Based on observation, interview, and record review, the facility failed to ensure medications were properly secured, physician's orders for self-administration of medications were clarified, and residents were adequately assessed for self-administration of medications for two Residents (R14 and R46) of three residents reviewed for self-administration of medications. Findings include: Resident #14 (R14) On 12/9/24 at 1:03 p.m., a clear plastic medication cup containing two medication tablets was observed on the over bed table in R14's room. R14 confirmed the nurse brought the cup of medications to the room and placed them on the table before exiting the room. A bottle labeled acetaminophen 500 mg (milligrams) was observed on the nightstand in R14's room. R14 said the bottle contained her pain medication, and she kept the bottle of medication in her room on the nightstand. The bottle was approximately half filled with white, circular tablets. When R14 was asked if the nurses followed up with her to ask her if she took her medications, R14 said, No. I think they just know I take it. On 12/10/24 at 8:01 a.m., the bottle of Acetaminophen was again observed on the nightstand in R14's room. On 12/11/24 at 10:34 a.m., two clear plastic medication cups were observed on R14's bedside table next to an untouched meal tray. One cup contained eight medication tablets and the other contained a white powder. R14's medical record revealed a Self-Administration of Medication evaluation completed on 11/29/24. The evaluation documented R14 as self-administering all scheduled medications. The evaluation further documented R14 had a secured, locked location to store the medications. R14's medical record contained a physician's order that read staff to set up evening medications, resident is able to self administer [sic] in the evening for MED PASS [sic]. There was no physician's order for R14 to self-administer medications during any other part of the day. The medical record of R14 had a physician's order that read resident may keep Tylenol [acetaminophen] at bedside in lock box for self-administration. A care plan for self-administration of medications was in R14's medical record. The care plan did not address the storage expectations for the acetaminophen. The care plan did not specify how the nurses were to administer medications ordered during day shift medication administration. The care plan interventions included only the following interventions: - Assist in securing medication after administration as needed - Document on MAR (Medication Administration Record)/TAR (Treatment Administration Record) resident administered medications after verification of administration with each ordered timeframe - Notify physician/NP (Nurse Practitioner)/PA (Physician Assistant) of any concerns related to self-administration of medication(s) - Periodically review with resident on proper storage of drug to prevent unauthorized access - Periodically review with resident on purpose and side-effects of medication(s) as needed The Director of Nursing (DON) was interviewed on 12/11/24 at 11:42 a.m. The DON said the acetaminophen should not have been on the nightstand in R14's room. The DON said R14 kept medication in a drawer in her room, and the drawer should be locked. The DON said residents who self-administer medications are required to have a physician's order to self-administer and the directive for self-administration should be documented in each physician's order for each medication order for which the resident self-administers. The DON reviewed the physician's orders and Medication Administration Record of R14 and confirmed each order did not contain the directive for self-administration. The DON did not provide a rationale when asked why there was a physician's order for self-administration for the evening medication pass, but not a self-administration order for day shift administration. The DON was asked where the nurses were documenting the self-administration of medications for the day shift. The DON confirmed the MAR did not contain documentation for self-administration on the day shift. Resident #46 (R46) On 12/9/24 at approximately 1:00 p.m., R46 was observed sitting in her recliner chair in her bedroom. R46 had her right hand holding her feeding tube (a device used to deliver nutrition, hydration and medications into the stomach) and was using her left hand to gather a syringe that was placed in a pink water cup. R46 stated that she administered her own water flushes through the tube. On 12/11/24 at 10:32 a.m., R46 was observed sitting in her recliner chair. On the table to the left of her chair was four plastic syringes and two cups of water. R46 stated that these were to be used by her for her next water flush. Review of R46's December 2024 MAR revealed the following orders: Enteral (through a tube) Feed Order one time a day Flush tube with (90) ML's (milliliters) H2O (water) before and after every feed (180 ml total) Start Date: 9/4/24 The times to complete this order were at 7:00 a.m., 10:00 a.m., 1:00 p.m., 5:00 p.m., and 10:00 p.m. Enteral Feed Order every shift flush tube with 50 ML H20 before and after medication administration and feedings Start Date: 9/1/24 .Check placement before administration of meds (medications)/tube feedings/water flushes every evening shift Start Date: 12/10/24 In review of R46's MAR, there was no physician order for R46 to self-administer her own water flushes. Review of R46's Assessments revealed that R46 had not been assessed to safely provide her own water flushes. Review of R46's Care Plans read, in part, .Resident is at risk for fluid volume deficit related to g (gastrostomy or stomach tube)-tube, swallowing problem so is NPO (nothing by mouth) All fluids provided by staff vis [sic] PEG tube; Date Initiated: 9/10/24 . An interview was conducted with the DON on 12/11/24 at approximately 11:30 a.m. The DON stated that the facility did not want R46 to administer her own flushes, but they were having difficulty addressing this with R46. The DON stated that R46 had a history of retrieving syringes out of the trash can or taking used syringes from her roommate. The DON confirmed that R46 did not have a physician order or Self-Administration of Medication assessment for her water flushes. The DON also did not explain why staff had not taken measures to prevent access to the medication/flush syringe. The policy Medication - Resident Self-Administration of dated as revised 1/30/24 read, in part: .2. The resident's preference will be documented on the appropriate form and placed in the medical record. 3. When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following .d. The resident's capability to follow directions .5. Upon notification of the use of bedside medication by the resident, the medication nurse records the self-administration on the MAR .7. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms .Lockable drawers or cabinets are required only if locked storage is ineffective .13. The care plan must reflect resident self-administration and storage arrangements for such medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure written bed-hold information was provided to two Residents/Representatives (#22 & #57) of three residents reviewed for written notice of bed hold. Findings include: Resident #22 (R22) Review of R22's electronic medical record (EMR), communication form and progress note, dated 9/15/24, read in part, .hypoxia [ an absence of enough oxygen in the tissues to sustain bodily functions]/oxygen needs . Review of the Clinical Census report revealed R22 was hospitalized from [DATE] through 9/25/24. Review of R22's EMR revealed there was no Bed Hold Authorization form completed. During an interview on 12/10/24 at 2:09 PM, the Nursing Home Administrator (NHA) was asked who was responsible for the bed hold authorization form and replied, Nursing is responsible for the SBAR (Situation, Background, Assessment, Recommendation), transfer form, and the bed hold authorization. Then the medical records staff is responsible to uploading the bed hold into the EMR. During an interview on 12/10/24 at 2:30 PM, Medical Records Staff C confirmed there was no bed hold notice provided at the time of transfer and none was scanned into the EMR for R22 on 9/15/24. Resident #57 (R57) Review of R57's EMR, progress note, dated 9/1/24, read in part, Resident is following another resident around holding a pillow above her head as if he is going to attack her .Resident is blocking the hallway, not letting staff or residents threw (sic). Resident slapped the RN (Registered Nurse) twice and tried to stab her with his fingernails. Resident is trying to hit staff with his sandals .RN is transferring resident to (Local Hospital) for further evaluation. EMS (Emergency Medical Services) has been called and resident has been transferred out. Review of the Clinical Census report revealed R57 was hospitalized from [DATE] through 9/9/24. Review of R57's EMR revealed there was no Bed Hold Authorization form completed. During an interview on 12/10/24 at 2:30 PM, Medical Records Staff C confirmed there was no bed hold notice provided at the time of transfer and none was scanned into the EMR for R57 on 9/1/24. An interview was conducted with the Director of Nursing (DON) on 12/11/24 at 12:30 PM. The DON stated nurses are responsible at the time of transfer to provide the resident and /or the representative with the bed hold policy as well as filling out the SBAR and transfer form. The DON also stated that the forms are to be scanned into the EMR. Review of the policy titled, Bed Hold Notice Upon Transfer, dated 2/1/22, read in part, Policy: At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed .

Resident #41 (R41) During an interview on 12/9/24 at 3:11 PM, R41 stated there were weeks the facility staff are offering only one shower a week, which made her feel unclean. R41 stated their showers were to be on Tuesdays and Fridays. R41's care plan indicated Resident has an ADL self-care performance deficit related to left sided hemiplegia (one sided paralysis) with neglect, chronic pain, anxiety depression. BATHING: 1 person assist. BED MOBILITY: 1 person assist PERSONAL HYGIENE: 1 person assist. A review of Electronic Medical Record (EMR) indicated R41's shower schedule was Tuesdays and Fridays, with preference for late afternoons between 7:00 PM and 9:00 PM. Shower logs indicated R41 had one shower during the weeks of 9/16/24, 9/23/24, 10/7/24, 10/14/24, 10/21/24, and 12/3/24. R41 did not have any shower during the week of 11/11/24, a refusal by R41 was noted on 11/12/24 at 9:59 PM which was outside of R41's preferred time, without documentation of another shower being offered. Review of policy titled, Activities of Daily Living, dated 12/28/23, read in part, Policy: The facility takes measures to minimize the loss of residents' functional abilities, including activities of daily living (ADL's). Activities of Daily Living include the ability to: 1. Bathe, dress, and groom .Policy Explanation and Compliance Guidelines .3. A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . This deficiency pertains to MI00147043 Based on interview and record review, the facility failed to provide necessary showers during preferred times for two Residents (#6 and #22) of eighteen residents reviewed for ADL's (Activities of Daily Living). Findings include: Resident #6 (R6) Review of R6's Minimum Data Set (MDS) assessment, dated 9/2/24, revealed a diagnosis that included diabetes mellitus. R6 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment, reflective of intact cognition. During an interview on 12/10/24 at 9:10 AM R6 was asked about staffing. R6 replied, There are not enough aides. I am only to have a female caregiver and there was a time about a week ago there were no female aides working, just the nurse was a female. I feel degraded. On 12/10/24 at 2:45 PM, during a follow-up interview R6 was asked about showers and replied, There is something wrong with the boiler. The water is cold and when that happens the staff must go reset it. I have to wait to take a shower. I prefer showers first thing in the morning, but if the boiler is not working properly then I have to wait. I have to wait for staff to reset it and for it to heat back up. I may refuse a shower if I have to wait so long and then I just don't feel like doing it in the afternoon. The boiler has not been working properly for about a month. I am not very happy about the boiler not working properly. Review of R6's task list for shower/bathe self (Prefers: shower Wednesday and Saturday AM), dated 11/16/24 through 12/11/24, revealed the following: a.) On 11/16/24 - resident refused at 1:59 PM; b.) On 11/20/24 - completed at 1:59 PM (late); c.) On 11/23/24 - completed at 1:16 PM (late); d.) On 11/27/24 - completed at 9:00 AM; e.) On 11/30/24 - completed at 1:59 PM (late); f.) On 12/4/24 - completed at 3:18 PM (late); g.) On 12/7/24 - completed at 12:36 PM and (late); h.) On 12/11/24 - completed at 8:22 AM. Resident #22 (R22) Review of R22's MDS assessment, dated 11/19/24, revealed a diagnosis that included type 2 diabetes mellitus. R22 scored 15 out of 15 on the BIMS assessment, reflective of intact cognition. During an interview on 12/10/24 at 7:58 AM, R22, who was asked about showers replied, There are times when the staff is short or too busy to provide a bed bath which I prefer twice a week. At times I only get one bath a week then two and vice versa. There are times that I have to beg for a bed bath. Last Saturday I had to beg for a bed bath. Review of R22's task list for shower/bathe on Wednesday/Saturday PM's, dated 11/16/24 through 12/4/24, revealed R22 did not receive a shower/bathe between 11/20/24 through 11/26/24 and 12/4/24 and 12/10/24. On 12/11/24 at 3:30 PM, an interview was conducted with Maintenance Assistant F who was asked if the boiler was working properly. Maintenance Assistant F replied, No, we have to reset it. It normally happens on the weekends. The Nursing Home Administrator (NHA) has educated some of the Certified Nurse Aides (CNA) on how to reset it if it happens on the weekends when we are not here. We have a work order in for it. We have already had someone out to look at it, but it is still not fixed. When the one goes out the back-up one is not triggered to go on and it should. Residents are having to wait for the water to heat back up. It has been like this for about a month.

Based on observation, interview, and record review the facility failed to implement interventions to prevent falls with further injury for one Resident (#3) of three residents reviewed for falls. This deficient practice resulted in the risk for further falls with injury. Findings include: Resident #3 (R3) Review of R3's Progress Notes revealed the following entry: 8/22/24: At 0220 this nurse heard a noise and resident yell out Help. This nurse entered room and noted resident lying on her left side in bathroom doorway with left arm underneath her. Has a basketball size amount of blood from left side of head. Resident states pain in left hip and left arm. Pressure dressing applied to left head laceration. Vitals taken. BP (blood pressure) very high 206/107, other vitals stable. No change from baseline in orientation. PERRLA (Pupils, Equal, Round, Reactive (to), Light, Accommodation). Neuro (neurological) checks WNL's (Within Normal Limit) for this resident. No internal/external rotation of legs. Hips symmetrical. Resident able to move arms and legs without difficulty. 911 called and resident sent to [Hospital Name]. Voicemail left with daughter. Hospice nurse notified. 8/22/24 07:00; ER (Emergency Room) provider called and states odontoid (tooth shaped portions extending from the sides of the 2nd cervical vertebra) neck fx (fracture). Has to wear collar to neck at all times except for bathing. Also states resident is not a surgical candidate and is on hospice. admin notified. Daughter also notified. On 12/11/24 at 10:30 a.m. R3 was observed sitting in her recliner wheelchair while her daughter was visiting. R3 was observed wearing regular socks with no grips on the bottom of her feet. An interview was conducted with R3 and her daughter who stated that she had purchased her socks with grips on the bottom of the feet as she does not like the ones provided at the facility. R3's daughter stated that she visits almost daily and has noticed that R3 has not been wearing the socks she has purchased, and they cannot be found in her dresser drawer. R3's daughter expressed concern that R3 could potentially fall and injure herself again. Review of R3's Care Plan read, in part, Resident has an ADL (Activities of Daily Living) performance deficit related to .neck fracture; Revision Date: 8/29/24 .Interventions: Ambulation: Supervision .Transfers: Independent .Resident uses a walker for ambulation/transfer . Resident is at risk for falls/injury related to .history of falls; Revision Date: 12/9/24 .Interventions: Gripper Socks . An interview was conducted with the Director of Nursing (DON) on 12/11/24 at 11:31 a.m. The DON confirmed R3's Care Plans should have been changed to something else as R3 does not like to wear gripper socks. Review of the facility's Fall Prevention Program revised 10/26/23 read, in part, each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls .Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. A) Interventions will be monitored for effectiveness. B) The plan of care will be revised as needed. Review of the facility's Accidents and Supervision policy revised 12/27/23 read, in part, Each resident will be assessed for accident risk and will receive care and services in accordance with their individualized care plan. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes .Implementing interventions to reduce hazard(s) and risk(s) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate catheter care and maintenance for one Resident (#22) of one resident reviewed for catheter care. Findings include: Resident #22 (R22) Review of the Clinical Census report revealed R22 was admitted to the facility on [DATE]. Review of R22's Minimum Data Set (MDS) assessment, dated 11/19/24, revealed a diagnosis that included type 2 diabetes mellitus. R22 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment, reflective of intact cognition. During an observation on 12/10/24 at 7:58 AM, an indwelling urinary catheter collection bag was observed hanging from the bottom of R22's bed. R22 was asked how long she had the urinary catheter and replied, Ever since I was at the hospital and then came here for rehab. Review of R22's discharge hospital instructions, dated 7/11/24, read in part, .The patient [R22] has a foley catheter for retention related to GBS [Guillain-Barre syndrome]. Would recommend voiding trail once more sensation is present. Last exchanged 7/2 would recommend monthly exchanges . Review of R22's physician order, dated 7/11/24, revealed the following, Change indwelling Foley catheter. (SPECIFY size:__16_fr [french]; balloon:___10_cc [cubic centimeter]) r/t (related to):__________ PRN (as needed) as clinically indicated: s/s (signs and symptoms) of obstruction (leakage, increased sediment, etc.), infection, or if closed system was compromised. Per recommended montly (sic) catheter change (Acute Care Hospital). Change catheter drainage bag as needed - as needed. No monthly urinary catheter exchange was ordered by the facility physician or nursing. Review of R22's Treatment Administration Record (TAR), dated 7/11/24 through 12/10/24 revealed R22's urinary catheter was not changed monthly in August 2024, September 2024, and October 2024. Review of the progress notes for R22 revealed a urinary catheter was documented as being changed at the facility was on 11/4/24 with no additional information. Procedure tolerance, equipment used, urinary return following insertion, amount used to inflate the balloon used to secure the catheter were all absent from the note. Review of R22's care plan, dated 7/12/24, read in part, .Focus: Resident has a need for indwelling urinary catheter .Goal: Resident will have reduced catheter-related complications .Interventions .Change catheter and drainage system as clinically indicated per order(s) . On 12/11/24 at 10:15 AM, an interview was conducted with Senior Director of Nursing (DON) D who agreed that if R22's discharge recommendations were to change the Foley monthly and assess for return of sensation for a voiding trial, then this should have been completed monthly by nursing and documented. On 12/11/24 at 10:30 AM, an interview was conducted with the DON who also agreed that if nursing was not addressing R22's sensation to void, then the physician should be monitoring. Recommendations should have been followed unless indicated differently by the facility physician. Documentation was requested to support not changing catheter monthly and monitoring of sensation returning for urgency to void for R22 at this time. On 12/11/24 at 1:45 PM, physician progress notes, dated 8/12/24 and 8/14/24, revealed the lack of any voiding trial and implemented urinary catheter change. Physician progress notes, read in part, .Urinary retention .Maintain Foley catheter with routine care, last changed 7/2. Discussed with patient and husband that routine care dictates change of Foley every 30 days . On 12/11/24 at 11:35 AM, an interview was conducted with the Senior DON D who was asked about a policy for inserting a Foley catheter and stated all she could find was a suprapubic (insertion site just above pubic area) catheter insertion. The Senior DON D was then asked what her expectation was and stated that the size, technique, resident tolerance of procedure, balloon size, and if urine was returned should all be documented in the medical record. Review of policy titled, Suprapubic Catheter Change Procedure, dated 1/1/22, read in part, .Documentation of the procedure shall include: a. The type of catheter inserted, including French size and balloon size. b. Amount of fluid used for inflation. c. Ease of insertion or any problems, such as resistance, bleeding, or pain. d. Amount and description of the urine return. e. Resident's response to the procedure.

Based on interview and record review, the facility failed to ensure Medication Regimen Reviews (MRRs) were addressed by the physician and maintained in the clinical record for one Resident (#9) of five residents reviewed for MRRs. Findings include: Resident #9 (R9) The pharmacist's documentation in R9's medical record revealed the monthly MRRs of 8/30/24 and 11/26/24 resulted in recommendations written to the physician. Neither the pharmacist's written recommendations nor the physician's written responses to the recommendations were in R9's medical record. On 12/10/24 at 1:43 p.m., The Director of Nursing (DON) was asked for the pharmacist's written recommendations and the physician's written responses to the recommendations for 8/30/24 and 11/26/24 for R9. The DON said, I don't know where those are. We looked for them, but couldn't find them. The DON said the physician's written responses to the recommendations were not in the resident's record because she (the DON) had previously been unaware she needed to obtain the written recommendations and provide them to the physician. The policy Addressing Medication Regimen Review Irregularities dated as implemented on 10/30/20 and revised on 12/28/23 read, in part: .4. The pharmacist must report any irregularities to the attending physician, the facility's medical director and director of nursing, and the reports must be acted upon .d. The attending physician must document in the resident medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer snacks in the evening for three Residents (#6, #22, and #31) of eighteen residents reviewed for evening snacks. Findings include: Resident #6 (R6) During an interview on 12/10/24 at 2:45 PM, R6 was asked if a bedtime snack was provided at bedtime. R6 stated, I did not get offered a bedtime snack last night on 12/9/24. Dietary staff wheel out the snack cart and place it in front of the nurse's station. The Certified Nurse (CNA) just leaves it sit there in front of the nurse's station and never pass out or offer snacks each night. It happens quite frequently that snacks are not passed out. Sometimes it is a free-for-all where some residents can get to the snacks and others can't. Then it becomes an infection control issue when you don't know where other resident hands have been. I would like a snack at night because I am diabetic and need a snack. The facility needs to have different snacks. I would prefer some grapes, and we never get them. The facility just basically gives us what they want, and we are not asked what we prefer. The choices we get are not very healthy. We get only two choices. We can only get one tiny snack, and it is not enough, especially not for me. Review of R6's Minimum Data Set (MDS) assessment, dated 9/2/24, revealed a diagnosis that included diabetes mellitus. R6 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment, reflective of intact cognition. Review of R6's task list for nutrition - HS [at bedtime] snack: routine, dated 11/12/24 through 12/10/24, revealed the following, no bedtime snack offered on 11/14/24, 11/22/24, 12/1/24, 12/5/24, and 12/6/24. Resident #22 (R22) During an interview on 12/10/24 at 3:05 PM, R22 was asked if a bedtime snack was provided. R22 stated, Snacks were not offered last night on 12/9/24. I would have liked a fig [NAME], but no one came by and offered a snack. I do not care for most of the things that are offered. I wished they would have a little more variety such as Oreo's, ice cream, or a banana. The apples that they bring by for snacks are yucky and look bad. I prefer fresh apples and not ones in a pre-made plastic package. Review of R22's MDS assessment, dated 11/19/24, revealed a diagnosis that included type 2 diabetes mellitus. R22 scored 15 out of 15 on the BIMS assessment, reflective of intact cognition. Review of R22's task list for nutrition - HS snack: routine, dated 11/12/24 through 12/10/24, revealed the following, no bedtime snack offered on 11/14/24, 11/20/24, 11/22/24, 12/1/24, 12/5/24, and 12/6/24. Resident #31 (R31) During an interview on 12/9/24 at 12:06 PM, R31 was asked if a bedtime snack was provided. R31 stated, The cookie jar needs tongs. I have seen other residents' just reach in the cookie jar bare-handed. That is so disgusting. We are to get snacks each night between 7 and 8 in the evening. There are not a whole lot of choices with the snack cart. I would like to see healthier choices such as fresh fruit. The prepackaged apple slices are yucky and brown. I need apple sauce because I can't chew an apple slice. They do not update the snacks that are offered. They are the same old snacks, and we get only two choices and if we don't like them, we just don't get a snack. I have brought it up in Resident Council that more options to honor preferences would be nice. Or a larger variety of snacks so we have more choices, but nothing ever happens. We just get what they say we get. I'm not happy with the snack choices. Review of R31's MDS assessment, dated 9/22/24, revealed a diagnosis that included diabetes mellitus. R31 scored 15 out of 15 on the BIMS assessment, reflective of intact cognition. Review of R31's task list for nutrition - HS snack: routine, dated 11/12/24 through 12/10/24, revealed the following, no bedtime snack offered on 11/14/24, 11/22/24, 12/1/24, 12/5/24, and 12/6/24. Review of R31's care plan, dated 6/17/24, read in part, .Focus: Resident is at risk for altered nutritional status related to BMI [body mass index] >70, CHF [congestive heart failure] T2DM [type 2 diabetes mellitus] .edentulous .Intervention .Other: (Specify) Offer HS snack . On 12/11/24 at 1:35 PM, an interview was conducted with Dietary Manager (DM) A and was asked who prepares the evening snack carts and what they looked like. DM A replied, They are plastic, and have three drawers to store snacks for residents. We have two, one for each side of the building. The dietary staff stocks them up with snacks depending on what day it is depends on what they are stocked with. DM A was asked how long ago the snack list was created and replied, I am not sure, but it has been that way for awhile now. Review of the undated snack list, revealed the following, Monday: Fig [NAME] or saltines, Tuesday: Potato chips or apple slices, Wednesday: Banana or graham crackers, Thursday: Assorted cookies or saltines, Friday: Apple slices or goldfish crackers, Saturday: Banana or assorted cookie, and Sunday: Oatmeal cream pie or graham crackers. Review of policy titled, Offering/Serving Bedtime Snacks, dated 8/29/24, read in part, Policy: It is the practice of this facility to offer and serve residents with a nourishing snack in accordance with their needs, preferences and requests at bedtime on a daily basis .Policy Explanation and Compliance Guidelines: 1. The nursing staff offers bedtime snacks to all residents in accordance with the resident's needs, preferences and requests on a daily basis. 2. All diabetic or special diet bedtime snacks are labeled and dated. Each label contains the resident's name and room number .

Based on interview and record review, the facility failed to administer a COVID-19 vaccination as requested by one Resident (R14) of five residents reviewed for immunizations. Findings include: Resident #14 (R14) R14 was interviewed on 12/9/24 at 3:03 p.m. R14 said she asked for a COVID-19 vaccination when she received the influenza vaccination in September 2024. R14 said, I never got the COVID shot. R14 said she contracted COVID-19 in the facility in November. R14 said she would still like to have the COVID-19 vaccination. A grievance resolution form Quality Assistance Form was submitted to the facility by R14's daughter on 11/12/24. The form documented R14's daughter was requesting an antiviral medication for R14 and was inquiring regarding the timing of the COVID-19 vaccine. The form documented a physician was notified and resident is eligible for booster, will order 3 mo [months] past COVID infection. The immunization history in R14's medical record revealed she received the Influenza Vaccination on 9/18/24. The COVID-19 vaccination status in the medical record was documented as pending immunization. The medical record documented R14 tested positive for COVID-19 on 11/11/24. The most recent COVID-19 vaccination was documented as being administered on 1/23/24. The Director of Nursing (DON) was interviewed on 12/11/24 at 8:32 a.m. The DON said she ordered the COVID-19 vaccine from the facility's contracted pharmacy but R14's dose was not included when the vaccines were delivered. The DON said she re-ordered the vaccine for R14, but it wasn't delivered in the second delivery either. The DON said she had to reorder the vaccine for R14 a third time but R14 contracted COVID-19 in the meantime. The DON said R14's physician ordered the vaccine to be administered in February, 90 days after the resident contracted COVID-19. On 12/11/24 at 11:42 a.m. The DON was asked regarding the process, what the facility does if there is concerns with pharmacy delivery. The DON said the facility utilized a local pharmacy as a back-up when they have concerns with ordered medications or concerns with delivery by their contracted pharmacy. The DON confirmed they had not attempted to secure a COVID-19 vaccine dose for R14 from the back-up pharmacy when it was not delivered from the contracted pharmacy. The DON confirmed she did not contact the health department to determine alternative source options to secure the vaccine R14 had requested since September 2024. The Centers for Disease Control (CDC) recommendations for COVID-19 vaccination (https://www.cdc.gov/covid/vaccines/stay-up-to-date.html) state, in part: .The COVID-19 vaccine helps protect you from severe illness, hospitalization, and death .Getting the 2024-2025 COVID-19 vaccine is especially important if you: .are 65 years and older . are living in a long-term care facility .People ages 65 and older are up to date when you have received: 2 doses of any 2024-2025 COVID-19 vaccine 6 months apart. While it is the recommended to get 2024-2025 COVID-19 vaccine doses 6 months apart, the minimum time is 2 months apart, which allows flexibility to get the second dose prior to typical COVID-19 surges . The facility policy COVID-19 Vaccination dated as revised 10/20/23 read, in part: .The facility may administer the vaccine directly or the vaccine may be administered indirectly through an arrangement with a pharmacy partner or local health department .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This deficiency pertains to Intake MI00147043 Based on observation, interview, and record review, the facility failed to maintain sufficient staff for four (Resident #8, #37, #41, and #63) of seventeen residents reviewed for staffing. Findings include: Resident #37 (R37) An interview was conducted on 12/9/24 at 12:13 PM with R37, who stated the quality of care has gone down since last year. R37 stated they constantly witnessed one nurse taking care of half the building. One nurse for both Orchard and Wharf, and one nurse for Cabin and Cedar. R37 stated the facility never really has four nurses at the same time and stated that it seemed there were a lot of call ins from the Certified Nursing Aides (CNAs) and it screws everything up. R37 then stated there were times Residents could not have lunch in the dining room because the facility did not have the help to assist the residents. Resident #41 (R41) While conducting an interview on 12/9/24 at 3:11 PM, R41 stated there were long waits for call lights to be answered and they were only getting one shower a week. R41 stated, during a conversation with the Nursing Home Administrator (NHA), R41 was told residents should expect a wait time of 15 minutes or less for call light responses. R41 felt current wait times were unsafe and informed the NHA, the described 15-minute wait time was often exceeded. On 12/9/24 the following observations were made: 3:25 PM upon exiting room [ROOM NUMBER], call lights for rooms [ROOM NUMBERS] were on. The unidentified CNA assigned to the hallway was located in the shower room with another resident and no other staff were in the hallway. 3:34 PM the resident of 214 (Resident #11) R11 started calling out for someone to help. 3:35 PM the unidentified CNA came out of shower room with another resident they had just showered who was being propelled in a wheelchair. 3:38 PM the unidentified CNA entered room [ROOM NUMBER] and found R11 on floor. The unidentified CNA asked a passing unidentified kitchen staff if they knew how to call code white, and the unidentified kitchen staff indicated he was unable to. The unidentified CNA then went to nurse's desk to page overhead for help. 3:40 PM, facility staff responded to overhead page and arrived at room [ROOM NUMBER] to address the fall. Three staff determined they were not needed, left the room and walked past two other call lights without answering them. 3:41 PM an unidentified CNA entered room [ROOM NUMBER] to answer call light, 16 minutes after initial observation of call light being on. 4:02 PM while passing room [ROOM NUMBER], R11 was observed on the floor again, the call light was not on, and no staff were in hallway. On 12/11/24 at 10:30 AM during the resident council, all in attendance raised concerns about staffing, expressing there were long wait times for call lights to be answered. Resident #63 (R63) stated there is not enough staff in the dining room to provide proper assistance with eating, to feed R11, who was R63's blind spouse. R63 stated, when he tries to assist with feeding R11, the facility staff yell at R63, stating it is the facility staff's job. R63 then stated, if the facility could not assist R11, it was R63's job to do so as R11's spouse. R63 stated, R11 would only get cold food or barely eat if it was not for R63's help. Resident #8 (R8) stated, due to the lack of staff in the dining room, R8 observed other residents who would eat food off other resident's plates, and those residents that needed assistance waited a long time to eat. R37 stated, when staff are in the dining room to assist with meals, that means there are no staff on the floor to assist residents who were not in the dining room with their needs, such as eating or answer their call lights. All residents who attended the meeting agreed this made them feel unsafe. During an interview on 12/11/24 at 1:18 PM, Licensed Practical Nurse (LPN) B stated there were not enough CNAs and nursing staff to care for the level of acuity of the residents in the facility. LPN B stated, between 6:00 AM and 8:30 AM there are just six staff members to care for all the residents. LPN B stated, during the 6-8:30 AM time, it was expected of staff that all residents would be gotten up, dressed, and to breakfast during that time, as well as medications passed. LPN B stated, if facility staff voiced concerns about staffing, the facility's corporate management would tell them they had bad attitudes. LPN B stated they felt the current NHA and (Director of Nursing) DON were not being allowed to staff according to the needs and acuity of the residents. Review of the facility's policy Call Lights: Accessibility and Timely Response, dated 12/28/23 read in part . 6. Ensure the call system alerts staff members directly or goes to a centralized staff work area. 7. Any staff member who sees or hears an activated call light is responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. The facility staff did not follow this policy when they walked by two call lights without answering them.

Based on interview and record review, the facility failed to conduct and document an annual facility wide assessment resulting in the potential for inadequate resources to meet the needs and care for all 68 facility residents. On 12/9/24 during the entrance conference at 11:50 AM the Nursing Home Administrator (NHA) was asked for a copy of the Facility Assessment. The NHA provided a Facility Assessment Tool for 7/2023 through 6/2024. The NHA was asked if there were any updates to the facility assessment to meet the requirement of being reviewed and updated annually. During a follow-up interview on 12/10/24 at 3:20 PM, the NHA stated all files provided were the most current. Review of the Facility Assessment tool section titled Average Daily Census Analysis indicated the patient population had an average of 63 which did not reflect the current resident population.

Based on interview and record review, the facility failed to update infection control policies annually. This deficient practice has the potential to affect all 68 residents regarding infection control practices. Findings include: On 12/10/24 at 3:20 PM, a review of the infection control policies was completed. The following infection control policies were found not to be updated annually: a. COVID-19 (virus capable of severe respiratory illness) Vaccination policy last updated on 10/20/23; b. Influenza (flu) Vaccination policy last updated on 10/26/23; c. Pneumococcal (pneumonia) Vaccine (Series) last updated on 10/30/23; d. Water Management Program undated and no last updated date; e. Transmission-Based (Isolation) Precautions last updated on 5/22/23; f. Laundry last updated on 10/26/23 and; g. Handling Clean Linen last updated on 10/30/23. On 12/11/23 at 12:21 PM, an interview was conducted with License Practical Nurse (LPN)/Infection Preventionist (IP) B who was asked if she was aware infection control policies should be updated annually and replied, No I was not aware that the policies needed to be updated annually. There have been three different IP managers in the last year and there are other management and corporate people that are in it and behind the scenes. On 12/10/24 at 3:20 PM, an interview was conducted with the Nursing Home Administrator (NHA) who was asked if the provided infection control policies were the most recent up to date policies for infection control The NHA replied, Yes, those are the most updated policies we have.

This citation pertains to intake: MI00146857 Based on interview and record review, the facility failed to report an allegation of staff to resident sexual abuse to the State Agency (SA) for one Resident (R900) of three residents reviewed for abuse. Findings include: Review of the complaint filed with the SA on 9/10/24 read, in part, .Complainant states the facility therapist (Occupational Therapist (OT) C) had been having sex with Resident (R900). Complainant states everyone knew about it and staff member [Certified Nurse Aide (CNA) D] went to the administrator about it . An interview was conducted with the Nursing Home Administrator (NHA) on 9/12/24 at 9:00 a.m. The NHA was asked if any abuse allegations were brought to him within the last 30 days. The NHA stated there were none reported in the last 30 days. An interview was conducted with CNA D on 9/12/24 at approximately 10:30 a.m. CNA D stated that while outside of the facility on 8/29/24, she was told that OT C and R900 were having sex. CNA D stated she reported this information directly to the NHA on 8/30/24 when she returned to work. An interview was conducted with the Director of Nursing (DON) on 9/12/24 at 10:54 a.m. The DON stated CNA D did report an allegation of sexual abuse between OT C and R900. The DON stated that the facility's legal team was contacted because it was believed R900 had been on a leave of absence (LOA) from the facility when the allegation occurred. The DON stated the legal team felt this was not reportable to the SA. This Surveyor requested the incident/accident report and interview statements from the DON. On 9/12/24 at approximately 11:05, the DON and NHA brought the file which contained one interview between the NHA and R900. There were no further interviews or witness statements. The NHA stated he misunderstood the request for abuse allegations in the last 30 days this morning and confirmed an allegation of sexual abuse was brought forward to him on 8/30/24 from CNA D. The NHA confirmed the facility did not report this allegation to the SA. Review of the facility's Abuse, Neglect and Exploitation policy dated 1/10/24 read, in part, .Reporting of alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes as required by state and federal regulations: immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .

This citation pertains to intake: MI00146857 Based on interview and record review, the facility failed to conduct a thorough investigation for a staff to resident sexual abuse allegation for one Residents (R900) of three residents reviewed for abuse. Findings include: Review of the complaint filed with the SA on 9/10/24 read, in part, .Complainant states the facility therapist (Occupational Therapist (OT) C) had been having sex with Resident (R900). Complainant states everyone knew about it and staff member (Certified Nurse Aide (CNA) D went to the administrator about it . An interview was conducted with CNA D on 9/12/24 at approximately 10:30 a.m. CNA D stated while outside of the facility on 8/29/24, she was told that OT C and R900 were having sex. CNA D stated she reported this information directly to the NHA on 8/30/24 when she returned to work. CNA D stated she was not asked to write a statement of what she had heard and was asked no further questions regarding the allegation. An interview was conducted with the Director of Nursing (DON) on 9/12/24 at 10:54 a.m. The DON stated CNA D did report an allegation of sexual abuse between OT C and R900. The DON stated the facility's legal team was contacted because it was believed R900 had been on a leave of absence (LOA) from the facility when the allegation occurred. This Surveyor requested the incident/accident report and interview statements from the DON. On 9/12/24 at approximately 11:05, the DON and NHA brought the file which contained one interview between the NHA and R900. There were no further interviews or witness statements. The NHA stated he did not gather further statements from staff, including from the alleged perpetrator per the legal team's advice. The NHA stated OT C was transferred to another facility at the discretion of the corporate therapy company. The NHA acknowledged this was not a complete investigation per the facility's abuse policy. Review of the facility's Abuse, Neglect and Exploitation policy dated 1/10/24 read, in part, .Investigation of alleged abuse, neglect and exploitation: An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include Identifying staff responsible for the investigation, exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence), Investigating different types of alleged violations. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, Focusing the investigation on determining if abuse, neglect, exploitation and/or mistreatment has occurred, the extent, and cause, and providing complete and thorough documentation of the investigation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide bathing/showers per individual resident needs and preferences for one resident (Resident #10) of 18 residents reviewed for Activities of Daily Living (ADL) care, resulting in psychosocial sadness, and the potential of poor hygiene, skin irritation, and breakdown. This citation is related to intake: MI00140257 Resident #10 (R10) According to the Minimum Data Set (MDS) dated [DATE], R10 scored 15/15 (cognitively intact) on his BIMS (Brief Interview for Mental Status), with diagnoses including Diabetes Mellitus, hypertension, and depression. These diagnoses along with impairment in both legs, required R10 to receive substantial maximum assistance from one person for turning/positioning in bed, and two-person assistance for transfers. R10 required one-person substantial maximum assistance for bathing/showers. According to the intake complaint dated 10/18/23, read in part, .Complainant states he was told he isn't getting his scheduled shower today because the facility doesn't have enough staff . On 1/22/23 at 1:04 PM, an interview was conducted with R10. R10 was asked about the date of the alleged incident when he did not receive a scheduled shower and how that made him feel and replied, It frustrates me, makes me sad, and I feel dirty when I do not get my scheduled showers. R10 was asked if he had ever refused a scheduled shower and replied, No. Review of R10's care plan, dated 9/29/23, read in part, .Focus: Resident has an ADL self-care performance deficit related to amputation bilateral lower extremities .generalized weakness .Interventions: Bathing: 1 person assist . Review of R10's tasks, printed on 1/23/24, revealed Shower/bathe (Prefers: showers Wednesday and Saturday AM). R10's tasks were reviewed between October 1, 2023, through January 23, 2024, and revealed, that R10 had a total of 32 opportunities to receive showers and during those opportunities 14 were not completed. Review of R20's progress notes, dated October 1, 2023, through January 23, 2024, revealed no documentation of refusals for scheduled showers. On 1/22/24 at 8:02, an observation was made of R10 in his room. R10 was lying in bed, covered in his bed sheet, and was waiting for his morning medications and to get up for breakfast. R10 stated, I had to wait for help last night when I needed to use the urinal for over a half an hour. On 1/23/24 at 1:18 PM, an interview was conducted with R10. R10 was asked about the 32 shower opportunities and specifically the dates of December 17th, 2023, through December 29th, 2023, when it was Christmas time and he did not receive any scheduled showers during that time and replied, That was awful. I had family visiting and I was unkept and felt embarrassed. On 1/23/24 at 2:00 PM, an interview was conducted with the Director of Nursing (DON). The DON confirmed residents should receive their scheduled showers unless they refuse and that should be documented as refused and if they are out of the facility, such as being in the hospital. Review of facility policy titled, Activities of Daily Living (ADLs), dated 12/28/23, read in part, Policy: The facility takes measures to minimize the loss of residents functional abilities, including activities of daily living (ADLs). Activities of Daily Living include the ability to: 1. Bathe, dress, and groom .3. A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation contains 2 deficient practices. Deficient Practice #1: Based on observation, interview, and record review, the facility failed ensure the environment remained free of accident hazards and failed to assess the amount of supervision required during smoking for two Residents (R23, and R63) of two residents reviewed for smoking. This deficient practice resulted in the potential for avoidable accidents including but not limited to harm from burns, fires, or falls. Findings include: Resident #23 (R23) During an interview with Resident #23 (R23) on 1/21/23 at 11:04 a.m., a strong odor of cigarette smoke was detected. When queried regarding smoking status, R23 acknowledged being an active smoker. When R23 was asked if they continued to smoke since admission to the facility. R23 responded she has smoked daily since being admitted to the facility. When asked regarding the designated smoking location, R23 stated, I just sit in my car to smoke. R23 was admitted to the facility 11/3/23 with diagnoses that included but were not limited to congestive heart failure, chronic obstructive pulmonary disease (COPD), diabetes, history of osteoporosis fracture, venous insufficiency, pain in right knee, and others. An admission Minimum Data Set (MDS) assessment dated [DATE] coded R23 as 88 for car transfers. The code reason for 88 was not attempted due to medical condition or safety concerns. The MDS documented R23 as requiring partial to moderate assistance from staff with all other transfer types. R23 was identified in the MDS as having functional limitation in range of motion to the lower extremity. A significant change MDS dated [DATE] did not document an assessment for R23s functional ability with car transfers. An Activities of Daily Living (ADL) care plan dated as initiated on 11/4/24 with most recent revision date of 12/27/24 read Resident has an ADL self-care performance deficit related to right knee pain, osteoarthritis, weakness. The interventions documented that R23 required supervision or direct staff assistance with all ADLs except eating. The care plan revealed Transfers: Supervision - offer setup help as needed. A care plan for falls documented R23 was at risk for falls/injury related to weakness and right knee pain. The care plan contained an intervention initiated on 1/13/24 for Bed Modification - bilateral ½ rails to aid with bed mobility and transfers. A smoking care plan dated as initiated on 11/4/23 and revised on 12/27/23 contained 3 interventions. The interventions were: (1) inform resident or/family/responsible regarding the center's smoking policy, designated smoking areas, and storage of smoking materials (date initiated: 11/4/23). (2) Observe the resident's safety during smoking (date initiated 11/4/23). (3) Remind/assist resident to remove oxygen prior to going out to smoke as needed if applicable. (date initiated 11/4/23). The facility policy titled 'Smoking/Non-Smoking Policy' with date reviewed/revised of 3/22/23 read in part it is the policy of this facility to establish and maintain safe resident smoking practices for a non-smoking campus. Use this policy for education with the resident. The policy directed in part A.1. Prior to, or upon, admission, residents shall be informed that smoking is not permitted inside of facility or outside the facility on any facility property. C. Smoking Articles: Residents with smoking privileges may not be permitted to retain any types of smoking articles, to include cigarettes, tobacco, etc. either on his person or within his/her living or sleeping area, at any time. During an interview on 1/22/24 at 9:20 a.m., R23 reiterated daily smoking in her car on the facility premises. R23 said her car was parked in the facility parking lot and stated, It's the one surrounded by all the ice and snow. R23 said she had possession of her smoking materials, including cigarettes and lighter. R23 said staff had never asked her to turn relinquish the cigarettes or lighter or any smoking materials to a staff member after smoking. R23 conveyed she had never been asked to leave the facility premises to smoke. R23 was queried regarding staff assessment for safe transfers to and from her car to smoke in inclement weather. R23 responded she had not been assessed by anyone at the facility regarding safe smoking. R23 denied having been offered a nicotine patch or alternative products or methods for smoking cessation. R23 denied receiving education on the facility policy for smoking. An interview was conducted with R23's day shift Certified Nurse Aide A (CNA A) on 1/22/24 at 12:24 p.m. CNA A was asked if a smoking apron or protective device was required for the safety of R23 while smoking. CNA A shook her head and said, I don't know. CNA A was asked regarding instruction received for the amount or type of supervision or assistance R23 required to transfer into and from her personal vehicle in the parking lot to smoke. CNA A confirmed she had not received any directive or instruction regarding R23 smoking. The Director of Nursing (DON) and Nurse Consultant D (Consultant D) were interviewed on 1/22/24 at 2:21 p.m. The DON confirmed the facility did not have a designated smoking area and said residents are expected to go off-site of the property if they choose to smoke. When asked regarding R23 smoking in her car the DON stated, she should not be allowed to smoke anywhere on the premises, including the parking lot. It's our policy. The DON admitted she had not provided instruction or direction to staff with R23s smoking, and stated she was unaware the resident was smoking until a couple of weeks ago. Consultant D was asked regarding the expectations regarding completion of smoking assessments. Consultant D conveyed assessments are completed upon admission to the facility, quarterly, and as needed if something changes with a resident. The DON and Consultant D reviewed R23s admission smoking assessment on 1/22/24 at 2:21 p.m. The smoking assessment was observed with unanswered, blank responses including: 18. Resident is able to light cigarette safely with a lighter, 19. Resident smokes safely, 20. Resident utilizes ashtray safely and properly, 21. Resident is able to extinguish cigarette safely and completely when finished smoking, 22. Resident may smoke at this time, and 23. Smoking aids needed. The portion of the assessment for applicable smoking care plan items had interventions checked including but not limited to: adaptive equipment for safe smoking, inform resident. regarding the center's smoking policy, designated smoking areas, and storage of smoking materials. Observe the resident's safety during smoking. After reviewing the assessment, the DON stated, We definitely need to do some education. The DON said nurses are expected to maintain all smoking materials in a secured location. The DON and Consultant D confirmed there were no additional smoking assessments completed for R23 until after surveyors entered the facility on 1/21/24. Resident #63 (R63) On 1/21/24 at 9:58 PM, an observation was made of R63 in his room. R63 was resting in his bed with his clothes on. R63's bedside table was next to his bed and was observed to have a pack of cigarettes on the bedside table with four cigarettes inside and a blue lighter. R63 was asked about the cigarettes and replied, I go outside to smoke by myself. I sign the leave of absence sheet out by the front door, and I usually go out in the morning and after meals and in the evening. I just walk outside in the parking lot and smoke there. I keep the cigarettes and lighter in my jacket pocket. I should have put them back in my jacket. R63 was asked if he ever is required to return his cigarettes to the nursing staff or get them from the nursing staff and replied, No. I keep them all the time. I have had them ever since I got here. R63 was asked if he had a smoking assessment or if staff had gone over a smoking policy with him and if he had some kind of smoking agreement with the facility and replied, No. Review of R63's census tab in the Electronic Medical Record (EMR), revealed an admission on [DATE] into the facility. Review of R63's nursing admission assessment, dated 12/3/23, revealed the lack of a Safe Smoking Evaluation. On 1/22/24 at 2:22 PM an interview was conducted with the Director of Nursing (DON). The DON was asked if it was facility policy for residents to have cigarettes and a lighter in their possession and replied, No. Nursing staff should have them locked in the medication cart and residents are supposed to ask for them. The DON was asked if residents were required to have a safe smoking assessment and replied, Yes. Any resident that wants to smoke needs a safe smoking assessment. The DON stated that the facility policy for smoking should also be discussed with the resident who desires the need to smoke. The DON confirmed that it is a safety concern for residents to have cigarettes and a lighter and that residents who smoke should have a care plan reflecting their smoking needs. The DON confirmed that no periodic checks for smoking articles had been completed for R63. Review of facility policy titled, Smoking / Non-Smoking Policy, dated 3/12/22, read in part, Policy: It is the policy of this facility to establish and maintain safe resident smoking practices for a non-smoking campus. Use this policy for education with the resident. Policy Explanation and Compliance Guidelines: A. Smoking Area: 1. Prior to, or upon admission, residents shall be informed that smoking is not permitted inside of facility or outside the facility property .C. Smoking Articles: Residents with smoking privileges may not be permitted to retain any types of smoking articles, to include cigarettes, tobacco, etc., either on his or her person or within his/her living or sleeping area, at any time .Periodic Checks for Smoking Articles: 1. This facility shall have the authority to make periodic checks to determine if residents have any smoking articles that are in violation of our smoking regulations . Based on observation, interview and record review, the facility failed to properly supervise and assess one Resident (R40). This deficient practice resulted in R40 having multiple knives in his possession unsupervised and open allowing for other residents, visitors, or staff access to use these knives without proper supervision. Findings include: Review of R40's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with readmission on [DATE] and diagnoses including: depression, congestive heart failure, chronic obstructive pulmonary disease (COPD), type 2 diabetes, and muscle weakness. R40's 11/7/23 Annual Minimum Data Set (MDS) assessment revealed he scored a 15/15 on the Brief Interview for Mental Status (BIMS) score indicating he was cognitively intact. On 1/21/24 at 11:20 a.m. an interview was attempted in R40's room. R40 was not located in his room at the time and was found to be visiting with another resident on the other side of the building. When R40 was located on 1/21/24 at 11:25 a.m., he stated, Oh, they must be looking for me for my yearly interview, I better go hide my knives. R40 and this Surveyor returned to his room where it was observed that 3 knives were located on his nightstand open. One knife was observed to be a pocket knife, and two were medium size switch blades. An interview was conducted with R40 who stated that he uses these knives to open and cut various things like saltine wrappers and meat served from the kitchen. R40 then placed the knives in the top drawer of his nightstand, that did not have a lock. After conclusion of this interview, this Surveyor noted that R40's door to his bedroom leading into the hallway does not lock. On 1/22/24 at 9:40 a.m., an observation of R40 was made in his room. R40 was in his bed sleeping with his door cracked open leading out into the hallway. R40 had one medium switch blade knife open and sitting on his nightstand. An interview was conducted with the Director of Nursing (DON) on 1/23/24 at 1:40 p.m. The DON confirmed that staff were aware of R40's knives and that R40 had been instructed to keep those knives in a locked box and not out in the open. The DON confirmed that R40's knives not being stored away properly in a locked box posed a risk to other residents, especially the cognitively impaired and wandering residents. Review of the facility's Firearm and Weapon Prohibition revised 1/1/2022 read, in part, A safe and secure environment is fundamental for fulfilling our company's mission of providing medical care and related health care services. Our company is committed to maintaining a safe workplace that is free of violence . The facility's policy did not specifically address residents ability to have firearms and weapons.

. Based on interview and record review the facility failed to follow their grievance process to act on resident concerns brought up in Resident Council. This deficient practice produced frustration and feelings of insignificance on the part of 10 out of 13 residents who attended the confidential group meeting. Findings include: On 1/22/24 at 2:00 PM, a confidential group meeting took place with 13 Residents in attendance. The group consensus was the leadership in the building did not listen to the Residents. Confidential Resident C4 stated We give the Nursing Home Administrator (NHA) notes, but we have to follow up all the time. They don't always get back to us. C4 continued saying Overall, they are not addressing our needs. Another Confidential Resident C5 stated while they could do much for themselves, they felt no one helped those who needed more help. No one comes to help for a long time. C5 stated this had been brought to the attention of leadership but the problem remained. A further issue of not getting water each day was brought up. C1 said she had to go out in the hallway and ask for it or get it. C1 reported the facility leadership present at the last meeting said this would be taken care of, but nothing had been done. The residents stated they did not get answers on their concerns in writing and things did not seem to change. Another example of this was bedtime snacks. The residents stated they had brought this up, but it was not taken care of. Several residents stated one Certified Nurse Aide (CNA) did bring bedtime snacks off and on but C5 stated this CNA had just quit and was no longer passing snacks. A review of the RESIDENT COUNCIL MINUTES revealed the following: - 8/23/23 at 2:00 PM New Business Issue: Treat Cart not being passed out - 9/13/23 at 2:10 PM Minutes of Previous Council Meeting: Concerns from previous meeting were not reviewed or accepted. (Box not checked) Old Business Issue: Snack Cart is better but still not everynight (sic) - 10/11/23 at 2:00 PM Minutes of Previous Council Meeting: Concerns from previous meeting were not reviewed or accepted. (Box not checked) Old Business Issue: Snack cart still not everynight (sic) During an interview on 1/23/24 at 12:50 PM, the NHA said the facility has a grievance process in place but has not been executed from the resident council issues that arise. The NHA stated this would be an easy format to use to bring the residents' concerns to the right person to find a solution. The residents would then have the answers in writing. The facility policy titled Resident Council dated as reviewed/revised 10/30/2023 read in part: Our centers support resident desires to be involved and have input into the operation of the facility through the Resident Council . a. The Administrator reviews the minutes to ensure i. all group concerns and grievances are investigated ii. Any responses from departments within the facility are provided back to the council. b. Responses are presented at the next meeting, or sooner, if indicated. .

Based on observation, interview, and record review, the facility failed to provide oxygen services per standards of practice and per physician orders for four residents (Resident #9, Resident #10, Resident #22, and Resident # 34) of four residents reviewed for oxygen services. This deficient practice resulted in the potential for the development of respiratory complications, including infections. Findings include: Resident #9 (R9) On 1/21/24 at 9:56 AM, an observation was made of R9's room. R9 had a gallon jug of distilled water in her room that was opened and lacked a date. The gallon of distilled water was ¾ full. R9 also had a nebulizer that was sitting on the back of her sink and was connected to a mask and the medication cup had visible condensation in the medication cup. R9's nebulizer was dated 1/17/24. On 1/21/24 at 2:00 PM, an observation was made of R9's room. R9 was absent form her room, and her oxygen tubing was coiled up on top of her oxygen concentrator. R9 had a storage bag for her oxygen tubing, but R9's oxygen tubing was not in the storage bag. Review of R9's physician order, dated 1/13/24, read in part, Oxygen: Run at 2 liters per minute via nasal cannula continuous. Review of R9's physician order, dated 12/14/23, read in part, Albuterol Sulfate Inhalation Nebulization Solution .twice daily . Resident #10 (R10) On 1/21/24 at 9:54 AM, an observation was made of R10's room. R10 had an oxygen concentrator with a humidification bubbler. R10 had a gallon of distilled water that was opened and lack and open date and was ¾ full. Resident #22 (R22) On 1/22/24 at 8:30 AM, an observation of R22's room was made. R22 had a nebulizer mask and tubing with medication cup all assembled and attached, with visible condensation in the medication cup. No storage bag was observed in the room for storage of the nebulizer mask when it was not in use. R22's nebulizer equipment was dated 1/17/24. On 1/23/24 at 4:20 PM, a second observation of R22's room was made. R22 had a nebulizer mask and tubing with medication cup all assembled and attached, with visible condensation in the medication cup. No storage bag was observed in the room for storage of the nebulizer mask when it was not in use. Resident #34 (R34) On 1/21/24 at 9:30 AM, an observation was made of R34 in her room. R34 was asleep in her recliner. R34 had an oxygen concentrator in her room in her bathroom and the door was closed. R34's oxygen concentrator was set to 3.5 liters and had a bubbler attached that was empty and not bubbling. R34 also had a gallon of distilled water in her bathroom on top of the sink that was ¾ full and without an opened date. On 1/21/24 at 1:30 PM, an interview was conducted with Registered Nurse (RN) E who was asked how many liters of oxygen R34 was supposed to have and if her bubbler should be empty. RN E replied, I would have to double check the order. The bubbler should be bubbling and have water. RN E confirmed that R34 was to have 2 liters of oxygen and not 3.5 liters and added water to her bubbler. RN E was asked if she had seen R34's oxygen concentrator today and replied, I was in here this morning. I must have overlooked it. On 1/22/24 at 1:45 PM, an observation was made of R34's room and oxygen concentrator wit the bubbler. Again, the bubbler was empty and not producing any bubbles. On 1/23/24 at 2:20 PM, and interview was conducted with the Director of Nursing (DON). The DON confirmed that the distilled water gallons should be dated when opened, the bubblers are to be maintained by the nursing staff and have water in the chamber, oxygen tubing should be stored in the storage bags when not in use, and nebulizers should be rinsed after each use, dried, and properly stored in a storage bag. Review of facility policy titled, Oxygen Administration, dated 10/26/23, read in part, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences .Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency .7. Cleaning and care of equipment shall be in accordance with facility policies for such equipment . Review of facility policy titled, Nebulizer Therapy, dated 1/1/22, read in part, Policy: It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. Policy Explanation and Compliance Guidelines: .2. Care of the equipment: a. Clean after each use .c. Disassemble parts after every treatment. d. Rinse the nebulizer cup and mouthpiece with water. e. Shake off excess water. f. Air dry on an absorbent towel. g Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag. h. Change nebulizer tubing every seventy-two hours .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #22 (R22) On 1/21/24 at 10:00 a.m., a Trelegy Ellipta inhaler and albuterol inhaler were observed lying on the bedside table in Resident #22's (R22) room. No nurse was present in the room at the time of the observation. R22 admitted to self-administering the inhalers since admission to the facility. When queried, R22 confirmed no one in the facility had observed the self-administration of the inhalers to determine if he could safely administer them. When asked about other medications, R22 said the nurse brings the medications into the room and drops them off and R22 self-administers those medications when I'm ready for them. When asked where the inhalers were stored when not in use, R22 responded the inhalers are always there and indicated the bedside table. R22's medical record was reviewed at 10:05 a.m. on 1/21/24. R22 was admitted to the facility 11/23/23 with diagnoses that included chronic obstructive pulmonary disease, chronic respiratory failure, major depressive disorder, hearing loss, age-related physical debility, cognitive communication deficit, and others. The admission evaluation dated as effective 11/25/23 was reviewed for medication administration preferences. The section titled Self-Administration of Medication contained the question Does the resident wish to self-administer medications? The radio button for no was selected. There were no other assessments for self-administration of medication in R22's record. R22's care plans did not include a care plan for self-administration of medications, medications left at bedside, or storage of medications in R22's room. The medical record of R22 did not contain an interdisciplinary assessment of R22's ability to safely self-administer medications. The facility policy Medication - Resident Self-administration of dated 1/1/22 stated in part: Policy: A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely; #11. When the interdisciplinary team determines that bedside or in-room storage of medications would be a safety risk to other residents, the medications of residents permitted to self-administer are stored in the medication cart or medication room. #12. The care plan must reflect resident self-administration and storage arrangements for such medications. On 1/23/24 at 4:21 p.m., R22 was observed to be sleeping in his room. A plastic medication-dispensing cup was visualized on the bedside table. No nurse was present in the room. The medication-dispensing cup contained 1 capsule and 2 tablets of medication. The medication cup was next to a bottle of Flonase nasal spray and an albuterol inhaler on the bedside table. Registered Nurse B (RN B) was interviewed on 1/23/24 at 4:25 p.m. RN B said the medications in the cup on R22's bedside table were Theophylline (a respiratory medication), Hydroxyzine (a medication for itching), and Eliquis (a blood thinning medication). RN B agreed there were residents in the facility who were cognitively impaired and at high-risk for wandering into the rooms of other residents and potentially accessing unsecured medications left openly available and unattended on a resident's bedside table. RN B said R22 had a physician's order to self-administer medications and maintain medications at bedside. R22's physician orders, Medication Record (MAR), and Treatment Administration Record (TAR) were reviewed with RN B. When asked where the order was, RN B confirmed there was no order for R22 to self-administer medications and no order for medications to be left at bedside. RN B stated, maybe it was a timed order for 2 weeks. RN B reported the concern to the Unit Manager, Licensed Practical Nurse C (LPN C). LPN C reviewed R22's medical record and confirmed there was no order for R22 to self-administer medications nor was there an order for medications to be left at bedside. LPN C stated, I'll take care of it. On 1/23/24 at 4:43 p.m. LPN C conveyed, there's an order in there now for [R22]. R22's medical record had an order entered on 1/23/24 that read, Staff to set up medication, resident can self-administer without supervision except for narcotic (Gabapentin and Norco). R22's medical record was reviewed on 1/23/24 at 4:55 p.m. A self-administration of medication assessment dated [DATE] at 1:29 p.m. was entered into R22's medical record, the day after the initial observation of medications at bedside was made on 1/21/24 at 10:00 a.m. A care plan had also been entered into R22's medical record on 1/22/24. Care plan interventions included in part: assist in securing medication after administration, as needed. Periodically review with resident on proper storage of drug to prevent unauthorized access. Based on observation, interview, and record review, the facility failed to securely store medication, securely deliver medications during medication pass, and maintain clean and sanitary medication carts for two of two medication carts reviewed for medication storage. This deficient practice had the potential for medications to be misappropriated, medication loss, and contamination. Findings include: On 1/21/24 at 9:30 AM, an observation was made of Resident #34's (R34) room. R34 was asleep in her recliner and had her bedside table pulled up next to her. On R34's bedside table there was a medication cup full of medications. On 1/21/24 at 9:38 AM, an interview was conducted with Registered Nurse (RN) E, who was called by this Surveyor to R34's room. RN E was asked why R34 had a full cup of medication left on her bedside table and replied, I brought them to her during breakfast. RN E was asked what time breakfast was served and replied, Around 8:00 AM. RN E was asked why she left the medication with R34 and replied, I thought she took them. I did not realize she did not take them yet. RN E confirmed the medication cup contained all R34's morning medications. RN E was asked if R34 was allowed to self-administer medications and replied, Well no. Review of R34's Medication Administration Record (MAR) for January 2024, revealed medications dispensed in R34's medication cup between 7:04 - 7:06 AM were: Losartan Potassium 25 mg (milligram) one tab, furosemide 40 mg one tab, acetaminophen extended release 650 mg two tabs, tizandine 2 mg one tab, duloxetine 20 mg one capsule, metformin 500 mg one tab, glipizide 5 mg one tab, gabapentin (controlled medication) 100 mg one tab, and meloxicam 7.5 mg one tab. Review of R34's Minimum Date Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) 3 out of 15, which indicated severe cognitive impairment. Review of R34's medical record, revealed no care plan and no assessment to safely self-administer medications. On 1/21/24 at 9:48 AM, an interview and observation was conducted of R8 in her room. R8 was sitting in her wheelchair and had her bedside table pulled up next to her. On top of R8's bedside table was a small empty glass and a medication cup inside the glass. R8 was asked why she had an empty glass with the medication cup inside of it and replied, The nurse brought in my medications and left the room. R8 was asked if this happens normally or if the nurse waits for her to watch her take her medications and replied, Sometimes she just comes in and leaves them on the table and does not watch me take them. R8 confirmed that her nurse left the medications without her watching her take the medications. Review of R8's medical record, revealed no care plan and no assessment to safely self-administer medications. On 1/21/24 at 10:11 AM, an interview and observation was made with Resident #4 (R4) in his room. R4 had a plastic bin on the top of his dresser on the right side of his bed that contained: three albuterol inhalers, all of which lacked dates when they were opened. One of the inhalers had a dispense date of 12/4/23, and all the inhaler counters showed doses had been administered with some doses remaining. One fluticasone 50 mcg nasal spray 0.05%, with lot number TX5321, lacked an opened or dispensed date. One saline 0.9 % sodium chloride irrigation solution 100 ml, lacked an opened date and was half gone. One nasal spray mist - 0.65% 44 ml (milliliters), lacked an opened or dispensed date. Two eye drops artificial tears opened and lacked an open date. Review of R4's medical record, revealed no care plan or assessment to safely self-administer medications. On 1/21/24 at 12:30 PM, an inspection of the medication cart for the 300-hall was conducted and found to be dirty with several small pieces of paper from dispensing medications out of blister packages that was observed in the bottom of the second and third drawers. In the third drawer was a bottle of protein supplement with visible drip marks and under the bottle was two globs of gooey sticky drops stuck to the bottom of the drawer. In the bottom of the second drawer an observation was made of one loose white round pill with markings 660. RN J confirmed the pill was spironolactone 25 mg. There was also powdery residue observed scattered on the floor of the medication drawer. On 1/21/24 at 12:35 PM, an interview was conducted with RN J who was asked if the medication carts are routinely cleaned by nursing staff and replied, They should be cleaned regularly, no sticky stuff should be left in the base of the drawers, and bottles should be wiped off if drips or dribbles happen. RN J stated that she asked the Assistant Director of Nursing (ADON) for a small portable vacuum to clean the medication carts out because they look disgusting but has not seen a vacuum yet. On 1/21/24 at 1:30 PM, an interview was conducted with RN E who was asked if there was any reason a resident would have an empty glass with a medication cup inside left on their bedside table and replied, No not really. When I do medication pass I throw out the medication cups and empty glass before I leave the room. On 1/22/24 at 8:24 AM, an inspection was conducted on medication cart on the 100-hall with Licensed Practical Nurse (LPN) C. In the second and third drawers there was an observation of multiple small pieces of paper in the bottom of the drawers from dispensing medications, and a powdery residue scattered on the floor of the medication drawers. An observation was made of one empty box from an inhaler (Resident #22's) and LPN C was asked if she knew where the inhaler was and replied, No. I just got here around 8:00 AM this morning. An observation was made of the third drawer to have one loose light-yellow round pill with identifier of L22 and identified by LPN C to be levothyroxine 125 mcg. On 1/22/24 at 8:30 AM, an observation was made of R22's room. R22 was asleep in his bed with his covers pulled over him. R22 had a nightstand which had one single packaged vial of nebulizer solution budesonide. A second observation was made of R22's bedside table to have one albuterol inhaler undated, and one breztri inhaler. Review of R22's physician order, dated 12/11/23, read in part, Ipratropium Albuterol Solution 0.5-2.5 MG/3 ML (milliliters) 3 ml inhale orally three times a day for COPD (chronic obstructive pulmonary disease) IN am and at HS (at night) may mix with budesonide, Start Date 12/11/2023 1200 and D/C (discontinue) Date 01/02/2024. Review of R22's medical record, revealed the lack of a care plan to safe self-administration of medication and an assessment to safe self-administer medications. On 1/22/24 at 8:25 AM, and observation was made of morning medication pass on the 300-hall. RN I was observed to enter room [ROOM NUMBER] with medication cup and insulin and then exit the room. On 1/22/24 at 8:46 AM, an observation was made of R37 in her room (302). R37 had her breakfast in front of her. Observed on the breakfast tray was a medication cup full on medication, a protein supplement in a medication cup, and a package of fiber source. Review of R37's MAR, dated January 2024, revealed medications dispensed in R37's medication cup between 8:38 - 8:45 AM were: protein supplement 30 ml, furosemide 40 mg one tab, dexamethasone 2 mg one tab, gabapentin (controlled medication) 100 mg one tab, lisinopril 20 mg one tab, methenamine 1 gram one tab, folic acid 1mg one tab, acetaminophen extended release 650 mg one tab, omeprazole 20 mg one capsule, psyllium 3.4 gram one package, levothyroxine 100 micrograms one tab, and metformin extended release 500 mg two tabs. On 1/22/24 at 9:30 AM, an interview was conducted with RN I who was asked if R37 had been assessed for safe self-administration of medications and replied, No. RN I was asked why she left R37's medications in their room without supervising R37 taking the medications and replied, I do not know. I guess I should have waited to make sure she was going to take them and not leave them with her. RN I confirmed R37 did not have a care plan or physician's order to safely self-administer medications. Review of R37's medical record, revealed no care plan or assessment to safely self-administer medications. On 1/23/24 at 11:06 AM, and interview was conducted with the Director of Nursing (DON) who confirmed no medications were to be left at the bedside. The DON stated residents needed to be care planned to self-administer medications and medications should be secure from other residents who may wander into other resident rooms. The DON also stated residents were to be assessed for safe self-administration of medication and if deemed appropriate then a physician order would have been written stating residents were ok to have medication(s) at the bedside. Review of facility policy titled, Medication Storage, dated 1/1/22, read in part, Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security . Review of facility policy titled, Medication Administration, dated 1/1/22, read in part, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .Policy Explanation and Compliance Guidelines: .15. Observe resident consumption of medication . Review of facility policy titled, Medication Orders, dated 1/1/22, read in part, Policy: This facility shall use guidelines for the ordering of medication. Policy Explanation and Compliance Guidelines: 1. Medications should be administered only upon the signed order of a person lawfully authorized to prescribe . Review of facility policy titled, Medication - Inhaler, dated 1/1/22, read in part, Policy: Medications are administered as prescribed, in accordance with current nursing principles and practices and only by persons legally authorized to do so. Policy Explanation and Compliance Guidelines: .16. Return medication to medication cart and store according to facility policy .

. Based on interview, and record review the facility failed to provide snacks in the evening for seven out of 13 Confidential Residents (C1, C2, C3, C5, C7, C8, and C13) interviewed in the confidential group meeting. This deficient practice resulted in residents verbalizing disappointment and dissatisfaction as well as the potential for hunger and weight loss. Findings include: On 1/22/24 at 2:00 PM, a confidential group meeting took place with 13 Residents in attendance. The issue of bedtime snacks not being received was a concern of the group. The residents stated they had brought this up to the facility leadership, but it was not taken care of. Several residents stated one Certified Nurse Aide (CNA) did bring bedtime snacks off and on but C5 stated this CNA had just quit and was no longer passing snacks. Review of the RESIDENT COUNCIL MINUTES revealed the following: 8/23/23 at 2:00 PM New Business Issue: Treat Cart not being passed out 9/13/23 at 2:10 PM Old Business Issue: Snack Cart is better but still not everynight (sic) 10/11/23 at 2:00 PM Old Business Issue: Snack cart still not everynight (sic) During an interview on 1/23/24 at 12:20 PM, CNA M stated Staffing is short .and HS (bedtime) snacks are not always passed out. During an interview on 1/23/24 at 1:50 PM, Dietary Manager M stated the dietary department made the HS snacks and the CNAs should be passing them out. The facility policy titled Offering/Serving Bedtime Snacks and dated as reviewed/revised 1/1/2022 read in part: It is the policy of this facility to offer and serve residents with a nourishing snack in accordance with their needs, preferences and requests at bedtime on a daily basis. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intakes: MI00140257 and MI00140613 Based on observation, interview, and record review, the facility failed to provide adequate staff to meet the needs of the residents as evidenced by: - lack of routinely passing water, - long wait times for assistance with reported bladder accidents and missing of scheduled activities, - lack of routinely offering bedtime snacks. This deficient practice resulted in feelings of frustration and insignificance on the part of 11 out of 13 residents who attended the confidential group meeting. Findings include: On 10/18/23 a complaint was filed with the State Agency (SA) which included allegations the facility was not adequately staffed to ensure residents were provided proper care and call lights were not answered timely to meet resident needs. On 11/7/23 a complaint was filed with the SA which included an allegation that the facility was short staffed. Payroll Based Journal data submitted by the facility to the Centers for Medicare and Medicaid Services (CMS) triggered the following notation: Submitted Weekend Staffing data is excessively low for the quarter of 07/01/23 through 09/30/23. On 1/22/24 at 2:00 PM, a confidential group meeting took place with 13 Residents in attendance. Confidential Resident C5 stated while they could do much for themselves, they felt no one helped those who needed more help. No one comes to help for a long time. C5 stated this had been brought to the attention of leadership but the problem remained. C6 explained this affected her as she had pressed her call light for assistance to be dressed and to be helped to get to the Rosary activity. She waited for over an hour and no one came. I missed Rosary . I go to Rosary and church every week. She stated she felt regret she had not made it as it was important to her. C3 stated they had to wait long periods of time to use the bathroom. C3 waited over 40 minutes and had an accident and wet themselves. C3 stated I felt degraded. C1 stated there was such a shortage and the Certified Nurse Aides (CNAs) leave the hall to give showers and the wait times were even longer when showers were being given. A further issue of not getting water each day was brought up in the confidential group meeting. C1 said she had to go out in the hallway in the middle of the night and ask for water. Confidential group members C3, C10, C11, and C13 also agreed they did not get water on a regular basis. Observations were made on 1/21/24 from 9:44 AM - 10:09 AM of rooms 401, 402, 403, 405, 406, and 412. These rooms had bedside waters dated 1/19/23 from two days prior. On 1/21/24 at 9:48 AM, room [ROOM NUMBER] was observed to have an empty Styrofoam water container dated 1/19/24 and timed 8:00 PM. Resident #8 (R8) was present and was asked if she regularly received water every shift and replied, No. Sometimes we get water and sometimes we do not. I have to ask sometimes to have water. On 1/21/24 at 10:09 AM, room [ROOM NUMBER] was observed to have an empty Styrofoam water container dated 1/19/24 and timed 8:00 PM. Resident #4 (R4) was present and was asked if he regularly received water every shift and replied, No. They need to bring me some water. I am thirsty. R4's lips were observed to be dried and cracked. During the confidential group meeting residents also stated they often did not receive bedtime snacks. Several residents stated one Certified Nurse Aide (CNA) did bring bedtime snacks off and on but C5 stated this CNA had just quit and was no longer passing snacks. Review of the RESIDENT COUNCIL MINUTES revealed the following: 8/23/23 at 2:00 PM New Business Issue: Treat Cart not being passed out 9/13/23 at 2:10 PM Old Business Issue: Snack Cart is better but still not everynight (sic) 10/11/23 at 2:00 PM Old Business Issue: Snack cart still not everynight (sic) During an interview on 1/23/24 at 12:20 PM, CNA M stated Staffing is short .and HS (bedtime) snacks are not always passed out. CNA M stated they all tried to get the work done but sometimes shortcuts were taken and not everything got done. During a phone interview on 1/23/24 at 10:45 AM, the area Ombudsman confirmed the residents had brought concerns of low staffing, staff with negative attitudes, and call light wait times to him during his visits over the past year. During an interview on 1/23/24 at 12:50 PM, the NHA stated the facility has been working on the staffing issues and he was aware of the related concerns such as sporadic water passes. He planned to bring this to the quality improvement team and find a solution. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 1/21/24 at 9:44 AM an observation was made of room [ROOM NUMBER] bed B. In room [ROOM NUMBER] bed-B there was a bedside table with a Styrofoam water container with a date of 1/19/24 and timed 8:00 PM and the container was half full. On 1/21/24 at 9:45 AM, an observation was made of room [ROOM NUMBER]. In the room [ROOM NUMBER] was a bedside table with a Styrofoam water container with a date of 1/19/24 and timed 8:00 PM and the container was empty. On 1/21/24 at 9:46 AM, an observation was made of room [ROOM NUMBER]. In the room [ROOM NUMBER] was a bedside table with a Styrofoam water container with a date of 1/19/24 and timed 8:00 PM and the container was ¼ full. On 1/21/24 at 9:48 AM, an observation was made of room [ROOM NUMBER] bed A. In the room [ROOM NUMBER] bed A was a bedside table with a Styrofoam water container with a date of 1/19/24 and timed 8:00 PM and the container was half full. On 1/21/24 at 9:48 AM, an observation was made of room [ROOM NUMBER] bed B. In the room [ROOM NUMBER] bed B was a bedside table with a Styrofoam water container with a date of 1/19/24 and timed 8:00 PM and the container was close to being empty. On 1/21/24 at 9:48 AM, an observation was made of room [ROOM NUMBER]. In the room [ROOM NUMBER] was a bedside table with a Styrofoam water container with a date 1/19/24 of and timed 8:00 PM and the container was empty. Resident #8 (R8) was the occupant of room [ROOM NUMBER] and was interviewed and asked about waters. R8 was asked if she regularly received water every shift and replied, No. Sometimes we get water and sometimes we do not. I have to ask sometimes to have water. On 1/21/24 at 10:09 AM, an observation was made of room [ROOM NUMBER]. In the room [ROOM NUMBER] was a bedside table with a Styrofoam water container with a date of 1/19/24 and timed 8:00 PM and the container was empty. Resident #4 (R4) was the occupant of room [ROOM NUMBER] and was interviewed and asked about waters. R4 was asked if he regularly received water every shift and replied, No. They need to bring me some water. I am thirsty. R4's lips were observed to be dried and cracked. On 1/21/24 at 10:15 AM, an interview was conducted with Certified Nurse Aid (CNA) O who was asked how often water is passed to residents and replied, They should get a water pass every shift. Two or three times a day. CNA O was asked about the water dated 1/19/24 and replied, I am not sure. That is two days old. I am getting everyone water now. I get here at ten and start passing water. R4 stated, He (CNA O) is one of the few people I see passing water. Based on observation, interview and record review, the facility failed to ensure fresh water was consistently offered and provided for 7 residents (R4, R8, R21, R31, R34, R51, R53) and 5 of 13 residents attending the confidential group meeting. This deficient practice resulted in resident dissatisfaction, and the potential for feelings of thirst and dehydration. Findings include: On 1/22/24 at 2:00 PM, a confidential group meeting took place with 13 Residents in attendance. The issue of not getting water each day was discussed. Confidential Resident C1 said she had to go out in the hallway in the middle of the night and ask for water. Confidential group members C3, C10, C11, and C13 also agreed they did not get water timely or on a regular basis and rarely was water passed without asking on the weekends. The facility policy titled Hydration dated as reviewed/revised on 10/26/23 read in part: The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation relates to Intake #MI00136512. Based on observation, interview, and record review, the facility failed to prevent physical abuse for two Residents (#502, #510) of 15 residents reviewed for abuse. This deficient practice resulted in Resident #502 receiving a bloody nose by Resident #510, and the potential for undetected abuse. Findings include: Review of Resident #502's Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #502 was admitted to the facility on [DATE], with diagnoses including peripheral vascular disease (progressive circulatory condition), heart failure, diabetes, and depression. Resident #502 required supervision for bed mobility, total assistance for transfers, extensive assistance for toileting, and was continent of bladder and bowel. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 15/15, which indicated Resident #502 was cognitively intact. The behavioral assessment revealed no behaviors. The depression assessment revealed a score of 1/27 which was not indicative of significant depression symptoms. Review of the Electronic Medical Record (EMR) revealed Resident #502 was his own responsible party and had bilateral lower extremity amputations. Review of Resident #510's MDS assessment, dated [DATE], revealed Resident #510 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, dementia with behaviors, anxiety disorder, and depression. Resident #510 required supervision with bed mobility and walking, extensive two-person assistance for toileting, and was independent with transfers. Resident #510 demonstrated rejection of care four to six times a week and wandering behaviors daily which significantly intruded on the privacy or activities of other. The BIMS assessment revealed a score of 99, which showed Resident #510 had marked cognitive impairment. The assessment revealed no symptoms of depression. Review of the EMR revealed Resident #510 had a death at the facility on [DATE] and had transferred to hospice care prior to his passing. Review of the facility incident investigation summary, dated [DATE], revealed there was a resident-to-resident incident between Resident #502 and Resident #510, when Resident #510 became physically aggressive towards Resident #502. A nurse assessed both residents, and found Resident #502's nose was bleeding, but he was otherwise physically ok. Resident #510 was sent to the hospital for evaluation after the incident. Resident #510 was placed on a 1 to 1 supervision after the incident until he was hospitalized and subsequently transferred to a neuropsychiatric hospital. The report revealed the police were notified of the incident. Review of Resident #502's Accident and Incident report, dated [DATE] at 18:15 (6:15 p.m.), revealed, .Resident [#502] reported that a male resident [#510] had hit him. Resident [#502's] Description: [Resident #510] came into my room. I was just laying [sic] in my bed. [Resident #510] had a fork with him. I told him that it wasn't his room and to get out. [Resident #510] then walked towards me and lifted the fork as if to stab me. I was able to block it but [Resident #510's] other hand hit me on my face and my glasses flew. I had some nosebleed. I do not have any new pain. [Staff] removed other resident [#510] from [Resident #502's] room; skin and pain assessments [completed], stop sign [placed at room entry] .No injuries observed post incident . The report showed Resident #502 was fully oriented, interviewable, and his overall baseline did not change after the incident. Review of Certified Nurse Aide (CNA) B's witness statement, dated [DATE], revealed, I was in another resident's room when I heard yelling coming from [Resident #502's] room. I entered the room and saw [Resident #510] at [Resident #502's] bedside, reaching towards [Resident #502]. I then tried to redirect [Resident #510]. [Resident #510] then turned toward me, grabbed me, shoving me into the cabinet and would not let go. I eventually got the resident [#510] out of [Resident #502's] room. During this incident, I did see blood coming from [Resident #502's] nose. Review of Registered Nurse (RN) F's witness statement dated [DATE] revealed, On [DATE]th, 2023, a suppertime aide said [Resident #510] entered [Resident #502's] room and stabbed [Resident #502] with a fork in the side, and punched [Resident #502] in the nose. I went to check on [Resident #502] immediately. The two [residents] were already separated by nurse aide. I assessed [Resident #502's] side .there were no puncture wounds. Skin was pink and intact. I noticed a small amount of blood coming from [Resident #502's] nostril but it wasn't actively bleeding .I asked [Resident #510] what happened and he didn't answer. I asked [Resident #502] what happened, and he stated [Resident #510] entered his room and stabbed a fork into his left side and [Resident #510] punched him in the nose in an upward position, knocking his glasses off. [Resident #502] stated [Resident #510] went for his face with the fork and [Resident #502] struck [Resident #510's] hand to knock the fork out of his hand. I called 911 .and the police came . During an interview on [DATE] at 3:45 p.m., Resident #502 was asked about any resident-to-resident incidences. Resident #502 described he was in his bed in his room with the curtain drawn closed on [DATE]th (2023), around dinner time. Resident #502 reported Resident #510 came into his room around the curtain, and he asked Resident #510 to leave twice. Resident #510 reportedly ignored him and approached the edge of his bed, holding a metal fork with an adaptive grey handle, and showed Surveyor a similar fork. Resident #502 stated he told Resident #510 to get out a third time, when [Resident #510] reached straight out with the fork and hit me on the left side ., showing Surveyor the left side of his abdomen. Resident #502 explained, I went up with my left arm and knocked it [the fork] out of his hand, and [Resident #510] swung with his other hand; his left hand hit me in the nose and knocked my glasses off and my nose started bleeding . Resident #502 clarified he had put his call light on earlier when Resident #510 entered his room, and when the aide arrived, [Resident #510] turned around with both arms and slammed her into the closet. Her name is [CNA B] .[Resident #510] assaulted me; that's the way I feel . Resident #510 reported the Director of Nursing (DON) was in the building, who called the police. Resident #510 reported the police interviewed him, took pictures of his injuries, made a report and asked him if he wanted to press charges, and he declined. Resident #510 clarified he understood Resident #510 had dementia however he was very violent and his [family member] told me she couldn't manage him [prior to admission] and [Resident #510] beat up on her [at home]. Resident #510 expressed concern CNA B had gotten slammed like this before by Resident #510, and Resident #510 had swung out at others. Further interview requested by Resident #502 yielded earlier the same day Resident #510 had picked the flowers off my hibiscus plant, and that same morning took my flowers and threw my plant, which he reported upset him. Resident #502 reported staff were aware of the earlier incident when it occurred, as he reported the incident to nursing staff. Resident #502 added, [Resident #510] was just a terror, and the women residents and staff were scared of him .[Resident #510] would grab the staff and punch them. I wasn't afraid of him .but I was afraid for others .From the day he came in February (2023) until May (2023) he had these behaviors . Regarding his injuries, Resident #502 reported he had a red mark from the fork in his side, and his nose bled a couple of hours, and denied pain. Resident #502 stated, I felt better by the next day; but I was worried it was going to start again. Emotionally, it made me more anxious and I was worried what was going to happen .[Resident #510] had a 1:1 [after the incident] .[Resident #510] did not have a 1:1 prior [to the incident]. One thing that was disconcerting to me .[Resident #510] was on the other hall, so he walked far to get here.[Resident #510] was in here almost every day . Resident #502 further described he felt targeted, as Resident #510 would come in his room, even when he wasn't there. Resident #502 stated, One time at 2:00 am., I woke up and [Resident #510] was standing over me .[Resident #510] took my white cross by my door [which he showed Surveyor had been returned], and [Resident #510] would pick up my wipes [on his sink] and take them . Resident #502 denied being aware of incidents with other residents, however reported Resident #510 took their personal items, blankets, and would either touch/poke them or follow them closely. Resident #502 clarified, I would think [Resident #510] knew what he was doing .as then he punched me [after stabbing his side with the fork] . and reported this made him feel harassed . Resident #502 currently felt safe, as Resident #510 was deceased , and had declined medically after his psychiatric hospitalization, and did not bother him again upon return to the facility on [DATE]. During an observation on [DATE] at approximately 4:15 p.m., Resident #502 wheeled his power wheelchair into the room adjacent to his and proudly showed Surveyor how he tended to the plants and flowers in the faciltiy, which he had provided, and explained how he was invested and encouraged by this hobby. It was observed Resident #502 had bilateral lower extremity amputations while he was seated in his wheelchair. Review of a police report, dated [DATE], revealed the local police came to the facility on [DATE] at 18:25 p.m. (6:25 p.m.) due to the report of an assault. Deputy N interviewed Resident #502 and facility staff, and made observations. Police attempted to interview Resident #510 who was not interviewable due to confusion. The report showed the incident occurred between 6:24 p.m. to 6:25 p.m., and RN F reported Resident #510 went into Resident #502's room and poked Resident #502 with a fork and then Resident #510 punched Resident #502 in his nose, causing Resident #502's nose to bleed. RN F reported Resident #510 had severe Alzheimer's disease and she was planning to have Resident #510 sent to the local hospital for further evaluation. CNA E reported Resident #502 was going into multiple resident rooms, and CNA B was assigned to Resident #502 when the incident occurred. CNA B reported she was close to the incident but did not see it occur. CNA B reported she did observe Resident #510 going into multiple resident rooms during the day. Resident #502 reported to the police Resident #510 came into his room and poked him with a fork in the left upper torso of his body, and he swatted the fork out of Resident #510's hand, and then Resident #510 lifted his hand quickly and struck Resident #502 in the nose, causing his nose to bleed. Resident #502 reported to the police Resident #510 tended to walk into people's rooms and took people's things and destroyed people's things CNA B reported Resident #510 was confused to law enforcement. The report revealed Resident #510 was later transported to the hospital for a mental evaluation, and showed the officer took four photos of Resident #502's injuries. The case status was closed, per Resident #502's directive, as he declined to press charges. The police report findings showed an assault occurred towards Resident #502 by Resident #510. During an interview on [DATE] at 4:57 p.m., CNA B was asked about the incident with Resident #502 and Resident #510 on [DATE]. CNA B recalled she was in another room providing another resident care when she heard Resident #510 yelling, and ran into Resident #502's room, when she saw Resident #510 reaching towards Resident #502. CNA B reported asking Resident #510 to leave Resident #502's room and would not listen. CNA B clarified they tried to gently guide Resident #510's arm to pull [Resident #510] away [from Resident #502] and he shoved me into the cabinet and wouldn't let go, and [Resident #510] pinned me there. CNA B broke free and walked Resident #510 out of the room, and he said he was sorry more than once. CNA B reported they did see blood coming from Resident #502's nose, and added, [Resident #502] was shouting [Resident #510] tried to stab him with a fork; I saw the fork on the tall dresser .from what he told [CNA E] it sounded like [Resident #510] punched [Resident #502]; I know [Resident #502] got hit .It happened around 5:00 to 6:00 p.m . During further interview, CNA B was asked if there had been any other resident to resident incidences with Resident #510. CNA B stated, [Resident #510] had dementia .[and] wandered into everyone's rooms .That's just what [Resident #510] did .[Resident #510] was in [Resident #502's] room on several occasions . and reported it bothered Resident #502 when this occurred. When asked if they would have expected Resident #510 to be aggressive, CNA B responded, Yes, it was not a surprise .with staff in general when we tried to get [Resident #510] to do something he didn't want to do he would slap or shove us .[Resident #510] wandered into a women's room [unnamed] and sat on her bed . CNA B was asked if any female residents were fearful of him. CNA B affirmed, Yes, they were., and reported Resident #517 and Resident #515 told them they were afraid of Resident #510. When asked about their ability to provide appropriate supervision for Resident #510, CNA B reported the nurses and management staff were all aware of Resident #510's behavioral concerns, and residents' fearfulness of him, and explained with one CNA assigned to at least 16 residents, they could not provide appropriate supervision to Resident #510 to prevent his behaviors including entering other residents' rooms. CNA B reported Resident #510 had never been on a 1 to 1 supervision since his admission in February 2023, until the incident on [DATE]. CNA B added, [Resident #510] looked scary; he would get that glare [in his eyes] . CNA B reported Resident #510 would take items from residents' rooms, including toilet paper, tissue, clothing, and would yell at staff and was combative with cares. CNA B stated, .[Resident #510] needed a 1 to 1 [supervision]. CNA B affirmed their nurses had talked to management staff and they declined to provide a 1 to 1 supervision for Resident #510. During an interview on [DATE] at 9:17 a.m., CNA D was asked about Resident #510's care and any resident-to-resident incidences. CNA D confirmed Resident #510 wandered into other residents' rooms, including Resident #502's, and reported Resident #510 was aggressive during cares, when he would hold up his fists, and had struck her once. When asked if residents were fearful of Resident #510, CNA D stated, Yes, and reported Resident #514 was fearful of Resident #510. When asked about the incident with Resident #502, CNA D clarified she found Resident #502 credible and reliable as a reporter, as he was fully oriented and advocated for the facility residents. When asked what occurred, CNA D reported Resident #502 confirmed the incident occurred, and he had a fork placed in his side, a bloody nose, and his glasses flew off. CNA D stated, [Resident #502] seemed pretty shaken up after the incident as he couldn't remove himself from the situation [as he was in bed]. Resident #502 is a two-person total lift . CNA D confirmed Resident #510 was not on a 1 to 1 supervision until after the resident-to-resident incident on [DATE]. Review of the EMR revealed Resident #514 score on the BIMS assessment was 15/15, which showed she was cognitively intact. During an interview on [DATE] at 9:37 a.m., Resident #514 was asked about any concerns with Resident #510 when he was at the facility. Resident #514 responded, [Resident #510] was scary .The night it happened [the resident-to-resident incident on [DATE]] I heard [Resident #502] yelling at [Resident #510], and then I heard that [Resident #510] stabbed [Resident #502]. The police were called by [Resident #502]. [CNA E] gave a written report to the police . Resident #514 reported Resident #510 came in her room several times, and stated, One night I was laying [sic] in bed and I heard a shuffle of slippers and [Resident #510] went into the bathroom. I called for the night aide because [Resident #510] was scary and they came and got him .One night [Resident #510] came in when I had company and he wouldn't leave. [Resident #510] was stubborn. One day when I was coming back from therapy and [Resident #510] was behind me .I was concerned about him being behind me. And the people in therapy were concerned about [Resident #510]. My roommate was fearful of him too. We kept saying to each other, Why would we have a patient like that here? Everyone had these [bad] feelings about [Resident #510] Review of Resident #515's EMR revealed a BIMS score of 15/15, which showed Resident #515 was cognitively intact. During an interview on [DATE] at 10:27 a.m., Resident #515 reported there was a man [clarified male resident] who was coming in her room [in the past] and it upset me. Resident #515 further clarified, [Resident #510] was in [her room] and sat on her bed .I talked very loudly [so staff would hear] . Resident #515 reported she was not scared but it made her feel uncomfortable, and the staff removed Resident #510 and he did not harm her. Resident #515 reported she was aware Resident #510 had been aggressive with Resident #502. Review of the EMR revealed Resident #516 has a BIMS score of 15/15, which revealed Resident #516 was cognitively intact. During an interview on [DATE] at 11:10 a.m., Resident #516 reported Resident #510 was in the room next to him. Resident #516 revealed an incident with Resident #510, and stated, .One time [Resident #510] came up to me [when Resident #516 was in his bed at night] and he thought I was sleeping and he touched me [on the arm] and he said, I'm sorry, I didn't mean to do that.[Resident #510] normally would sit down [in Resident #516's room]. I said, Go to your room, and [Resident #510] would slap the wall when he didn't want to leave. Resident #516 reported he got past it and had no fearfulness as Resident #510 was deceased . Resident #516 reported Resident #510 would push someone's wheelchair and take it for a walk. Resident #516 reported Resident #510 had taken a pair of craft pliers out of his room he used for crafting but they were returned by staff. During a phone interview on [DATE] placed at 11:57 a.m., CNA E reported they recalled the resident-to-resident incident on [DATE] perpetrated by Resident #510 towards Resident #502, as they were assigned to their care. CNA E reported Resident #510 had extra energy that morning and seemed to need a 1 to 1 supervision with him, which they told nursing staff. CNA E felt something was off, and Resident #510 could not sit still. CNA E stated the aide on the prior shift said, You may want to keep a close eye on him .[Resident #510's] very active and moving around a lot more . CNA E reported they stepped away to help another resident go to bed after dinner and left Resident #510 in the care of the nurse, as Resident #510 was eating dinner. Shortly after, only a couple minutes later, they heard Resident #502 yell, and they learned from RN F Resident #510 went into Resident #502's room, and they observed Resident #502 had blood on tissues and was wiping his nose. Resident #502 described how Resident #510 had entered his room with a fork and tried to stab him in the side and when Resident #502 put his hand in between, that's when Resident #510 punched him in the face. CNA E reported the blood was flowing, as Resident #502 was on blood thinners, and his nose bled for at least 45 minutes. CNA E reported it was alarming as earlier Resident #502 reported Resident #510 came in his room and popped the tops off his flowers and scattered them like confetti everywhere, and Resident #502 was very upset when CNA E arrived at their shift, and staff were aware. Resident #502 said to CNA E, Please keep an eye on [Resident #510] tonight. CNA E reported they mentioned this to RN F and the two hospitality aides, to keep a close eye on Resident #510, on the evening of the incident on [DATE], prior to the incident occurring. CNA E further explained when Resident #510 was residing in the facility, it was very overwhelming every shift they worked as staff did not have time to provide him with a 1 to 1 supervision, which he typically needed, and none were ever assigned despite staff requests. CNA E reported Resident #510 would go into other residents' rooms, some who could not speak for themselves, and he would stand there and stare at them and made them feel uncomfortable. CNA E added Resident #510 needed a staff person with him prior to the incident, for extra supervision to prevent Resident #510 from entering other residents' rooms. CNA E clarified Resident #510 was also combative with cares. CNA E reported it was stressful trying to keep Resident #510 out of other residents' rooms while needing to care for their other residents, and this was an ongoing concern during Resident #510's stay. CNA E reported management and nursing staff were aware of the concerns with direct care staff struggling to manage Resident #510's wandering and aggressive behaviors. During an interview on [DATE] at 1:05 p.m., RN F was asked about the resident-to-resident incident between Resident #502 and Resident #510 on [DATE]. RN F acknowledged the incident occurred as described in their witness statement, and confirmed, [Resident #502] said [Resident #510] stabbed him with a fork, and CNA B was pushed against Resident #502's armoire [closet]. RN F reported Resident #502 called the police and the DON (who was in the facility) told them to work on getting Resident #510 out of the faciltiy as he was being harmful to others, so they called 911 as it was a mental health crisis on the part of [Resident #510] as he was being aggressive and harmful to others. RN F reported they put Resident #510 on a 1 to 1 supervision after the incident. RN F was asked about Resident #510's behavior prior to the incident. RN F explained Resident #510 .did enter other residents' rooms, including Resident #514's . RN F clarified, I had heard some residents saying they were scared of him entering their rooms. RN F was asked about any prior concerns on their shift between Resident #502 and Resident #510. RN F reported Resident #502 was upset earlier as [Resident #510] had entered his room at the beginning of the shift and was playing around with flowers his family had got him . RN F confirmed resident #510 had not been placed on a 1 to 1 supervision after the incident with Resident #502 and his flowers, and only received a 1 to 1 supervision after the incident of physical aggression towards Resident #502. RN F reported CNA B was the only aide on their hall, and had at least 17 residents in their care, and stated, We [nursing staff] could have used more [aides]. RN F reported they had 32 residents they were responsible for and could only provide limited assistance as a result. RN F confirmed the incident may not have occurred if they had extra staff to provide additional supervision for Resident #510. Review of Resident #517's BIMS assessment revealed a score of 15/15, which showed Resident #517 was cognitively intact. During an interview on [DATE] at 2:24 p.m., Resident #517 was asked about any residents who wandered into their room. Resident #517 stated, [Resident #510] did in the past .[Resident #510] came in my room and took some treats I had on my desk, and he opened them and threw them, and he took my remote control and wouldn't give it back, and he said he didn't have it, and they [staff] found it in his pocket. One morning I woke up and [Resident #510] was right at my bed, and they [staff] came and got him right away as I was asleep. [Resident #510] came in my room quite often .I didn't like it. I felt scared the morning I woke up and he was in here .I was afraid of him. I heard he stabbed somebody. The first time he came in [Resident #510] grabbed my shoulders. And he said, Oh, you're strong.That made me scared of him. Resident #517 reported they did not think about it anymore, but it was scary to them when it was happening. Resident #517 reported Resident #510 would move her things off her chair and sit in her room. Resident #517 further described, Once [Resident #517] discovered my room, he discovered [visited] it on a regular basis. Resident #517 was aware Resident #510 had passed away, and reported no current symptoms of psychosocial outcome and denied any physical harm towards her. Surveyor notified the SS designee, Staff H, immediately after Resident #517's description of the occurrences and notified the DON soon after. Both reported they were not aware of the incidences towards Resident #510 and would follow up. Review of Resident #510's Care Plan revealed, Cancelled. The resident [specify is/has] the potential to be physically aggressive or agitated r/t dementia, history of harm to others. Date initiated [DATE] .Cancelled. [DATE]. Use plastic utensils only .The resident could react to touch by swinging his arms or fist at staff, hitting wall . Date initiated [DATE] . During an interview on [DATE] at 2:46 p.m., the Rehabilitation Director, Physical Therapy Assistant (PTA) J, and Certified Occupational Therapy Assistant (COTA) K were asked about any concerns reported regarding Resident #510 by facility residents, per earlier interviews. PTA J and COTA K affirmed residents had collectively mentioned Resident #510 made them feel uneasy. Both acknowledged Resident #510 wandered into other residents' rooms during his stay, mainly at night, and facility staff were aware. They reported due to staffing levels a 1 to 1 supervision was not possible, but would have been of benefit, as Resident #510 tried to leave the facility occasionally, and needed supervision to not enter other residents' rooms. They reported Resident #510 was ambulatory without a device and had no balance concerns, and poor comprehension, so they did not pick him up for therapy during his stay and had no therapy notes. Review of Resident #518's BIMS assessment revealed a score of 15/15, which indicated Resident #518 was cognitively intact. During an interview on [DATE] at 3:09 p.m., Resident #518 reported Resident #510 would come in his room and sit in his chair during his stay. Resident #518 reported Resident #510 would take items from his room, such as his jacket and papers, but then would try to give them back to him, and denied any aggression towards him. Review of Resident #510's Social Services (Staff H) progress notes, revealed: [DATE] at 09:39 a.m.: .Behavior displayed: Going into other resident rooms during care, agitation, aggression .medication adjustment .Resident sent to [name of psychiatric hospital] .Resident is currently out of facility . [DATE]: .IDT [Interdisciplinary team] met to review resident. Behaviors that have been monitored over the past 30 days are .verbally aggressive towards staff documented 17 days, posturing, standing with fists closed, intruding into staff personal space documented 14 days, intrusive behavior, going in others rooms and standing over them documented 19 days, and physical aggressive towards other documented 11 days . [DATE]: Behavior displayed: hitting, kicking, wandering, throwing feces, physically and verbally aggressive . [DATE]: Behavior displayed: hitting, kicking, throwing feces, going into other residents' rooms, pushing, struck [family member] in face while providing care. [Behavioral Care Provider] referral made. [DATE]: IDT met to review resident .Behaviors that have been monitored over the past 30 days are .verbally aggressive toward staff documented 12 times, posturing, standing with fists closed, including into staff personal space documented most days in the look back, intrusive behavior, going in to others rooms and standing over them documented most days, and physically aggressive towards other documented daily . Review of Resident #510's progress notes revealed: [DATE] 01:00 (1:00 a.m.): IDT review: Another resident [#502] had reported that [Resident #510] came into his room on [DATE] [at] 6:45 p.m. Other resident [#502] was in bed. [Resident #510] had a fork with him and was told by the other resident [#502] that it wasn't his room and to get out. [Resident #510] then walked towards him and lifted his fork as if to stab [Resident #502]. Other resident [#502] was able to block the motion but [Resident #510's] other hand hit [Resident #502] in the face and his glasses flew. No injuries to [Resident #510] . Signed by the DON. [DATE] 00:23 (12:23 a.m.): Nursing Communication to Dietary .Do not put metal utensils on resident's tray for safety . [DATE] 19:42 (7:42 p.m.): Resident [#510] poked a fork into resident's side [#501] and punched this resident [#502] in the nose. This occurred at suppertime. 1:1 [staff direct supervision] with resident [#510] after this occurred . [DATE] 21:44 (9:44 p.m.): Patient [Resident #510] was found wandering in many resident rooms this evening and needed lots of redirecting. [DATE] 17:03 (5:03 p.m.): CNA [unnamed] stated that Resident [#510] swung at her and hit her hand . [DATE] (no time): Resident [#510] is highly active in and out of peer rooms. Redirection is intermittently effective however not for long . [DATE] 04:44 (4:44 a.m.): .[Resident #510] becomes agitated during toileting times, raising fist to hit, flung small amount bm [bowel movement] at nurse and tried to stand on toilet instead of sitting . [DATE] 10:30 (a.m.): Behavior displayed: hitting, kicking , wandering, throwing feces, physically and verbally aggressive . [DATE] 09:59 [a.m.]: Behavior displayed: Hitting, kicking, throwing feces, going into other residents' rooms, pushing, struck [family member] in face while providing care . [DATE] 18:24 (6:24 p.m.): Patient [Resident #510] continues to wander into resident's private rooms; continues to resist peri-care with staff . [DATE] 18:04 (6:04 p.m.): Resident [#510] combative in shower, hit [family member] in the face and started to kick the CNA . [DATE] 4:57 [a.m]: Behavior Displayed: Resident difficult to redirect, following

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00134831. Based on interview and record review, the facility failed to ensure availability of prescribed medications for two Residents [#504 and #512] of three residents reviewed for pharmacy services. This deficient practice resulted in the potential for harmful adverse effects of abrupt opioid withdrawal for Resident #504 and the potential for infection for Resident #512. Findings include: Resident #504 [R504] R504 was admitted to the facility on [DATE] and had diagnoses including chronic pain syndrome, fibromyalgia, PTSD [post-traumatic stress disorder] and bipolar disorder. A review of R504's Minimum Data Set [MDS] assessment, dated 2/07/2023, revealed the Resident experienced pain almost constantly. A review of R504's Emergency Department Report, dated 2/12/2023 at 6:13 a.m., revealed R504 was transferred from the facility to the Emergency Department [ED] on 2/11/2023 with complaints of nausea, vomiting, diarrhea and pain all over. Further review of the report revealed the following, in part: . history of chronic pain fibromyalgia she is maintained on Percocet [narcotic pain medication] 10 [10 milligrams] every 4 hours. Looking back she has been having consistent prescriptions for Percocet tens for at least the last 3 months . patient states that she was told there was a problem with her prescriptions and they [facility] did not have the Percocet and that the last dose she had [was at] 3 AM 2/11/2023. Patient states that she tried to go all day without it she actually had a wedding rehearsal party tonight that she left [leave of absence from nursing home] . she was getting too nauseated had abdominal cramping overall not feeling well and increasing pain . came back to nursing home . they did not have her medication . does still have nausea vomiting diarrhea cramping . Medical Decision Making: . She is feeling better . she was able to take her Percocet 10 here . The nurse at the nursing home stated that they do not have the ability to provide short term opiate therapy over the weekend, and thus why they had to send her and she was having uncontrolled pain in [sic] the signs of withdrawal . This visit problems: 1. Opiate withdrawal, 2/11/2023 . A review of the facility admission History and Physical, dated 2/09/2023, revealed the following, in part: [R504] notes her neuropathy is very uncomfortable. Has been having increased symptoms in arms and legs. She is upset today stating that staff told her that she was not allowed to take Percocet during the day . this is a long-time medication for her . Chronic Pain: Longstanding chronic pain. Reassured her that Percocet is prescribed exactly how it was at [hospital] . continue current dose. A review of R504's hospital summary, dated 2/02/2023 at 9:49 a.m., revealed the Resident's discharge medication list included Percocet 10-325 mg tablets with instructions to take 1-2 tablets every four hours as needed for pain. A review of R504's February 2023 Medication Administration Record [MAR] revealed the following order: Percocet Oral Tablet 10-325 MG [milligram] (oxycodone w/ acetaminophen) Give 2 tablet by mouth every 4 hours as needed for pain. Start Date: 02/02/2023 1515 [3:15 p.m.]. D/C Date: 02/22/2023 0749 [7:49 a.m.]. Further review of R504's February 2023 MAR revealed the Resident was administered two tablets of Percocet 10-325 mg tablet, averaging three to six administrations daily from 2/02/2023 through 2/10/2023. After 2/10/2023, R504 was administered the medication on 2/11/2023 at 2:30 a.m. It was noted no doses were administered after the 2/11/2023, 2:30 a.m. dose, prior to R504 leaving the facility on leave of absence on 2/11/2023 at 10:00 a.m. or upon returning to the facility on 2/11/2023 at 8:00 p.m. A review of R504's progress notes revealed the following entry: 2/12/2023 13:50 [1:50 p.m.]: Late Entry: Event Date 02/11/2023. Resident upset due to not having her Percocet. Working with pharmacy to resolve the issue. During an interview on 6/01/2023 at 2:35 p.m., the Director of Nursing [DON] reported the facility does not keep Percocet 10-325 mg tablets in their back-up medication supply. The DON stated the facility was not prepared for how much of the medication R504 required therefore did not have enough on hand for the Resident. The DON confirmed the Resident did not receive the medication from 2/11/2023 at 2:30 a.m., prior to the Resident going on leave of absence on 2/11/2023 at 10:00 a.m. This was noted to be a seven hour and thirty-minute timeframe without the medication. The DON reported upon the Resident's return to the facility on 2/11/2023 at 8:00 p.m., nursing assessed the Resident as acting funny and sent the Resident to the ED for evaluation. No doses of the medication were administered after the Residents return and prior to her being transferred to the ED on 2/11/2023 at 11:21 p.m., noting more than 20 hours between doses of the pain medication. Resident #512 [R512] R512 was admitted to the facility on [DATE] and had diagnoses including diabetes, chronic kidney disease and frequent urinary tract infections [UTIs]. A review of R512's MDS assessment, dated 5/29/2023 revealed she was cognitively intact. During an interview on 6/01/2023 at 2:05 p.m., R512 reported she was prescribed methenamine [medication used to prevent bacterial growth and infection] as a measure to help prevent her from getting UTIs. She stated she had been taking the medication for quite some time. R512 reported she recently had to go without the medication for a few days due to the facility running out of the medication. A review of R512's May MAR revealed the following order: Methenamine Hippurate Oral Tablet 1 GM [gram] . give 1 tablet by mouth two times a day for UTI prevention. Start Date: 5/02/2023 1600 [4:00 p.m.] Further review of R512's May MAR revealed she missed five doses of the medication on 5/11/2023 through 5/13/2023. During an interview on 6/01/2023 at 9:00 a.m., Registered Nurse [RN] L reported R512's ran out of the medication on 5/11/2023. RN L stated the mediation was reordered more than one time and the facility still did not received it from the pharmacy until 5/14/2023. On 6/01/2023 at 2:35 p.m., the DON reported staff should be reordering medication when noticing the resident only has a one-week supply remaining to ensure acquisition of the medication before the last dose is administered. The DON stated R512's medication required prior authorization. The DON reported R512's methenamine was not reordered until 5/10/2023, the day the supply was exhausted. Due to the need for prior authorization, receiving the medication from pharmacy took longer than anticipated. The DON confirmed R512 was prescribed methenamine to prevent UTIs and confirmed the risk of infection when the Resident missed doses of the medication. The DON stated at the time R512 ran out of the medication the facility did not have the medication in their back-up medication supply. A request for the facility policy related to medication ordering and pharmacy services was requested at the time of the interview. A review of the facility policy titled Provider Pharmacy Requirements, provided by the DON with a revision date of 8/2020, revealed the following, in part: Regular and reliable pharmaceutical service is available to provide resident with prescription and nonprescription medications . The pharmacy agrees to perform all of, but not only, the following pharmaceutical services . Providing routine and timely pharmacy service as contracted, as well as emergency pharmacy service 24 hours per day, seven days per week . It was noted the policy did not list the procedure for reordering medications from the pharmacy or information on pharmacy turn-around time for reordering.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #MI00136512. Based on observation, interview, and record review, the facility failed to provide comprehensive behavioral care management for four facility Residents (#502, #510, #514, and #517) of nine residents reviewed for behavioral care. This deficient practice resulted in Resident #510 demonstrating ongoing aggressive, intrusive behaviors related to undirected wandering towards facility residents, causing Residents #502, #514, and #517 to verbalize anxiety and fearfulness from these behaviors, with the potential for additional adverse outcomes for other facility residents who verbalized concerns. Findings include: Review of Resident #502's Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #502 was admitted to the facility on [DATE], with diagnoses including peripheral vascular disease (progressive circulatory condition), heart failure, diabetes, and depression. Resident #502 required supervision for bed mobility, total assistance for transfers, extensive assistance for toileting, and was continent of bladder and bowel. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 15/15, which indicated Resident #502 was cognitively intact. The behavioral assessment revealed no behaviors. The depression assessment revealed a score of 1/27 which was not indicative of significant depression symptoms. Review of the Electronic Medical Record (EMR) revealed Resident #502 was his own responsible party and had bilateral lower extremity amputations. Review of Resident #510's MDS assessment, dated [DATE], revealed Resident #510 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, dementia with behaviors, anxiety disorder, and depression. Resident #510 required supervision with bed mobility and walking, extensive two-person assistance for toileting, and was independent with transfers. Resident #510 demonstrated rejection of care four to six times a week and wandering behaviors daily which significantly intruded on the privacy or activities of others. The BIMS assessment revealed a score of 99, which showed Resident #510 had severe cognitive impairment. The assessment did not show symptoms of depression. Review of the EMR revealed Resident #510 had a death at the facility on [DATE] and had transferred to hospice care prior to his passing. Review of the facility incident investigation summary, dated [DATE], revealed there was a resident-to-resident incident between Resident #502 and Resident #510, when Resident #510 became physically aggressive towards Resident #502. A nurse assessed both residents, and found Resident #502's nose was bleeding, but he was otherwise physically ok. Resident #510 was sent to the hospital for evaluation after the incident. Resident #510 was placed on a 1 to 1 supervision after the incident until he was hospitalized and subsequently transferred to a neuropsychiatric hospital. The report revealed the police were notified of the incident. Review of Resident #502's Accident and Incident report, dated [DATE] at 18:15 (6:15 p.m.), revealed, .Resident [#502] reported that a male resident [#510] had hit him. Resident [#502's] Description: [Resident #510] came into my room. I was just laying [sic] in my bed. [Resident #510] had a fork with him. I told him that it wasn't his room and to get out. [Resident #510] then walked towards me and lifted the fork as if to stab me. I was able to block it but [Resident #510's] other hand hit me on my face and my glasses flew. I had some nosebleed. I do not have any new pain. [Staff] removed other resident [#510] from [Resident #502's] room; skin and pain assessments [completed], stop sign [placed at room entry] .No injuries observed post incident . The report showed Resident #502 was fully oriented, interviewable, and his overall baseline did not change after the incident. During an interview on [DATE] at 3:45 p.m., Resident #502 was asked about any resident-to-resident incidences. Resident #502 described he was in his bed in his room with the curtain drawn closed on [DATE]th (2023), around dinner time. Resident #502 reported Resident #510 came into his room around the curtain, and he asked Resident #510 to leave twice. Resident #510 reportedly ignored him and approached the edge of his bed, holding a metal fork with an adaptive grey handle, and showed Surveyor a similar fork. Resident #502 stated he told Resident #510 to get out a third time, when [Resident #510] reached straight out with the fork and hit me on the left side ., showing Surveyor the left side of his abdomen. Resident #502 explained, I went up with my left arm and knocked it [the fork] out of his hand, and [Resident #510] swung with his other hand; his left hand hit me in the nose and knocked my glasses off and my nose started bleeding . Resident #502 clarified he had put his call light on earlier when Resident #510 entered his room, and when the aide arrived, [Resident #510] turned around with both arms and slammed her into the closet. Her name is [CNA B] .[Resident #510] assaulted me; that's the way I feel . Resident #502 clarified he understood Resident #502 had dementia however he was very violent and his [family member] told me she couldn't manage him [prior to admission] and [Resident #510] beat up on her [at home]. Resident #502 expressed concern CNA B had gotten slammed like this before by Resident #510, and Resident #510 had swung out at others. Further interview requested by Resident #502 yielded earlier the same day Resident #510 had picked the flowers off my hibiscus plant, and that same morning took my flowers and threw my plant, which he reported upset him. Resident #502 reported staff were aware of the earlier incident when it occurred, as he reported the incident to nursing staff. Resident #502 added, [Resident #510] was just a terror, and the women residents and staff were scared of him .[Resident #510] would grab the staff and punch them. I wasn't afraid of him .but I was afraid for others .From the day he came in February (2023) until May (2023) he had these behaviors . Regarding his injuries, Resident #502 reported he had a red mark from the fork in his side, and his nose bled a couple of hours, and denied pain. Resident #502 stated, I felt better by the next day; but I was worried it was going to start again. Emotionally, it made me more anxious and I was worried what was going to happen .[Resident #510] had a 1:1 [after the incident] .[Resident #510] did not have a 1:1 prior [to the incident]. One thing that was disconcerting to me .[Resident #510] was on the other hall, so he walked far to get here [to his hall] .[Resident #510] was in here [in his room] almost every day . Resident #502 further described he felt targeted, as Resident #510 would come in his room, even when he wasn't there. Resident #502 stated, One time at 2:00 am., I woke up and [Resident #510] was standing over me .[Resident #510] took my white cross by my door [which he showed Surveyor had been returned], and [Resident #510] would pick up my wipes [on his sink] and take them . Resident #502 reported this made him feel harassed . During an observation on [DATE] at approximately 4:15 p.m., Resident #502 wheeled his power wheelchair into the room adjacent to his and proudly showed Surveyor how he tended to the plants and flowers in the faciltiy, which he had provided, and explained how he was invested and encouraged by this hobby. It was observed Resident #502 had bilateral lower extremity amputations while he was seated in his wheelchair. During an interview on [DATE] at 4:57 p.m., CNA B was asked if there had been any other resident to resident incidences with Resident #510, CNA B stated, [Resident #510] had dementia .[and] wandered into everyone's rooms .That's just what [Resident #510] did .[Resident #510] was in [Resident #502's] room on several occasions . and reported it bothered Resident #502 when this occurred. When asked if they would have expected Resident #510 to be aggressive, CNA B responded, Yes, it was not a surprise .with staff in general when we tried to get [Resident #510] to do something he didn't want to do he would slap or shove us .[Resident #510] wandered into a women's room [unnamed] and sat on her bed . CNA B was asked if any female residents were fearful of him. CNA B affirmed, Yes, they were., and reported Resident #517 and Resident #515 told them they were afraid of Resident #510. When asked about their ability to provide appropriate supervision for Resident #510, CNA B reported the nurses and management staff were all aware of Resident #510's behavioral concerns, and residents' fearfulness of him, and explained with one CNA assigned to at least 16 residents, they could not provide appropriate supervision to Resident #510 to prevent his behaviors including entering other residents' rooms. CNA B reported Resident #510 had never been on a 1 to 1 supervision since his admission in February 2023, until the incident on [DATE]. CNA B added, [Resident #510] looked scary; he would get that glare [in his eyes] . CNA B reported Resident #510 would take items from residents' rooms, including toilet paper, tissue, clothing, and would yell at staff and was combative with cares. CNA B stated, .[Resident #510] needed a 1 to 1 [supervision]. CNA B affirmed their nurses had talked to management staff and they declined to provide a 1 to 1 supervision for Resident #510. During an interview on [DATE] at 9:17 a.m., CNA D was asked about Resident #510's care and any resident-to-resident incidences. CNA D confirmed Resident #510 wandered into other residents' rooms, including Resident #502's, and reported Resident #510 was aggressive during cares, when he would hold up his fists, and had struck her once. When asked if residents were fearful of Resident #510, CNA D stated, Yes, and reported Resident #514 was fearful of Resident #510. CNA D stated, [Resident #502] seemed pretty shaken up after the incident [physical altercation with Resident #510] as he couldn't remove himself from the situation [as he was in bed]. Resident #502 is a two-person total lift . CNA D confirmed Resident #510 was not on a 1 to 1 supervision until after the resident-to-resident incident on [DATE]. Review of the EMR revealed Resident #514 score on the BIMS assessment was 15/15, which showed she was cognitively intact. During an interview on [DATE] at 9:37 a.m., Resident #514 was asked about any concerns with Resident #510 when he was at the facility. Resident #514 responded, [Resident #510] was scary .The night it happened [the resident-to-resident incident on [DATE]] I heard [Resident #502] yelling at [Resident #510], and then I heard that [Resident #510] stabbed [Resident #502]. Resident #514 reported Resident #510 came in her room several times, and stated, One night I was laying [sic] in bed and I heard a shuffle of slippers and [Resident #510] went into the bathroom. I called for the night aide because [Resident #510] was scary and they came and got him .One night [Resident #510] came in when I had company and he wouldn't leave. [Resident #510] was stubborn. One day when I was coming back from therapy and [Resident #510] was behind me .I was concerned about him being behind me. And the people in therapy were concerned about [Resident #510]. My roommate was fearful of him too. We kept saying to each other, Why would we have a patient like that here? Everyone had these [bad] feelings about [Resident #510] Review of Resident #515's EMR revealed a BIMS score of 15/15, which showed Resident #515 was cognitively intact. During an interview on [DATE] at 10:27 a.m., Resident #515 reported there was a man [clarified male resident] who was coming in her room [in the past] and it upset me. Resident #515 further clarified, [Resident #510] was in [her room] and sat on her bed .I talked very loudly [so staff would hear] . Resident #510 reported she was not scared but it made her feel uncomfortable. Review of the EMR revealed Resident #516 has a BIMS score of 15/15, which revealed Resident #516 was cognitively intact. During an interview on [DATE] at 11:10 a.m., Resident #516 reported Resident #510 was in the room next to him. Resident #516 revealed an incident with Resident #510, and stated, .One time [Resident #510] came up to me [when Resident #516 was in his bed at night] and he thought I was sleeping and he touched me [on the arm] .[Resident #510] normally would sit down [in Resident #516's room]. I said, Go to your room, and [Resident #510] would slap the wall when he didn't want to leave. Resident #516 reported he got past it and had no fearfulness after Resident #510 was deceased . During a phone interview on [DATE] at 11:51 a.m., CNA E explained when Resident #510 was residing in the facility, it was very overwhelming every shift they worked as staff did not have time to provide him with a 1 to 1 supervision, which he typically needed, and none was ever assigned despite staff requests. CNA E reported Resident #510 would go into other residents' rooms, some who could not speak for themselves, and he would stand there and stare at them and made them feel uncomfortable. CNA E added Resident #510 needed a staff person with him prior to the incident, for extra supervision to prevent Resident #510 from entering other residents' rooms. CNA E clarified Resident #510 was also combative with cares. CNA E reported it was stressful trying to keep Resident #510 out of other residents' rooms while needing to care for their other residents, and this was an ongoing concern during Resident #510's stay. CNA E reported management and nursing staff were aware of the concerns with direct care staff managing Resident #510's wandering and aggressive behaviors. During an interview on [DATE] at 1:05 p.m., RN F was asked about the resident-to-resident incident between Resident #502 and Resident #510 on [DATE]. RN F acknowledged the incident occurred as described in their witness statement, and confirmed, [Resident #502] said [Resident #510] stabbed him with a fork, and CNA B was pushed against Resident #502's armoire [closet]. RN F reported they put Resident #510 on a 1 to 1 supervision after the incident. RN F was asked about Resident #510's behavior prior to the incident. RN F explained Resident #510 did enter other residents' rooms, including Resident #514's . RN F clarified, I had heard some residents saying they were scared of him entering their rooms. RN F was asked about any prior concerns on their shift between Resident #502 and Resident #510. RN F reported Resident #502 was upset earlier as [Resident #510] had entered his room at the beginning of the shift and was playing around with flowers his family had got him . RN F confirmed resident #510 had not been placed on a 1 to 1 supervision after the incident with Resident #502 and his flowers, and only received a 1 to 1 supervision after the incident of physical aggression towards Resident #502. RN F reported CNA B was the only aide on their hall, and had at least 17 residents in their care, and stated, We [nursing staff] could have used more [aides]. RN F reported they had 32 residents they were responsible for and could only provide limited assistance as a result. RN F confirmed the incident may not have occurred if they had extra staff to provide additional supervision for Resident #510. Review of Resident #517's BIMS assessment revealed a score of 15/15, which showed Resident #517 was cognitively intact. During an interview on [DATE] at 2:24 p.m., Resident #517 was asked about any residents who wandered into their room. Resident #517 stated, [Resident #510] did in the past .[Resident #510] came in my room and took some treats I had on my desk, and he opened them and threw them, and he took my remote control and wouldn't give it back, and he said he didn't have it, and they [staff] found it in his pocket. One morning I woke up and [Resident #510] was right at my bed, and they [staff] came and got him right away as I was asleep. [Resident #510] came in my room quite often .I didn't like it. I felt scared the morning I woke up and he was in here .I was afraid of him. I heard he stabbed somebody. The first time he came in [Resident #510] grabbed my shoulders. And he said, Oh, you're strong.That made me scared of him. Resident #517 reported fearfulness when the indicents occurred. Resident #517 reported Resident #510 would move her things off her chair and sit in her room. Resident #517 further described, Once [Resident #517] discovered my room, he discovered [visited] it on a regular basis. Review of Resident #510's Care Plan revealed, Cancelled. The resident [specify is/has] the potential to be physically aggressive or agitated r/t dementia, history of harm to others. Date initiated [DATE] .Cancelled. [DATE]. Use plastic utensils only .The resident could react to touch by swinging his arms or fist at staff, hitting wall . Date initiated [DATE] . During an interview on [DATE] at 2:46 p.m., the Rehabilitation Director, Physical Therapy Assistant (PTA) J, and Certified Occupational Therapy Assistant (COTA) K were asked about any concerns reported regarding Resident #510 by facility residents, per earlier interviews. PTA J and COTA K affirmed residents had collectively mentioned Resident #510 made them feel uneasy. Both acknowledged Resident #510 wandered into other residents' rooms during his stay, mainly at night, and facility staff were aware. They reported due to staffing levels a 1 to 1 supervision was not possible, but would have been of benefit, as Resident #510 tried to leave the facility occasionally, and needed supervision to not enter other residents' rooms. They reported Resident #510 was ambulatory without a device and had no balance concerns. Review of Resident #510's Social Services (Staff H) progress notes, revealed: [DATE] at 09:39 a.m.: .Behavior displayed: Going into other resident rooms during care, agitation, aggression .medication adjustment .Resident sent to [name of psychiatric hospital] .Resident is currently out of facility . [DATE]: .IDT [Interdisciplinary team] met to review resident. Behaviors that have been monitored over the past 30 days are .verbally aggressive towards staff documented 17 days, posturing, standing with fists closed, intruding into staff personal space documented 14 days, intrusive behavior, going in others rooms and standing over them documented 19 days, and physical aggressive towards other documented 11 days . [DATE]: Behavior displayed: hitting, kicking, wandering, throwing feces, physically and verbally aggressive . [DATE]: Behavior displayed: hitting, kicking, throwing feces, going into other residents' rooms, pushing, struck [family member] in face while providing care. [Behavioral Care Provider] referral made. [DATE]: IDT met to review resident .Behaviors that have been monitored over the past 30 days are .verbally aggressive toward staff documented 12 times, posturing, standing with fists closed, including into staff personal space documented most days in the look back, intrusive behavior, going in to others rooms and standing over them documented most days, and physically aggressive towards other documented daily . Review of Resident #510's progress notes revealed: [DATE] 01:00 (1:00 a.m.): IDT review: Another resident [#502] had reported that [Resident #510] came into his room on [DATE] [at] 6:45 p.m. Other resident [#502] was in bed. [Resident #502] had a fork with him and was told by the other resident [#502] that it wasn't his room and to get out. [Resident #510] then walked towards him and lifted his fork as if to stab [Resident #502]. Other resident [#502] was able to block the motion but [Resident #510's] other hand hit [Resident #502] in the face and his glasses flew. No injuries to [Resident #510] . Signed by the Director of Nursing (DON). [DATE] 00:23 (12:23 a.m.): Nursing Communication to Dietary .Do not put metal utensils on resident's tray for safety . [DATE] 19:42 (7:42 p.m.): Resident [#510] poked a fork into resident's side [#501] and punched this resident [#502] in the nose. This occurred at suppertime. 1:1 [staff direct supervision] with resident [#510] after this occurred . [DATE] 21:44 (9:44 p.m.): Patient [Resident #510] was found wandering in many resident rooms this evening and needed lots of redirecting. [DATE] 17:03 (5:03 p.m.): CNA [unnamed] stated that Resident [#510] swung at her and hit her hand . [DATE] (no time): Resident [#510] is highly active in and out of peer rooms. Redirection is intermittently effective however not for long . [DATE] 04:44 (4:44 a.m.): .[Resident #510] becomes agitated during toileting times, raising fist to hit, flung small amount bm [bowel movement] at nurse and tried to stand on toilet instead of sitting . [DATE] 10:30 (a.m.): Behavior displayed: hitting, kicking , wandering, throwing feces, physically and verbally aggressive . [DATE] 09:59 [a.m.]: Behavior displayed: Hitting, kicking, throwing feces, going into other residents' rooms, pushing, struck [family member] in face while providing care . [DATE] 18:24 (6:24 p.m.): Patient [Resident #510] continues to wander into resident's private rooms; continues to resist peri-care with staff . [DATE] 18:04 (6:04 p.m.): Resident [#510] combative in shower, hit [family member] in the face and started to kick the CNA . [DATE] 4:57 [a.m]: Behavior Displayed: Resident difficult to redirect, following residents, going into other residents' rooms, playing with his own feces, etc . [DATE] 12:25 (12:25 p.m.): Resident's [#510's] undergarment soiled. Attempts made to assist resident [#510] in the bathroom and he became combative. Struck out at female caregivers. Male caregiver also attempted to assist resident and the resident slapped the caregiver . [DATE] 21:50 [9:50 p.m.]: Resident [#510] continues to wander the facility. He becomes agitated during redirection . [DATE] 2:45 [2:42 a.m.]: Resident [#510] resistive to personal care, physically and verbally combative . Review of the EMR revealed Resident #510 was not seen by a behavioral care provider until [DATE]. Facility management acknowledged no outside behavioral care services referral was completed until this visit. Further review of the EMR revealed no clinical explanation for the referral delay, considering Resident #510 adverse behaviors in EMR documentation beginning in March, 2023. Review of Resident #510's Behavioral Care services provider consult, dated [DATE], revealed, .Complaint: Violent behaviors, Combative, Agitation. HPI [History of Present Illness]. [AGE] year-old male that was admitted with senile dementia .mdd [major depressive disorder], and gad [generalized anxiety disorder] .The patient was confused and combative at home over many months. He then went to [Hospital name] and was transferred here [Long Term Care Facility] .Per staff - he has been violent and combative since admission .Because of the violence, he was started on Haldol PO [by mouth]. That has helped somewhat but he still gets combative and agitated with ADLS [activities of daily living - cares]. Review of Resident #510's Psychiatric Evaluation, provided by the DON, dated [DATE], from Resident #510's psychiatric hospital admission on [DATE], revealed, .Patient [Resident #510] is a [AGE] year-old male who suffers from major neurocognitive disorder, Alzheimer's type with behavioral disturbance. Chief Complaint: I'm upset I'm here .Presenting Illness: Patient [Resident #510] also suffers from homicidal ideation, physical aggression, verbal aggression, impulsivity .He is currently with unreliable history due to severe cognitive impairment, presenting with stabbing gesture with a fork. Patient was stopped by the resident's [sic] who knocked the other resident's [Resident #502's] glasses off his nose and caused a nosebleed. Patient was aggressive to other residents and staff members with recent medication changes .He is currently on Depakote, Seroquel for care .Diagnostic impression: Major neurocognitive disorder, Alzheimer's type, moderate with behavioral disturbance .Psychiatry will adjust psychotropic medications . During an interview on [DATE] at 3:29 p.m., the Social Services designee, Staff H was asked how they had managed Resident #510's behaviors including undirected wandering, and the resident-to-resident incident perpetrated towards Resident #502 by Resident #510 on [DATE]. Staff H stated, [Resident #502] had a bloody nose and there was some physical contact .Yes, it was physically abusive. Surveyor reviewed they did not provide supportive visits to Resident #502 after the incident, and reported they understood the concern. Staff H acknowledged they were aware Resident #502 entered multiple resident rooms during his stay. When asked how they were addressing, Staff H reported they tried to place Resident #510 in an alternate setting such as a locked unit but could name no other interventions other than medication management and staff redirection, and no non-pharmacological interventions, which was confirmed by their documentation reviewed with Surveyor. Staff H acknowledged they provided no behavioral management strategies other than asking the family to come into the facility and assist and provide extra supervision, and trying to place Resident #510. Staff H confirmed no 1 to 1 supervision was assigned to Resident #510 until after the abusive incident towards Resident #502, and understood the concerns aforementioned related to lacking coordination of care and education with nursing staff, as well as Resident #510 needing increased supervision during their stay. Staff H could not explain why Resident #510 was not referred to an outside behavioral provider earlier than mid-April (2023), given their ongoing concerning aggressive and intrusive behaviors towards staff and residents during their stay, soon after admission in February 2023. Surveyor reviewed Staff H's follow up documentation with them after the incident, which addressed screening for potential abuse towards other residents after the incident. Staff H confirmed they interviewed five facility residents per their abuse log. When asked why they only reviewed five residents for abuse, given Resident #510 was frequently walking ad lib throughout the facility, Staff H had no response. Surveyor shared several residents' collective concerns related to Resident #510 entering their rooms uninvited including anxiety, fearfulness, and feeling unsettled, related to taking their personal items, standing over them, pushing their wheelchairs, sitting in their rooms, etc.Staff H confirmed they did not do a facility abuse sweep, despite Resident #510 returning to the facility in May, 2023. Staff H reported they understood the concerns, given Resident #510's behaviors, which were affecting other residents. Surveyor asked Staff H for their job description/duties, and they did not have a copy, to confirm if their role was to provide coordination of care for behavioral care management. Staff H verbally affirmed this was in their job responsibilities. During an interview on [DATE] at approximatley 4:15 p.m., the NHA, DON, and Regional Director of Clinical Operations, Staff O, were asked about their findings related to the [DATE] resident-to-resident incident between Resident #502 and Resident #510. The management team reported they understood this incident rose to physical abuse perpetrated by Resident #510 towards Resident #502. They confirmed law enforcement was involved, and Resident #502 was transferred to an out of state psychiatric hospital after the incident due to his aggression and abusive behavior. Given Resident #510's undirected wandering throughout the facility in and out residents' rooms, rising to physical abuse, aggression, fearfulness, and anxiety for multiple facility residents, the management team was asked if there was a facility sweep for abuse. The team confirmed this was not done and affirmed only the five residents had been interviewed for a potential abuse, with none reporting abuse, and they were not aware of the other residents' concerns reviewed with them by Surveyor. The NHA and DON confirmed there was no staff education, disciplinary action, monitoring, or audits done to address the resident-to-resident physical abuse, to discover/prevent additional abuse, and Resident #510 was not placed on a 1:1 supervision until after the incident occurred. Surveyor shared concern some staff were aware a number of facility residents were fearful of Resident #510 entering their rooms, taking their items, standing over them in their beds, touching them, and following behind them, with no interventions to prevent these ongoing behaviors when Resident #510 was in the facility. The management team reported they understood the behavioral and supervision concerns, and the NHA affirmed they understood the abuse concerns, as their investigation concluded Resident #510 perpetrated physical abuse towards Resident #502, which was substantiated by Surveyor. Surveyor shared concerns Resident #510 had entered Resident #502's room earlier in the day and destroyed his flowers, which upset Resident #502, and Resident #510 was wandering undirected into other residents' rooms since their admission, per interviews and record review, causing fearfulness, distress, unsettlement, and anxiety among some of facility residents sampled. Surveyor clarified Resident #510 had not been referred to an outside behavioral provider until mid-April (2023), and had demonstrated consistent, alarming patterns of behavior towards staff and facility residents ongoing during his stay, per social services and nursing documentation, with limited documentation or staff reports of successful interventions other than redirection and attempts at alternate placement. Surveyor reviewed Resident #502's police report included documentation of assault per police and facility staff, and confirmation of Resident #510 entering multiple rooms on the date of incident ([DATE]), placing other residents at risk for abuse and fearfulness. Upon review of concerns, the management team understood it was the responsibility of facility to adequately supervise Resident #510, regardless of how, whether via a 1 to 1 supervision, or another intervention, despite attempts at placement, which were unsuccessful. The facility management did not provide any clear explanations for Resident #510's aggressive and intrusive behaviors towards residents, and reported they supervised Resident #510 to the extent possible, and provided redirection, despite limited evidence of such in facility documentation.[TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide dressing changes according to professional standards of practice for one Resident (#34) reviewed for professional standards of practice. This deficient practice resulted in the potential for skin breakdown and infections to occur. Findings include: On 12/12/22 at 11:43 AM, an observation was made of Resident #34 (R34) in his room. R34 was noted to have a tracheostomy (a surgical airway) and a peg tube (a feeding tube placed through the skin into the stomach). R34's tracheostomy ties (used to secure the tracheostomy tube) were visibly soiled, tinged light brown in color, and were undated. R34's PEG (percutaneous endoscopic gastrostomy) tube, located on his abdominal area, was a split gauze dressing dated 12/10/22 (not changed in two days). Further observation of R34's room and supplies revealed an opened bottle of Sodium Chloride Solution of 1000 milliliters (ml), undated with 200 ml remaining, and a suction machine with a Yankauer (suctioning catheter) undated. On 12/13/22 at 11:40 AM, Licensed Practical Nurse (LPN) E confirmed R34's PEG tube dressing should have been changed on 12/11/22, and tracheostomy ties are to be changed on shower days regardless of being showered or not. Review of R34's physician orders revealed an order for PEG tube dressing changes, and read in part, Cleanse area with soap & H2O (water), rinse, pat dry. Apply split gauze 4 by 4 (gauze size in inches). Change daily 7p-7a and prn [as needed] . Review of R34's Treatment Administration Record (TAR) for December 2022 revealed a blank under the PEG tube dressing change date 12/11/22 indicating it was not completed. On 12/14/22 at 2:30 PM, an interview was conducted with the Director of Nursing (DON). The DON confirmed orders for dressing changes are to be followed per physician orders, and R34's peg tube dressing and tracheostomy ties should have been changed by nursing staff and dated properly. The Sodium Chloride and Yankauer should have been dated when open and placed. Review of facility policy titled, Tracheostomy Care, dated 01/01/2022, read in part, Policy: The facility will ensure that residents who needs (sic) respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice .6. Procedure with Use of Reusable Cannula: .m. Change trach ties/tube holder when soiled or wet . Review of facility policy titled, Clean Dressing Change, dated 01/01/2022, read in part, Policy: It is the policy of this facility to provide wound care in manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. Policy Explanation and Compliance Guidelines: .2. Multi-use wound care supplies will be dated and initialed when opened .14. Secure dressing. [NAME] with initials and date .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #29 (R 29) Review of R 29's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with readmission on [DATE] and diagnoses including: metabolic encephalopathy (damage or loss of brain function caused by illness unrelated to the brain), dehydration, dysphagia, cognitive communication deficit, and food in respiratory tract causing asphyxiation. Review of her 11/27/22 Annual MDS assessment revealed a BIMS score of 9/15 indicating mild cognitive impairment. R 29 also was noted to need set-up assistance while eating and was marked as having complaints of difficulty or pain with swallowing in section K of the MDS assessment. On 12/12/22 at 12:30 p.m., an interview was conducted with R 29's activated Designated Power of Attorney (DPOA) M about the care R 29 receives at the facility. DPOA M stated that R 29 had recently been sent to the hospital for dehydration and returned to the facility on [DATE] with orders for a dysphagia diet and regular liquids with no straws. During this interview, it was observed that R 29's two juices which were placed on her bedside table had straws. On 12/13/22 at 12:05 p.m., R 29 was observed to be in the main dining room for the lunch meal service. R 29 was given five full sized chicken nuggets and two drinks with straws. R 29 was observed assisting herself with the lunch meal. Review of R 29's Hospital Summary dated 12/10/22 read, in part, .date of admission [DATE] .discharge date [DATE] .issues for follow up .staff at (facility name) to please offer sips of fluids (without straw) each time they enter and leave the room to assist in preventing dehydration .pt (patient) should have soft, bite size diet with sips of regular liquids WITHOUT STRAW. Pt was evaluated by ST (speech therapy) while inpt (inpatient) and straw use put pt at risk for aspiration . An interview with Certified Dietary Manager (CDM) A on 12/13/22 at approximately 2:00 p.m. revealed that he had just received the new recommendation for R 29's diet order and added it to the meal ticket. When asked if R 29 should have received chicken nuggets for the lunch meal service, CDM A stated that he would have to check, but they (chicken nuggets) should have been cut up. Review of R 29's nutrition care plan read, in part, The resident is at risk for nutritional declines .h/o (history of) dysphagia .choking episode on food w/ (with) aspiration PNA (pneumonia) . An interview with the DON on 12/13/22 at approximately 3:30 p.m. confirmed that the DON had yet to go through the discharge orders from the hospital for R 29. The DON confirmed that R 29's care plans or orders had not yet been updated to reflect the recommendations from the hospital on [DATE]. Based on observation, interview, and record review, the facility failed to ensure that foods and fluids in the appropriate consistency were provided per physicians order for two Residents (R22 and R34) out of four reviewed for nutrition. This deficient practice resulted in the potential for choking, aspiration, and pneumonia. Findings include: R62 On 12/12/22 at approximately 9:28 a.m., R62's call light was observed to be on, and Administrative Assistant AA was observed stepping into the room reporting she would be back to answer the call light. At 9:30 a.m., the Business Office Manager (BOM) Z was observed answering R62's call light. She was heard asking R62 what she needed and the resident asked for water. BOM Z exited the room and approximately three minutes later returned to the room with a large Styrofoam glass of water. Administrative Assistant AA was in R62's room when BOM Z returned and told BOM Z that R62 could not have the water, but could have swabs for her mouth. BOM Z was not aware of R62 being unable to safely consume liquids and had Administrative Assistant AA not intervened R62 would likely have had issues drinking the water and potentially could have aspirated (inhaled the fluid into her lungs). A review of R62's medical record revealed she admitted to the facility on [DATE] with diagnoses including stroke, dysphagia (swallowing impairment), left sided weakness. A review of her 12/3/22 Minimum Data Set (MDS) assessment revealed she scored 7/15 on the Brief Interview for Mental Status (BIMS) assessment indicating moderately impaired cognition and received her nutrition through a feeding tube. A review of a physician's order dated 11/28/22 for R62 revealed, NPO diet (nothing by mouth). On 12/14/22 at approximately 9:00 a.m., the Regional Nursing Home Administrator (NHA) O was notified of the observation of BOM Z attempting to bring water to R62. The Regional NHA O confirmed that BOM Z did not normally answer call lights regarding clinical concerns and understood the potential outcome if Administrative Assistant AA had not intervened.

Based on observation, interview, and record review, the facility failed to implement interventions to address range of motion (ROM) for one resident (Resident #47) of two residents reviewed for limited range of motion. This deficient practice resulted in the potential for extreme pain, discomfort, and worsening of contractures. Findings include: Review of Resident #47's (R 47's) Electronic Medical Record (EMR) revealed an admission date of 1/15/20 and diagnoses including: neurocognitive disorder with lewy bodies, Alzheimer's disease, muscle weakness, and contracture of the right knee, left knee, right ankle and left ankle. Her 10/17/22 Quarterly Minimum Data Set (MDS) assessment revealed she was unable to complete the Brief Interview for Mental Status (BIMS) score and was marked with severely impaired cognition. In Section E of her 10/17/22 MDS, she was noted to have functional limitation in Range of Motion to one side of her upper extremity and both sides of her lower extremity. In Section O of her 10/17/22 MDS, she was noted to have received zero days treatment in a Restorative Nursing Program which included Range of Motion (passive), Range of Motion (active) or Splint or brace assistance. On 12/13/22 at approximately 10:15 a.m., R 47 was observed sitting in a geri chair in her room watching television. R 47 was nonverbal during this interaction, but it was observed that her right hand was contracted with the fingers folding into her palm. R 47's right hand was on her chest. There were no splints or pads in place. On 12/14/22 at approximately 10:00 a.m., R 47 was observed in her bed sleeping. Her right fingers remained folded into her palm, with no protectors or padding in place. An interview was conducted with Registered Nurse (RN) J on 12/14/22 at approximately 10:05 a.m. When asked if R 47 had always had a right-hand contracture, RN J stated that she believed she did. When asked if R 47 was supposed to have a splint or device in her right hand to prevent discomfort or worsening of her contracture, RN J stated that she is on comfort measures and that it would not do her any good at this time. Review of R 47's therapy referrals on 12/14/22 revealed R 47 was last screened for therapy services on 9/20/21 and it was not indicated to begin therapy at that time. A telephone interview was conducted with Therapy Director/Staff N on 12/15/22 at approximately 12:30 p.m. Staff N stated that R 47 had been screened by therapy in October 2022, and it was recommended to use a carrot splint in her right hand to help with her contracture. Staff N stated that they relayed this message to the hospice service that R 47 was using, but that it did not make it on to R 47's care plan, and the splint had not been in use. Staff N stated that they went into R 47's room and found the carrot splint in her drawer, and again relayed the message to hospice staff to use to splint. When asked if all staff, including hospice and those working at the facility, should be made aware to use the carrot splint for R 47's right hand, Staff N stated that all staff should be using the carrot splint. When asked why the communication form was not in R 47's EMR record, Staff N stated that they forgot to scan the document in from October 2022, but it would be scanned into her EMR now. Review of R 47's task list for staff revealed no task description or anywhere for staff to document the use or refusal of R 47's right hand carrot splint. Review of R 47's Rehab Referral Screen dated 10/5/22 read, in part, .Occupational Therapy Symptoms/Problems: Splint causing pain and/or redness .Cont (continue) with use of carrot in R (right) hand daily as tolerated with hospice and restorative/CNAs (Certified Nurse Aides). This document was scanned into R 47's EMR on 12/15/22.

Based on observation, interview, and record review, the facility failed to ensure accurate and consistent recording of narcotic medications dispensed per policy for one Resident (#11) out of three residents reviewed for medication storage. This deficient practice had the potential for inaccurate record keeping and possible loss/drug diversion. Findings include: On 12/13/22 at approximately 4:00 PM, an observation of medication pass for Resident #11 (R11) by Registered Nurse (RN) L was made. RN L was observed to dispense medication of Hydrocodone/acetaminophen 10/325 milligram (mg), two tabs. RN L was questioned about the orders for R11's Hydrocodone/acetaminophen and stated, He gets Hydrocodone/acetaminophen 10/325 mg one scheduled and then one as a prn (as needed), so we give his two pills at four o'clock because that is how he wants it and is very adamant he gets it this way. Review of physician orders for R11, revealed a physician order which read in part, Hydrocodone/acetaminophen (a schedule two narcotic pain medication) 10/325mg, one tab, two times a day, for pain, scheduled at 0800 (8 AM) and 1600 (4 PM), and as a prn, one tab, every twelve hours, for moderate pain. On 12/13/22 at approximately 4:05 PM, an interview was conducted with RN L regarding the timing of R11's prn pain medication. RN L was asked when the last time R11 received his prn pain medication and responded, He got it this morning with his scheduled one around 8 AM. RN L was asked how many hours it had been since his last prn medication, and responded, Well it has not been twelve hours yet. I guess it has only been about eight. Review of controlled substance narcotic logs for R11, dated November 2022 through December 14, 2022, revealed Resident #11 consistently received two tabs of the Hydrocodone/acetaminophen at approximately 8 AM and 4 PM almost every day. Review of R11's Medication Administration Record (MAR) for November 2022, revealed thirty prn pain medication blank areas where nurses should have signed out a second narcotic medication, but failed to sign out appropriately to reflect administration. Review of R11's MAR for December 2022, revealed twelve prn pain medication blank areas where nurses should have signed out a second narcotic medication, but failed to sign out appropriately to reflect administration. On 12/14/22 at 2:30 PM, an interview was conducted with the Director of Nursing (DON). The DON confirmed that the nurses were not signing out the narcotics correctly and should be signing out the narcotic medication on both the control substance log and in the MAR. The DON also confirmed that there is a potential for drug diversion and nurses should follow physician orders when dispensing prn medications. Review of facility policy titled, Medication Administration, dated 01/01/2022, read in part, Policy: Medications are administered by license nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: .10. Review MAR to identify medication to be administered .14. Administer medication as ordered .17. Sign MAR after administration .20. Correct any discrepancies and report to nurse manager.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement and operationalize policies and procedure for dating multi-use solutions used for dressing changes for two Residents (R20 and R34) reviewed for medication storage. This deficient practice resulted in the potential for altered potency and efficacy, and for treatments being conducted with expired solutions. Findings include: Resident #34 (R34) On [DATE] at 11:43 AM, an observation was made of R34 in his room. R34 was noted to have a tracheostomy (a surgical airway) and a PEG (percutaneous endoscopic gastrostomy) tube (a feeding tube placed through the skin into the stomach). Further observation of R34's room and supplies revealed an opened bottle of Sodium Chloride Solution of 1000 milliliters (ml), undated with 200 ml remaining, and a suction machine with a Yankauer (suctioning catheter) undated. On [DATE] at 11:40 AM, Licensed Practical Nurse (LPN) E, confirmed R34's Sodium Chloride Solution and Yankauer should be dated. LPN E then stated that she was going to dispose of these items because they were not correctly dated. Resident #20 (R20) On [DATE] at 8:43 AM, an observation was made of R20 in his room, lying in his bed. LPN P was preparing to do a dressing change on R20. R20 had dressing change supplies in his room. A solution of [Name Brand wound cleanser] diluted with Normal Saline 500 ml was observed to be undated and had approximately 150 ml left in the bottle. A second solution of [Name Brand wound cleanser] diluted with Normal Saline 500 ml was observed to be undated and had approximately 400 ml left in the bottle. On [DATE] at 8:58 AM, an interview with LPN P was conducted. LPN P was asked if the bottles of Betadine diluted with Normal Saline should be dated when opened and responded, Yes. The multi-use solutions for dressing changes should be dated when opened. On [DATE] at 2:30 PM, an interview was conducted with the Director of Nursing (DON). The DON confirmed that the nurses are to date solutions and supplies when opened and put into use for multi-use items for resident cares. Review of facility policy titled, Clean Dressing Change, dated [DATE], read in part, Policy: It is the policy of this facility to provide wound care in manner (sic) to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. Policy Explanation and Compliance Guidelines: .2. Multi-use wound care supplies will be dated and initialed when opened.

Based on observation, interview, and record review, the facility failed to ensure that non-certified nurse aids were appropriately reviewed for competency prior to working independently with residents with the potential to affect all 65 residents residing in the building. This deficient practice resulted in the potential for inappropriate care or injury. Findings include: A review of staffing records revealed the following: A review of former Nurse Aide (NA - nurse aide who has not yet passed the CNA certification exam) U. NA U was hired on 9/28/22 and completed the CNA class on 10/29/22. A review of a Certified Nursing Assistant Orientation/Competency Skills Checklist revealed a sign-off date of 11/12/22 by the Director of Nursing (DON) and 11/18/22 by the NA himself. A review of NA V revealed she was hired 10/13/22 and completed the CNA class on 11/18/22. A review of her Certified Nursing Assistant Orientation/Competency Skills Checklist revealed the skills areas were signed off by former NA U on 11/25/22. The DON had signed off on 11/25/22. At the time of the survey NA had not taken the CNA certification exam. A review of NA R revealed she was hired on 11/4/22 and passed the CNA class on 11/18/22. A review of her Certified Nursing Assistant Orientation/Competency Skills Checklist revealed she had signed herself off as being completed on all the skills on 11/22-11/23/22. The DON had signed off on 11/28/22. At the time of the survey NA R had not taken the CNA certification exam. A review of NA X revealed she was hired on 9/22/22 and finished the CNA class on 10/21/22. A review of her Certified Nursing Assistant Orientation/Competency Skills Checklist revealed she was signed off as competent by the DON on 10/28/22. A review of NA W revealed she was hired on 10/13/22 and passed the CNA class on 11/18/22. A review of her Certified Nursing Assistant Orientation/Competency Skills Checklist revealed she was signed off on the majority of the skills by NA X from 11/20/22-11/23/22. The DON signed off on 11/22/22 despite some of the skill not being reviewed until 11/23/22. At the time of the survey NA W had not taken the CNA certification exam. A review of NA Y revealed she was hired on 10/13/22 and completed the CNA class on 11/18/22. A review of her Certified Nursing Assistant Orientation/Competency Skills Checklist revealed she was signed off on skills from 11/21/22-11/27/22, yet the DON had signed off on 11/21/22 before all of the skills checks were completed. On 12/15/22 at 11:25 a.m., an interview was conducted with the DON regarding the process of ensuring that the non-certified NA's were competent to provide care independently to residents prior to taking the certification exam. The DON reported that the NA's were given an orientation and then were paired up with CNA's to check on their competency and see what they are able to do. When asked who observed their care to ensure competency, the DON reported it was the CNA that they were following. When asked if she herself observed all the skill areas for each NA, the DON reported that she tried to, but because some worked night shifts she couldn't see it all. The DON reported that sometimes she would ask them how to do things instead of observing it. When asked about NA's signing other NA's off as competent, the DON stated, Usually they are going with a CNA. When asked about NA R who signed off her own skills, the DON reported that sometimes people didn't understand who was supposed to sign and where.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate less than 5% during the medication administration task. Four medication errors were observed for three Residents (R11, R22 and R34) out of 37 medication administration opportunities for three out of three residents reviewed. This deficient practice resulted in a medication error rate of 10.81% and the potential for additional medication errors for facility residents. Findings include: During an observation on 12/13/22 at 3:21 PM, License Practical Nurse (LPN) E attempted to prepare multiple medications for Resident #34 (R34), which included, but were not limited to: 1. Acetaminophen 160 milligrams (mg) per 5 milliliters (ml) [liquid form], 20 ml dispensed in medication cup. Review of R34's Physician Order Summary, revealed: Acetaminophen 325 milligrams (mg), give two tablets via PEG (percutaneous endoscopic gastrostomy) tube, three times a day for pain. During preparation of the acetaminophen, LPN E was asked why she was using a liquid form and not the tablets that were ordered per the physician's orders and responded, This is how we always do it. We use the liquid instead of the tablets. I guess we should have the order clarified to use the liquid form. During an observation on 12/13/22 at 4:25 PM, Registered Nurse (RN) L prepared a nebulizer treatment medication for Resident #22 (R22), which included ipratroprium bromide/salbutamol 0.5mg/2.5mg per 3ml via nebulizer (sterile inhalation solution). RN L was asked how long the treatment usually took and responded, About ten minutes. After the nebulizer treatment for R22 was finished, RN L went into R22's room to assess him and care for the nebulizer. RN L was asked if he offered to rinse R22's mouth with water post treatment and responded, No. I never do that. During an observation on 12/14/22 at 8:24 AM, RN I attempted to prepare multiple medications for Resident #11 (R11), which included, but were not limited to: 1. [Name Brand] long-acting insulin, 55 units administered via insulin syringe, and 2. [Name Brand] short-acting insulin, 11 units administered via insulin syringe. During an observation on 12/14/22 at approximately 8:30 AM, RN I was administering the prepared insulin to R11. During the first subcutaneous injection of insulin to R11, RN I did not pinch the skin and only held the site for two seconds post injection. During the second subcutaneous injection of insulin to R11, RN I again did not pinch the skin and only held the site for one second post injection. On 12/14/22 at 2:30 PM, an interview was conducted with the Director of Nursing (DON). The DON confirmed that the nurses are to follow physician orders when dispensing medications, offer to rinse residents' mouths after nebulizer treatments, and hold insulin injection sites post injection for five to ten seconds. Review of facility policy titled, Medication Administration, dated 01/01/2022, read in part, Policy: Medications are administered by license nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: .11. Compare medication source with MAR [Medication Administration Record] to verify resident name, medication name, form, dose, route, and time of administration .14. Administer medication as ordered .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #11 (R11) On 12/15/22 at approximately 10:09 AM, an observation was made of R11 in his bed. R11 was covered with a sheet. R11 pulled back the sheet and the pad beneath R11 was wet and soaked with urine. On 12/15/22 at 10:10 AM, an interview was conducted with R11 regarding his request pertaining to his Activities of Daily Living (ADL) care. R11 stated that he is frustrated, angry, and embarrassed. R11 went on to further explain that he had put his call light on at 9:31 AM that morning in anticipation that facility staff would come and assist him with his urinal. R11 reported that facility staff did not come to answer his call light until 10:07 AM, when he could not hold his urine any longer and soiled himself. R11 further explained that he prefers female care givers over males. The male who is scheduled to work on his end was overheard by him talking and walking about the hall and deliberately ignoring his call light. R11 stated that this happens two to three times per week. R11 stated that he is not sure why they put him on his end of the hall knowing that he prefers female care givers and is frustrated that this assignment delays his care and leads to his humiliation and embarrassment. On 12/15/22 at 10:12 AM, an interview with Non-Certified Nurse Aide (NA) K. NA K was asked why it took so long for R11's call light to be answered, and responded, I was in the shower with another resident at the time, and as soon as I could I came to help R11. On 12/15/22 at 10:15 AM, and interview with License Practical Nurse (LPN) E was conducted. LPN E stated that there is not enough staff to provide morning cares, assist with the feeding of residents, and assist with toileting. LPN E also stated that there is normally a float care aide and there has not been a float aide for some time now. Review of R11's Care Plan, date initiated 12/03/20, read in part, Focus: The resident has preferences for Activities of daily living. Goal: The resident's preferences will be honored. Interventions: Prefers female caregivers-please communicate at beginning of shift if staffing assignments don't a lot for female caregiver on this resident section. On 12/15/22 at 10:20 AM, an interview with the Director of Nursing (DON) was conducted. The DON was asked about staffing and what is ideal for morning shift and responded, Well now we have four to five aides. Ideally it should be six. Current staffing for aides on 12/15/22 at the facility was four aides. On 12/15/22 at 10:45 AM, an interview with Regional Nursing Home Administrator (NHA) O was conducted. Regional NHA O stated that her expectation for call light response time was five to ten minutes. On 12/13/22 at 10:00 a.m. an interview was conducted with Confidential Resident (CR) 501. CR 501 stated that there is not enough staff at the facility to meet the needs of the residents. CR 501 stated that this issue has been brought up to the facility, but that the residents have not seen a significant change in the number of staff. CR 501 stated that call light times continue to be an issue. During a group interview conducted on 12/14/22 at 2:00 p.m., this surveyor asked 15 confidential Residents about any staffing concerns. 15 out of 15 Residents stated that there is not enough staff to help them with their needs. CR 500 stated, There is not enough, and you have to wait a long time to get help. CR 501 stated, It has gotten to the point that they don't offer us snacks before bed, and now you have to walk down to the kitchen if you want a snack. CR 502 stated, They have a hard time scheduling appointments outside of the facility, and what staff are going to take you. Sometimes the bus driver has to work the floor, or they need to pull someone else to ride in the bus and the appointment may get rescheduled. They don't tell you what is going on. CR 508 stated, You ask them for help or to do something and they tend not to do it. Last week I asked for help, and I'm still waiting. CR 514 stated, They just don't help. Most of the staff are nice and try, but there is just not enough of them. It is very sad. Based on observation, interview, and record review, the facility failed to ensure sufficient staffing to meet residents care needs with the potential to affect all 65 Residents residing in the building. This deficient practice resulted in resident concerns for dignity and safety, episodes of incontinence, and the potential for injury or neglect. Findings include: On 12/12/22 at approximately 9:30 a.m., the Business Office Manager (BOM) Z was observed answering R62's call light. She was heard asking R62 what she needed and the resident asked for water. BOM Z exited the room and approximately three minutes later returned to the room with a large Styrofoam glass of water. Administrative Assistant AA was in R62's room when BOM Z returned and told BOM Z that R62 could not have the water, but could have swabs for her mouth. BOM Z was not aware of R62 being unable to safely consume liquids and had Administrative Assistant AA not intervened, R62 would likely have had issues drinking the water and potentially could have aspirated (inhaled the fluid into her lungs). A review of R62's record revealed she admitted to the facility on [DATE] and per a physicians order dated 11/28/22 was on an NPO diet (nothing by mouth). On 12/14/22 at approximately 2:30 p.m., an interview was conducted with Confidential Staff (CS) BB. When asked about staffing, CS BB reported that there were not enough aides to safely meet the resident's care needs. CS BB reported that there were many non certified aides and hospitality aides that made it look like there was staff but they were not providing care. When asked what the non-certified staff were doing during their shift, CS BB reported some were taking out garbage and sometimes she didn't know what they were doing. CS BB reported that at times she had to transfer residents by herself despite the resident requiring a two-person assist. CS BB reported that other staff were doing it as well and she had concerns about safety, but denied being aware of any accidents or injuries related to the unsafe transfers. CS BB also reported that non-clinical staff were turning off resident call lights and not addressing their needs, and named R23 as an example as he had asked many staff to empty his urinal but was told they were not qualified to do that task. On 12/14/22 at 4:27, the current CNA (Certified Nurse Aide) schedule was reviewed and revealed there were two CNA's on duty (CNA T and CNA Q) and three non-certified Nurse Aides (NA's) (NA R, NA S, and NA K). On 12/14/22 at 4:34 p.m., CNA Q was observed answering R23's call light. CNA Q entered the room and asked what he needed. R23 asked if she was qualified or allowed to empty his urinal as he had been waiting for it to be emptied all afternoon. CNA Q reported that she was. On 12/14/22 at 4:38 p.m., NA R was observed wearing a nametag that designated her as a CNA. NA R was asked if she was a CNA or an NA and stated, Well my nametag says I'm a CNA, but I haven't tested yet. NA R reported that she was the only aide on the Cedar unit. A review of the staffing schedules from November 2022 through December 2022 revealed the following: On 12/4/22 from 10 p.m. through 2 a.m., there were no CNA's and three non-certified NA's. On 12/5/22 from 2 p.m., through 10 p.m., there was one CNA and four non-certified NA's. On 12/6/22 from 2 p.m. through 10 p.m. there was only one CNA and four non-certified NA's. From 10 p.m. through 6 a.m., there was only one CNA and three non-certified NA's. On 12/13/22 from 6-10 p.m., there was only one CNA staffed and four non-certified NA's. On 12/13/22 from 10 p.m. through 2 a.m., there were no CNA's staffed and only three NA's on duty. A review of the staffing records for the non-certified NA's revealed concerns with the competency evaluations for NA U, NA V, NA R, NA X, NA W and NA Y. The concerns were related to the competencies being reviewed by other non-certified NA's and with no return-demonstration or observation from the Director of Nursing (DON). On 12/15/22 at approximately 1:10 p.m., an interview was conducted with Regional Nursing Home Administrator (NHA) O. When asked about the concerns with staffing, the Regional NHA O acknowledged the concerns and reported they were continuing to hire and recruit.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to ensure the mechanical dish machine was properly sanitizing food contact surfaces, including plates, glasses, flatware and cooking utensils. 2. Failing to maintain one food product on the steam table at proper temperature. This deficient practice has the potential to result in food borne illness among any or all 65 residents in the facility. Findings include: 1. On 12/12/22 at 11:41 AM, observations of the mechanical dish washing machine were conducted. During the observation period, the machine's digital thermometer reading was noted to report a temperature of 128°F during the sanitizing cycle. An additional three cycles were run with all three having a maximum reading of 129°F during the sanitizing cycle. A review of the data plate attached to the machine and was determined the machine was a high temperature sanitizing system, which required a final rinse water temperature of 180°F minimum. On 12/12/22 at 11:55 AM, an interview with the Certified Dietary Manager (CDM) A was conducted while observing the dish machine's wash, rinse and sanitize cycle. When the sanitize cycle reached only 128°F, CDM A stated he would get the Maintenance Director (MD) B to look at it. At 12:05 PM MD B removed a panel on the water booster heater for the dish machine. Four additional cycles of the dish machine were observed and on the fourth reached 180°F during sanitizing. An interview with MD B was conducted and learned he had hit a re-set switch on the booster heater which then was able to achieve the proper sanitizing water temperature. CDM A stated this was the first he had been made aware of any problem with the dish machine. On 12/12/22 at 2:38 PM observations of the dish washing operations, following the noon meal were made. Dietary Aide (DA) C was observed pushing racks of soiled dishes into the dish machine. Three cycles/racks of soiled dishes were observed being put through the machine during this time. None of the three cycles demonstrated the sanitizing cycle temperature reached the minimum 180°F temperature threshold, with the maximum temperature reached being 128°F. An interview with DA C was conducted at this time and asked if she was aware the machine was not reaching the proper sanitizing temperature. DA C replied Yes. I saw that. I just kept pushing them (soiled dishes) dishes through. When asked if she had reported the issue to anyone, DA C stated No. On 12/12/22 at 3:15 PM, MD B returned to the kitchen, removed the panel from the booster heater and re-set the unit. After 5 cycles the machine was reaching the minimum 180°F threshold for sanitizing. MD B was asked why the unit was kept requiring to be re-set to have proper sanitizing, to which MD B replied I don't know. When asked if this was the first day he had been made aware of the problem, MD B stated it was not, and had been ongoing for over a week. MD B further stated It was happening so much I showed [NAME] D how to do it. On 12/12/22 at 3:45 PM this surveyor suggested that observation of the primary water heater for the kitchen be made. Observations were made with MD B in the boiler room of the water heating boiler system supplying water to the kitchen. A thermometer was present on the exit line from the water heater and was reporting a water temperature of 128°F. A sign located on the storage tank for the hot water read Minimum temperature is 160°F. When asked about this, MD B confirmed that the booster heater in the kitchen required an input water temperature of 160°F to raise the water temperature for the sanitizing cycle of the dish machine to a minimum of 180°F. Further investigation into the boiler system revealed the thermostat on the system had been set at 130°F. MD B stated he did not know how that had occurred, but stated the boiler inspector was here last week and must have turned it down. On 12/13/22 at 8:45 AM, an interview with [NAME] D was conducted. [NAME] D confirmed he had been told how to re-set the booster heater for the dish machine by MD B. [NAME] D stated that he had not shared that information with CDM A and had not conducted any monitoring of the dish washing activities. The FDA Food Code 2017 states: 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature. (A) The temperature of the wash solution in spray type warewashers that use hot water to SANITIZE may not be less than: (1) For a stationary rack, single temperature machine, 74°C (165°F); 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90oC (194°F), or less than: Pf (1) For a stationary rack, single temperature machine, 74°C (165°F); 2. On 12/13/22 at 7:50 AM, observations of the morning meal were made. Food was observed in stainless steel pans in the steam table. [NAME] D was asked if all food was ready to be served. [NAME] D stated Yes. An pan, identified by [NAME] D as pureed eggs was measured for temperature with a digital metal steam probe thermometer and found to have a maximum temperature of 115°F. [NAME] D was requested to measure the temperature of the product using a facility thermometer, and reported a temperature of 115°F. When asked what the temperature of the pureed eggs had been when placed in the steam table, [NAME] D stated 185°F. When asked the time period when the temperature had been measured, [NAME] D stated About 20 minutes ago. When asked how the temperature could have decreased so much while sitting in the steam table, [NAME] D stated I don't know. The FDA Food Code 2017 states: 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57°C (135°F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54°C (130°F) or above

Based on interview and record review, the facility failed to ensure that resident and facility infection control documentation was accurate and complete with the potential to affect all 65 residents residing in the building. This deficient practice resulted in the potential for incorrect data related to infections and outbreaks as well as the potential for the spread of infection. Findings include: A review of the 2022 Infection Control and Surveillance Program revealed the following concerns: Monthly Summaries were not completed for every month and the infection data including numbers and types of infections did not match the surveillance line listings or the Quality Assurance Report data. Outbreak investigations for January 2022 and May-June 2022 revealed discrepancies with dates of onset of illnesses for Residents as well as numbers of infected residents and staff when compared with the monthly summaries and surveillance line listings. Surveillance line listings did not consistently document the organisms or type of infection. The monthly data and surveillance were not organized correctly by month (some pages of the June outbreak were mixed with pages from the September documentation) making it difficult to determine if it was an additional outbreak or just disorganized documentation. Half of the infection program was on paper and the other half was maintained in electronic form and then printed to be included in the infection binders. February 2022 surveillance, line listings, and mappings were not in the infection control binder and had not been printed from the computer program. Review of the mappings revealed a paper mapping with colors that were not filled out completely and also printed mappings from the computer. The computer printed mappings were by unit and did not show the layout of the rooms within the building for the Infection Preventionist (IP) to review for the potential of clustering/staff assignment. On 12/15/22 at approximately 11:55 a.m., the Infection Control program was discussed with Regional Nursing Home Administrator (NHA) O. Regional NHA O reported that the infection control program was now being managed by the Director of Nursing (DON) as they were aware that the person who was in charge of it prior was not working well in the role. The concerns of inconsistent infection data between the summaries and line listings were discussed and Regional NHA O acknowledged the concern and reported the facility was initiating an action plan to get the documentation back on track. Regional NHA O confirmed that despite the lack of organized documentation, there had been no large outbreaks or resident outcomes. A review of the facility policy titled, Infection Surveillance revised 10/24/2022 revealed, .1. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents .