehead. Interview on 05/19/2023 at 9:50 a.m. with S5 LPN revealed she worked with Resident #27 on the night shift on 05/06/2023. S5 LPN stated she was informed by a CNA that Resident #27 was in the dayroom, and was standing over Resident #14 and hitting her. S5 LPN stated by the time she got to the day room, the CNAs had separated the residents. S5 LPN stated she texted the Psych NP to inform her about the incident, and received an order to increase Resident#27's Seroquel by 50 mg BID via a text back from the Psych NP. S5 LPN stated she did not receive the text back from the Psych NP until she was off duty and at home. S5 LPN stated she forwarded the text of the order to S2 DON when she received it because she was not on duty, or at the facility. Interview on 05/19/2023 at 9:59 a.m. with S7 LPN revealed she was the day shift nurse on 05/06/2023 and 05/07/2023. S7 LPN stated she did not remember getting a message to increase the Seroquel on Resident #27 due to aggressive behaviors. Interview on 05/19/2023 at 10:20 a.m. with S2 DON confirmed she received a message from S5 LPN regarding an order from the Psych NP to increase Seroquel on Resident #27. S2 DON stated the order was to increase Seroquel by 50 my BID. S2 DON stated she forwarded the order via message to S7 LPN. S2 DON confirmed the order on 05/06/2023 to increase Seroquel by 50 mg BID was never carried out and administered. Interview on 05/19/2023 at 2:42 p.m. with S3 LPN revealed she worked 05/09/2023, the night Resident #27 was exhibiting aggressive behaviors and injured Resident #12. S3 LPN stated Resident #27 was exhibiting aggressive behaviors most of the night, and was continuously being redirected by staff. S3 LPN stated Resident #27 had been slamming doors before she flung open the bathroom door causing the injury to Resident #12. S3 LPN stated after the incident with Resident #12, Resident #27 continued to exhibit aggressive behaviors and broke the magnet on the door to the secured unit by pushing aggressively and with force on the locked door; broke the magnetized door to the secured unit; and broke a window in the dayroom of the secured unit. Psych NP was notified of Resident #27's behaviors on 05/09/2023 at 8:43 a.m. Resident #27 was PEC'd and assigned 1:1 supervision while awaiting transfer. Resident #27 was transferred via ambulance on 05/09/2023 at 5:10 p.m. to a Behavioral Center. Interview on 05/19/2023 at 12:47 a.m. with Psych NP revealed Seroquel is a mood stabilizer and has a calming effect. Psych NP stated that if the facility had increased the Seroquel as ordered on 05/06/2023, Resident #27's aggressive behaviors would have decreased. Interview on 05/22/2023 at 7:40 a.m. with S11 LPN revealed Resident #27, who resides on the women's locked unit, was PEC'd to a behavioral hospital on [DATE] at 5:10 p.m, and returned to the facility on [DATE]. Resident #27 has had no further incidences of resident to resident abuse since her return to the facility from a behavioral hospital on [DATE]. Resident #14 Review of a facility investigative report dated 05/06/2023 revealed Resident #27's hand made contact with Resident #14's arm. The report revealed both residents were immediately separated. Resident #27 was placed 1:1 supervision until interventions effective. Resident #14 assessed with a small skin tear noted. Psych, NP, RPs contacted, safe surveys and in-service on abuse/neglect/exploitation initiated. Review of Resident #14's medical record revealed Resident #14 was admitted to the facility on [DATE]. Diagnoses included in part .Alzheimer's disease, Anxiety Disorder, Unspecified Psychosis not due to Substance or Known Physiological Condition, and Major Depressive Disorder. Review of Resident #14's Significant Change MDS with an ARD of 04/12/2023 revealed a BIMS of 00 indicating severe cognitive impairment. The MDS revealed Resident #14 exhibited no physical or verbal behaviors; and required 2 plus persons physical assist with transfer, walk in room, walk in corridor, and locomotion on/off unit. Review of Resident #14's Progress Notes revealed in part . 05/06/2023 5:32 a.m. Resident #14 was hit in bed asleep when Resident #27 stood over her and hit her in the face. The resident was removed from the room and into another room for safety. Noted skin tear to right side of face. Resident showed no signs of pain at this time. VS taken. NP, RP, ADM notified. Observation on 05/16/2023 at 9:44 a.m. revealed Resident #14 in the day room of the women's secure unit, seated in her wheelchair. Interview on 05/16/2023 at 9:44 a.m. with Resident #14 revealed she felt safe at the facility. Resident #12 Review of a facility's investigative report dated 05/09/2023 revealed the Floor nurse reported that Resident #27 was walking to the hallway bathroom and shove door open, door making contact with Resident #12 attempting to exit from the other side. Residents separated and assessed with mark noted on Resident #12's forehead. Resident #12 sent out for evaluation and Resident #27 placed on 1:1 while psych was contacted. RP and NP contacted. Safe surveys and in-service on abuse/neglect/exploitation initiated. Review of Resident #12's medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses that included: History of Traumatic brain Injury, Major Depressive Disorder, PTSD, Muscle Weakness and Lack of Coordination. Review of Resident #12's Annual MDS with an ARD of 04/06/2023 revealed a BIMS score of 11, indicating moderate cognitive function. Resident #12 required limited assistance with one person physical assist with walk in corridor and supervision with one person physical assist with walk in room. Review of Resident #12's progress notes revealed in part . 05/09/2023 at 3:55 a.m. - Resident #12 was on the floor when summoned to the bathroom. Noted bleeding from the left side of the forehead .There was a laceration above the left eyebrow. Resident #12 alert, oriented and able to explain what happened. 05/09/2023 at 8:15 a.m. - Resident #12 returned to facility via ambulance with 7 sutures above left eye with dressing clean, dry, and intact. Resident stable at this time and is requesting breakfast. Observation on 05/19/2023 at 8:30 a.m. revealed Resident #12 seated in a wheelchair in the day room of the women's secured unit. Yellow-green bruising was observed to the left side of her forehead and left cheek, and sutures noted to her left eyebrow. Interview on 05/19/2023 at 8:30 a.m. with Resident #12 revealed she received the bruises on her face and the cut to her eyebrow when another resident flung open the door to the bathroom hitting her in the face, and causing her to fall to the floor. 3. Resident #22 Review of the facility's investigations revealed resident #22 was accused of resident to resident physical abuse of Resident #31 on 02/17/2023 and 03/01/2023, and Resident #12 on 04/24/2023. Review of Resident #22's medical record revealed Resident #22 was admitted to the facility on [DATE]. Diagnoses included in part . Hemiplegia and hemiparesis following Cerebral Infarction affecting Left Dominant Side. Seizures, Anxiety Disorder, GERD, Schizoaffective Disorder-Bipolar Type, Insomnia, and Vascular Dementia Severe with Behavioral Disturbance. Review of Resident #22's Quarterly MDS with an ARD date of 03/30/2023 revealed the following: BIMS score of 00, indicating severe cognitive impairment. Physical behavioral symptoms directed toward others - Behavior of this type occurred 1 to 3 days Resident wandered - Behavior of this type occurred 1 to 3 days. Functional Status: Transfer with supervision, setup help only. Walk in room, walk in corridor with supervision, setup help only. Locomotion on and off unit with supervision, set up help only. Review of Resident #22's Care plan with a target date of 07/18/2023 revealed: I have episodes of verbal or physical behaviors symptoms as evidenced by history of harm to others. Goal: I will not harm self or others through the review date. Interview on 05/22/2023 at 7:40 a.m. with S11 LPN revealed Resident #22 had been PEC'd to a behavior hospital on [DATE], and had not returned to the facility. Resident #31 Review of a facility investigative report dated 02/17/2023 revealed Resident #22's hand make contact with Resident #31's head. Staff immediately intervened and separated the residents. Resident #31 was placed 1:1 supervision while a PEC was being issued. Nurse assessed Resident #31 with no signs of injury, vitals within normal ranges, and Resident #31 denied pain or trauma. Safe surveys and in-service on abuse, neglect, and exploitation were initiated. Resident #22 was on 1:1 supervision until PEC'd on 02/17/2023. Resident #22 returned to the facility on [DATE]. Review of a facility investigative report dated 03/01/2023 revealed Resident #22's hand made contact with Resident #31's neck. The residents were immediately separated and Resident #31 was assessed with only redness reported. Resident #31's vital signs were within normal range. Resident #22 was ordered 1:1 supervision until PEC was obtained to send to a behavioral center. Safe Surveys and in-service on abuse, neglect, and exploitation initiated. Resident #22 was on 1:1 supervision until PEC'd on 03/02/2023. Resident #22 returned to the facility on [DATE]. Review of Resident #31's medical record revealed Resident #31 was admitted to the facility on [DATE]. Diagnoses included in part . Schizoaffective Disorder-Depressive Type, Anxiety Disorder, Unspecified Dementia with Agitation, Essential Hypertension and Personal History if TIA. Review of Resident #31's admission MDS with an ARD of 01/31/2023 revealed the following: BIMS score of 99, indicating cognitive assessment unable to be completed. Behaviors: Delusions was marked yes. Functional Status: Transfer - extensive assistance with one person physical assistance. Walk in room and walk in corridor with supervision, set up help only. Locomotion on and off unit with extensive assistance one person physical assistance. Review of Resident #31's care plan revealed: Limited physical mobility related to dementia and general medical condition. Goal: Remain free from complications related to immobility. Interventions reviewed and appropriate. I have episodes of verbal or physical behavioral symptoms. Goal: The resident will not self-harm or harm others. Interventions reviewed and appropriate. I have impaired cognitive function related to Dementia. Goal: Resident will attempt to make routine decisions with cues/supervision. Interventions reviewed and appropriate. Resident #31 had been discharged from the facility. Resident #12 Review of a facility investigative report dated 04/24/2023 revealed Resident # 22's hand made contact with the back of Resident #12's head. Both were immediately separated and Resident #12 assessed with no injury noted. Resident #22 placed 1:1 supervision until interventions effective. Psych NP, RPs notified, safe surveys and in-service on abuse, neglect and exploitation initiated. Resident #22's care plan was reviewed and revised on 04/24/2023 to address verbal and physical behaviors. Review of Resident #12's medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses that included: History of Traumatic brain Injury, Major Depressive Disorder, PTSD, Muscle Weakness and Lack of Coordination. Review of Resident #12's Quarterly MDS with an ARD date of 04/06/2023 revealed the following: BIMS of 11, indicating moderate cognitive function. Behavior: Physical and verbal behavioral symptoms directed toward others - Behavior of this type occurs 1 -3 days. Wandering - Behavior of this type occurred 1 to 3 days Functional Status: Transfer with limited assistance - one person physical assist. Walk in room with supervision - one person physical assist. Walk in corridor with limited assistance - one person physical assist. Locomotion on and off unit with limited assistance - one person physical assist. Observation on 05/16/2023 at 10:32 a.m. revealed Resident #12 resting in bed. Resident #12 stated she doesn't know if any of the other residents have hit her. She closed her eyes and did not answer any more questions. 4. Resident #17 Review of the facility's investigations revealed resident #17 was accused of resident to resident physical abuse of Resident #36 on 01/13/2023, Resident #37 on 02/21/2023, and Resident #10 on 04/10/2023. Review of Resident #17's medical record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses that included: Anemia, Diabetes Mellitus, Hemiplegia, Seizure Disorder, Depression and Schizophrenia. Review of Resident #17's Quarterly MDS with an ARD of 03/23/2023 revealed the following: BIMS of 15, indicating cognitively intact. Behaviors: No physical or verbal behaviors were exhibited. Functional Status: Transfers - total dependence with one person physical assist. Locomotion on and off unit - supervision with one person physical assist. Observation on 05/16/2023 at 9:58 a.m. revealed the Resident #17 seated in a wheelchair outside smoking. Interview at that time with Resident #17 revealed he does not have any problems with any of the residents here at the facility. Resident #17 stated none of the other residents are getting on his nerves. Resident #17 stated he has not been fighting with any other residents. Review of Resident #17's Care plan with a completed date of 04/16/2023 revealed Resident #17 was care planned for behaviors and can be aggressive towards others due to medical diagnosis of Schizophrenia. Review of Resident #17's medical record revealed the Psych NP and MD were contacted after the incidences on 01/13/2023, 02/21/2023 and 4/10/2023 with no new orders. Review of facility investigation reports, and Resident's #17's medical record revealed no further incidences of resident to resident abuse since 04/10/2023. Resident #36 Review of the facility investigation report dated 01/13/2023 revealed Resident #17's hand made contact with Resident #36. Residents were separated immediately. Resident #36 was assessed and no injuries observed, denies pain. Resident #17 was assessed and no injuries observed, denies pain. Resident #17 was redirected to his room on 1:1 pending PEC order. Safe surveys have been initiated. In-services initiated on abuse, neglect, misappropriation and caring for residents with challenging behaviors. Resident #17 was on 1:1 supervision until PEC'd on 01/13/2023. Resident #17 returned to the facility on [DATE]. Review of Resident#36's medical record revealed Resident #36 was admitted to the facility on [DATE] with diagnoses that included in part .Seizures, COPD, Intellectual Disabilities, Cerebral Infarction, Schizoaffective Disorder-Depressive Type, Anxiety disorder and Encephalopathy. Review of Resident #36's Quarterly MDS with an ARD of 02/09/2023 revealed the following: BIMS of 13, indicating cognitively intact. Behaviors: No physical or verbal behaviors were exhibited. Functional Status: Transfer - supervision, one person physical assist. Locomotion on and off unit - supervision, one person physical assist. Review of Resident #36's care plan with a target date of 05/27/2023 revealed: I have behaviors as a result of my diagnoses of Schizophrenia. Goal: I will have minimal to no evidence of behavioral problems by review date. Interventions reviewed and appropriate. Interview on 05/25/2023 at 11:25 a.m. with Resident #36 revealed he was not afraid, and has no problems with any of the other residents at the facility. Resident #37 Review of a facility investigation report dated 02/12/2023 revealed Resident #17's hand came in contact with Resident #37 while they were in a verbal altercation. Residents were separated and assessed. Both deny trauma and pain, no injuries or redness noted either resident. Resident #17 placed on 1:1 supervision until he was sent out to ER, NP and RPs notified. Safe surveys and in-service on abuse, neglect, and exploitation initiated. Resident #17 was transferred to a local hospital for evaluation. Resident #17 returned to the facility that same day. Review of Resident#37's medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses that included in part .Epilepsy, Major Depressive Disorder, with Psychotic Symptoms, Undifferentiated Schizophrenia, Insomnia, PTSD, Restlessness and Agitation. Review of Resident #37's Quarterly MDS with an ARD of 04/12/2023 revealed the following: BIMS of 15, indicating cognitively intact. Behaviors: No physical or verbal behaviors were exhibited. Functional Status: Transfer - extensive assistance, two plus person physical assist. Locomotion on and off unit - supervision, set up help only. Review of Resident #37's care plan with a target date of 07/25/2023 revealed: I attend Compass behavioral health IOP Monday - Thursday. Goal: I will attend and actively participate in the program. Interventions reviewed and appropriate. Impaired thought processes r/t schizophrenia. Verbal aggression. Goal: I will maintain current level of cognitive function through the review date. Interventions reviewed and appropriate. Interview on 05/25/2023 at 11:15 a.m. with Resident #37 revealed he was not afraid in the facility. Resident #37 stated he felt safe, and that he has no problems with any of the other residents. Resident #10 Review of a facility investigative report dated 04/10/2023 revealed Resident #17 hand was observed making contact with Resident #10's face. Resident #17 told CNA who observed and separated residents that Resident #10 ran over his foot with his wheelchair. Once separated, Resident #17 was placed 1:1 supervision while NP, RPs and psych were contacted. Both residents assessed with no injuries noted. Safe surveys and in-service on abuse, neglect, and exploitation initiated. Resident #17 apologized to Resident #10 and were no further incidents. Review of Resident #10's medical record revealed Resident #10 was admitted to the facility on 12/01[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents are free of any significant medication errors. The facility failed to ensure a resident was administered an increase in an antipsychotic medication due to aggressive behaviors, for 1 (#27) of 37 (1-37) residents reviewed. Findings: Review of the facility's policy titled Physician's Orders revealed in part . Policy Interpretation and Implementation . 2. Orders must be put into the Electronic Medical Record by the person receiving the order and recorded in the resident's medical record. Review of Resident #27's medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses that included in part .Schizoaffective Disorder: Bipolar Type, Epilepsy, TIA and Cerebral Infarction without Residual Effects, Anxiety Disorder and Insomnia. Review of Resident #27's admission MDS with an ARD of 03/17/2023 revealed the following in part . BIMS score of 8, indicating moderate cognitive function; exhibited verbal behaviors directed towards others, and other behavioral symptoms not directed towards others - occurred 1 to 3 days; and refused care and wandered - occurred 1 to 3 days. Resident #27's functional status revealed he required supervision with setup help only for bed mobility, transfers, walk in room and corridor, locomotion on and off the unit; and no ROM impairment for upper and lower extremities. Review of the Physicians Orders revealed the following in part . 1. Seroquel (an antipsychotic used to treat schizophrenia and bipolar disorder), 50 mg give 5 tablets at bedtime - Start Date 04/24/2023. 2. Seroquel 50 mg give 3 tablets daily - Start Date 04/25/2023, and Divalproex (an anticonvulsant) 500 mg 2 tabs 2 times a day. Review of Resident #27's care plan with a target date of 06/26/2023 included the following problem: I have behavioral problems related to bipolar schizophrenia, resident has rejected care, has attempted to wander. Goal: I will have fewer episodes of behavior by review date. Interventions: Administer medications as ordered, explain /reinforce why the behavior is inappropriate and/or unacceptable to the resident. Review of Resident #27's Progress Notes dated 05/06/2023 and documented by S5 LPN read as followed in part . 05/06/2023 at 5:30 a.m. - Resident #27 was found by S4 CNA standing over Resident #14 hitting/fighting with her. S4 CNA removed Resident #27 from her room and escorted her into the dayroom. When asked Resident #27 why she hit her roommate, this resident states I didn't hit nobody she took my man. 05/06/2023 at 11:27 a.m. - NP ordered to increase Seroquel by 50 mg BID. If resident starts hitting again send to hospital. Interview on 05/19/2023 at 9:50 a.m. with S5 LPN revealed she worked with Resident #27 on the night shift on 05/06/2023. S5 LPN stated she was informed by a CNA that Resident #27 was in the dayroom, and was standing over Resident #14 and hitting her. S5 LPN stated by the time she got to the day room, the CNAs had separated the residents. S5 LPN stated she texted the Psych NP to inform her about the incident, and received an order to increase Resident#27's Seroquel by 50 mg BID via a text back from the Psych NP. S5 LPN stated she did not receive the text back from the Psych NP until she was off duty and at home. S5 LPN stated she forwarded the text of the order to S2 DON when she received it because she was not on duty, or at the facility. Interview on 05/19/2023 at 9:59 a.m. with S7 LPN revealed she was the day shift nurse on 05/06/2023 and 05/07/2023. S7 LPN stated she did not remember getting a message to increase the Seroquel on Resident #27 due to aggressive behaviors. Interview on 05/19/2023 at 10:20 a.m. with S2 DON confirmed she received a message from S5 LPN regarding an order from the Psych NP to increase Seroquel on Resident #27. S2 DON stated the order was to increase Seroquel by 50 my BID. S2 DON stated she forwarded the order via message to S7LPN. S2 DON confirmed the order on 05/06/2023 to increase Seroquel by 50 mg BID was never carried out and administered. Review of the MAR for 05/2023 revealed the order on 05/06/2023 at 11:27 a.m. to increase Seroquel 50 mg BID was never transcribed to the MAR, and was never administered to Resident #27. Interview on 05/19/2023 at 2:42 p.m. with S3 LPN revealed she worked 05/09/2023, the night Resident #27 was exhibiting aggressive behaviors and injured Resident #12. S3 LPN stated Resident #27 was exhibiting aggressive behaviors most of the night, and was continuously being redirected by staff. S3 LPN stated Resident #27 had been slamming doors, and broke the magnet on the door to the secured unit by pushing aggressively and with force on the locked door; broke the magnetized door to the secured unit; and broke a window in the dayroom of the secured unit. Psych NP was notified of Resident #27's behaviors on 05/09/2023 at 8:43 a.m. Resident #27 was PEC'd and assigned 1:1 supervision while awaiting transfer. Resident #27 was transferred via ambulance on 05/09/2023 at 5:10 p.m. to a Behavioral Center. Interview on 05/19/2023 at 12:47 a.m. with Psych NP revealed Seroquel is a mood stabilizer and has a calming effect. Psych NP stated that if the facility had increased the Seroquel as ordered on 05/06/2023, Resident #27's aggressive behaviors would have decreased.

Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for 3 (Resident #1, Resident #3, and Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. Findings: Review of the Facility's Policy titled Acute Condition Changes - Clinical Protocol revealed in part Assessment and Recognition 7. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response. 10. The nurse and the physician will discuss and evaluate the situation. a. The physician should request information to clarify the situation; for example, vital signs, physical findings, a detailed sequence of events and description of symptoms. Monitoring and Follow-Up 4. Documentation shall follow current standards of practice. Resident #1 Review of Resident #1's medical record revealed an admit date of 10/26/2022 with diagnoses that included: Bipolar Disorder; Other Psychoactive Substance Use, unspecified, with Psychoactive Substance-Induced Mood Disorder; Type 2 Diabetes Mellitus; Post-Traumatic Stress Disorder; Acute and Chronic Respiratory Failure; and Chronic Obstructive Pulmonary Disease. Review of Resident #1's Quarterly MDS with an ARD of 01/26/2023 revealed a BIMS score of 15, indicating intact cognition. Resident #1 required set up help and supervision with locomotion on and off unit. Review of Resident #1's Progress Notes revealed in part . 02/21/2023 5:47 p.m. Type: Behavior Note Administrator was alerted by activity staff to suspicious activity outside of the facility pertaining to Resident #1 smoking an illicit substance, Administrator and staff approached Resident #1 and the other two residents outside . Administrator and staff addressed the smell of marijuana and Resident #1 surrendered the joint that she claimed all three were sharing. The three were observed to have altered mental statuses . Author: S1 Administrator Resident #3 Review of Resident #3's medical record revealed an admit date of 05/19/2022 with diagnoses that included: Congestive Heart Failure, Dysphagia, Alcohol Abuse, Other Psychoactive Substance Abuse, Chronic Kidney Disease, and Chronic Obstructive Pulmonary Disease. Review of Resident#3's Quarterly MDS with an ARD of 02/13/2023 revealed a BIMS score of 15, indicating intact cognition. Resident #3 required one person physical assist and supervision with locomotion on and off unit. Review of Resident #3's Progress Notes revealed in part . 02/21/2023 5:48 p.m. Type: Behavior Note Administrator was alerted by activity staff to suspicious activity outside of the facility pertaining to residents smoking an illicit substance, Administrator and staff approached Resident #3 and the other two residents outside . Administrator and staff addressed the smell of marijuana and a resident surrendered the joint that she claimed all three were sharing. The three were observed to have altered mental statuses . Author: S1 Administrator Resident #4 Review of Resident #4's medical record revealed an admit date of 11/02/2022 with diagnoses that included: Other Secondary Parkinsonism, Neuropathy, Muscle Weakness, Spinal Stenosis, and Chronic Viral Hepatitis C. Review of Resident #4's Quarterly MDS with an ARD of 02/09/2023 revealed a BIMS score of 15, indicating intact cognition. Resident #4 required one person physical assist and supervision with locomotion on and off the unit. Review of Resident #4's Progress Notes revealed in part . 02/21/2023 5:48 p.m. Type: Behavior Note Administrator was alerted by activity staff to suspicious activity outside of the facility pertaining to residents smoking an illicit substance, Administrator and staff approached Resident #4 and the other two residents outside . Administrator and staff addressed the smell of marijuana and a resident surrendered the joint that she claimed all three were sharing. The three were observed to have altered mental statuses . Author: S1 Administrator Interview on 04/26/2023 at 1:03 p.m. with S3 Medical Records revealed she was the facility's Activities Director but recently changed positions to Medical Records. S3 Medical Records reported she was with S1 Administrator when Resident #1 was found with marijuana on facility grounds. S3 Medical Records stated Resident #3 and Resident #4 were sitting outside with Resident #1 at that time. S3 Medical Records reported Resident #4 was spaced out and said that he wished he was a bird so that he could fly freely. S3 Medical Records stated Resident #1 looked like a zombie and had no facial expressions or changes in her voice when speaking. In an interview on 04/26/2023 at 2:55 p.m. S1 Administrator, with S2 DON present, revealed Resident #1, Resident #3, and Resident #4 all had an altered mental status at the time of the marijuana discovery on 02/21/2023. S1 Administrator reported they were high. S1 Administrator confirmed he notified their nurses but did not inform their physician. S2 DON confirmed there was no documentation the physician was notified of Resident #1 smoking marijuana, an illegal substance, on facility grounds and she appeared high with an altered mental status, but there should have been. S2 DON confirmed there was no documentation the physician was notified Resident #3 and Resident #4 were found sitting with Resident #1 when the marijuana was discovered and they appeared high with an altered mental status, but there should have been. S2 DON reported the physician should have been notified of the altered mental status immediately.

Based on interview and record review the facility failed to ensure a personal funds statement was provided quarterly to the Resident's Representative for 4 (#1, #3, #4 and #6) of 6 (#1, #2, #3, #4, #5 and #6) sampled Residents. Findings: #1 Review of Resident #1's clinical record revealed diagnoses that included Unspecified Dementia with other behavioral disturbance, Schizoaffective disorder and Post-Traumatic Stress Disorder. Review of Resident #1's face sheet revealed it contained a Responsible Party with contact information. Telephone interview on 03/24/2023 at 5:00 p.m. with Resident #1's Responsible Party revealed financial statements had never been received from the facility. #3 Review of Resident #3's clinical record revealed diagnoses that included Schizophrenia, Impulse Control Disorder and Dementia. Review of Resident #3's face sheet revealed it contained a Responsible Party with contact information. Attempted telephone interview with Resident #3's Responsible Party was unsuccessful. #4 Review of Resident #4's clinical record revealed diagnoses that included Schizoaffective disorder and Seizure disorder. Review of Resident #4's face sheet revealed it contained a Responsible Party with contact information. Attempted telephone interview with Resident #4's Responsible Party was unsuccessful. #6 Review of Resident #6's clinical record revealed diagnoses that included Impulse Disorder, Personal history of traumatic brain injury, Schizoaffective Disorder; Bipolar type and Alzheimer's disease Review of Resident #6's face sheet revealed it contained a Responsible Party with contact information. Telephone interview on 03/27/2023 at 2:15 p.m. with Resident #6's Responsible Party revealed she was aware Resident #6 received $38.00 a month back from his check. Resident #6's Responsible Party also stated Resident #6 had another sister that sends him $25.00 month. Resident #6's Responsible Party revealed she had no idea if Resident #6 had money in his account at the facility because she has never received a statement. Interview on 03/28/2023 at 12:00 p.m. with S2 Business Office Manager revealed Resident's #1, #3, #4 and #6 did have trust accounts with the facility. S2 Business Office Manager stated he did not send out quarterly financial statements to Residents or Responsible Parties. S2 Business Office Manager stated he was not aware he was supposed to send out quarterly statements. S2 Business Office Manager stated S3 Corporate Business Office Manager may be responsible for sending out statements to Residents and/or Responsible Parties. Telephone interview on 03/28/2023 at 12:10 a.m. with S3 Corporate Business Office Manager revealed it was the responsibility of the facility's Business Office Manager to send out financial statements to Residents and Responsible Parties. Interview on 03/28/2023 at 12:12 a.m. with S1 Administrator revealed he was not aware the facility was required to send or provide Resident's and/or Responsible Parties quarterly financial statements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Resident to Resident abuse was thoroughly investigated for 1 (#4) of 3 Residents ( #2, #3, and #4) reviewed for abuse, in a total sample of 6 residents (#1, #2, #3, #4, #5 and #6). Findings: Review of the Facility's Policy titled Abuse Investigation and Reporting read in part: Role of Administrator: 5. The Administrator will ensure that any further abuse, neglect exploitation or mistreatment is prevented. Role of the Investigator: b. Review the Resident's medical record .events leading up .incident. c. Interview the person (s) reporting the incident. d. Interview any witness .incident. f. Interview the Resident's Attending Physician as needed Resident's current level of cognition function and medical condition. g. Interview staff members .contact with the Resident during the alleged incident. h. Interview the Resident's roommate, family members .visitors. i. Review all events leading .alleged incident. Observation on 03/27/2023 at 11:05 a.m. revealed Resident #4 was up in wheel chair in the hallway. The surveyor attempted to interview Resident #4 on the above date and time; however, Resident #4 would only say yea, yea to all questions asked. Review of Resident #4's EHR revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that included in part . Schizoaffective Disorder, Depressive Type, Anxiety Disorder, Acute Respiratory Failure with Hypoxia, Dysphasia, Metabolic Encephalopathy, Cerebral Infarction, Seizures, and Muscle wasting and Atrophy, right lower leg. Review of Resident #4's Quarterly MDS with an ARD of 03/02/2023 revealed Resident #4 had a BIMS of 01 (severely cognitively impaired). Resident #4 required supervision with set-up help for bed mobility, transfer from bed/chair, wheelchair, locomotion between rooms/adjacent corridor, locomotion on/off unit; limited 1 person physical assist for dressing; extensive 1 person physical assist with toilet use and personal hygiene; and total dependence on staff for bathing. Resident #4 uses a wheelchair for mobility. Review of Resident #4's Care Plan with a target date of 02/01/2023 revealed the following problems in part: 1. Self-care deficit as related to ADLs with interventions that included 1 person assistance with transfer; extensive 1 person assistance with bed mobility, dressing, personal hygiene care, toilet use (wears briefs), transfer; and one person total assistance for bathing/shower. 2. Deficit in communication r/t mental health disorder- allow ample time to communicate, be conscious of Resident position when in groups, activities, dining room to promote communication with others, monitor for /record confounding problems: decline in cognitive status, mood, decline in ADL, deterioration in respiratory status, oral motor function, and hearing. Review of the facility's investigation read in part: An incident occurred on 02/14/2023 at 11:15 a.m. - Staff reported Resident #5's hand made contact with Resident #4's face. Staff immediately separated the Residents. Head to toe assessment obtained for Resident #4. The investigative report for Resident #4 revealed there was no documentation of specific staff who were interviewed, the dates and times of the interviews or the results of the interviews. There were no documentation of a description of Resident #4's injury, if treatment was rendered, or treatment orders. Interview on 03/29/2023 at 9:45 a.m. with S2 ADON revealed there were no documentation of specific staff who were interviewed, the dates and times of the interviews or the results of the interviews. S2 ADON stated she did not know specific documentation regarding staff/potential witness interviews had to be documented. Interview on 03/29/2023 at 10:00 a.m. with S5 LPN revealed he and S1 Administrator typed up a statement this morning (03/29/2023) regarding the incident of resident to resident abuse that involved Resident #4 and Resident #5, which took place on 02/14/2023. S5 LPN confirmed he signed the statement this morning (03/29/2023), and dated the statement 02/14/2023. Interview on 03/29/2023 at 10:05 a.m. with S1 Administrator revealed the computerized investigations presented to surveyors were for the Resident to Resident altercation that occurred on 02/14/2023 involving Resident #4 and Resident #5. S1 Administrator confirmed the one document he presented that was typed and signed by S5 LPN this morning (03/29/2023) and dated for 02/14/2023, was the only documented evidence of staff interviewed. S1 Administrator confirmed there were no witness statements, and that according to the facility's policy, he didn't think that he needed to document potential witness interviews or obtain witness statements.

Based on interview and record review the facility failed to ensure each Resident's drug regimen was free from unnecessary drugs. The facility failed to evaluate the appropriateness for the continued use of a PRN psychotropic medication beyond 14 days for 1 (#5) of 6 (#1, #2, #3, #4, #5 and #6) Resident's sampled receiving psychotropic medications. Findings: Review of Resident #5's clinical record revealed diagnoses that included Schizoaffective disorder; Bipolar type, Unspecified Dementia, Psychotic Disturbance and Metabolic Encephalopathy. Review of Resident #5's Physician Order Summary Report revealed an order dated 01/03/2023 for Geodon (antipsychotic/psychotropic) Intramuscular Solution Reconstituted 20mg. Inject 20mg intramuscularly every 6 hours as needed for agitation. Review of Resident #5's inpatient behavioral hospital discharge medication list dated 01/25/2023 revealed Geodon was not listed as a discharge medication. Review of Resident #5's inpatient behavioral hospital discharge medication list dated 03/09/2023 revealed Geodon was not listed as a discharge medication. Review of Resident #5's 02/2023 and 03/2023 Medication Administration Record revealed Resident #5 received administrations of Geodon 20mg intramuscularly on 02/13/2023 and 03/11/2023. Review of the above Medication Administration Records revealed medication order dates for both administrations was 01/03/2023. Interview on 03/29/2023 at 3:20 p.m. with S6 ADON revealed Resident #5's order for PRN (as needed), psychotropic medication, Geodon, had been continued for longer than 14 days and should not have been. Interview on 03/29/2023 at 3:28 p.m. with S6 ADON revealed the PRN, psychotropic medication order for Geodon 20mg intramuscularly had not been continued on the inpatient behavioral hospital discharge medication lists dated 01/25/2023 and 03/09/2023. S6 ADON confirmed the order for Geodon 20mg intramuscularly every 6 hours as needed for agitation, should have been discontinued and had not been. S6 ADON confirmed Resident #5 received Geodon (antipsychotic/psychotropic) 20mg intramuscularly on 02/13/2023 and 03/09/2023 without having new orders based on evaluations to do so.

Based on observation, interview and record review, the facility failed to ensure an injury of unknown origin was investigated thoroughly in order to determine whether abuse or neglect occurred for 1 (#4) of 3 (#2, #4 and #5) investigations reviewed out of a total of 24 sampled residents (#1 - #24). The total facility census was 126 residents. Findings: Review of Resident #4's Face Sheet revealed an admission date of 07/29/2021. Diagnoses included Dementia with Behavioral Disturbance, Schizophrenia, Major Depressive Disorder, Post-Traumatic Stress Disorder and Cerebral Infarction. Resident #4's Quarterly MDS with an ARD of 12/02/2022, revealed a BIMS score of 99 (severely cognitively impaired). Resident #4's Care Plan, with a target date of 03/23/2023 revealed an ADL self-care performance deficit related to Dementia and Behavior. Resident sometimes refuses care. Resident has episodes of socially inappropriate behaviors- can be aggressive at times. Resident wanders and is disoriented to place. Observation of Resident #4 on 01/10/2023 at 9:30 a.m. revealed he was wandering about the dining room/unit. He was observed to be barefooted, and the back of his pants were wet. Resident #4 was not interviewable. Review of a facility investigation involving Resident #4 revealed an incident occurred/was discovered on 12/19/2022. The incident was listed as an injury of unknown origin and was described as a bruise and scratch. Review of documentation in the facility's investigation revealed S2 DON was notified on 12/19/2022 at approximately 4:45 p.m. of .some discoloration under the left eye . of Resident #4 and a .small 1 ½ cm scratch to the left side of his nose. The resident was unable to report what happened to cause the injuries. The NP was notified and ordered lab work due to the .resident being a little more confused than normal. Further documentation in the investigation revealed facility staff who worked the weekend prior to finding the discoloration were interviewed, and there were reports of a fall. Facility staff who were interviewed denied the resident having any discoloration or scratch prior to 12/19/2022. Review of the investigation revealed the results of the lab work ordered by the NP were attached. Those were the only attachments included in the investigation. There was no documentation of the names, dates or times of any staff who were interviewed. There was no documentation of the results of any of the staff interviews. Interview with S2 DON on 01/10/2023 at 11:10 a.m. revealed she began the investigation when she was notified of Resident #4's injury on 12/19/2022. S2 DON stated interviews were conducted with staff who worked with Resident #4 on the weekend prior to 12/19/2022, and no staff reported any falls. S2 DON stated there was a mistake in the facility investigation documentation where documentation revealed there were reports of falls. S2 DON stated the report should have read that there were no reports of any falls. S2 DON stated there was no documentation of specific staff who were interviewed, the dates and times of the interviews or the results of the interviews. S2 DON stated she did not know specific documentation regarding staff/potential witness interviews had to be documented. S2 DON confirmed the only information she had at that time of the investigation was the summary, Resident #4's Face sheet and results of the lab work completed on 12/21 and 12/23/2022. Review of the staffing schedule provided by S2 DON revealed the following staff worked with Resident #4 on 12/17 and 12/18/2022: S7 CNA, S8 CNA, S12 CNA, S13 CNA, S14 CNA, S15 CNA, S10 LPN and S11 LPN. Interview with S2 DON on 01/10/2023 at 1:40 p.m. revealed she was not aware she needed to document potential witness interviews or obtain witness statements. S2 DON stated interviews were conducted with S10 LPN, S11 LPN, S7 CNA, S12 CNA, S13 CNA and S15 CNA, but she stated there was no documentation of these interviews. On 01/13/2023, S2 DON provided documentation of interviews with three staff (S5 CNA, S12 CNA and S11 LPN) she conducted. Review of the documentation revealed the interviews were dated 12/19/2022. There was no additional documentation that all other potential witnesses were interviewed (S10 LPN, S7 CNA, S13 CNA and S15 CNA).

Based on observation and interview the facility failed to ensure garbage and refuse were disposed of properly. This deficient practice had the potential to affect all 126 Residents who resided in the facility. Findings: Observation on 01/11/2023 at 8:05 a.m. revealed 2 large blue dumpsters with white trash bags stacked to the top and unable to be closed shut. Interview on 01/11/2023 at 8:30 a.m. with S16 Maintenance Supervisor stated the trash had not been picked up for over a week, and the dumpsters were overflowing. He stated there was an area in the back of the Facility where more trash was being stored. He stated S14 Housekeeping/Laundry Supervisor was in charge of the trash pick. He confirmed that the dumpsters should not have had trash stacked so high and should have been closed, and they were not. Observation on 01/11/2023 at 8:45 a.m., accompanied by S14 Housekeeping/Laundry Supervisor, revealed a strong rotten/sour odor as we approached the rear of the Facility. There were numerous large white bags of trash (too many to count) on the ground, boxes on the ground and additional trash bags stacked on 3 old rolling carts inside of an aluminum fence which was unlocked and open. There were broken wheelchairs in corner of the fenced in area. On the outside of the aluminum fence, approximately 20 feet diagonally against a wooden fence, there were 5 large gray trash bags on the ground and folded boxes on a table. Interview on 01/11/2023 at 9:00 a.m. with S14 Housekeeping/Laundry revealed the last day trash was picked up at the Facility was on 01/02/2023. He stated the scheduled trash pick-up day were 3 times per week (Monday, Wednesday and Friday). He stated S1 Administrator was notified and contacted the local waste pick company and was informed that the trash would not be picked up until the bill was paid. He stated that the last email he received from the Cooperate office was the bill had been paid, and the trash would be picked up today (01/11/2023) and on Friday. Interview on 01/11/2023 at 9:30 a.m. with S1 Administrator confirmed that he was aware of the trash not being picked up for several days and had been in contact with Accounts Payable. He further confirmed that account had been suspended for non-payment but was now current. He stated the trash was scheduled for pick up today (01/11/2023) and Friday of this week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide adequate supervision for 1 (#24) of 20 residents on a locked unit to prevent accidents. This failed practice created an environment that was not free from accident hazards for the remaining 19 residents who had Psychiatric and/or behavioral diagnoses and were mobile (#4 and #s 7 - #24). The facility's total census was 126 residents. Findings: Review of the facility's Medication Administration policy revealed in part that the nurse should .Remain with the resident until all medications have been taken. Review of Resident #24's Face Sheet revealed a re-admit date of 01/02/2023. Diagnoses included: Schizophrenia, Muscle Weakness, Lack of Coordination, Chronic Lymphocytic Leukemia of B Cell type not having achieved remission and MRSA . Review of Resident #24's admission MDS with as ARD of 01/12/0223 revealed the admission MDS assessment was still in progress/not completed. Review of Resident #24's Plan of Care with a completion date of 01/04/2023 revealed in part . 1. I have Schizophrenia and had an episode of physical behavioral symptoms as evidence by packing up my roommate's clothes as well as mine. Interventions included: analyze times of day, places, circumstances, triggers and what de-escalate behavior and document; Communication - provide physical and verbal cues to alleviate anxiety, give positive feedback; resides on male unit. 2. At risk for falls dues to abnormalities of gait/mobility and lack of coordination. Interventions included: Keep call light in reach, encourage resident to voice needs as well as seek/await staff assist for transfers, ensure resident wears appropriate, well-fitting footwear to minimize risk of slipping, and keep environment clear of unnecessary objects. Observation on 01/10/2023 at 9:50 a.m. revealed three pills were noted on the floor next to Resident #24's bed. Interview with S7 CNA at that time confirmed the three pills were on the floor, and S7 CNA stated that Resident #24 received medications that morning from S4 LPN. Interview with S4 LPN on 01/10/2023 at 9:57 a.m. confirmed the three pills on the floor were some of the pills he administered to Resident #24 that morning. S4 LPN pointed to one of the medications on the floor and stated that's his cancer pill right there. S4 LPN confirmed he normally does check Resident #24's mouth for pill pocketing, but stated this morning I guess I didn't do a very good job. S4 LPN was unable to determine what the 2 other pills were. The following residents, with psychiatric and/or behavioral diagnoses, were observed on the unit and would have had access to the pills on the floor: Resident #4 had an admit date [DATE]. Diagnoses included: Dementia with behavioral disturbance, Schizophrenia, Major Depressive Disorder and Post- Traumatic Stress Disorder. Review of Resident #4's Quarterly MDS with an ARD of 12/02/2022 revealed a BIMS of 99 (unable to complete interview). Review of Resident #4's Care Plan with a target date of 03/23/2023 revealed an ADL self-care performance deficit related to Dementia and Behavior. Resident #4 sometimes refuses care. Resident has episodes of socially inappropriate behaviors- can be aggressive at times. Resident wanders and is disoriented to place. Resident #7's diagnoses included: Schizophrenia and Schizoaffective Disorder, and Bipolar Type. Review of Resident #7's admission MDS with an ARD of 11/08/2022 revealed a BIMS of 00 (severely cognitively impaired). Resident #7 required limited one person physical assistance for dressing, personal hygiene and bathing; and supervision/oversight for bed mobility, transfer, walking in room/corridor, and locomotion on/off unit. Resident #8's diagnoses included: Schizoaffective Disorder, Bipolar Type and Anxiety. Review of Resident #8's MDS Quarterly with ARD of 10/14/2022, revealed a BIMS of 9 (moderately cognitively impaired). Resident #8 required limited one person physical assistance for bed mobility, dressing and toilet use; extensive one person physical assistance for personal hygiene and bathing; supervision of one person for transfers; and supervision with set-up help for walk in room and corridor, locomotion on and off the unit, and eating. No ROM impairments for upper and lower extremities. Review of Resident #8's Plan of Care with a target date of 12/23/2022 revealed the following identified problems: ADL self-care deficit related to muscle wasting, Encephalopathy, difficulty walking, abnormality of gait, lack of coordination and history of falls. Identified problem of Schizophrenia with impaired cognitive functioning, impaired decision making, altercations with other residents, and physical aggression towards other residents. Resident #9's diagnoses included: Schizoaffective Disorder - Bipolar Type. Review of Resident #9's Quarterly MDS with an ARD of 10/06/2022 revealed a BIMS of 3 (severely cognitively impaired). Resident #9 required supervision with set-up help for bed mobility, transfers, walk in room and corridor, locomotion on and off unit and toilet use; limited one person physical assistance for dressing and personal hygiene; and total dependence of one person for bathing. Resident #10's diagnoses included: Neuro-syphilis, Vascular Dementia, Severe with other Behavioral Disturbance, Schizoaffective Disorder and Major Depressive Disorder. Review of Resident #10's Quarterly MDS with an ARD of 11/03/2022 revealed a BIMS score of 00 (severely cognitively impaired). Resident #10 required supervision with no set-up help for bed mobility, toileting, walk in room and corridor, and locomotion on and off unit; supervision with set-up help for transfers, dressing, eating, and personal hygiene; and limited assistance/set-up help for bathing. Resident #10 had no upper and lower ROM limitations. Resident #11's diagnoses included: Major Depressive Disorder, Schizoaffective Disorder- Bipolar Type, Dementia, Psychotic Disorder with Delusions and Schizophrenia. Review of Resident #11's Quarterly MDS with ARD of 10/31/2022 revealed a BIMS of 01 (severely cognitively impaired). Resident #11 required limited one person physical assistance for bed mobility, walk in room and corridor, locomotion on and off unit, toilet use and bathing; supervision of one person for transfers; and extensive one person physical assistance for dressing, eating and personal hygiene. Resident #11 did not have upper and lower ROM impairment. Resident #12's diagnoses included: Schizoaffective Disorder, Alzheimer's, Paranoid Schizophrenia, Anxiety and Dementia with Behavioral Disturbance. Review of Resident #12's Annual MDS with ARD of 12/06/2022 revealed a BIMS of 99 (severely cognitively impaired). Resident #12 required one person physical assist with toileting, bathing and hygiene. All other ADLs required set up help only. Resident #13's diagnoses included: Bipolar Disorder, Schizophrenia and History of mental and behavioral disorders. Review of Resident #13's MDS with an ARD of 10/14/2022 revealed a BIMS of 9 (moderately cognitively impaired). Resident #13 required one person physical assist with bathing and hygiene. All other ADLs required supervision with set up help only. Resident #14's diagnoses included: Dementia with Behavioral Disturbance, Anxiety Disorder and Bipolar Disorder. Review of Resident #14's MDS with an ARD of 12/09/2022 revealed a BIMS score of 00 (severely cognitively impaired). Resident #14 was independent with ADLs. Review of Resident #14's Care plan with target completion date of 01/11/2023 revealed little or no activity involvement related to Psychosis, Wernickle Disorder, Agitation and cursing. Resident believes he was killed and lives in another world. Resident #15's diagnoses included: Vascular Dementia - Severe with Behavioral Disturbance and Anxiety Disorder. Review of Resident #15's Quarterly MDS dated [DATE] revealed a BIMS of 99 (unable to complete interview). Functional status revealed Resident #15 required one person physical assistance for transfers, locomotion on and off unit, dressing, toilet use, personal hygiene and bathing; supervision of one person for bed mobility, and supervision with set-up help for eating. Resident #15 had no upper and lower ROM impairment. Review of Resident #15's Care Plan with a goal date of 02/12/2023 revealed a problem of ADL self-care performance deficit related to Dementia and Impaired balance- requires assistance from one staff with ADLs. Resident was identified as being at risk for falls related to impaired balance - history of falls. On 08/22/2022 - attempted to ambulate without assistance and fell. 08/23/2022 - fell while trying to get supper tray. Resident #16's diagnoses included: Vascular Dementia with Behavioral Disturbance, Impulse Disorder, Schizophrenia, Mild Intellectual Disability and Generalized Anxiety Disorder. Review of Resident #16's Quarterly MDS with an ARD of 09/30/2022 revealed a BIMS of 03 (severely impaired cognitively), and requires supervision and set-up help for bed mobility, transfers, dressing, eating, and toilet use; limited one person assistance for personal hygiene and bathing. ROM - impairment on one side for upper extremities, and no impairment for lower extremities. Review of Resident #16's Plan of Care with a completion date of 12/23/2022 revealed in part . 1. I have limited physical mobility due to disease process, weakness. Interventions included: Provide supportive care, assistance with mobility as needed. 2. I have occasional urinary incontinence. Interventions included: notify nurse if incontinent during activities, clean peri-area with each incontinent episode. Resident #17's diagnoses included: Impulse Disorder, Anxiety Disorder, Schizophrenia, Schizoaffective Disorder, Bipolar Disorder and Alzheimer's Disease. Review of Resident #17's Annual MDS dated [DATE] revealed a BIMS of 12 (cognitively intact), and indicated Resident #17 was Independent with ADLs. Resident #18's diagnoses included: Impulse Disorder, Paranoid Schizophrenia, Vascular Dementia with Behavioral Disturbance, Major Depressive Disorder-Recurrent and Severe with Psychotic Symptoms and Bipolar Disorder. Review of Resident #18's Annual MDS dated [DATE] revealed a BIMS of 15 (cognitively intact). Resident #18 required supervision with set-up help for all ADLs. Resident #19's diagnoses included: Dementia - Severe with Psychotic Disturbance, Depression and Mild Cognitive Impairment. Review of Resident #19's Baseline Care Plan as of admission to the facility revealed in part .Resident #19 cannot communicate easily with staff. Functional status documented in the Care Plan revealed: No set-up or physical help needed for bed mobility, transfer; set-up help only for eating, personal hygiene and toilet use; and 1 person physical assistance for dressing and bathing. Resident #20's diagnoses included: Vascular Dementia with Behavior Disturbance- Severe, Generalized Anxiety Disorder and Schizophrenia. Review of Resident #20's Annual MDS dated [DATE] revealed a BIMS of 15 (cognitively intact). Resident #20 required supervision with set-up help for bed mobility, transfers, walk in room and corridor, locomotion on and off unit, dressing, eating and toilet use; and one person assistance for personal hygiene and bathing. Resident #21's diagnoses included: Dementia and Major Depressive Disorder. Review of Resident #21's Quarterly MDS dated [DATE] revealed a BIMS of 8 (moderately impaired cognitively). Resident #21 required limited one person assistance for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing; and supervision with set-up for locomotion on and off unit and eating. Resident #22's diagnoses included: Bipolar Disorder, Dementia, Mood Disturbance and Anxiety. Review of Resident #22's Quarterly MDS dated [DATE] revealed a BIMS of 6 (severe cognitive impairment). Resident #22's functional status for ADLS included: supervision with set up help for bed mobility, transfers, toileting, personal hygiene, bathing eating, walk in room and corridor, and locomotion on and off unit; and assistance of one person for dressing. Resident #23's diagnoses included: Schizophrenia and Anxiety Disorder. Review of Resident #23's Medicare 5 day MDS dated [DATE] revealed a BIMS of 8 (moderate cognitive impairment). Resident #23 required supervision with one person assistance for bed mobility; extensive one person physical assistance for transfers, dressing, toilet use and personal hygiene; total dependence and one person physical assistance for bathing; supervision with set-up help for locomotion of and off unit; and independent for eating. Interview with S2 DON on 01/11/2023 at 12:45 p.m. revealed nurses would have to be re-educated on the medication administration policy.

Based on record reviews, observations, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable 4, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, & #24. The facility failed to: 1. Ensure staff performed hand hygiene before/after providing incontinent care, linen changes, and cleaning Resident care equipment to 4 Residents (#8, #15, #18, and #19) ; and 2. Ensure staff offered and/or encouraged 20 Residents (#4, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, & #24) of 21 Residents ( #4, #5, #6 #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, & #24) to use hand hygiene, or assist Resident #18 with hand hygiene care after use of the urinal. Findings: Observation on 01/10/2023 at 10:00 a.m. revealed 20 Residents on Hall D, and 2 male CNAs. The room had a strong smell of urine. There were 4 wall mounted Purell hand sanitizer dispensers noted. 2 of the dispensers were located in an area that were visible and readily accessible to residents and staff, and 2 were covered by the privacy curtains between Residents' beds, and were not visible. There were no sinks for hand washing, and no other means of water available if handwashing was needed. Observation on 01/10/2023 at 10:07 a.m. revealed S7 CNA removing linens soiled with urine from a Resident's bed. After removing the soiled linen, S7 CNA removed his gloves, and placed another pair of gloves on without use of ABHR. Interview with S7 CNA at the time of the observation, revealed S7 CNA confirmed that he failed to use hand sanitizer and/or use soap and water. S7 CNA stated there were 4 hand sanitizer dispensers on the wall, and he was in a hurry to get the beds changed and to start his baths. S7 CNA stated the wall dispensers were located in 4 areas, and with all the curtains in place, he would forget to go and use them. S7 CNA stated because of the behavior with most of the Residents, if you start on something with them, they are not going to wait on me to find a hand dispensers and come back to them. S7 CNA stated that he was aware that he needed to use hand sanitizer, but he had none on him and the Facility didn't provide him with any to keep on him. S7 CNA stated he had to leave off of Hall D and go to Hall A if at any time he needed to use soap & water to wash his hands. Observation on 01/10/2023 10:15 a.m. revealed there were urine puddles observed under the beds of Resident #24 and Resident #13. A housekeeper was observed sweeping the urine using a broom and dust pan, and spraying under both beds with Clorox spray. The Housekeeper had on gloves and failed to use hand hygiene after removing his gloves. Observation on 01/10/2023 at 11:10 a.m. revealed Resident #18 walking with a full urinal in his hands. S8 CNA took the urinal from Resident #18, and did not offer Resident #18 hand hygiene/sanitizer. S8 CNA did not wear gloves and/or perform hand hygiene after handling the urinal. Observation on 01/10/2023 at 11:30 a.m. revealed S7 CNA providing incontinent care to Resident #19. S7 CNA did not perform hand hygiene before/after providing incontinent care to Resident #19. Observation on 01/10/2023 at 11:50 a.m. revealed S7 CNA wheeled Resident #8 back on Hall D and placed him at a table. Resident #8's wheelchair was noted to have stool on the side panel. S7 CNA confirmed that it was stool, and wiped the wheelchair with a plain wipe instead of disinfectant wipe. S7 CNA failed to perform hand hygiene before and after wiping the wheel chair. Observation on 01/10/2023 at 12:15 p.m. revealed lunch trays were served to 21 Residents. Hand sanitizer was not offered to any of the Residents prior to eating. During an interview on 01/10/2023 at 1:55 p.m., S7 CNA stated these type of Residents are hard to get to do anything that we want them to do, so rather than aggravate them, we just leave them alone. Observation on 01/12/2023 at 8:53 a.m., revealed a Resident's bed was saturated with a pink substance. S18 CNA was observed changing the linens without wearing gloves. S18 CNA did not perform hand hygiene before or after changing the soiled linens. Requests were made to S9 RN for The Facility's Hand Hygiene P/P on 01/10/2023 at 11:45 a.m., and on 01/11/2023 at 10:00 a.m. and 4:35 p.m. As of the date of the Exit on 01/13/2023, no hand hygiene P/P was provided to the Survey Team despite several requests throughout the survey. Interview on 01/11/2023 at 10:00 a.m. with S9 RN confirmed that hand hygiene should be practiced at all times, and all residents should be offered and encouraged to use hand sanitizer with staff supervision.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** FACILITY Resident Assessment Based on record review and interview the facility failed to ensure a Death and a Discharge MDS assessment were transmitted to the CMS system in a timely manner for 2 (#1, #2) of 2 residents reviewed for Resident Assessment. Findings: Resident #1 Review of Resident #1's medical record revealed his last MDS completed was a significant change MDS on [DATE]. Further record review revealed the resident expired in the facility on [DATE]. In an interview on [DATE] at 8:54 a.m., S7 MDS nurse confirmed a death in facility MDS should have been completed on Resident #1 and was not. Resident #2 Review of Resident #2's medical record revealed the last MDS completed for the resident was a quarterly MDS on [DATE]. Further record review revealed Resident #2 discharged to the community on [DATE]. In an interview on [DATE] at 8:54 a.m., S7 MDS nurse confirmed a discharge MDS should have been completed for Resident #2 and was not.

Resident #65 Position, Mobility Based on observation, interview and record review the facility failed to ensure that a resident's person-centered plan of care for use of hand rolls was followed for 1 (#65) of 34 sampled residents. The facility census was 126. Findings. Observation on 10/17/2022 at 10:10 a.m. revealed Resident #65 resting in bed. His hands were placed across his chest and were deformed with contractures. There were no positioning devices placed in his hands. Observation on 10/18/2022 at 2:01 p.m. revealed Resident #65 lying in bed. Further observation revealed there were no hand rolls placed in the resident's hands. Review of Resident #65's care plan revealed a focus on ADL self-care performance deficit related to limited and decreased mobility, and bilateral hand contractures. Interventions included rolled wash cloths to bilateral hands for contracture management. Date initiated: 09/20/2022. Interview with S3 ADON on 10/19/2022 at 8:42 a.m. confirmed Resident #65 did not have hand rolls in place for his contractures. She stated she did not realize that Resident #65 had an intervention in his care plan for hand rolls. She stated Resident #65 should have hand rolls in place according to his care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure that a resident, who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 (#39) of 1 Residents reviewed for Activities of Daily Living in a total Stage 2 sample of 34. Findings: Review of Resident #39's medical record revealed he was admitted to the facility on [DATE] and re-admitted on [DATE]. Diagnoses included Muscle Spasms, Muscle Weakness, Lack of Coordination, Hypertension, Bipolar Disorder, Deaf nonspeaking, and Major Depressive Disorder. Review of Resident #39's Quarterly MDS with an ARD of 07/27/2022 revealed a BIMS of 8 (indicating the resident was moderately impaired). The MDS revealed Resident #39 did not reject care during the assessment period. The MDS revealed Resident #39 required limited assistance of 1 person for personal hygiene and extensive assistance of 1 person for dressing, and supervision and setup help for bed mobility. Review of Care Plan revealed resident was at risk for self-care deficit related to diagnosis of muscle weakness, muscle wasting, and lack of coordination. Interventions revealed bathing by staff with limited assistance x 1 staff. Review of Resident #39's Visual/Bedside [NAME] Report revealed staff assist x 1 with limited assistance with care. Review of Resident #39's Hygiene Log revealed he received a bath on 10/17/2022. There was no documentation indicating Resident #39 was shaved on 10/17/2022. Observation of Resident #39 on 10/17/2022 at 10:19 a.m. and 10/18/2022 at 10:00 a.m. revealed the resident was sitting in his wheelchair. The resident's face was not shaved with facial hair ¼ inch long. Observation on 10/18/2022 at 10:15 a.m. revealed Resident #39 lying in bed. Resident #39 acknowledged he wanted to be shave by nodding his head up and down. Observation on 10/19/2022 at 1:40 p.m. revealed Resident #39 sitting in his wheelchair. Resident #39 acknowledged to the surveyor and S1 Administrator that he would like to be shaved on his bath days by nodding his head up and down. Interview on 10/18/2022 at 10:15 a.m. with S9 CNA revealed Resident #39 bath days were on Monday, Wednesday, and Friday. S9 CNA stated Resident #39 was not shaved on Monday (10/17/2022). S9 CNA revealed Resident #39 was only shaved when he indicated he wanted to be shaved. S9 CNA confirmed Resident #39 was not shaved on his bath day. Interview on 10/18/2022 at 10:40 a.m. with S8 LPN revealed Resident #39 should have been shaved on his bath days. S8 LPN revealed no one reported Resident #39 had refused to be shaved on 10/17/2022. S8 LPN confirmed Resident #39 needed to be shaved. Interview on 10/18/2022 at 12:15 p.m. with S3 ADON stated the CNAs should follow the resident's Visual/Bedside [NAME] Report to provide care. Further interview with S3 ADON revealed Resident #39 should have been shaved on his bath day 10/17/2022 (Monday). S3 ADON stated that there was no documented evidence in Resident #39's medial record of the resident refusing to be shaved. S3 ADON confirmed that Resident #39 should have been shaved during ADL care and wasn't. Interview 10/19/2022 at 1:35 a.m. with S2 DON confirmed Resident #39 was not shaved and he should have been shaved on his bath day Monday (10/17/2022).

Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #73) of 1 sampled residents reviewed for respiratory care. The facility failed to ensure respiratory equipment was properly changed, labeled and stored. Findings: Review of Resident #73's Clinical Record revealed an admit date of 08/18/2022 with diagnoses which included: Chronic Obstructive Pulmonary Disease Unspecified, Acute Respiratory Failure , Other Emphysema, Dependence on Supplemental Oxygen and Human Immunodeficiency Virus Disease. Review of Resident #73's Physician Orders dated 10/2022 revealed an order for nebulizer treatments (Ipratropium-Albuterol Solution 0.5-2.5 MG/ML) every 4 hours as needed for Shortness of Breath related to Chronic Obstructive Pulmonary Disease. Change Nebulizer Tubing/Mask weekly and PRN. Review of Resident #73's Care Plan with a target date of 12/01/2022 revealed Resident #73 is at risk for impaired gas exchange and ineffective therapeutic management related to chronic/reoccurring respiratory infection/disease. Chronic Obstructive Pulmonary Disease Process, Cough, Pulmonary Hypertension, Chronic Respiratory Failure, Emphysema and Asthma with interventions to give medications as ordered and Oxygen as ordered. Observation on 10/17/2022 at 9:39 a.m. revealed two nebulizer masks and tubing were lying undated and uncovered on Resident #73's nightstand. Resident #73 stated he uses the nebulizer due to his Bronchitis and Asthma. Observation on 10/18/2022 at 8:37 a.m. revealed two nebulizer masks and tubing were lying undated and uncovered on Resident #73's nightstand. Observation and interview on 10/18/2022 at 8:40 a.m. with S1 Administrator (who is an RN) confirmed Resident #73's nebulizer masks and tubing should have been dated and covered and were not.

Based on record review, observation, and interview, the facility failed to ensure a resident maintained acceptable parameters of nutritional status by failing to provide ordered supplements for a resident with significant weight loss for 1 (#11) of 4 (#11, #29, #51, #105) residents reviewed for nutrition. Findings: Resident #11 Review of the medical record for Resident #11 revealed an admit date of 01/01/2011 with diagnoses that included, in part, Vascular Dementia, Muscle Wasting and Atrophy, Abnormal Weight Loss, and Dysphagia. Review of the quarterly MDS with an ARD date of 7/12/2022 revealed Resident #11 had a BIMS score of 9, which indicated moderately impaired cognition. The MDS further revealed Resident #11 required supervision with eating, bed mobility, transferring, and toilet use. Review of Resident #11's physician orders revealed an order dated 10/12/2022 for a regular diet, chopped meats texture, thin liquids consistency with instructions to add fortified foods to all meals and mighty shake with breakfast tray. Review of Resident #11's medical record revealed the following recorded weights which indicated a 12.90% weight loss: 120.2 lbs on 10/07/2022 122.0 lbs on 09/07/2022 122.8 lbs on 08/08/2022 127 lbs on 07/08/2022 133 lbs on 04/21/2022 138 lbs on 03/30/2022 Review of the nurses' notes revealed the following entry: 10/12/22 at 19:05 by S3 ADON: Weight warning note: Value: 120.2, vital date: 10/07/2022, MDS: -10% change over 180 days; Action: IDT meeting held this date; Slow gradual weight loss noted; MD orders obtained to add mighty shake with breakfast tray; Response: Plan to add to weekly weights; Consult RD for evaluation; RP aware of above. In an interview on 10/19/2022 at 12:29 p.m., S4 Dietary Manager provided a copy of Resident #11's diet tray card for breakfast. Observation at that time with S4 DM revealed the diet/tray card did not have instructions for mighty shakes. S4 DM confirmed the tray card was how kitchen staff know if a resident needs a mighty shake added to their tray at meal time. S4 DM confirmed Resident #11's tray card did not have the mighty shake instructions listed on it and Resident #11 had not begun to receive them yet. In an interview on 10/19/2022 at 2:33 p.m., S3 ADON confirmed the IDT met on the 12th of October and consisted of herself, the Dietary Manager, the MDS nurse, and the Social Worker. S3 ADON confirmed she called the physician and obtained the order for the mighty shakes at breakfast. S3 ADON reported the order was put in the computer on 10/12/2022 and acknowledged Resident #11 had not received the mighty shakes yet and should have.

FACILITY Kitchen Based on observation, record review, and interview the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety by having an air conditioner vent that dripped onto the food prep area. This deficient practice had the potential to affect 123 residents who received food trays out of the kitchen. Findings: In an observation on 10/17/2022 at 11:30 a.m. during the lunch meal, it was noted that an air conditioner vent box hanging down about 12 inches from the ceiling was dripping liquids down onto the floor and on staff who were serving food from the steam table. It was noted liquids were dripping down where the kitchen staff are standing in front of the steam table and the liquid was falling within 6 inches of the serving table where trays with plates are prepared and about 12 inches from the food in the steam table. In an interview on 10/17/2022 at 11:35 a.m., S6 Maintenance Supervisor confirmed he was aware of the unit dripping within 6 inches of the food prep and 12 inches of the food. S6 Maintenance Supervisor reported he had wrapped the vent box in insulation and didn't know anything else he could do to stop it from dripping. In an interview at 10/17/2022 at 11:38 a.m., S4 Dietary Manager confirmed the air conditioner vent box had been dripping constantly for the two years she has worked here. S4 DM reported S5 RD had put this issue in her kitchen inspection report as well but no one had addressed it. Review of the kitchen inspection report dated 03/30/2022 revealed an entry by S5 RD that stated, Lots of moisture buildup on AC vents over prep area. Dripping onto ground. Possible mildew. Work order in to fix this. In an interview on 10/17/2022 at 11:40 a.m., S5 RD confirmed it was dripping too close to the food. S5 RD stated she had been putting the issue in her kitchen report for months but nothing had been done to fix it.