**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure appropriate care and services consistent with professional standards of practice were implemented for 1 of 1 resident (# 19) reviewed for dialysis. The facility failed to ensure Resident #19's dialysis access site was assessed and monitored every shift. Findings: Review of the facility's Monitor Dialysis Site policy dated 12/15/2023 revealed in part: I. The nurse will ensure that the dialysis access site (e.g. [exempli gratia for example] AV [Arteriovenous] shunt or graft) is checked every shift. The nurse will check for a bruit and palpating for a thrill . II. The site will also be monitored every shift for signs and symptoms of infection . Review of Resident #19's medical record revealed an admit date of 06/15/2017 with a re-admission on [DATE] with diagnoses which included, but not limited to, end stage renal disease, chronic kidney disease, and dependence on renal dialysis. Review of Resident #19's current physician's orders revealed an order dated 01/03/2025 for outpatient hemodialysis on Monday, Wednesday, and Friday. Further review of Resident #19's current physician's orders revealed an order for 01/13/2025 to remove dialysis dressing to left upper arm at bedtime on Monday, Wednesday, and Friday. Review of Resident #19's medical record failed to reveal documentation Resident #19's dialysis access site was assessed and monitored every shift. During an interview on 02/25/2025 at 11:22 a.m. S13 LPN (Licensed Practical Nurse) reported Resident #19's dialysis access site was in her left upper arm. S13 LPN reviewed Resident #19's medical record and confirmed there was no documentation Resident #19's dialysis access site was assessed and monitored every shift. During an interview on 02/25/2025 at 12:04 p.m. S2 DON (Director of Nursing) confirmed dialysis access sites should be assessed and monitored every shift. S2 DON reviewed Resident #19's medical record and confirmed there was no documentation Resident #19's dialysis access site was assessed and monitored every shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews the facility failed to ensure, prior to installation and use of bed rails, residents were assessed for the risk of entrapment, a consent was obtained from the resident or resident's representative, and residents had a physician order and care plan for use of bed rails for 7 (#7, #26, #27, #28. #148, #149, #196) out of 7 (#7, #26, #27, #28. #148, #149, #196) residents reviewed for bed rails. Findings: Review of the facility's Proper use of Side Rails dated 08/28/2017 (approved on 09/14/2017) revealed in part: Purpose: It is the policy of _____ that _____ utilize these guidelines to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. Procedure: Physical restrains are defined by the Centers for Medicare and Medicaid Services (CMS) as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. (Note: the definition of restraints is based on the functional status of the resident and not on the device; therefore any device that has the effect on the resident of restricting freedom of movement or normal access to one's body could be considered a restraint.) 1. Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). (Note: The side rails may have the effect of restraining one individual but not another, depending on the individual resident's condition and circumstances.) 2. Side rails are only permissible if they are used to treat resident's medical symptoms or to assist with mobility and transfer of residents. 3. An assessment will be made to determine the resident's symptoms or reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. bed mobility; and b. ability to change positions, transfer to and from bed or chair, and to stand and toilet. 4. The use of side rails as an assistive device will be addressed in the resident care plan. 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. Resident #7 Review of Resident #7's medical record revealed an initial admit date of 10/17/2008 with diagnoses including, but not limited to chronic obstructive pulmonary disease and morbid obesity. Review of Resident #7's most recent MDS (Minimum Data Set) assessment dated [DATE] revealed Resident #7 had a BIMS (Brief Interview for Mental Status) of 15 indicating intact cognition. Further Review of Resident #7's most recent MDS revealed Resident #7 required extensive assistance with bed mobility and transfers. Review of Resident #7's medical record failed to reveal an entrapment risk assessment was completed and an informed consent was obtained from the resident or resident's representative prior to installation and use of bed rails. Review of Resident #7's comprehensive care plan failed to reveal Resident #7 was care planned for use of bed rails as an assistive device. Review of Resident #7's physician orders failed to reveal an order for the use of bed rails. An observation 02/24/2025 at 9:00 a.m. revealed Resident #7 was awake in bed with bilateral upper quarter bed rails in use. An observation on 02/26/2025 at 7:40 a.m. revealed Resident #7 sitting upright in bed with bilateral upper and lower quarter bed rails in use. During an interview on 02/26/2025 at 7:40 a.m. Resident #7 reported she used the lower bed rails for mobility and not the upper bed rails. During an interview on 02/26/2025 at 7:45 a.m. S4 ADON (Assistant Director of Nursing) acknowledged Resident #7 had both upper and lower bilateral bed rails in use. Resident #26 Review of Resident #26's medical record revealed an initial admit date of 11/20/2018 with diagnoses including, but not limited to hemiplegia following other cerebrovascular disease affecting the left non-dominant side, aphasia following unspecified cerebrovascular disease, unspecified dementia, and anxiety disorder. Review of Resident #26's most recent MDS assessment dated [DATE] revealed Resident #26 had a BIMS of 05 indicating severely impaired cognition. Further review of the most recent MDS revealed Resident #26 required extensive assist with bed mobility and transfers. Review of Resident #26's medical record failed to reveal an entrapment risk assessment was completed and an informed consent was obtained from the resident or resident's representative prior to installation and use of bed rails. Review of Resident #26's comprehensive care plan failed to reveal Resident #26 was care planned for use of bed rails as an assistive device. Review of Resident #26's physician orders failed to reveal an order for the use of bed rails. An observation on 02/24/2025 at 8:25 a.m. revealed Resident #26 was resting in bed with bilateral upper bed rails in use. An observation on 02/25/2025 at 8:40 a.m. revealed Resident #26 was awake in bed with bilateral upper and lower bed rails in use. During an interview on 02/26/2025 at 7:50 a.m. S7 CNA (Certified Nursing Assistant) confirmed Resident #26's bilateral upper and lower bed rails were used most of the time. Resident #27 Review of Resident #27's medical record revealed an initial admit date of 01/03/2025 with diagnoses including, but not limited to, acute pain not elsewhere classified, fusion of spine-lumbar region, other spondylosis lumbar region, generalized muscle weakness, unspecified lack of coordination, bed confinement status, other reduced mobility, and history of falling. Review of Resident #27's most recent MDS assessment dated [DATE] revealed Resident #27 had a BIMS of 14 indicating intact cognition. Further Review of Resident #27's most recent MDS revealed Resident #27 required extensive assistance with bed mobility and transfers. Review of Resident #27's medical record failed to reveal an entrapment risk assessment was completed and an informed consent was obtained from the resident or resident's representative prior to installation and use of bed rails. Review of Resident #27's comprehensive care plan failed to reveal Resident #27 was care planned for use of bed rails as an assistive device. Review of Resident #27's physician orders failed to reveal an order for the use of bed rails. An observation on 02/24/2025 at 9:32 a.m. revealed Resident #27 had bilateral upper quarter bed rails in use. During an interview on 02/24/2025 at 9:32 a.m. Resident #27 reported he required assistance to transfer out of bed and utilized the bed rails for bed mobility. An observation on 02/25/2025 at 2:10 p.m. revealed Resident #27 sitting in a wheelchair next to the bed which had bilateral upper bed rails in use. An observation on 02/26/2025 at 7:45 a.m. revealed Resident #27 resting in bed with bilateral upper quarter bed rails in use as well as bilateral lower quarter bed rails in use. During an interview on 02/26/2025 at 7:47 a.m. S9 CNA reported Resident #27 required assistance to get out of bed and utilized bilateral upper quarter bed rails for bed mobility. S9 CNA acknowledged bilateral upper and lower quarter bed rails were in use. During an interview on 02/26/2025 at 7:50 a.m. S10 LPN (Licensed Practical Nurse) reported Resident #27 required assistance to get out of bed and utilized bilateral upper quarter bed rails for bed mobility. S10 LPN reported lower quarter bed rails should not be utilized. Resident #28 Review of Resident #28's medical record revealed an admit date of 02/05/2025 with diagnoses including, but not limited to, atherosclerotic heart disease of native coronary artery, and polyosteoarthritis unspecified. Review of Resident #28's MDS assessment dated [DATE] revealed Resident #28 had a BIMS score of 11, which indicated a moderate cognitive impairment. Further Review of Resident #28's MDS revealed Resident #28 required extensive assistance with bed mobility and transfers. Review of Resident #28's medical record failed to reveal an entrapment risk assessment was completed and an informed consent was obtained from the resident or resident's representative prior to installation and use of bed rails. Review of Resident #28's comprehensive care plan failed to reveal Resident #28 was care planned for use of bed rails as an assistive device. Review of Resident #28's physician orders failed to reveal an order for the use of bed rails. An observation on 02/24/2025 at 11:33 a.m. revealed Resident #28 in bed with the bed rails up on each side of upper bed and bed rail up on left side of lower bed. During an interview on 02/24/2025 at 11:33 a.m. Resident #28 reported he liked having his bed rails up to help him move in bed. An observation on 02/25/2025 at 07:58 a.m. revealed Resident #28 was in bed with bed rails up on each side of upper bed and one bed rail up on left side of lower bed. During an interview on 02/26/2025 at 7:55 a.m. S11 LPN reported Resident #28 would request his bed rails to be up. Resident #148 Review of Resident #148's medical record revealed an initial admit date of 02/18/2025 with diagnoses including, but not limited to, other chronic pain, heart failure unspecified, and presence of cardiac pacemaker. During an interview on 02/26/2025 at 9:35 a.m. S8 SSD (Social Services Director) reported Resident #148's BIMS interview had been completed and Resident #148 had a BIMS score of 11, which indicated a moderate cognitive impairment. Review of Resident #148's medical record failed to reveal an entrapment risk assessment was completed and an informed consent was obtained from the resident or resident's representative prior to installation and use of bed rails. Review of Resident #148's comprehensive care plan revealed Resident #148 required extensive to maximum assistance with mobility and transfers. Further review of Resident #148's comprehensive care plan failed to reveal Resident #148 was care planned for use of bed rails as an assistive device. Review of Resident #148's physician orders failed to reveal an order for the use of bed rails. An observation on 02/24/2025 at 11:46 a.m. revealed Resident #148 lying on her back in bed, with bed rails up on each side of upper and lower bed. During an interview on 02/26/2025 at 07:50 a.m. S12 CNA reported Resident #148 would request to have all her bed rails up and would use the bed rails to reposition when in bed. Resident #149 Review of Resident #149's medical record revealed an admit date of 02/19/2025 with diagnoses including, but not limited to non-displaced fracture of upper end left humerus and history of falling. During an interview on 02/26/2025 at 8:32 a.m. S8 SSD reported Resident #149's BIMS interview had been completed yesterday and Resident #149 had a BIMS score of 06, which indicated severe cognitive impairment. Review of Resident #149's medical record failed to reveal an entrapment risk assessment was completed and an informed consent was obtained from the resident or resident's representative prior to installation and use of bed rails. Review of Resident #149's comprehensive care plan revealed Resident #149 required extensive to maximum assistance with mobility and transfers. Further review of Resident #149's comprehensive care plan failed to reveal Resident #149 was care planned for use of bed rails as an assistive device. Review of Resident #149's physician orders failed to reveal an order for the use of bed rails. An observation on 02/24/2025 at 12:36 p.m. revealed Resident #149 with bed rails up on each side of upper bed. During an interview on 02/24/2025 at 12:36 p.m. Resident #149 reported she liked having the bed rails up to help her move in bed. An observation on 02/25/2025 at 07:53 a.m. revealed Resident #149 was lying in bed with bed rails up on each side of upper bed. During an interview on 02/26/2025 at 07:50 a.m. S12 CNA reported Resident #149 would request her bed rails to be elevated and used them for bed mobility. Resident #196 Review of Resident #196's medical record revealed an admit date of 02/10/2025 with diagnoses including, but not limited to, malignant neoplasm of cerebellum, malignant neoplasm of brain stem, and cerebral edema. Review of Resident #196's most recent MDS dated [DATE] revealed Resident #196 had a BIMS of 11 indicating moderately impaired cognition. Further review of Resident #196's MDS revealed Resident #196 required limited to extensive assistance with mobility. Review of Resident #196's medical record failed to reveal an entrapment risk assessment was completed and an informed consent was obtained from the resident or resident's representative prior to installation and use of bed rails. Review of Resident #196's comprehensive care plan failed to reveal Resident #196 was care planned for use of bed rails as an assistive device. Review of Resident #196's physician orders failed to reveal an order for the use of bed rails. An observation on 02/24/2025 at 9:50 a.m. revealed Resident #196 had bilateral upper quarter bed rails and bilateral lower quarter bed rails in use. During an interview on 02/24/2025 at 9:50 a.m. Resident #196 reported he required assistance to transfer out of bed and utilized the bed rails for bed mobility. An observation on 02/25/2025 at 2:12 p.m. revealed Resident #196 sitting in a wheelchair next to the left side of the bed which had bilateral upper quarter bed rails and the right lower quarter bed rail in use. An observation on 02/26/2025 at 7:45 a.m. revealed Resident #196 resting in bed with bilateral upper quarter bed rails and the left lower quarter bed rail in use. During an interview on 02/26/2025 at 7:47 a.m. S9 CNA reported Resident #196 required assistance to get out of bed and utilized bilateral upper quarter bed rails for bed mobility. S9 CNA acknowledged bilateral upper and lower left quarter bed rails were in use. During an interview on 02/26/2025 at 7:50 a.m. S10 LPN reported Resident #196 required assistance to get out of bed and utilized bilateral upper quarter bed rails for bed mobility. S10 LPN reported lower quarter bed rails should not be utilized. During an interview on 02/26/2025 at 8:35 a.m. S6 MDS and S1 Administrator reviewed Resident #7, #26, #27, #28, #148, #149, and #196's records and confirmed that prior to installation and use of bed rails, the residents were not assessed for the risk of entrapment from bed rails, a consent was not obtained from the residents or residents' representative for use of bed rails, and residents did not have a physician order or a care plan for use of bed rails.

Based on record review and interviews, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 (#148) of 5 (#11, #32, #36, #148, #149) residents reviewed for unnecessary medications. The facility failed to monitor Resident #148 for bleeding while receiving an anticoagulant and for behaviors and side effects while receiving an antidepressant. Findings: Review of Resident #148's medical record revealed an admission date of 02/18/2025 with diagnoses that included, in part, depression, atherosclerotic heart disease of native coronary artery, heart failure unspecified, and presence of cardiac pacemaker. Review of Resident #148's physician orders revealed a 02/18/2025 order for Eliquis 2.5mg (milligram) tablet - give one tablet by mouth twice a day and 02/18/2025 order for Celexa 10mg tablet - give one tablet by mouth at bedtime. Review of February 2025 MAR (Medication Administration Record) failed to reveal monitoring for bleeding had been conducted with 8:00 a.m. dose of Eliquis on 02/21/2025, 02/22/2025, and 02/24/2025 and the 8:00 p.m. dose of Eliquis on 02/24/2025. Further review of the MAR failed to reveal monitoring for behaviors and side effects had been conducted from 02/21/2025 to 02/24/2025. Review of Resident #148's care plan revealed: New symptoms of depression with approaches that included, in part, evaluate resident's effectiveness of anti-depressant medication therapy, monitor resident for suicidal ideation, record/monitor resident for patterns of target behaviors, and resident prescribed Celexa. Decreased cardiac output with approaches that included, in part, administer medication as ordered, document adverse reactions, notify MD (medical doctor) of concerns, and treat as ordered. Resident is prescribed Eliquis. During an interview on 02/26/2025 at 12:06 p.m. S2 DON (Director of Nursing) reviewed Resident #148's February 2025 MAR and reported there was no evidence that monitoring for behaviors and side effects had been conducted from 02/21/2025 to 02/24/2025. During an interview on 02/26/2025 at 1:06 p.m. S3 RN (Registered Nurse) reviewed Resident #148's February 2025 MAR and confirmed there was no evidence monitoring for bleeding had been conducted with the morning dose of Eliquis on 02/21/2025, 02/22/2025, and 02/24/2025 and the evening dose of Eliquis on 02/24/2025 and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection for 2 (Resident #32 and #149) residents out of a total sample of 20 residents. The facility failed to ensure: 1. Enhanced Barrier Precautions (EBP) were in place for Resident #32 and Resident #149; 2. Staff donned with proper Personal Protective Equipment (PPE) when performing high-contact resident care for Resident #149. Findings: Review of the facility's Enhanced Barrier Precautions Policy and Procedure dated 03/25/2024 revealed in part: Policy: It is the policy of ____________ to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organism (MDRO). Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and gloves use during high contact resident care activities. Policy Explanation and Compliance Guidelines: 2. Initiation of Enhanced Barrier Precautions: 2. An order for enhanced barrier precautions will be obtained for residents with any of the following: 1. Wounds (for example chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds .) and/or indwelling medical devices (for example central lines, urinary catheters .) even if the resident is not known to be infected or colonized with a MDRO . 3. Implementation of Enhanced Barrier Precautions: 1. Make gowns and gloves available immediately near or outside of the resident's room . 2. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. 4. Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room . 4. High-contact resident care activities include: 8. Wound care; any skin opening requiring a dressing. 1. Resident #32 Review of Resident #32's medical record revealed an admit date of 02/09/2023 with diagnoses including, in part, peripheral vascular disease, dysphagia, type 2 diabetes mellitus, unspecified dementia, cerebral ischemia, acquired absence of right leg above knee, acquired absence of left leg above knee and peripheral vascular disease. Review of Resident #32's physician orders dated 12/16/2024 revealed and order to clean coccyx wound until resolved. Further review revealed an order dated 09/21/2024 for Foley catheter care every shift. Review of Resident #32's physician orders dated 05/03/2024 revealed an order for Enhanced Barrier Precautions while providing direct patient car, such as, bathing, grooming and transferring. Gown and gloves must be worn. Ensure that dedicated disposable equipment or cleaning and disinfecting equipment before use on another resident. Review of Resident #32's MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 02 indicating severe cognitive impairment. Further review of Resident #32's MDS revealed Resident #32 was marked as having an unhealed, unstageable pressure ulcer and an indwelling catheter. An observation on 02/24/2025 at 8:25 a.m. revealed Resident #32 did not have Enhanced Barrier Precautions signage on the door or PPE readily available. An observation on 02/24/2025 at 10:45 a.m. revealed Resident #32 with an indwelling Foley catheter. During an interview on 02/24/2025 at 11:51 a.m. S4 ADON (Assistant Director of Nursing) confirmed Resident #32 did have a catheter and a PU (Pressure Ulcer). S4 ADON acknowledged Resident #32 should have PPE available and Enhanced Barrier Precaution signage. Resident #149 Review of Resident #149's medical record revealed an admit date of 02/19/2025 with diagnoses including, in part, chronic diastolic (congestive) heart failure, type 2 diabetes mellitus with hyperglycemia and stage 2 pressure ulcer of other site. Review of Resident #149's physician orders revealed a 02/20/2025 order for Mid Upper Spine-Clean with wound cleanser, pat dry, apply adaptic non-adherent film then apply a dry dressing to the wound bed every 3 days until resolved. Further review of the orders revealed a 02/20/2025 order for Currently on enhanced barrier precautions. While providing direct patient care, bathing, grooming, transferring etc. gown and gloves must be worn. Ensure that dedicated disposable equipment or cleaning disinfecting equipment before use on another resident. Observation on 02/25/2025 at 9:45 a.m. failed to reveal EBP signage was in place on Resident #149's door. During an interview on 02/25/2025 at 9:45 a.m. S5 Treatment Nurse reported Resident #149 had an open wound and should be on EBP. S5 Treatment Nurse further confirmed there was no EBP signage on Resident #149's door and no gowns available on the hall and should be. During an interview on 02/25/2025 at 10:02 a.m. S6 LPN (Licensed Pratical Nurse) confirmed there were no gowns available on Resident #149's hall for residents on EBP and should be. 2. Observation of wound care for Resident #149 on 02/25/2025 at 10:50 a.m. by S5 Treatment Nurse with S2 DON (Director of Nursing) at bedside revealed S5 Treatment Nurse had donned a sleeveless PPE gown over her scrub jacket. Further observation revealed S5 Treatment Nurse was observed removing the bandage from Resident #149's spinal wound while wearing the sleeveless PPE gown. During an interview on 02/25/2025 at 10:50 a.m. S5 Treatment Nurse and S2 DON (Director of Nursing) acknowledged the sleeveless PPE gown did not provide full arm coverage as a protective barrier and should have.

Based on record reviews and interviews, the facility failed to protect the resident's right to be free from physical and verbal abuse by staff for 1 (#1) resident out of 3 (#1, #2, #3) sampled residents. Findings: Review of the facility's Abuse Policy (undated) revealed the following: It is the policy of the facility to ensure residents have the right to be free from abuse. It is the responsibility of the employees, facility consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown origin, and theft or misappropriation of resident property to facility management. Procedure: IV. Comprehensive policies and procedures have been developed to aid in preventing abuse, neglect or mistreatment of our residents. The facility's abuse prevention program at a minimum includes: G. The implementation of changes to prevent future occurrences of abuse. IX. To assist one in recognizing incidents of abuse, the following definitions of abuse are provided: B. Verbal abuse is defined as any use of oral, written or gestures language that willfully includes disparaging and derogatory terms directed to residents or at residents with hearing distance, regardless of their age, ability to comprehend, or disability. D. Physical abuse is defined as hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through punishment. Review of Resident #1's medical record revealed a readmit date of 12/21/2020 with the following diagnoses of in part: Sequelae of cerebral infarction, generalized anxiety disorder, shortness of breath, unspecified hemiplegia following cerebral infarction affecting the left non-dominant side. Review of Resident #1's Quarterly MDS (minimum data set) dated 05/08/2024 revealed a BIMS (brief interview for mental status) score of 15 indicating intact cognition. Resident #1 used a wheelchair and required 1 person extensive assist with transfers. Review of Resident #1's Resident Grievance Report dated 07/23/2024 revealed in part I (Resident #1) am tired of being verbally and physically abused by my CNA (Certified Nursing Assistant) (S3 CNA). I cannot take it anymore. We do not get along. She (S3 CNA) calls me a crippled m_____ f_____ and slings me into the chair when transferring me just hoping I land into the chair. I do not want her taking care of me anymore; it's S3 CNA. Review of the Abuse and Neglect in-service dated July 24th, 25th and 26th of 2024 failed to reveal all staff were in-serviced. During an interview on 08/13/2024 at 8:42 a.m. Resident #1 reported on 07/23/2024, S3 CNA slung him into his wheelchair roughly and called him a mother f___ honky. Resident #1 further reported he was happy and had no mental or physical trauma from the incident. During an interview on 08/13/2024 at 10:05 a.m. S2 DON (Director of Nursing) reported Resident #1 came to her about the incident with S3 CNA on 07/23/2024 saying S3 CNA slung him in his wheelchair and called him an ugly name. S2 DON further reported S3 CNA left early from her shift that day and has not been back to work since. After the investigation, S3 CNA was no longer permitted to work at the facility. S2 DON acknowledged not all staff were in-serviced on abuse and neglect after the incident on 07/23/2024. During an interview on 08/14/2024 at 10:40 a.m. S1 Administrator acknowledged not all staff participated the in-service training on abuse and neglect after the incident on 07/23/2024 with Resident #1 and should have. S1 Administrator further reported S3 CNA has not worked at the facility since the day of the incident and was no longer employed at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure a resident received adequate supervision for 1 (#1) of 3 (#1, #2 and #3) sampled residents who receive a whirlpool bath. Findings: Review on 05/06/2024 of facility's current undated policy titled Giving the Resident a Shower/Whirlpool Policy and Procedure revealed in part: Be sure that the bath area is at a comfortable temperature for the resident. Stay with the resident throughout the bath/whirlpool. Never leave the resident unattended in the tub or shower. Use the emergency call signal to summon assistance, if needed. Review of the facility's Incident Report with occurrence date of 04/12/2024 revealed in part, Resident #1 was left alone in the whirlpool room. Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including, but not limited to: acquired absence of left leg below the knee, type 2 diabetes mellitus with neuropathy, and hypertensive heart disease. Review of Resident #1's quarterly MDS (Minimum Data Set) dated 03/15/2024 revealed a BIMS (Brief Interview for Mental Status) score of 15 out of 15 indicating cognition intact. Further review of the MDS dated [DATE] revealed Resident #1 had a limb prosthesis and required partial/moderate assistance with shower/bathing. During an interview on 05/06/2024 at 12:50 p.m., Resident #1 confirmed he was left alone in the whirlpool a few weeks ago. Resident #1 further reported he was unsure of the exact date in which the incident occurred. During an interview on 05/06/2024 at 4:25 p.m., S2 CNA confirmed she had assisted Resident #1 out of the whirlpool after she entered the whirlpool room and observed Resident #1 in the whirlpool without a staff member present. During an interview on 05/07/2024 at 2:15 p.m., S1 Administrator confirmed Resident #1 had been left unsupervised in the whirlpool and should not have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews the facility failed to develop and implement a comprehensive person centered plan of care for 2 residents (#36, #5) out of 14 residents investigated for plan of care. The facility failed to: 1. Develop and implement a plan of care for Resident #36's indwelling catheter. 2. Implement administration of Resident #5's medication as ordered by the physician. Findings: 1. Resident #36 An observation on 02/05/2024 at 8:15 a.m. revealed Resident #36's indwelling catheter bag hanging on Resident #36's bed and draining dark amber urine in catheter bag. Review of Resident #36's nurses notes revealed on 02/05/2024 Resident #36's indwelling catheter was patent and draining dark amber urine. Review of Resident #36's Quarterly MDS dated [DATE] revealed the following diagnoses in part: Heart failure, urinary tract infection, diabetes mellitus, cirrhosis of liver, chronic kidney disease stage 3. Review of Resident #36's physician orders failed to reveal an order for an indwelling catheter. Review of Resident #36's comprehensive care plan failed to reveal a care plan had been developed for an indwelling catheter. Review of the January and February 2024 Completed Care documentation for Resident #36 failed to revealed catheter care was being done. Review of Resident #36's readmission MDS (Minimum Data Sets) dated 01/17/2024 revealed Resident #36 entered the facility. Review of Resident #36's January and February 2024 (MAR) Medication Administration Record failed to reveal documentation an indwelling catheter was being monitored and/or indwelling catheter care was being provided. During an interview on 02/07/2024 at 10:51 a.m. S5 LPN (License Practical Nurse), confirmed Resident #36 did have an indwelling catheter. S5 LPN further reported Resident #36 did not have an order for an indwelling catheter and catheter care was not being provided and should have been. During an interview on 02/07/2024 at 1:36 p.m. S2 DON (Director of Nursing) confirmed Resident #36 should have an order for an indwelling catheter and catheter care and should have been provided. S2 DON further reported she enters the orders and missed the order for Resident #36's indwelling catheter. 2. Resident #5 Review of Resident #5's revealed an order dated 11/22/2023 for Lovenox 40 mg (milligram) / 0.4 ml (millimeter) syringe give 40 milligrams subcutaneous daily (monitor bruising/bleeding). Review of Resident #5's January 2024 Medication Administration Record (MAR) failed to reveal documentation of physician ordered daily administration of Lovenox 40mg subcutaneous for the following days: 01/04/2024 through 01/14/2024, 01/16/2024 through 01/22/2024, and 01/24/2024 through 01/31/2024. Review of Resident #5's February MAR failed to reveal documentation of physician ordered daily administration of Lovenox 40mg subcutaneous for 02/01/2024 through 02/06/2024. During an interview on 02/06/2024 at 2:20 p.m. S4 Nurse Practitioner (NP) reviewed Resident #5's record and acknowledged there was an order dated 11/22/2023 for Lovenox 40mg subcutaneous daily. S4 NP reviewed Resident #5's January 2024 and February 2024 MARs and acknowledged there was not documentation of administration of Resident #5's physician ordered daily Lovenox for 01/04/2024 through 01/14/2024, 01/16/2024 through 01/22/2024, 01/24/2024 through 01/31/2024 and for 02/01/2024 through 02/06/2024. S4 NP further reported the Lovenox had not been discontinued and should have been given according to physician orders. During an interview on 02/06/2024 at 2:40 p.m. S3 Registered Nurse (RN)-Unit Manager reviewed Resident #5's record and acknowledged there was an order dated 11/22/2023 for Lovenox 40mg subcutaneous daily. S3 RN-Unit Manager reviewed Resident #5's January 2024 and February 2024 MARs and acknowledged there was not documentation of administration of Resident #5's physician ordered daily Lovenox for 01/04/2024 through 01/14/2024, 01/16/2024 through 01/22/2024, 01/24/2024 through 01/31/2024 and for 02/1/2024 through 02/6/2024 and should have been. S3 RN-Unit Manager further acknowledged there was not documentation as to why the medication was not given and there was not documentation of resident refusal of medication. During an interview on 02/06/2024 at 2:40 p.m. S2 Director of Nursing (DON) reviewed Resident #5's record and acknowledged there was an order dated 11/22/2023 for Lovenox 40mg subcutaneous daily. S2 DON reviewed Resident #5's January 2024 and February 2024 MARs and acknowledged there was not documentation of administration of Resident #5's physician ordered daily Lovenox for 01/04/2024 through 01/14/2024, 01/16/2024 through 01/22/2024, 01/24/2024 through 01/31/2024 and for 02/1/2024 through 02/6/2024 and should have been. S2 DON further acknowledged there was not documentation as to why the medication was not given and there was not documentation of resident refusal of medication.

Based on record reviews and interview, the facility failed to ensure an RN (Registered Nurse) was on duty for 8 consecutive hours per day, 7 days a week, for 4 days within FY (Fiscal Year) Quarter 4 2023 (July 1- September 30). Findings: Review of the facility's PBJ (Payroll Based Journal) Staffing Data Report for FY Quarter 4 2023 (July 1- September 30) revealed there were no RN hours for four or more days within the quarter. Further review revealed no RN hours for the dates of 07/24/2023, 07/25/2023, 08/07/2023, and 08/08/2023. During an interview on 02/06/2024 at 1:10 p.m. S1 Administrator reported she was responsible for completing the PBJ staffing report. S1 Administrator reviewed the PBJ for FY (Fiscal Year) Quarter 4 2023 (July 1- September 30) and reported during that time period the facility only had one RN. S1 Administrator confirmed there was not RN coverage for at least 8 consecutive hours a day for 07/24/2023, 07/25/2023, 08/07/2023, and 08/08/2023 and there should have been.

Based on interviews and record reviews the facility failed to ensure grievances or complaints were addressed and investigated. The facility failed to follow their policy by ensuring a resident can file a grievance or complaint without fear of threats or reprisal. The facility had a total census of 42 residents. Findings: Review of the facility's Grievance/Complaint policy reveal in part the following: Purpose: It is the policy of this facility to assist its residents, or person on behalf of the resident, in filing grievances or complaints when such requests are made. The following procedure outlines the steps needed to accomplish this task. Procedure: Any resident, his or her representative, family member or appointed advocate, may file grievance or complaint concerning treatment, medical care, behavior of other residents, staff members, missing property, etc., without fear of threat or reprisal. Staff member will delegate the responsibility of the grievance and/or complaint investigation to the department staff member who is best able to carry out the investigation and report the findings. This person will sign the grievance form as the person completing the investigation. This person will document the follow up/conclusion to the investigation. The resident or person filing the grievance on behalf of the resident will be informed of the findings of the investigation. Review of Resident Council Meeting minutes dated 08/29/2023 revealed complaint/grievance addressed to nursing documented: Residents fear retaliation when complaints are reported to S3 ADON (Assistant Director of Nursing). CNAs (Certified Nursing Assistant) come back to the residents confronting them because S3 ADON tells them the residents complained about them. During an interview on 12/20/2023 at 8:52 a.m. S4 Activity Director reported she gets the residents together for the Resident Council meetings. She reported during the meeting her job is to take notes and type up the minutes. She reported within 24 hours the minutes with a Grievance Report form are given to the Department Heads or whoever the complaint/grievance is directed to. S4 Activity Director reported she does not always get a response back. S4 Activity Director reported the Department Head or the person the complaint/grievance is direct to has 72 hours to respond. Reviewing of the Resident Council minutes dated 08/29/2023 at 1:00 p.m. with S4 Activity Director, S4 Activity Director reported during the Resident Council meetings, residents reported they are fearful to voice their complaints. S4 Activity Director reported the residents complained of fearing retaliation when things are reported to S3 ADON. S4 Activity Director reported the residents voiced they have had CNAs confront them about complaints they have made to S3 ADON. S4 Activity Director reported she did not get a response back from S3 ADON and she should have. During an interview on 12/20/2023 at 9:15 a.m. S3 ADON was asked about the facility's Grievance Procedure. S3 ADON stated, A complaint/grievance is put on a grievance form. The S3 ADON reported anyone can take a grievance. When asked if he responded to the complaint/grievance from the Resident Council meeting on 08/29/2023 regarding the resident fearing retaliation when things are reported to him due to him telling the CNAs who the complaint came from, S3 ADON stated, What do you think, these residents are living in a place where they are dependent on other people to take care of them. I don't know anything about protecting the residents from threats or reprisal. You come in here and accuse me of doing something. During an interview on 12/20/2023 at 09:30 a.m. S2 DON (Director of Nursing) reported the Grievance/Complaint Procedure was the department head or the person that could best answer the grievance/complaint would respond. S2 DON reported S3 ADON should have responded to the complaint/grievance from the resident council meeting 08/29/2023. During an interview on 12/20/2023 at 11:50 a.m. S1 Administrator reported the Grievance /Complaint was not handled properly and should have been taken care of by one of the Nursing Department Heads. S1 Administrator reported this Grievance/Complaint form never got to her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews the facility failed to ensure a resident with a urinary catheter received appropriate care and services to prevent urinary tract infections by having the Foley catheter drainage bag on the floor for 1 (#29) of 2 (#10, #29) residents reviewed for Urinary Catheter or UTI (Urinary Tract Infection). Findings: Review of Policy named Catheter Care, Urinary dated 04/12/19 revealed: Purpose: It is the policy of Progressive Care Center to prevent catheter-associated urinary tract infections among Health Center residents . Infection Control: 1. Use standard precautions when handling or manipulating the drainage system. 2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. b. Be sure the catheter tubing and drainage bag are kept off the floor. Review of Resident #29's medical record revealed Resident #29 was admitted to the facility on [DATE] and had diagnoses that included, in part, Other obstructive and reflux uropathy, Benign prostatic hyperplasia with lower urinary tract, Hemiplegia following cerebral infarction affecting right nondominant side and Hypertensive heart disease without heart failure. Review of Resident #29's February 2023 physician orders revealed the orders included: 09/21/2022 22FR (French)/30cc (cubic centimeters) Foley cath-3 way catheter do not attempt to change Foley only can be done by urologist _______ Urology Clinic. Review of Resident #29's care plan revealed: At risk for urine retention due to BPH with obstructive uropathy, requires a Foley Cath due to obstruction with interventions that included, in part, keep Foley catheter drainage below bladder with GU (genitourinary) bag off floor. Observation on 02/14/2023 at 12:35 p.m. revealed Resident #29 was dressed and seated in his wheelchair and Foley drainage bag with privacy cover was noted to be on the floor. During an interview on 02/14/2023 at 12:40 p.m. S4 CNA (Certified Nursing Assistant) observed and agreed Resident #29's Foley bag with privacy cover was under the seat of Resident #29's wheelchair and on the floor. CNA further reported the Foley bag should not have been on the floor. During an interview on 02/14/2023 at 12:55 p.m. S1 DON (Director of Nursing) observed Resident #29's Foley drainage bag with privacy cover was under the seat of Resident #29's wheelchair and on the floor and reported Resident #29's Foley bag was on the floor and should not have been on the floor.

Based on observation, interview and record review, the facility failed to ensure medications were stored in a locked compartment on 1 of 2 medication carts observed. Findings: A record review of the Storage of Medications policy revealed in part: Policy Interpretation and Implementation 7.) Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. An observation on 02/14/2023 at 12:02 p.m. revealed the medicine cart on the 2nd floor was unlocked and unattended. During an interview on 02/14/2023 at 12:09 p.m. S9 LPN (Licensed Practical Nurse) confirmed the 2nd floor medicine cart was left unlocked and unattended and should not have been.

Based on observations, interviews, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 2 (#4, #26) of 18 sampled residents reviewed. The facility failed to ensure residents had a call light in reach in order to call for assistance. Findings: Review of the facility's Answering the Call Light Policy revealed the following: V. When the resident is in bed or confined to a chair, be sure the call light is within easy reach of each resident. Resident #4 Observation on 02/13/2023 at 8:30 a.m. revealed resident #4's pad call light/button was lying to the floor on the left side of resident's bed out of resident #4's reach. During an interview on 02/13/23 at 8:30 a.m. S6 CNA (Certified Nursing Assistant) confirmed resident #4's pad call light/button was out of reach and should have been placed on her pillow within her reach. Resident #26 Observation on 02/13/2023 at 8:45 a.m. revealed resident #26's call light /button was lying on the floor and out of resident #26's reach. Observation on 02/13/2023 at 8:45 a.m. with S7 CNA revealed resident #26's call light was lying on the floor and out of resident #26's reach. During an interview on 02/13/2023 at 8:45 a.m. S7 CNA confirmed resident #26's call light/button was lyimg on the floor out of resident #26's reach and stated, It should have been put on his pillow within his reach. During an interview on 02/15/2023 S1 DON (Director of Nurses) confirmed resident #4 and resident #26's call light/button should have been within reach at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide quarterly personal funds statements to 3 (#3,#5, #6) of 3 residents whose personal funds were reviewed. The facility failed to provide quarterly statements to residents who were their own responsible party. Findings: Resident #3 Review of resident #3's Medical Record revealed an admit date of 12/4/2014 with a diagnosis of but not limited to Chronic Kidney Disease, Sleep Apnea, Hypokalemia, Overactive Bladder, History of Kidney Transplant and History of COVID 19. Review of resident #3's Quarterly MDS (Minimum Data Set) dated 01/13/2023 revealed resident #3 had a BIMS (Brief Interview Mental Status) score of 15 indicating intact cognition. During an interview on 02/13/2023 at 10:50 a.m. resident #3 stated, they don't give us any type of statement, I have to ask them how much money is in my account. During an interview 02/15/2023 at 9:05 a.m. S3 Business Manager reported resident #3 was her own responsible party and should have received a statement of her resident account quarterly. Resident # 5 Review of resident #5's medical record revealed an admit date of 10/29/2007 with a diagnosis of but not limited to Type 2 Diabetes, Kidney Disease, Hypothyroidism, Unspecified Convulsions, Gout, Vitamin D deficiency, Stroke, and Anxiety Disorder. Review of resident #5's Yearly MDS dated [DATE] revealed resident #5 was assessed to have BIMS score of 15 indicating intact cognition. During an interview on 02/15/2023 at 9:41 a.m. resident #5 stated, I try to keep up with my balance myself, I have never received a statement with a balance on it, sometimes I go down there and ask what the balance is. During an interview on 02/15/2023 at 9:05 a.m S3 Business Manager reported resident #5 was his own responsible party and should have received a statement of his resident account quarterly. Resident #6 Review of resident #6's medical record revealed an admit date of 10/17/2008 with a diagnosis of but not limited to Cerebral Infarc, Hemiplegia right dominant side, COPD, Type 2 Diabetes, Heart Failure, Osteoarthritis, Morbid Obesity, Unspecified Psychosis, Contracture of Muscle, Chronic pain, Convulsions, and History of Covid-19. Review of resident #6's Quarterly MDS dated [DATE] revealed resident #6 had a BIMS score of 15 indicating intact cognition. During an interview on 02/15/2023 at 9:50 a.m. resident #6 stated, I haven't gotten a statement in a while, they used to bring them around to me, its probably been a year since I have gotten a statement. During an interview on 02/15/2023 at 9:05 a.m. S3 Business Manager stated, I do not track the deliverance of resident quarterly statement, I do not personally send quarterly statements. S3 Business Manager confirmed she did not have any evidence of residents #3, #5, or #6 receiving quarterly statements. S3 Business Manager confirmed all residents and or resident representatives should have received quarterly statements of their resident accounts.

Based on observations, interviews and record reviews the facility failed to ensure respiratory care was provided consistent with professional standards of practice by not following the facility's policy regarding oxygen administration for 2 (#17, #85) of 2 (#17, #85) residents reviewed for respiratory care. Findings: Facility Policy named Oxygen Administration revealed in part: Purpose: It is the policy of Progressive Care Center to provide guidelines for safe oxygen administration among residents. Reporting: After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 5. Tubing should be changed and dated weekly, on Sunday's. Resident #85 An observation on 02/13/2023 at 8:42 a.m. revealed resident #85 was receiving oxygen by nasal cannula and no date was on the nasal cannula tubing. During an interview on 02/13/2023 at 8:42 a.m. S5 LPN (Licensed Practical Nurse) confirmed resident #85's oxygen tubing was not dated and should have been. Review of resident #85's Physician Orders dated 02/10/2023 revealed O2 (Oxygen) at 2LPM (Liters Per Minute) via NC (nasal cannula). Resident #17 An observation on 02/13/2023 at 11:40 a.m. revealed resident #17's O2 tubing was not dated. Review of resident #17's Physician Orders revealed an order dated 12/1/2022 for O2 at 3LPM per NC. During an interview on 02/13/2023 at 11:42 a.m. S8 LPN confirmed resident #17's O2 tubing was not dated and should have been.

Based on observation and interview the facility failed to store food in accordance with professional standards for food service safety. This had the potential to effect 30 residents who received trays served from the kitchen. Findings: Observation on 02/13/2023 at 7:40 a.m. revealed the following items were found not dated: Freezer contained french fries, salami, diced chicken and, cheese pizzas that were not dated. Refrigerator contained Italian dressing, green olives, sweet potatoes, sliced jalapenos, and sliced pickles that were not dated. Pantry contained hamburger buns that were not dated. Kitchen cabinets contained an open bag of grits, a box of instant potatoes, and a jar of peanut butter that was not dated. Milk refrigerator contained a bottle of lemon juice that was not dated. During an interview on 02/13/23 at 7:55 a.m., S2 Dietary Manager verified food items that were in the refrigerator, freezer, pantry, cabinets, and the milk refrigerator were not dated and the items should have been dated.