Based on observation, staff interview, record review and facility policy review, the facility failed to ensure resident information was not accessible to the public during medication administration for one (1) of four (4) residents observed during medication administration. Resident #82. Findings Include: Record review of the facility policy, Administration of Drugs with revised date of 09/08 revealed, .Medication Administration Records should be kept covered to ensure privacy of information An observation on 12/03/24 at 9:00 AM, of a medication cart on the A-Hall, revealed an open computer screen with Resident #82's Electronic Medication Administration Record (EMAR) information visible to anyone passing by the medication cart. The visible information included Resident # 82's name, medications, and room number. An interview on 12/03/24 at 9:10 AM, with Licensed Practical Nurse (LPN) #1 revealed that she was assigned to the medication cart on A-Hall. She confirmed that the EMAR for Resident #82 was visible on the computer screen and that she should have clicked the privacy screen on before she walked away from the cart. LPN #1 agreed that this was a privacy issue and that the resident's information in the medical record should be kept confidential. An interview on 12/03/24 at 9:55 AM, with LPN Supervisor revealed that the nurses were supposed to lock the computer screen prior to leaving the medication cart unattended. She revealed that the purpose of the locked screen was to prevent anyone who might be walking by from seeing a resident's personal health information. LPN Supervisor stated, It's always a given to lock the cart and have the privacy screen on while administering medicine. An interview on 12/03/24 at 10:05 AM, with Director of Nursing (DON) revealed that a resident's personal information should never be left up on the computer screen while the medication cart is unattended. She revealed that there was a privacy button that was supposed to be pushed before the nurse stepped away from the computer. The DON confirmed that this was a privacy issue and that residents information should be kept confidential. Record review of Resident #82's admission Record revealed an admission date of 01/26/23.

Based on staff interview, record review, and facility policy review, the facility failed to accurately complete a section of the Minimum Data Set (MDS) for a resident with significant weight loss for one (1) of 22 sampled residents MDS reviewed. Resident #6 Findings Include: Review of the facility policy titled Resident Assessment Instrument (RAI) revised September 2010, revealed under, Policy Interpretation and Implementation: . 3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. 4. Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning . 7. All persons who have completed any portion of the MDS Resident Assessment Form must sign such document attesting to the accuracy of such information. Record review of the Weight Summary for Resident #6 revealed the following values: 7/2/2024 176.6 Lbs. 7/8/2024 175.2 Lbs. 7/17/2024 173.6 Lbs. 7/24/2024 169.2 Lbs. 8/13/2024 169.2 Lbs. 9/5/2024 158.0 Lbs. 10/2/2024 157.6 Lbs. 10/9/2024 156.4 Lbs Record review of the Registered Dietician (RD) Assessment Summary dated 9/13/24 for Resident #6 revealed under, Weight changes: (minus) -6.6 % (percent) SWL (significant weight loss) x (times) 30 days . Record review of the Weight Note for Resident #6 dated 9/26/24 revealed the resident had an 11.2-pound weight loss in 30 days. Record review of Resident #6's Quarterly MDS, with an Assessment Reference Date (ARD) of 10/9/24, revealed under section K0300, loss of 5% (percent) or more in the last month or loss of 10% (percent) or more in last 6 months was answered and marked as No. An interview with the MDS Nurse on 12/3/24 at 2:25 PM, confirmed that section K was not completed accurately to reflect Resident #6's weight loss. She revealed the Dietary Manager (DM) was responsible for completing that section of the MDS and confirmed that it was missed. An interview with the DM on 12/3/24 at 3:06 PM revealed, she made a mistake completing Resident #6's section K and explained that she did not go back and look at the weights like she should have. She confirmed if the MDS was not completed accurately, it would not reveal the complete needs of the resident's health status. An interview with the Director of Nursing (DON) on 12/3/24 at 3:20 PM revealed her expectations were for all sections of the MDS to be completed accurately. Record review of the admission Record revealed the facility admitted Resident #6 on 7/2/24 with medical diagnoses that included Unspecified Dementia and Heart Failure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record reviews, and facility policy reviews, the facility failed to develop and implement an Activities of Daily Living (ADL) comprehensive care plan for residents' hygiene, grooming, and nail care for two (2) of 19 sampled residents. Resident #38 and Resident #147 Findings include: Record review of the facility policy titled Care Plans, Comprehensive Person-Centered with a revision date of December 2016 revealed under Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Resident #38 Record review revealed a care plan revised on 9/26/24 for Resident #38 with a focus on ADL's/Falls/Pain: I have impaired physical functioning and require assistance with ADL's related to chronic pain and (Right) R-sided Hemiplegia. The care plan for the resident with impairments has no personal hygiene, grooming, or nail care interventions. On 12/02/24 at 2:10 PM, an observation of Resident #38's nails revealed bilateral fingernails were approximately one-half (1/2) inch long and jagged with a brown substance under the nails. On 12/03/24 at 10:45 AM, an observation and interview with Certified Nurse Aide (CNA) #1 revealed the CNAs were responsible for doing Resident #38's nail care. CNA #1 confirmed that Resident #38's fingernails were long and had a brown substance under them, revealing they needed to be cleaned and trimmed. During an interview on 12/04/24 at 11:35 AM, the Director of Nurses (DON) revealed that the purpose of the care plan is to indicate the resident's individualized care that is needed for that resident, so the staff will know the resident's needs. She confirmed that the care plan was not developed to reflect Resident #38's hygiene or grooming needs, which included nail care. Record review of Resident #38's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Vascular Dementia, Depressive disorders, and Hemiplegia and Hemiparesis following Cerebral infarction. Resident #147 Record review of the care plan for Resident #147 date initiated 11/25/24 revealed, Focus: ADLs .I have impaired physical functioning and require assistance with ADLs . This care plan did not address bathing, hygiene, grooming, or nail care. On 12/02/24 at 10:25 AM, during an observation and interview, Resident #147 revealed she would like her nails to be trimmed. She stated she had never had long nails, and she preferred her nails to be kept short. Observation of her nails revealed seven (7) of her 10 nails were long with the thumb nails approximately 3/4 inch long and some of her nails were jagged and rough. During an interview on 12/3/24 at 11:20 AM, the DON stated the purpose of the care plan was to drive the resident's individualized plan of care and to inform staff of the care that was needed. She confirmed the facility failed to develop an ADL care plan for this resident's nail care. During an interview on 12/3/24 at 3:30 PM, the Minimum Data Set (MDS) Coordinator Registered Nurse revealed she was responsible for the development of the care plans and the purpose of the care plan was to give the staff information on the needed care and preferences for each resident. She confirmed the facility failed to develop the care plan for ADL nail care for Resident #147. Record review of Resident #147's admission Record revealed the facility admitted the resident on 11/12/24 with diagnoses of Stress Fracture to right ankle and Hypertension. Record review of Resident #147's MDS with Assessment Reference Date (ARD) of 11/22/24 revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had a moderate cognitive impairment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide care to maintain personal hygiene, as evidenced by the failure to provide nail care for two (2) of nineteen sampled residents. Resident #38 and Resident #147 Findings include: A review of the facility policy titled Fingernails/Toenails, Care Of revised 09/08 revealed Purpose: . To clean the nail bed, to keep nails trimmed, and to prevent infections .Nail care cleaning should be done daily. Resident #38 An observation on 12/02/24 at 2:10 PM of Resident #38's nails revealed bilateral fingernails were approximately one-half (1/2) inch long and jagged with a brown substance under the nails. An observation on 12/03/24 at 9:03 AM and again at 10:30 AM revealed Resident #38's fingernails on bilateral hands remained long and jagged with a brown substance under the nails. An observation and interview on 12/03/24 at 10:45 AM, Certified Nurse Aide (CNA) #1 revealed the CNAs are responsible for doing Resident #38's nail care. She revealed we do the nail care when we see that it needs to be done and confirmed that the resident's fingernails were long and had a brown substance under them, revealing they needed to be cleaned and trimmed. An observation and interview on 12/03/24 at 11:05 AM, the Director of Nurses (DON) confirmed that Resident #38's fingernails needed cleaning and trimming and revealed that this could cause skin concerns for the resident. Record review of Resident #38's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Vascular Dementia, Depressive disorders, and Hemiplegia and Hemiparesis following Cerebral infarction affecting right dominant side. Resident #147 During an observation and interview on 12/02/24 at 10:25 AM, Resident #147 revealed she would like her nails to be trimmed. She stated she had never had long nails and she preferred her nails to be kept short. Observation of her nails revealed seven (7) of her 10 nails were long with thumb nails approximately 3/4 inch long and some of her nails were jagged and rough. An interview with Registered Nurse (RN) #1 with an observation of Resident #147's nails on 12/3/24 at 10:25 AM, revealed the resident's long and rough nails. The resident informed RN #1 that she preferred to have short nails. During an interview on 12/3/24 at 11:20 AM, the DON revealed each resident's nails should be maintained as the resident preferred and since this resident preferred short nails, the staff should ensure they are kept clean and short. Record review of Resident #147's admission Record revealed the facility admitted the resident on 11/12/24 with a diagnosis of Stress Fracture to right ankle. Record review of Resident #147's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/22/24 revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had a moderate cognitive impairment.

Based on observation, staff interview, and facility policy review, the facility failed to properly secure medications as evidenced by leaving a medication cart unlocked for one (1) of four (4) medication administration observations. Findings include: Record review of the facility policy, Storage of Medications with revision date of 09/08 revealed, Purpose: Is to ensure that medications are stored in a safe, secure, and orderly manner .Compartments containing medications are locked when not in use. Carts used to transport such items are not left unattended. (Compartments include .drawers, cabinets, rooms, refrigerators, carts . An observation on 12/03/24 at 9:45 AM, with Licensed Practical Nurse (LPN) #1 revealed an unlocked medication cart left unattended on A-Hall during administration of a resident's medications. At 9:48 AM, LPN #1 revealed that she was assigned to the medication cart on A-Hall and confirmed that she did not lock the medication cart and stated, I don't usually lock it. LPN #1 confirmed that she should have locked the medication cart prior to walking away to prevent others from taking medications out of the cart. An interview on 12/03/24 at 9:53 AM, with LPN Supervisor, revealed that the medication carts should always be locked when unattended to prevent others from opening the drawers and taking the medications. She stated, It's always a given to lock the carts .and they all know this. An interview on 12/03/24 at 10:03 AM, with Director of Nursing (DON), revealed that the medication carts should always be locked when unattended to keep the medications secure and for safety reasons. She revealed that LPN #1 should have locked the medication cart before she walked away from it to keep the medications secure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff interviews, resident interviews, and policy and procedure review, the facility failed to prevent Resident #1, a vulnerable adult, from being verbally abused by Certified Nursing Assistant (CNA) #1. Resident #1 was one (1) of three (3) residents reviewed for abuse/neglect. Findings include: Review of the facility's policy titled : CMS definition of Abuse and Neglect dated 12/20/23 and signed by the facility's Acting Director of Nursing read: Abuse The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. Record Review of the facility's written investigation conducted on 12/19/24 revealed that at approximately 10:30 PM the Director of Nursing (DON) was notified that CNA #1 was assisting resident (Res #1) when Resident #1 fell to the floor during a wheelchair to bed transfer. CNA #1 reported to the nurse supervisor, Licensed Practical Nurse (LPN #1) that he needed assistance and that Resident #1 was on the floor. LPN #1 assessed Resident #1 and found no injuries. Nurses proper name (LPN #2) and another CNA , (CNA #2) went to assist with Resident #1. Resident #1 was upset and began yelling out at the staff as a result of the fall. CNA #1 pointed his finger in the face of Resident #1 and said who do you think you are talking too, it sure ain't me cause I ain't got nothing to lose. CNA #1 was confronted by the nurse supervisor (LPN #1) and was asked to leave the facility until a thorough investigation could be conducted. CNA #1 replied: I quit. The facility attempted to reach CNA #1 several times to no avail. The record review revealed that the facility reported the incident as verbal abuse to the State Agency (SA). The written facility investigation contained 3 witness statements from CNA #2; LPN #1; and LPN #2. All 3 witnesses heard and saw CNA #1 verbally abuse Resident #1, in an intimidating manner. The facility reported to the State Agency on 12/20/23 that verbal abuse had occurred to Resident #1 by CNA #1. Interview on 02/15/24 at 3:09 PM, with LPN #2 revealed that she was the medication nurse on the second shift on the evening of 12/19/23. She was asked to assist with Resident #1 who was on the floor of his room after a fall. She stated that she, LPN #1 (nurse supervisor ), CNA #1 and CNA #2 were in the process of placing the sling for the full body lift, under Resident #1 when CNA #1 accidentally bumped the leg of Resident #1, he then yelled out and was hollering and cursing. CNA #1 then got up in the resident's face, pointed his finger at Resident #1 and in a loud intimidating tone told Resident #1 that he better not be yelling at him. LPN #2 stated that since the incident had happened so long ago, that the exact words of CNA #1 she could not remember. LPN #2 stated that all she could clearly remember was the inappropriate manner that CNA #1 spoke to Resident #1. LPN #2 confirmed that she felt that CNA #1 was verbally abusive to Resident #1. Interview on 02/15/24 at 3:30 PM with CNA #2 revealed that she had been asked to assist in the fall of Resident #1 along with CNA #1, LPN#1 and LPN #2. CNA #2 stated that CNA #1 was verbally abusive to Resident #1 and had yelled up close in the face of Resident #1 as the four (4) of them were assisting to get Resident #1 off the floor after a fall. CNA #2 stated that LPN #1 tried to council with CNA #1 and he got mad and clocked out and did not come back. CNA #2 stated that LPN #1 and LPN #2 along with her had witnessed CNA #1 verbally and in a threatening manner, abuse Resident #1 on 12/19/24. The SA attempted to contact LPN #1 for an interview but was unable to reach her during the investigation on 02/15/24. The SA did obtain copies of the written statements of all three (3) witnesses. The SA attempted to obtain an interview on 02/15/24 with CNA #1 to no avail. Record review of the written statement of LPN #1 dated 12/19/23 read: Reported to this writer of resident fall entered room with (CNA #1; CNA #2; and LPN #2). During placement of sling for use of total lift staff member (CNA #1) grabbed resident left leg, resident hollered out at staff not to hurt his leg, screaming that's my sore leg staff member (CNA #1) moved from resident side and stood over resident and hollered while pointing his finger in resident's face who do you think your talking too, it sure aint me cause I got nothing to lose. This nurse prompted staff to be aware of communication between staff and resident during interaction. Staff member (CNA #1) exited room. Communication for education prepared. Approached staff member (CNA #1) for counseling. Staff member immediately began stating resident was cursing him. Attempted to redirect staff member regarding his actions, his demeanor, and educated that he could sign the information or he needed to clock out for the evening. Staff member continued to become agitated, this nurse walked away at this time and phoned DON for further actions needed. After receiving directions from DON, staff member (CNA #1) was approached and informed he would need to clock out for the evening and reach out to (DON) in the A.M., he became agitated and began hollering at this writer that he quit and I could call and inform them. No further interaction occurred between this writer and (CNA #1). The written statement was signed by LPN #1 and dated 12-19-23. Interview and observation of Resident #1 on 02/15/24 at 4:00 PM, revealed Resident #1 recalled the evening of the incident on 12/19/24 as: He talked to me real ugly and it made me feel bad, he hurt my feelings. Resident #1 stated that CNA #1 yelled at him. Resident #1 stated that CNA #1 had not worked at the facility since that event. Record review of Resident #1's Facesheet revealed that he had been admitted to the facility on [DATE] and readmitted to the facility on [DATE]. He had diagnoses of Personal history of Traumatic Brain injury,Type 2 Diabetics; and Unspecified mood (affective) disorder; among other diagnoses. The record review of Resident #1's (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated that he was not cognitively impaired. The State Agency (SA) identified an isolated incident of verbal abuse to Res #1 by a facility staff (CNA#1) which began on 12/19/23. The facility immediately put in place a corrective action plan and the deficient practice was corrected on 12/21/23. Based on the facility's implementation of corrective actions on 12/19/23-12/21/23 the SA determined that the isolated incident was Past Non Compliance (PNC) and was fully corrected on 12/21/23, prior to the SA's entrance on 02/15/24. Record review of the facility's action plan confirmed and validated through staff interviews, resident interviews, and record reviews that the facility's action plan had been effective and the isolated deficient practice was corrected on 12/21/23 prior to the State Agency entering the facility on 02/15/24. The facility's action plan included the following: 1-Removed the alleged perpetrator from the facility 2-Protected all the residents in the facility 3-Assessed all residents for safety and freedom from abuse/neglect 4-Contacted the facility DON and Administrator 5-Educated and In-Serviced all staff on Abuse and Neglect 6-Conducted a full thorough investigation and obtained statements from witnesses 7-Conducted a Quality Assurance (QA) meeting with the QA committee members including the Medical Director 8-Contacted the appropriate State Agencies and provided a written report of the full investigation's findings in a timely manner. 9-Conducted on-going surveillance and monitoring of all residents for signs and symptoms of Abuse/neglect 10-Updated and reviewed the care plans for all residents on 12/20/23. Through interviews and record reviews the SA determined that all ten (10) aspects of the facility's action plan were validated and the SA determined that the isolated incident of verbal abuse had been corrected on 12/21/23, prior to the SA's entrance to the facility on [DATE]. The isolated deficient practice was cited at F600 S/S=D Past Non Compliance (PNC).

Based on observation, staff interview, and facility policy review, the facility failed to date and label foods in the walk in refrigerator and dispose of expired foods in the refrigerator for one (1) of two (2) kitchen tours. Findings include: Review of the facility policy, dated 9/04 and most recently revised on 10/17, titled, Storage of Refrigerated Food, revealed it is the policy that the facility ensures the quality and safety and sanitation of refrigerated foods through accepted storage practices. Procedure 5. revealed all opened foods are labeled with common name of food, date stored and use-by date. During the initial tour of the dietary department on 1/24/22 at 10:15 AM, an observation of the walk-in refrigerator revealed the following out of date foods in the refrigerator: Three (3) five (5) pound containers of Tuna salad with an expiration date of 1/9/22. Two of the containers were unopened and one was one-fourth (1/4) full. Two (2) five pound containers of cottage cheese with an expiration date of 9/17/21 One (1) plastic container of meat mixture, 1 half quart of yellow liquid, and 1 quart of red liquid unlabeled and with no expiration dates. 1 opened, partially used case of individual packets of sour cream with an expiration date of 8/9/21 1 opened partially used case of individual serving cups of Blue cheese dressing expired 11/28/20. 1 opened partially used case of Thousand Island packets out of date 3/21 Six (6) 1/2 gallon cartons of soy milk out of date on 11/8/21 1/2 full one gallon jug of mayonnaise not labeled /dated for expiration. An interview, on 1/24/22 at 10:30 AM, with the Dietary Manager (DM), revealed that the yellow and red liquid was chicken soup and tomato soup and it should be labeled and dated. The DM stated that she told her staff that they should be checking the dates and throwing these things (expired items) away. An interview, on 1/26/22 at 02:20 PM, with the Administrator (ADM) confirmed that out of date foods could cause illness. An interview on 1/27/22 at 10:35 AM, with the DM confirmed the dietary staff had not been following the facility policy for labeling food in the refrigerator.