**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews, the facility failed to ensure each resident had the right to be free from physical abuse by another resident for 2 (#61 and #99) of 27 residents reviewed for abuse in the final sample. The facility failed to ensure: 1.Resident #99 was free from physical abuse by Resident #61. 2.Resident #61 was free from physical abuse by Resident #99. Findings: Review of the facility's Abuse Components Plan Elder Justice Act and Affordable Care Act policy dated 10/24/2022 revealed the following, in part: 1.5 Policy: Residents have the right to be free from abuse . 2.0 Definitions Abuse is defined as the willful infliction of injury Instances of abuse .cause physical harm, pain or mental anguish. Willful means the individual must have acted deliberately. 1. Resident #99 Review of the Clinical Record revealed Resident #99 was admitted to the facility on [DATE] with diagnoses, which included Bipolar Disorder and Anxiety. Review of the Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 06/04/2024 revealed Resident #99 had a BIMS (Brief Interview of Mental Status) score of 14, which indicated he was cognitively intact. Review of Resident #99's Incident Report revealed the following: Date: 08/07/2024 at 11:06 a.m. Resident Incident Description: Resident #99 reported the aggressor (Resident #61) purposefully rolled into him while he was getting coffee. At the time Resident #99 attempted to defend himself resulting in the altercation. On 08/12/2024 at 10:30 a.m., an interview was conducted with Resident #99. He stated there was an incident where Resident #61 purposefully ran into him with his electric wheelchair. He stated he felt threatened so he defended himself. 2. Resident #61 Review of the Clinical Record revealed Resident #61 was admitted to the facility on [DATE] with diagnoses, which included Depression. Review of the Quarterly MDS with an ARD of 06/03/2024 revealed Resident #61 had a BIMS of 12, which indicated he was cognitively moderately intact. Review of Resident #61's Incident Report revealed the following: Date: 08/07/2024 at 11:06 a.m. Resident Incident Description: Resident #61 reported he ran into Resident #99 due to feeling the other resident told on him and got him in trouble with the Administrative staff. On 08/14/2024 at 3:50 p.m., an interview was conducted S10LPN. She stated she was working the day of the altercation between Resident #99 and Resident #61. She stated she was in another resident's room when she heard screaming. She stated when she walked out into the dining area she saw Resident #61 in his wheelchair with blood on his forehead and skin tear to his arm. She stated Resident #61 was alert, oriented and was aware of the situation. On 08/14/2024 at 4:04 p.m., an interview was conducted with S7WC. She stated she witnessed the incident that occurred between Resident #99 and Resident #61. She stated Resident #99 was sitting in his wheelchair when Resident #61 purposefully rammed his electric wheelchair into him. She stated after being hit, Resident #99 was half out of his wheelchair with one knee to the ground. She stated Resident #61 started to punch Resident #99 and Resident #99 began to defend himself and hit back. She stated Resident #61was noted to have cuts on his face and forearm. On 08/15/2024 at 8:50 a.m., an interview was conducted with S3DON. She stated on 08/07/2024 Resident #99 and Resident #61 were involved in an altercation. She stated Resident #61 purposefully rammed his electric wheelchair into Resident #99. She stated out of self-defense Resident #99 began punching Resident #61. She stated both resident's actions were purposeful. On 08/15/24 09:03 a.m., an interview was conducted with S1ADM. S1ADM stated he was informed there had been an altercation between Resident #61 and Resident #99. He stated after speaking to the residents, Resident #61 told him he was upset with Resident #99, so he rammed into him using his electric wheelchair. On 08/15/2024 at 10:00 a.m., an observation and interview was conducted with S1ADM. The video surveillance of the 08/07/2024 incident occurring between Residents #61 and #99 was reviewed. Resident #61 was observed entering into the dining area where Resident #99 was sitting in his wheelchair. Resident #61 was observed running his electric wheelchair into Resident #99. Resident #61 continued to push Resident #99 in his wheelchair. Resident #99 stood up from his wheelchair and hit Resident #61. At that time both residents began hitting each other. S1ADM confirmed the above observation of Resident #61 and Resident #99 was purposeful and considered abuse.

Based on record review and interview, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1(#83) of 27 sampled residents by failing to ensure Resident #83 was coded correctly for active diagnoses. Findings: Review of Resident #83's clinical record revealed admission date of 02/27/2020. Further review revealed Resident #83 had a diagnosis of Cataracts with onset date of 06/06/2024. Review of Resident #83's Quarterly MDS with ARD of 07/08/2024 revealed Cataracts was not coded as an active diagnosis in Section I. Review of Resident #83's optometrist progress note dated 06/06/2024 revealed, in part: diagnosis of Cataracts of left eye. Review of Resident #83's physician's progress notes dated 07/05/2024 revealed diagnoses which included Cataracts. History of Present Illness section revealed, in part: Resident #83 reported visual loss in the left eye for the last 3 weeks and was seen by the optometrist on 06/06/2024 who diagnosed him with cataracts which will require surgery. On 08/14/2024 at 9:40 a.m., an interview was conducted with S9MDS. She stated the process was for MDS department to review progress notes and add diagnosis to resident's diagnoses. After reviewing, Resident #83's progress note from optometrist appointment dated 06/06/2024, S9MDS confirmed the diagnosis for cataracts should have been added to the quarterly MDS with ARD of 07/08/2024 as an active diagnosis and was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure services were provided by failing to follow physician orders for 1 (#18) of 26 residents investigated in the final sample. Findings: Review of the facility's policy titled Administering Oral Medications, dated 10/2010 revealed in part, the following: Steps in the procedure: 6. Check the label on the medication and confirm the medication name and dose with the MAR. 8. Check the medication dose. Re-check to confirm the proper dose. Review of Resident #18's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Acute on Chronic Diastolic Congestive Heart Failure and Chronic Respiratory Failure. Review of Resident #18's Physician's Orders revealed the following: Lorazepam Oral Concentrate 2 mg/mL. Give 0.25 mL by mouth every 4 hours as needed for agitation or shortness of breath, start date 08/06/2024. Review of Resident #18's MAR for August 2024 revealed the following: Lorazepam Oral Concentrate 2 mg/mL. 0.25 mL administered on 08/11/2024 at 2:06 p.m. by S4LPN. Review of the narcotic log for Resident #18 for August 2024 revealed the following: Medication: Lorazepam Name of Individual Administering: S4LPN Date: 08/11/2024 Time: 2:06 p.m. Amount on Hand: 21 mL Amount Administered: 0.5 mL Amount Remaining: 20.5 mL A phone interview was conducted on 08/13/2024 at 3:15 p.m. with S4LPN. She stated Resident #18 was having some shortness of breath on 08/11/2024 around 2:00 p.m. She stated she checked the narcotic log for the last administered time of Lorazepam for Resident #18. She stated Resident #18 had Lorazpam 0.5 mL ordered every 4 hours as needed. She stated she documented on the narcotic log and the MAR after she drew up the 0.5 mL of Lorazepam and administered it to Resident #18. An interview was conducted on 08/13/2024 at 4:00 p.m. with S3DON. She reviewed the narcotic log and MAR for Resident #18. She confirmed S4LPN did document a dose of 0.5 mL of Lorazepam given on 08/11/2024.

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Based on observation and interviews, the facility failed to maintain an infection control program to ensure staff performed proper hygiene administering medication for 1 (#12) of 4 (#12, #38, #41, and #386) residents observed for medication administration. Findings: On 08/13/2024 at 7:35 a.m., an observation was made of S8MAC preparing medication for Resident #12. S8MAC dropped a pill onto the floor, picked up the pill, discarded the pill, and then continued to prepare additional medications without performing hand hygiene. On 08/13/2024 at 7:39 a.m., an interview was conducted with S8MAC. She confirmed she did not perform hand hygiene after picking up the pill off the floor and administering medication to Resident #12 and should have. On 08/13/2024 at 4:30 p.m., an interview was conducted with S3DON. She stated she expected staff to perform proper hand hygiene during medication administration. S3DON confirmed S8MAC should have performed hand hygiene after picking up the pill off the floor before continuing medication administration.

Based on observations, interviews, and record review, the facility failed to ensure medications were properly stored in 2 (Med Cart 2 and Med Cart 3) of 3 (Med Cart 1, Med Cart 2, and Med Cart 3) medication carts observed for medication storage. Findings: Review of the facility's policy titled, Storage of Medications, dated 11/2020 revealed in part, the following: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature. 7. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Review of the Lorazepam medication insert, which was located within the Lorazepam box, revealed in part, the following: How should I store Lorazepam? Store Lorazepam at a cold temperature. Refrigerate at 36 degrees Fahrenheit to 46 degrees Fahrenheit. Review of research information given to surveyor by facility's Pharmacy Consultant revealed in part, the following: Lorazepam storage: Refrigerate between 36 degrees Fahrenheit to 46 degrees Fahrenheit. Review of additional document given to surveyor by facility's Pharmacy Consultant titled Oral and Enteral Medications revealed in part, the following: Lorazepam Solution: Store in refrigerator. An observation was made on 08/12/2024 at 9:40 a.m. of Med Cart 2 with S5LPN. Observed 1 opened bottle of Lorazepam 2mg/mL for Resident #18, which was warm to touch, located in the narcotic lock box drawer of the medication cart. The Lorazepam bottle and box revealed a label which read Refrigerate located on the box and bottle. An interview was conducted on 08/12/2024 at 9:40 a.m. with S5LPN. S5LPN confirmed the label on Resident #18's bottle and box of Lorazepam read Refrigerate and should have been placed back into the refrigerator after each dose. S5LPN confirmed the bottle of Lorazepam was room temperature and opened. S5LPN reviewed the narcotic log book for Resident #18's Lorazepam and stated the last dose administered was on 08/11/2024. An observation was made on 08/12/2024 at 10:10 a.m. of Med Cart 3 with S6LPN. Observed 1 opened bottle of Lorazepam 2mg/mL for Resident #97, which was warm to touch, located in the narcotic lock box drawer of the medication cart. The Lorazepam bottle and box revealed a label which read Refrigerate located on the box and bottle. An interview was conducted on 08/12/2024 at 10:10 a.m. with S6LPN. S6LPN confirmed the label on Resident #97's bottle and box of Lorazepam read Refrigerate and should have been placed back into the refrigerator after each dose. S6LPN confirmed the bottle of Lorazepam was room temperature and opened. S6LPN reviewed the narcotic log book for Resident #97's Lorazepam and stated the last dose administered was on 08/12/2024. S6LPN stated she gave the last dose on 08/12/2024 at 9:32 a.m., and the bottle of Lorazepam was already located in Med Cart 3 prior to administering it. S6LPN stated the bottle of Lorazepam was left in Med Cart 3 for at least a week. An interview was conducted on 08/13/2024 at 12:05 p.m. with a local pharmacist. She stated liquid Lorazepam required refrigeration and would lose its potency if left in room temperature for extended periods of time. An interview was conducted on 08/13/2024 at 12:11 p.m. with the facility's pharmacist. She stated liquid Lorazepam required refrigeration and would lose its potency if left at room temperature for extended periods of time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure injuries of unknown source without serious bodily injury were reported within 24 hours to the State Survey Agency for 1 (#3) of 6 (#1, #2, #3, #R1, #R2 and #R3) residents reviewed for abuse. Findings: Review of the facility's policy titled Abuse Components Plan dated 10/24/2022, revealed the following, in part: Policy The facility administrator and their designee shall be responsible for the implementing of this policy. Definitions Injuries of unknown source - An injury should be classified as an injury of unknown source when all of the following criteria are met: 1) The source of the injury was not observed by any person; and 2) Or the source of the injury could not be explained by the resident; and 3) The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. Reporting 1. All alleged violations involving injuries of unknown source will be reported by the Administrator or designee, to the following persons or agencies as required to provide notification: a. State Agency online tracking incident system(required); 2. An alleged violation involving injuries of unknown will be reported immediately, but no later than: b. Twenty-four (24) hours if the alleged violation does not involve abuse, AND has not resulted in serious bodily injury. Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Dementia and Long Term Use of Anticoagulants. Review of the Quarterly MDS with ARD of 05/25/2024 revealed Resident #3 had a BIMS of 5, which indicated the resident was severely cognitively impaired. Review of the facility's Incident log dated March 2024 through current revealed Resident #3 had an incident on 05/27/2024 related to bruising. Review of the facility's Incident report dated 05/27/2024, revealed in part: Incident Description: Bruising found on Resident #3 by S2DON Bruises Measured: Left Upper Outer Arm Lateral 8 cm x 4.4 cm Left Outer Forearm 6 cm x 9 cm Left Inner Forearm 10.1 cm x 6 cm Right Upper Outer Arm Lateral 3.5 cm x 2.8 cm Right Upper Outer Arm Medial 2.8 cm x 3.4 cm Right Elbow 4.7cm x 7 cm Right Outer Forearm 3 cm x 3.9 cm Right Outer Forearm Inferior 9 cm x 10.2 cm Right Outer Wrist 8.5 cm x 5.1 cm Review of the facility's state agency reported incidents for the past six months revealed no reports of the above incident. On 06/13/2024 at 9:25 a.m., an observation was made of Resident #3. An interview attempt was made with Resident #3, but due to cognitive impairment she was unable to answer questions regarding how she got the bruises. Resident #3 was noted to have one bruise to her left outer forearm and side of forearm. Resident #3's left upper arm was noted to have two sets of bruises. Resident #3's right arm was noted to have a small bruise to the outer wrist area, outer and side of forearm, and upper arm near outer arm crease, and one bruises to right elbow. On 06/13/2024 at 10:58 a.m., a telephone interview was conducted with S4LPN. She confirmed she was the oncoming nurse for the 6:00 a.m. to 6:00 p.m. shift on 05/27/2024 for Resident #3. She stated S5CNA reported to her on the morning of 05/27/2024 Resident #3 had bruises on both of her forearms. She stated she then reported the findings to S3ADON. On 06/13/2024 at 12:01 p.m., a telephone interview was conducted with S3ADON. She stated on the morning of 05/27/2024, S4LPN informed her of the bruises to Resident #3's bilateral upper extremities. She stated she assessed Resident #3 immediately and noted bruises to bilateral upper extremities and right elbow. She stated she immediately reported her assessment of Resident #3's bilateral upper arm bruising to S2DON and S1NFA. On 06/12/2024 at 3:11p.m., an interview was conducted with S2DON. She stated was responsible for completing the 05/27/2024 incident report for Resident #3. She stated after S3ADON notified her of the incident with Resident #3, she went directly to S1NFA. S2DON stated after bringing it to the S1NFA's attention, she started her investigation. She stated Resident #3 could not tell her how she received the bruises due to Dementia. She stated the bruises to Resident #3's bilateral upper extremities were consistent with hand placement during moving Resident #3. She stated they determined the bruising was not abuse related, and did not report it. On 06/12/2024 at 4:00 p.m., an interview was conducted with S1NFA. He stated he was responsible for reporting or injuries of unknown origin to the required agencies. He stated he could not recall the exact time on 05/27/2024 in which the bruises to Resident #3's bilateral upper extremities were brought to his attention. He stated as soon as he was informed by S2DON of Resident #3's bruising, he went to Resident #3's room to investigate. He stated he was made aware by S2DON of Resident #3 being on a blood thinner and antiplatelet medication. He stated there was no clear occurrence to have caused the bruises, and Resident #3 has a BIMS of 5 which makes her severely cognitively impaired. S1NFA stated based on the placement of the bruises, he determined it was caused by resident care. He confirmed after observing the bruising he did not report it to the state agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that a resident with an identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required for 2 (#9 and #82) of 4 (#9, #17, #30, and #82) sampled residents reviewed for PASRR Level II. Findings: Resident #9 Review of the Clinical Record revealed Resident #9 was admitted to the facility on [DATE]. Further review revealed she was diagnosed with Severe Major Depressive Disorder with Psychotic Symptoms on 09/07/2021. On 09/20/2023 at 2:05 p.m., an interview was conducted with S4SW. She stated she was responsible for submitting Level II PASRR request to the OBH. She reviewed Resident #9's Level I PASRR dated 02/26/2019, then reviewed Resident #9's diagnoses. She stated due to Resident #9's diagnosis of Major Depressive Disorder with Psychotic Symptoms dated 09/07/2021, a Level II PASRR request was required. She stated she had not submitted Resident #9's PASRR Level II request to the OBH prior to the survey team's entrance. She confirmed the Level II PASRR request should have been submitted to the OBH when Resident #9 received the new mental health diagnosis. Resident #82 Review of the Clinical Record revealed Resident #82 was admitted to the facility on [DATE]. Further review revealed she was diagnosed with Bipolar Disorder on 04/16/2020 and Major Depressive Disorder on 03/12/2021. On 09/18/2023 at 2:50 p.m., an interview was conducted with S4SW. She reviewed Resident #82's Level I PASRR dated 02/04/2019, then reviewed Resident #82's diagnosis of Bipolar Disorder on 04/16/2020 and Major Depressive Disorder on 03/12/2021. She verified she had not submitted Resident #82's PASRR Level II request to the OBH prior to the survey team's entrance. She confirmed the Level II PASRR request should have been submitted to the OBH when Resident #82 received the new mental health diagnoses. On 09/19/2023 at 10:16 a.m., an interview was conducted with the OBH Program Manager. She stated in 2019, Resident #82 was reviewed for a Level II PASRR which was not required as she did not meet criteria for a serious mental illness. She stated a new diagnosis of Bipolar Disorder would require a Level II PASRR to be submitted. She stated the OBH received a Level II PASRR request at 2:41 a.m. on 09/19/2023 for Resident #82. She stated there had been no former Level II PASRR requests submitted for Resident #82 since 2019. She stated she received Resident #9's Level II PASRR request on 09/18/2023 at 9:09 p.m. She stated if any resident was diagnosed with a new mental health disorder, a Level II PASRR request should have been submitted to the OBH. On 09/18/2023 at 2:30 p.m., an interview was conducted with S1ADM. He stated he was aware there were multiple residents who needed Level II PASRR requests submitted to the OBH.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practice for 1 of 1(#117) resident reviewed for oxygen therapy. Findings: Review of the facility's policy titled, Oxygen Administration revealed the following, in part: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review of Resident #117's clinical record revealed Resident #117 was admitted on [DATE] with diagnoses, which included Chronic Obstructive Pulmonary Disease and Asthma. Review of Resident #117's MDS with an ARD of 09/06/2023 revealed a BIMS of 12, which indicated intact cognition. Review of Resident #117's Physician Orders revealed no order for oxygen therapy services in the electronic health record. Review of Resident #117's Medication Administration Record from July to current revealed no clinical documentation for oxygen therapy services were provided or documented accordingly to accurately reflect services provided. Review of Resident #117's Care plan revealed the following: Problem: I am currently receiving oxygen therapy as needed. Goal: I will have no signs and symptoms of poor oxygen absorption through the review date. Approaches: Oxygen Settings: Administer oxygen per MD orders, may remove for ADL. Review of Resident #117's Oxygen Saturation summary report from 06/01/2023-09/30/2023 revealed Oxygen services were provided on the following dates: 07/18/2023- Oxygen via Nasal Cannula 08/01/2023- Oxygen via Nasal Cannula 08/09/2023- Oxygen via Nasal Cannula 09/06/2023- Oxygen via Nasal Cannula 09/08/2023- Oxygen via Nasal Cannula 09/12/2023- Oxygen via Nasal Cannula 09/13/2023- Oxygen via Nasal Cannula On 09/19/2023 at 11:05 a.m., an interview was conducted with Resident #117. She stated she had been wearing oxygen on and off for all her life due to a history of Chronic Obstructive Pulmonary Disease. She stated since admission she wore 2 liters of oxygen as needed. An observation was made at that time of Resident #117 wearing oxygen via nasal cannula. On 09/19/2023 at 11:50 a.m., an interview was conducted with S6LPN. She stated Resident #117 was oxygen dependent since returning from the hospital on [DATE]. She confirmed the resident was currently wearing 2 liters of oxygen per nasal cannula. She confirmed there were no physician order for oxygen therapy services in the electronic health record. She confirmed a Physician's Order for oxygen services would be needed to initiate standing orders and should have been placed in the clinical record. On 09/19/2023 at 12:15 p.m., an interview was conducted with S2DON. She stated standing orders, continuous and prn orders for oxygen therapy services should be manually placed in the clinical record per physician order. She confirmed Resident #117 did not have an order for use of oxygen therapy services and an order should have been placed in the clinical record. On 09/20/2023 at 8:55 a.m., an interview was conducted with S7LPN. She confirmed when Resident #117 returned to the facility on [DATE], she was wearing 2 liters of oxygen via nasal cannula. She stated prior to Resident #117's hospital admission on [DATE] the resident wore oxygen intermittently. She stated she did not place an order for oxygen due to the assumption the order was already placed in the electronic health record from past oxygen usage. She stated when a standing order was initiated, nursing staff was expected to manually enter the order into clinical record so it would show up on the MAR and Physician Orders. She confirmed she did not enter a standing order for oxygen therapy services. On 09/20/2023 at 11:07 a.m., an interview was conducted with S5NP. She stated nursing staff could initiate standing orders for oxygen use if needed. She stated nursing staff were expected to manually input orders into clinical record when initiating any standing order. She confirmed an order should have been placed in Resident #117 electronic health record to accurately reflect services being provided and was not.

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