Based on records reviewed and interviews for one of three sampled residents (Resident #1) who, on 03/20/25, reported that he/she had been physically abused by Certified Nurse Aide #1, the Facility failed to ensure Administration reported the reasonable suspicion of a crime, when although the Administrator was aware on 03/20/25, the facility did not notify local law enforcement until 04/15/25, the day of survey. Findings include: Review of the Facility's Policy titled, Abuse Reporting and Investigation, dated as revised May 2021, indicated that each staff member must report any actual/known, suspected, or alleged incident of physical abuse, neglect, or financial abuse, abandonment or isolation to his/her supervisor and/or other community leadership immediately. This includes incidents/actions that the staff member observes, suspects, or is informed of by a resident. Under the Elder Justice Act, staff in the nursing home have an additional responsibility to report incidents to the state agency and law enforcement. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted 03/20/25, indicated that Resident #1 reported to CNA #2 that CNA #1 hit him/her. Review of the Facility's Investigation Report, undated, indicated that on 03/20/25, Resident #1 reported to CNA #2 that CNA #1 hit and punched him/her all over. The Facility's Investigation Report indicated that CNA #2 said she and CNA #1 transferred Resident #1 and said Resident #1 told her (CNA #2) that CNA #1 is a bitch and she had hit him/her. The Facility's Investigation Report indicated that nursing performed a skin check and found three small bruises on Resident #1's right thigh. The Facility's Investigation Report indicated that CNA #1 was terminated based on the findings of the Facility's Investigation, and that the Police had not been notified of Resident #1's abuse allegation. Resident #1 was admitted to the Facility in August of 2024, diagnoses included Alzheimer's Disease, agitation, and depression. Review of Resident #1's Quarterly Minimum Set Data (MDS) Assessment, dated 02/07/25, indicated he/she had severe cognitive impairment and was dependent on staff to meet his/her care needs. During an interview on 04/15/25 at 11:45 A.M., CNA #2 said that on 03/20/25 in the morning, CNA #1 helped her (CNA #2) transfer Resident #1 with the mechanical lift from his/her bed to his/her wheelchair. CNA #2 said that after CNA #1 left the room, Resident #1 told her (CNA #2) that CNA #1 was a bitch and that she hits him/her. CNA #2 said she reported the allegation it to Nurse #2 immediately. During a telephone interview on 04/23/25 at 9:36 A.M., Nurse #2 said that on 03/20/25, CNA #2 reported to her that Resident #1 told her that CNA #1 hit him/her (Resident #1). Nurse #2 said she went to Resident #1's room and said he/she (Resident #1) told her (Nurse #2) that CNA #1 had hit him/her, but did not know where on his/her body. Nurse #2 said she immediately reported Resident #1's allegation of physical abuse to Administration. During an interview on 04/15/25 at 3:03 P.M., the Administrator said that on 03/20/25, Nurse #2 notified her that Resident #1 had reported that CNA #1 had physically abused him/her. The Administrator said she immediately suspended CNA #1 and then terminated her, based on the findings of their investigation. The Administrator said she had not notified local law enforcement of the allegation of physical abuse until 04/15/25 (day of the survey).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure all drugs and biologicals were stored in a safe and secure manner as required. Specifically, the facility failed to ensure medications were not left unattended in six Residents' (58, #21, #2, #61, #20, and #267) rooms. Findings include: Review of the facility's policy titled Storage of Medication Administration, Receipt, Storage and Disposal, revised 10/23, indicated but was not limited to the following: -Medication Management in Continuing Care (CC) will include ordering, transcribing, receiving, proper storage, accurate documentation and safe administration of a residents' medications by authorized staff, consistent with state requirements. Receipt of Medications from Pharmacy Courier: -The Licensed nurse or Certified Medicine Aide/Tech (CMA/CMT) will place medications in the medication room on the neighborhood and medications will be placed in the resident medication cabinet or overflow medication. On 2/21/25 at 10:26 A.M., the surveyor observed the following medications stored on the top of the locked medication cabinet in Resident #58's room: -A box of Lidoderm 4% patches (pain patch). On 2/21/25 at 10:37 A.M., the surveyor observed the following medications stored on the top of the locked medication cabinet in Resident #21's room: -Two boxes of Albuterol sulfa (bronchodilator) 92.5 milligrams (mg)/3milliliter (ml) vial-neb. Inhale by mouth three times a day for shortness of breath. -Benefiber powder 3 grams (gm)/4 gm (prebiotic fiber supplement). -Tube of Aspercreme (pain relief) with 10% trolamine salicylate cream. -In the unlocked drawer below the medication cabinet a bottle of Benefiber powder 3 gm/4 gm. On 2/21/25 at 10:44 A.M., the surveyor observed the following medications stored on the top of the locked medication cabinet in Resident #2's room: -Three small bottles of Nystatin (antifungal) 100000 unit/1gm powder, one with no cap and two sealed with caps. -One larger bottle of Nystatin topical powder. On 2/21/25 at 11:00 A.M., the surveyor observed the following medications stored on the top of the locked medication cabinet in Resident #61's room: -One bottle of guaifenesin (chest congestion)100 mg/5 ml liquid, almost empty. -One bottle chest congestion [NAME] (treat chest congestion)100mg/5 ml liquid. Stored in the unlocked cabinet below the medication cabinet the following medications were observed: -One bottle chest congestion [NAME] 100 mg/5 ml liquid. -Three bottles of Polyethylene Glycol 3350 (treat constipation). On 2/21/25 at 11:35 A.M., the surveyor observed the following medications stored on the top of the medication cabinet in Resident #20's room: -Mirtazapine (antidepressant) 7.5 mg give one tab at bedtime, 15 pills in blister pack (packaging in which a pill is sealed in plastic individually on a cardboard backing). -Pantoprazole (Reduces acid in stomach) 40 mg 1 tab every day, 15 pills in blister pack. On 2/21/25 at 11:36 A.M., the surveyor observed the medication cabinet unlocked in Resident #267's room and observed 23 blister packages of medications and a box of Albuterol Sulfate 2.5 mg/3 ml vial-neb. During an interview on 2/21/25 at 1:31 P.M., the Director of Nurses said all prescription medications in the residents' rooms should be locked in the medication cabinet. If a resident is assessed to self-administer medications, then the medication can be stored in their locked drawer.

Based on record review, observation, and interview, the facility failed to ensure services provided by the facility met professional standards of practice for two Residents (#5 and #14), out of a total sample of 15 residents. Specifically, the facility failed 1.) For Resident #5, to ensure that pressure relieving booties were applied per the physician's order; and 2.) For Resident #14, to a.) obtain a physician's order specifying an air mattress setting; and b.) to document that the air mattress was checked for functioning and setting every shift. Findings include: 1.) Resident #5 was admitted to the facility in June 2021 with diagnoses that included cardiovascular accident (stroke), hemiplegia (paralysis of one side of the body), and decreased mobility. Review of the Minimum Data Set (MDS) assessment, dated 2/25/22, indicated the Resident requires extensive assist with bed mobility and had impairment of range of motion to his/her lower extremity. Further review of the MDS indicated the Resident was at risk for developing pressure ulcers and was receiving pressure relieving devices in the bed and wheelchair. Review of Resident #5's Physician's Orders, dated May 2022 and June 2022, indicated the following: - heel booties on at bedtime. To be removed when out of bed (8/17/21) On 5/31/22 at 9:30 A.M., the surveyor observed Resident #5 in bed. He/she was lying on their back with their feet flat on the mattress with no booties on. On 6/1/22 at 9:52 A.M., the surveyor observed Resident #5 in bed. He/she was lying on their back with their feet flat on the mattress with no booties on. Review of the Treatment Administration Record (TAR) for May 2022 and June 2022, indicated the staff were documenting that the heel booties were in place on 5/31/22 and 6/1/22 on the 7:00 A.M. - 3:00 P.M. shift. During an interview on 6/2/22 at 2:50 P.M., the Director of Nurses (DON) said if a Resident has orders for booties while in bed it would be her expectation that the booties would be on the Resident. The DON said she was unsure why the booties were not on the Resident. During an interview on 6/2/22 at 5:43 P.M., the DON said the nurse on the 11:00 P.M. - 7:00 A.M. shift was supposed to put the booties on the Resident. The DON said the Resident said the staff never put them on him/her. 2.) Resident #14 was admitted to the facility in September 2020 with diagnoses that included diabetes, hypertension, and chronic obstructive pulmonary disorder (COPD- lung disease that blocks airflow and makes it difficult to breathe). Review of the Minimum Data Set (MDS) assessment, dated 3/18/22, indicated the Resident was at risk for pressure ulcers and had a pressure relieving device to his/her bed and wheelchair. On 5/31/22 at 10:30 A.M., the surveyor observed Resident #14 lying in his/her bed on an alternating air mattress (a mattress designed to protect against pressure ulcers by allowing air to flow through). The mattress was set at #5. On 6/1/22 at 8:30 A.M., the surveyor observed Resident #14 lying in his/her bed on an alternating air mattress. The mattress was set at #5. On 6/2/22 at 2:42 P.M., the surveyor observed Resident #14 lying in his/her bed on an alternating air mattress. The mattress was set at #5. Review of the Physician's Orders, dated May 2022 and June 2022, indicated the following: - Skin: pressure reducing mattress - Notes: air mattress in place: check functioning and setting every shift (4/5/22) Further review of the Physician's Orders failed to indicate orders for a mattress number setting. Review of the Treatment Administration Record (TAR), dated May 2022 and June 2022, failed to indicate documented evidence that the air mattress was being checked every shift for functioning and setting. Review of the Nursing Progress Notes, dated 5/1/22 - 6/2/22, failed to indicate any documented evidence that the air mattress was being checked every shift for functioning or setting. Observation of the air mattress indicated a sticker on the air mattress pump machine that indicated that the setting of the air mattress should be set according to the weight of the Resident. Setting #5 indicated a weight of 300-425 pounds. Review of the Resident's weights indicated the Resident's current weight was 177 pounds. During an interview on 6/2/22 at 12:53 P.M., Unit Manager #1 said there should be a physician's order for what setting the air mattress should be on. During an interview on 6/2/22 at 3:00 P.M., the Director of Nurses said air mattresses are set at a number based on the Resident's weight.

Based on observation, record review, and staff interview, the facility failed to ensure treatment and services for the care of an indwelling catheter (tube inserted into the bladder for urine drainage) were provided in accordance with professional standards and facility policy for one Resident (#32), out of a total sample of 15 residents. Findings include: On 5/31/22 at 10:00 A.M., the surveyor observed Resident #32 sitting up in his/her wheelchair with a Foley catheter bag attached to the side. Review of the facility's policy titled Urinary Catheters, dated 6/2021, indicated, but was not limited to the following: - provide catheter care every shift. Wash with warm soap and water. - change drainage bag monthly (label with date, and time changed) unless otherwise specified by the provider - nursing staff will assess for potential evidence of symptomatic UTI (urinary tract infection), pain at insertion site, or other changes in urine condition and notify the provider if change is noted - nursing staff will assess catheter for leakage from site of insertion to the bag Resident #32 was admitted to the facility in January 2022 with diagnoses that included right femur fracture and UTI. Review of the Minimum Data Set (MDS) assessment, dated 4/14/22, indicated the Resident had an indwelling catheter. Further review of the MDS indicated the Resident required extensive assist with transfers and toileting. Review of the Physician's Orders, dated May 2022, indicated the following: - Foley catheter care per protocol Review of the Treatment Administration Record (TAR), dated May 2022, failed to indicate documented evidence the Foley catheter bag was changed in May 2022 or that the nursing staff were assessing for pain or for symptoms of a UTI per the facility policy. Further review of the Physician's Orders indicated there were no orders for the care and treatment of the Foley catheter per the facility policy. Specifically, the physician orders failed to have orders for the size and type of catheter and changing of the catheter bag. The Physician's Orders did not indicate to monitor placement of the catheter or to ensure there were no kinks in the tubing or leakage. Review of the Nursing Progress Notes, dated 5/1/22 - 6/1/22, did not provide documented evidence that Foley catheter care was being done per facility policy and physician's orders. During an interview on 6/2/22 at 3:12 P.M., Nurse # 2 said that usually if a Resident has a Foley catheter then the Resident would have orders for the size and type of catheter along with the care and treatment of the catheter. She said she was unsure why this Resident did not have these orders.