Based on observation and staff interview, the facility failed to ensure a resident had a wheelchair in good repair for one (1) of 86 residents requiring a wheelchair for mobility. Resident #51 Findings include: The facility provided a statement on letter head that read, The Proper Name of facility does not, currently, have a formal written policy regarding resident equipment being in good condition. Any issues of resident equipment not being in good condition or malfunctioning are to be reported to maintenance upon discovery. An observation on 10/7/24 at 12:05 PM, revealed Resident #51 sitting in his wheelchair with arm rests on the wheelchair that were torn and tattered with sharp plastic edges and the yellow foam visible. An observation on 10/8/24 at 11:01 AM, revealed Resident #51 lying in bed. His wheelchair was in the room, with the arm rest in disrepair. The right arm rest had the yellow foam torn away, and the black hard plastic was exposed, which had jagged edges. The left arm rest had the black vinyl torn, and the yellow foam was exposed. An interview with Licensed Practical Nurse (LPN) #1 on 10/8/24 at 11:04 AM, confirmed Resident #51's arm rest needed to be repaired and revealed the resident could scratch the skin on his arms. She revealed the resident's equipment should be in good repair and explained that staff must let maintenance know by telling him or doing a work order for issues to be addressed. An interview with Maintenance #2 on 10/8/24 at 11:14 AM, revealed he would be responsible for any maintenance on the wheelchairs. He revealed the staff fill out a work order for anything that needs repairing. He revealed he had not received a work order for Resident #51's wheelchair and explained he was not aware it was in bad condition. Record review of the admission Record revealed the facility admitted Resident #51 on 1/17/18 with a medical diagnosis of Hemiplegia and Hemiparesis following cerebral infarction affecting the left non-dominant side.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to implement a care plan for shaving a dependent resident for one (1) of 25 resident care plans reviewed. Resident #80 Findings include: Record review of facility policy titled, Care Plan Policy dated 11/21, revealed, It is the policy of this facility that an individualized, interdisciplinary care plan will be developed and maintained for each resident in the facility. If the resident has a working care plan, you may use this and update it as indicated. Record review of Resident #80's Care Plan date initiated 9/4/24 revealed, the resident has an ADL, self-care performance deficit related to congestive heart failure and diabetes mellitus which includes an intervention for bathing/showering. On 10/07/24 at 12:30 PM, during an observation and interview Resident #80 stated he wanted to be shaved and felt that the staff would do this today since it was shower day. He stated he was unsure when he was last shaved and told his family that if they would bring him a razor, he would shave himself. Observation revealed the resident had an approximate one-third inch long, scruffy stubble of facial hair on bearded areas of his cheeks, chin, and upper lip. On 10/8/24 at 8:40 AM, an observation and interview revealed Resident #80 was still unshaved. He stated he preferred to be clean shaven and was not used to being unshaven. On 10/8/24 at 2:30 PM Resident #80 was observed and interviewed in the hallway propelling himself in the wheelchair and was still unshaved. He stated the staff had not shaved him and he wanted this to be done. During an interview on 10/8/24 at 2:40 PM, the Director of Nursing (DON) stated the resident was scheduled for bathing and showering on Monday, Wednesday, and Friday, and he did not typically refuse care, but the care record from yesterday revealed the resident refused his shower. She stated each resident has the right to refuse care, but the process to ensure care is done as desired included any refusal of care to be reported to the nurse and the nurse should followed up with the resident for options for care and document that in the resident's notes and that was not done. She also stated the staff are to follow up with the resident at a later time to see if care is wanted at that time and there was no documentation that was done. The DON acknowledged that grooming and shaving was part of the bathing activities of daily living (ADL) care. She confirmed the facility failed to shave the facial hair of a resident that preferred to be clean shaven. She confirmed the care plan was to give staff information on the care needed and preferences of each resident and the ADL care plan was developed but it was not followed since shaving and grooming was a part of the bathing care plan. An interview with the Minimum Data Set (MDS) Coordinator on 10/9/24 at 9:15 AM revealed she was the person responsible for the development of care plans and stated the care plan should be followed by the staff since it guides the staff in the care and preferences of each resident. She stated this resident had a care plan developed for ADL bathing care which included grooming/shaving, but confirmed this was not followed. Record review of Resident #80's admission Record revealed the facility admitted the resident on 6/22/22. Diagnoses included Type 2 Diabetes Mellitus and Osteoarthritis. Record review of Resident #80's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/28/24, revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to shave a resident that was dependent on staff for care for one (1) of three (3) residents reviewed for Activities of Daily Living (ADL). Resident #80 Findings include: Record review of facility policy titled, Activities of Daily Living Policy, undated, revealed, It is the policy of the facility to encourage resident choice and participation in activities of daily living (ADL) and provide oversight cuing and assistance as necessary. ADL's included bathing, dressing, grooming, hygiene, toileting, and eating. CNA (Certified Nursing Assistant) will review the resident care card for information on individual care needs and preferences. CNA will provide needed oversight, cuing or assistance to resident. CNA will report any changes in ability or refusals to the nurse. During an observation and interview on 10/07/24 at 12:30 PM, Resident #80 stated he wanted to be shaved and felt that the staff would do this today since it was shower day. He stated he was unsure when he was last shaved and he told his family that if they would bring him a razor, he would shave himself. Observation revealed the resident had an approximate one-third inch scruffy stubble of facial hair on bearded areas of his cheeks, chin, and upper lip. An observation and interview on 10/8/24 at 8:40 AM, revealed Resident #80 was still unshaved and stated he preferred to be clean shaven and was not used to being unshaven. Resident #80 was observed on 10/8/24 at 2:30 PM and was still unshaved. He stated the staff had not shaved him and he wanted this to be done. The Director of Nursing (DON) came to the resident and Resident #80 informed her that he wanted to be shaved and had asked staff for this, but it had not been done. The DON informed him that it was the responsibility of the Certified Nursing Assistants (CNAs) to shave him and she assured him she would get this done for him. The DON acknowledged that grooming and shaving was part of the bathing activity of daily living (ADL) care and confirmed the facility failed to shave the facial hair of a resident that preferred to be clean shaven. Record review of an ADL care summary revealed Resident #80 was scheduled for baths on Monday, Wednesday, and Friday. Record review of Resident #80's admission Record revealed the facility admitted the resident on 6/22/22. Diagnoses included Type 2 Diabetes Mellitus and Osteoarthritis. Record review of Resident #80's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/28/24, revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment.

Based on observation, resident and staff interview, and record review the facility failed to ensure the residents had a environment free of potential hazards as evidenced by cleaning chemicals not being securely locked in a janitors storage closet for two (2) of five (5) units in the building. 400 Hall and Dementia Unit. Findings include: Review of a document provided by the facility,on facility letterhead revealed the facility does not currently have a formal written policy specific to resident accident prevention or monitoring. An observation on 10/7/24 at 11:20 AM on the Dementia Unit revealed a door with a sign that read Janitor's Closet was unlocked and held three full bottles of disinfectant. An interview and observation on 10/7/24 at 11:25 AM with Certified Nurse Assistant (CNA) #1 confirmed the Janitors Closet has a coded lock that was broke and the room was unlocked. She confirmed there were three full bottles of liquid disinfectant in the closet. She stated that she had not told maintenance and is not sure if they know. She revealed that the closet with the cleaning supplies should always be locked. This observation revealed this unit was an open unit with all resident rooms, day room and janitors closet within view from all areas and the nurses station is directly across from the janitors closet. She confirmed that the janitors closet could always be seen by the staff because it is a small open unit with three (3) CNA's and one nurse in the unit at all times. An observation on 10/7/24 at 11:45 AM of the 400-hall revealed there was a door labeled Janitors Closet that had a coded lock that was not locked with four bottles of liquid disinfectant. An interview and observation on 10/7/24 at 11:50 AM with Licensed Practical Nurse (LPN) #1 confirmed that the Janitors Closet on the 400 hall was unlocked but should always be locked, because there were chemicals that they would not want the residents to have access to. This observation revealed the janitors closet was directly across from the nurses station and was in view from the 300 and 400 hall. She confirmed that there was a staff member that sat at the nurses desk at all times, answering phone calls and call lights and also the dining area was open and within view of the closet. An interview on 10/7/24 at 11:55 AM with Housekeeping #1 confirmed that the Janitors Closet on the 400 hall had a coded lock that had been broken for a few days, but she is not sure if maintenance knows about it. An interview on 10/8/24 at 9:15 AM with Maintenance #2 confirmed that the locks on the Janitors Closets on the 400 hall and the Dementia Unit were both broken. He stated he put batteries in the lock on the 400-hall last week and thought it was fixed, but he had not been told about the one on the Dementia Unit. An interview on 10/8/24 at 9:30 AM with the Administrator confirmed the Janitors Closets should always be locked.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure an informed consent was obtained for the application of bed rails for one (1) of 25 sampled residents. Resident #30 Findings Include: Review of the facility policy titled Side Rails Policy with a revision date of 10/19 revealed under, Policy: it is the policy of this facility to keep residents as safe as possible while they are in the bed, as well as enable them to be as active in their care physically as they are able. An observation of Resident #30 on 10/7/24 at 4:05 PM revealed he was lying in bed. The left side of the bed was against the wall, and one-half (1/2) side rails were raised on both sides of the bed. Record review of the Physician's Orders for Resident #30 revealed an order dated, 10/27/20, 1/2 (one half) siderails up x (times) 2 (two) when in bed for increased bed mobility & (and) independence. An interview with the Minimum Data Set (MDS) Nurse on 10/9/24 at 8:20 AM revealed bed rail assessments were completed on admission and quarterly. She revealed the benefits, and the risk of the bed rails were explained to the family and a consent was signed as part of the admission paperwork. Record review of the Bed Rail Assessment dated 8/12/24 for Resident #30 revealed, Bilateral Side Rails/Assist Bar are indicated and serve as an enabler to promote independence. Record review of the Resident Dashboard revealed, Resident #30 required one-person extensive assist with bed mobility. An interview with the Assistant Director of Nursing (ADON) on 10/9/24 at 10:20 AM, confirmed a consent was not signed for bed rails for Resident #30 and revealed this should have been done before applying the bed rails to ensure the family was notified of the risk. Record review of the Resident Dashboard revealed the facility admitted Resident #30 on 10/26/20 with a medical diagnosis of Hemiplegia following cerebral infarction affecting the left non-dominant side.

Based on interview, record review, and facility policy review, the facility failed 1) to ensure a medication order, medication administration record, and narcotic record label were all labeled correctly for one (1) of five (5) medication carts reviewed during medication pass, (100 hall medication cart) and; 2) the facility failed to securely store medications when two medication capsules were found sitting in a clear medication cup in a resident's room for 1 of 124 residents observed on initial tour. (Resident #28). Findings include: 100 Hall Medication Cart Review of the facility policy, Narcotic Medication Accountability updated 1/02, revealed 3. As narcotic medication is used/wasted, the nurse responsible should document the usage and any wastage on the accountability record. Observation of Resident #80's Controlled Substance Record revealed instructions for Hydrocodone/APAP(acetaminophen) 10-325 MG (milligrams), Give 1 TABLET by mouth every 4 (four) hours as needed for pain. Review of Resident #80's Physician orders dated 08/01/2024 revealed Hydrocodone/APAP 10-325 MG, Give 1/2 TABLET by mouth every 4 hours as needed for pain. The label on the medication card was not changed to reflect the new order. Interview on 10/09/2024 at 8:10 AM with Licensed Practical Nurse (LPN) #4 on 100 Hall revealed LPN #4 confirmed 09/25/2024, 09/26/2024, 09/28/2024, 09/29/2024, and 10/07/2024 (1) tablet signed out by LPN #7 but 1/2 tablet was not recorded as wasted for Resident #80. LPN #4 also confirmed a missing tablet and stated the card was received from the pharmacy with dose #41 missing. Resident #28 During the initial tour rounds on 10/07/24 at 11:00 AM, an observation of Resident # 28's room from the hallway doorway revealed a clear medication cup with what appeared to medication in the cup sitting next to the television. Upon entrance to the room, the clear medication cup sitting next to the television on the dresser contained two bright yellow and white capsules. An observation of the two yellow and white capsules in Resident # 28 room with Registered Nurse (RN) # 1 on 10/07/24 at 11:05 AM, he confirmed the capsules were on the dresser and should not be in the room and removed the capsules from the room. In a continued observation with RN #1 of Resident#28's medications, he revealed the yellow and white capsules that were found in Resident #28's room were identified as Gabapentin 300 milligrams (mg) and confirmed Resident #28 receives one 300 mg tablet every night at bedtime. He also confirmed the resident did not have an order to self-administer medications and revealed that staff should always ensure each resident has taken their medications before leaving the resident. RN #1 then stated concerns about medications being left in the room is that the resident could have taken the extra pills and had a reaction. Review of the Active Orders for Resident #28 revealed and order for Gabapentin 300 mg capsule give one capsule by mouth at bedtime. In an interview with Resident # 28 on 10/07/24 at 11:10 AM, he revealed that the pills in his room were for his bowels and stated the nurse last night left him an extra pill, and he was saving them until he needed them. He then stated, I will take them both when I get back to the room. In an interview with LPN # 3 on 10/07/24 at 11:22, she confirmed that Resident #28 cannot self-administer medications and revealed that staff should always watch residents take their medications. She then revealed that with the medications being left in the room, it placed residents at risk for accidentally ingesting the medications, causing possible adverse reactions. In an interview with the Director of Nursing (DON) on 10/08/24 at 11:38 AM, she revealed no medications should ever be left in a resident's room. She stated the resident could have accidentally ingested extra doses, or a wandering resident could have gotten the medication. The DON stated she spoke with Resident #28 on 10/7/24 and stated he was saving the medication to give it back to the nurse, and he stated he paid for it and was not going to waste it. The DON revealed in her professional opinion that the nursing staff could not have observed Resident #28 take his medications because if they did, he would not have been able to save the medications that were found in his room. Review of the admission Record revealed the facility admitted Resident # 28 on 8/20/24 with a diagnosis of Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and Anxiety. Record review of Resident # 28's Section C of the admission Minimum Data Set (MDS) revealed on 8/26/24 a Brief Interview for Mental Status (BIMS) score was 11, indicating the resident was moderately cognitively impaired.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were initiated for one (1) of five (5) residents reviewed for EBP. Resident #370 Findings include: Review of the facility's Enhanced Barrier Precautions Policy, dated 04/2024, revealed, Purpose: Enhanced Barrier Precautions (EBP) refer to infection control interventions designed to reduce transmission of multidrug-resistant organisms (MDRO) by wearing gown and gloves during high contact resident care activities. The use of EBP does not restrict room placement or out of room activities. 4. High-contact resident care activities include: g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes On 10/08/24 at 10:40 AM, observation revealed Registered Nurse (RN) #1 performed hand hygiene and used a barrier on overbed table for supplies. Resident #370's RN #1 accessed the Peripheral Inserted Central Catheter (PICC) line using standard precautions. EBP was not done during the administration of the medication. Observation also revealed no EBP sign posted on the room door for Resident #370. On 10/08/24 at 11:40 AM, an interview with RN #1 revealed she was unaware of the need to implement EBP for a resident with a PICC line. On 10/08/24 at 11:55 AM, an interview with the facility's Training Coordinator and Director of Nurses (DON) revealed the facility policy is for EBP to be used with central lines which would include Resident #370. Record review of Resident #370's admission Record revealed the facility admitted the resident on 10/07/24.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain an account of all controlled medications and provide evidence of periodic reconciliation for two (2) of five (5) medication carts reviewed during medication pass. 100 hall and 200 hall. Findings include: Record Review of the facility policy titled, Pharmacy Delivery, Revised 9/4/15, revealed the policy read, The dispensing pharmacy will transport medication to the facility in a manner that prevents contamination, degradation, and diversion of medications. Review of Resident #80's Physician orders dated 08/01/2024 revealed Hydrocodone/APAP(acetaminophen) 10-325 MG(milligrams), Give 1/2 TABLET by mouth every 4 hours as needed for pain. The label on the medication card was not changed to reflect the new order. Observation of Resident #80's Controlled Substance Record during medication pass on 10/09/24 at 8:10 AM revealed instructions for Hydrocodone/APAP 10-325 MG, Give 1 TABLET by mouth every 4 hours as needed for pain. On 09/25/2024, 09/26/2024, 09/28/2024, 09/29/2024, and 10/07/2024 the record revealed (1) tablet signed out by Licensed Practical Nurse (LPN) #7 but 1/2 tablet was not recorded as wasted or witnessed. Review of the medication card for Resident #80's Hydrocodone/APAP 10-325 MG, revealed dose #41 was missing from the card and was not accounted for on the Controlled Substance Record. Interview on 10/09/2024 at 8:10 AM with LPN #4 on 100 Hall revealed LPN #4 confirmed 09/25/2024, 09/26/2024, 09/28/2024, 09/29/2024, and 10/07/2024 (1) tablet signed out by LPN #7 but 1/2 tablet was not recorded as wasted for Resident #80. LPN #4 also confirmed a missing tablet and stated the card was received from the pharmacy with dose #41 missing. Review of the pharmacy delivery Packing Receipt dated 5/4/24 revealed LPN #6 and LPN #4 signed as receiving the 60 Hydrocodone/APAP 10-325 MG pills medication card with no notation of a missing dose. Review of the Controlled Substance Record narcotic count record revealed 60 Hydrocodone/APAP 10-325 MG pills received by LPN #6 with no notation of pill missing for dose #41. Review of the shift count signature records revealed no notations of a missing dose or waste of Hydrocodone/APAP 10-325 MG dose #41. Record review of the facility's narcotic sheets Controlled Substance Record revealed no Received By (Sign): Date nurse signature or date received for 18 Controlled Substance Records. In an interview on 10/09/24 at 9:15 AM, the facility's Consultant Pharmacist stated he performs random audits of the narcotic sign in sheets and narcotic counts but has not noted any issues during the audits. The facility's Consultant Pharmacist stated he did not have evidence of audits, but the facility keeps a record of medication deliveries. Interview by phone on 10/09/24 at 11:45 AM with the Pharmacy Technician from (proper name of pharmacy) revealed that the pharmacy delivers resident medications as needed and facility keeps the original receipt sheet then faxes a copy signed by a facility nurse back to the pharmacy. Interview on 10/09/24 at 12:50 PM with the Director of Nurses (DON) and Assistant Director of Nurses (ADON) revealed the facility keeps the pharmacy medication delivery receipts in the business office. DON stated that discontinued narcotics are removed from the carts and placed in a locked box in the medication room which is also locked. She stated that when the pharmacist makes monthly rounds, the DON and Pharmacist remove the narcotics and destroy the medications with a liquid designed for this purpose and then disposed. DON provided the logbook with evidence of destruction with signatures of Pharmacist and DON noted. An interview on 10/09/24 at 1:50 PM with the Business Office Representative confirmed the pharmacy medication delivery receipts were kept by the business office. Record review of the pharmacy medication delivery receipts Packing Slip revealed receiving nurse's signature on each delivery form.

Based on observation, staff interview, and facility policy review, the facility failed to label and date open items in the pantry, refrigerator, and freezer for one (1) of two (2) kitchen tours during the survey. Findings Include: Review of the facility policy titled Food Storage undated, revealed under, Policy . Foods will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination . 14. Refrigerated food storage . f. All foods should be covered, labeled and dated. Also revealed under, 15. Frozen Foods: c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. During initial tour of the kitchen on 10/7/24 at 11:20 AM, with the Dietary Manager (DM) #1, an observation of the walk-in refrigerator revealed, a 5-pound (lb.) clear bag of shredded mozzarella cheese that had been opened and had one-fourth (1/4) of the bag remaining, which was unlabeled and undated. Also revealed a 5 lb. container of low-fat cottage cheese that was opened and was undated. An observation of the walk-in pantry revealed a 32-ounce (oz) box of chicken broth, which was open and undated. DM #1 confirmed the box read refrigerate after opening and revealed it was not stored properly after opening and must be trashed. An observation of the walk-in freezer revealed a blue bag of six meat-like patties, which the DM confirmed were pork fritters and had not been labeled and dated after opening. Also revealed a blue bag that contained a round breaded food that the DM #1 confirmed was breaded squash and was opened and was also not labeled and dated. An interview with the Dietary Manager #1 on 10/7/24 at 11:55 AM, revealed the kitchen staff had been educated on making sure foods were labeled and dated when they were opened to ensure they use the oldest foods first. She confirmed, if the food was not dated when opened or stored appropriately, it could make someone sick. An interview with the Administrator (ADM) on 10/9/24 at 9:34 AM revealed his expectations were for the kitchen staff to label and date things that were opened and to ensure the foods were not out of date and stored appropriately. He confirmed this should be done so it did not make anybody sick.

Based on staff and Resident Representative (RR) interviews, record review, and facility policy review, the facility failed to notify the physician of a significant change in a resident's physical status for one (1) of three (3) residents samples. Resident #1 Findings include: Record review of facility policy titled, Change in Resident's Medical Status Policy, with revision date of 4/19, revealed, It is the policy of this facility to notify the resident's physician in any of the following circumstances: . 2. A significant change in resident's physical, mental, or psychosocial status (i.e. [for example], deterioration in health, mental, or psychosocial status in either life-threatening or clinical complications). During a phone interview with Resident #1's RR on 5/16/24 at 9:30 AM, the RR reported the resident had a decrease in blood pressure and had a urinary tract infection. The RR stated she did not feel like the physician was notified regarding these issues. An interview with the Assistant Director of Nursing (ADON) on 5/16/24 at 12:20 PM, revealed Resident #1 had a urine culture obtained on Wednesday, 4/3/24 at 5:05 PM, and the lab had the results available on Friday, 4/5/24 at 9:24 PM. This report was not obtained by the facility until Monday, 4/8/24, at which time the physician was notified, and antibiotics were started for the resident. She confirmed that the facility staff should have contacted the lab to obtain results over the weekend and should have notified the physician. During a phone interview on 5/16/24 at 3:00 PM, the facility's physician confirmed he was not notified of the urine culture results until 4/8/24, when the antibiotics were started. He confirmed timely treatment was needed for resident's well-being. A phone interview on 5/16/24 at 3:45 PM, with the Nurse Practitioner (NP) revealed she was not notified of Resident #1's urine culture results which were available on 4/5/24. She stated notification to the physician and NP allows for timely treatment. An interview with the Administrator on 5/16/24 at 4:00 PM, revealed he was unaware that the staff did not contact the hospital lab to obtain culture results timely. He confirmed the facility failed to notify the physician timely when lab results were ready. Record review of the Culture Urine report revealed the specimen was collected on 4/3/24 at 17:05 (5:05 PM). The last result time and date was listed as 4/5/24 at 21:25 (9:25 PM). This report also noted that it was printed by facility staff on 4/8/24 at 7:25 AM, and the Medical Director was notified on 4/8/24 and an order for an antibiotic was given. Record review of Resident #1's Face Sheet, revealed an admission date of 3/29/24. Diagnoses included Type 2 diabetes mellitus and Cystitis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, record review, and facility policy review, the facility failed to resolve a grievance in a timely manner for four of five residents in Resident Council. Resident # 14, Resident #64, Resident #96, and Resident #101. Findings Include: Record review of the Facility's Grievance Policy dated February 8, 2023, revealed, Policy: It is the policy of (facility name) to investigate all concerns/grievances and provide the results of the investigation to the party filing the concern/grievance .Standard: .The facility will make prompt efforts to resolve all grievances .Policy Explanation and Compliance Guidelines: Process 5. All staff involved in a grievance investigation shall take steps to preserve the confidentiality of files and records relating to grievances and share only with those who have a need to know. 6. The Grievance Official or designee shall keep the resident appropriately apprised of progress towards resolution of the grievances. During interviews in the Resident Council Meeting held on 07/25/23 at 2:30 PM, with five residents in attendance revealed that when they have a grievance voiced in resident council, they do not always hear back about the resolution for their grievances that are voiced. Resident #96, Resident Council President, revealed during the meeting that she felt like all the staff who come to work really worked hard, there's just not enough of them. She stated that there just didn't seem to be enough staff to take care of everybody at times. Resident #96 revealed that they used a stand-up lift to help her to the bathroom during the day; but there had been times when getting to the bathroom was an issue. She revealed that she had to take diuretics and laxatives and getting the staff to get her to the bathroom when she needed to go was often a problem. She stated, When you take these medicines, you can't wait very long when the urge hits you. She revealed that when they didn't have time to get her to the bathroom right away, they would sometimes tell her, Go in the bed and we will be happy to clean you up. She could not recall the date or the staff member who told her this; but she just couldn't do that. She also stated that there had been times they were so short staffed, that they could not get her up at all and she had to stay in the bed all day and night. She confirmed that this happened more often on the weekend and stated, Short staffed is the name of the game especially on the weekend. She also revealed that the facility had addressed the issue before back several months ago; but it continues to be a problem and they voice it all the time and they never hear back from their grievance. She revealed that she still had to wait until later in the day to be assisted out of bed because of the staffing issues here and this was unacceptable. She stated that back in January that low staffing issues began to be discussed and voiced in resident council and it was supposed to be fixed; but Easter Weekend was also not a good time due to low staffing. During the resident council meeting, Resident #14 revealed that they always tried to fix problems brought to their attention, but they sometimes just couldn't do it. She revealed that they were sometimes late on getting her showers and she sometimes had to wait awhile when she pushed her call light because of not having enough people to work the halls. Resident #96 revealed that issues brought up in Resident Council Meetings were written down by the Activities Director and she stated, We don't always know that it ever goes further than the meeting. She also revealed that when she gets the Resident Council Minutes back to file, resolved was often marked under old business but that she (Resident #96) didn't always know what had been done to resolve the issues or if it had been resolved because nobody told them any resolutions to the problems. Resident #64 revealed that he felt like the Certified Nursing Assistants (CNAs) got their training and then they just didn't come back to work. He stated that he sometimes had to wait awhile for his call light to be answered and it was mainly on the 11PM - 7AM shifts that they were so shorthanded. He revealed that so many people just don't come in and it happens often. Resident #101 revealed that she felt like they needed more hall keepers (Nurse Aides). She confirmed that staffing was worse on weekends and sometimes during the week. She also revealed that sometimes they only had two Certified Nursing Assistants (CNAs) on the halls and the facility would have to send one to another hall (B-Hall) to help out and then sometimes they had to request one to be pulled to this side (A-Hall) to help. She stated that they were supposed to have four or five aides working the halls and they don't. She confirmed that not having enough to work the halls caused a longer wait time to get call lights answered and that the staff members were not updating the residents on the status of their grievances reported. She revealed that they did bring up old business at the resident council meetings, but this was the only communication they had regarding their issues. These complainants confirmed that they had discussed these issues in previous resident council meetings, but it had not been resolved and they feel like the facility does not have enough staff on duty and they do not answer all of their grievances and do not update them on progress of grievances and when they are resolved. On 07/26/23 at 8:37 AM, an interview with the Activities Director revealed the residents have voiced some concerns in resident council about staffing and she stated that she filled out a concern form and gave it to the appropriate departments. Then the next morning in the staff meeting, they discussed the concerns that were addressed during the resident council meeting. She revealed a lot of the residents have voiced staffing issues in the last several resident council meetings and that the Director of Nursing (DON) came to the last resident council meeting and addressed questions and concerns which included staffing. She confirmed the DON was aware of the staffing issue. On 07/26/23 at 8:45 AM an interview with the DON revealed any issues or concerns that had been voiced during resident council was handled by the Activities Director. She revealed that the Activities Director filled out a concern form and gave it to the appropriate department and then the grievances were discussed in the morning meetings. She also revealed that whenever there was a grievance with anything regarding nursing, that either she (DON) or the charge nurse would address the issue and then would be signed off by herself (DON) and the Administrator. The State Agency inquired if there had been any issues voiced during resident council regarding staffing concerns and the DON stated not as far as being short staffed but rather not answering the call lights timely. The DON revealed that she met with the resident council members last month, but she did not document any of the issues that were discussed and can't remember what exactly they were, and stated that the activities director should have documented the issues and that she didn't recall discussing any staffing issues. On 07/27/23 at 9:55 AM, an interview with Licensed Social Worker (LSW), revealed that anyone could write up a grievance; then the grievance would be taken to the appropriate supervisor who would investigate the issues and would be signed off by Director of Nursing and Administrator. She also revealed that the grievances were all brought up and discussed in morning meetings. The LSW revealed that she logged in all grievances and that they were usually resolved within a week. She also revealed that they were supposed to let the resident or family members who filed the grievance know when the issue was resolved and what the resolution was to the issue. An interview on 07/26/23 at 2:35 PM, with the Administrator confirmed that staffing is a constant ongoing issue and confirmed that it was hard to resolve the issues residents have sometimes when his staff members wouldn't show up to work. He revealed that he was trying to hire more staff; but it was hard to keep them. He confirmed that staffing the 3PM-11PM shift was a challenge due to call ins and sometimes day shift staff will stay over and the 11PM-7AM shift would come in early. Record review of the Resident Council Meeting Minutes revealed the following: Record review of Resident Council minutes, dated 01/13/23 revealed . Told that weekend is rest day and CNA not getting her up or that they are short. Record review of Resident Council minutes dated 2/6/23 revealed . old business from 1/13/23 regarding .weekend rest day was not mentioned as unresolved or resolved. Record review of Resident Council Minutes dated 03/08/23 documented under List of old business (unresolved): All resolved. The list of old business included Customer Service with Staff. Review of Resident Council Minutes dated 04/10/23 documented under Summary of the issue . CNA Shortage and Call Ins. Record review of Resident Council Minutes dated 5/1/23 revealed .No list of old business resolved. Record review of Resident Council Minutes dated 6/5/23 revealed, Activities Director, Dietary Manager, DON, and Infection control nurse present .Resident #96 had questions concerning nursing dept. DON answered all questions and some vaccination questions. Record review of Grievances form titled, Record of Concern, included statement of concern, investigation, action taken/findings and were found to have been completed on the problems discussed in Resident Council Meetings on 01/13/23, 02/06/23, and 05/01/23. The previous documents mentioned were signed as completed; but, based on resident interviews and information collected during the Resident Council Meeting on 07/25/23, the problems resulting from being short-staffed continues. Record review of Resident #14's Face Sheet revealed that she was admitted on [DATE] with the following diagnoses to include: Unspecified osteoarthritis, Muscle Weakness, Need for assistance with personal care, and Chronic Systolic (congestive) heart failure. Record review of Resident #14's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 07/06/23 under Section C documented her Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Record review of Resident #64's Face Sheet revealed that he admitted on [DATE] with the following diagnoses to include: Cerebral Infarction, Essential Hypertension, History of Falling, and Unspecified Dementia. Record review of Resident #64's MDS with ARD 06/19/23 under Section C documented BIMS score of 15 which indicated the resident was cognitively intact. Record review of Resident #96's Face Sheet revealed admit date of 12/09/21 with the following diagnoses to include: Chronic Obstructive Pulmonary Disease, Rheumatic Heart Disease, Chronic Atrial Fibrillation, Muscle Weakness, and Dysphagia following Cerebral Infarction. Record review of Resident #96's MDS with an ARD 05/26/23 under Section C documented a BIMS score of 15 which indicated the resident was cognitively intact. Record review of Resident #101's Face Sheet revealed admit date of 01/17/23 with the following diagnoses to include: Essential Hypertension, Scoliosis, Muscle Weakness, and Need for assistance with personal care. Record review of Resident #101's MDS with ARD of 07/24/23 under Section C documented BIMS score of 15 which indicated resident was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility policy review, the facility failed to update Advance Directives for code status to ensure the residents' preferences were honored for three (3) of 32 residents in the initial pool. Resident #16, Resident #81 and Resident #99. Findings included: Record review of facility policy titled, Advance Directives Policy, dated 04/2021, revealed, Upon admission, the facility shall provide information regarding Advance Directives to the resident and/or the responsible party in accordance with the state law. The facility will observe the wishes of the resident and/or responsible party in regard to the Advance Directives. Advance Directives will be updated annually and/or as needed pending a change in resident condition to ensure that is valid and current. An interview on 7/25/23 at 4:00 PM, with Social Service Assistant #2 revealed Resident #16, Resident #81, and Resident #99 did not have an Advance Directive in place and on the medical record. She stated these residents were cognitive and the Resident/Family Consent for Cardiopulmonary Resuscitation forms were signed by each Resident's Representative. An interview on 7/26/23 at 9:00 AM, with Social Service Designee #1 revealed the admission Nurse and the Social Service Representative meet with the resident and/or Resident Representative on admission and that the Advance Directive was signed by the resident or the resident's representative during this meeting. She confirmed that if the resident has a Power of Attorney in place, a copy is placed in the resident's chart. The interview revealed that the Advance Directive is reviewed yearly and updated depending on the resident's or the representative's choice. An interview with Social Service Designee #2 on 7/26/23 at 9:10 AM, revealed the Advance Directive is signed on admission and updated yearly or with any significant change. She stated that if a resident was alert and oriented or had a high Brief Interview for Mental Status (BIMS) score, they would usually sign the form, but there are times the resident's representative signed, even if the resident was capable. She revealed on admission, Social Services, admission Nurse or Charge Nurse, and the resident and/or family are in the admission meeting. An interview with the Licensed Social Worker on 7/26/23 at 9:40 AM, revealed the Advance Directive is signed on admission and annually and that the Advance Directive is discussed during care plan meetings quarterly with long term care residents and more frequently with the Medicare residents. She confirmed that residents' Advance Directives were not updated when the resident's abilities improve, therefore, it was possible that the resident's desires were not documented. An interview with the Administrator on 7/27/23 at 11:12 AM, revealed the resident's Advance Directive should indicate the wishes of the resident and it was each resident's right to choose end of life care. He confirmed the facility failed to ensure that once a resident was able to receive the information and to state his or her wishes related to end of life care, they were not given the opportunity to sign the Advance Directive for their preference to be honored. Record review of Resident #16's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses of Hypertension, Type 2 Diabetes Mellitus, acquired absence of left leg below knee, acquired absence of right leg above knee. Record review of Resident #16's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/13/23, revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. Record review of Resident #16's Resident/Family Consent for Cardiopulmonary Resuscitation dated 5/7/21, revealed the Resident's Representative signed the form on admission. Notation dated 2/10/22 on this form revealed No change in code status remain a full code per RP (Responsible Party) and patient request without the signature of resident. Record review of Resident #81's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses of Heart Disease, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Hypertension, and Chronic Kidney Disease Stage 4. Record review of Resident #81's MDS with an ARD of 6/15/23, revealed a BIMS of 10 which indicated mild cognitive impairment. Record review of Resident #81's Resident/Family Consent for Cardiopulmonary Resuscitation dated 6/9/23 revealed the Resident's Representative signed the form. Record review of Resident #99's Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses that included Chronic Kidney Disease Stage 4 and Muscle Weakness. Record review of Resident #99's MDS with an ARD of 6/19/23, revealed a BIMS of 15 which indicated the resident was cognitively intact. Record review of Resident #99's Resident/Family Consent for Cardiopulmonary Resuscitation dated 12/13/22, revealed the Resident's Representative signed this consent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, record review and facility policy review, the facility failed to ensure a resident was free from verbal abuse for one (1) of 32 residents reviewed. Resident #84. Findings include: Record review of the facility policy titled Abuse, Neglect, Exploitation, and the Vulnerable Adults Act Policy with a revision date of 2/6/23 revealed, It is the policy of this facility that residents and patients are to be treated with dignity and respect at all times under any circumstance. Mistreatment in the form of verbal or physical abuse of any nature will not be tolerated . Record review of the Record of Concern dated 5/18/23 revealed resident #84's daughter called the facility and spoke with the Social Worker (SW) on 5/18/2023 at 1:53 PM to report an incident that occurred on 5/17/2023 around 8/8:30 PM. The residents' daughter stated that Resident # 84 had pushed her call light to be changed. The resident waited for a while, and no one ever responded to her call light. The resident transferred herself into the wheelchair and propelled herself to the nurse's station, where she reported several staff members standing around. Resident #84 asked if someone would change her and put her in bed, and a staff member responded, You got yourself in the wheelchair, so you can get back in bed; We aren't coming to your room. Resident # 84 stated, I need changed. The staff member responded, I already changed you and I will change you during my last rounds. Record of Concern revealed under, Action taken at time of concern; Reported to the Charge Nurse. Revealed under, Investigation Activity if needed; Upon investigation resident was assisted back to bed and changed. Also revealed under, Action taken/Findings; Verbal counseling attached to the Record of Concerns provided to the State Agency (SA) was a Disciplinary Report that was signed by the Administrator (ADM) and Director of Nursing (DON) with a date of 5/23/23 and under Offense warrants suspension or discharge: Yes; No was left blank. On 7/27/23 at 9:20 AM, an interview with Resident #84 revealed she recalled the incident. She stated, I was told by someone behind the desk that I could put myself back to bed; I'm not coming down to your room. She revealed that she did not recall the name of the staff member and described her as an African American female. The resident stated, I reported it to Registered Nurse (RN) # 1. On 7/27/23 at 9:30 AM, interview with the Director of Nursing (DON) revealed she was aware of the incident that occurred to Resident #84 on 5/17/23. She confirmed that she did sign off on a disciplinary action form on 5/23/23 for Certified Nurse Aide (CNA) # 7, and she was given a verbal counseling by the Registered Nurse (RN) supervisor. On 7/27/23 at 9:45 AM, an interview with the ADM revealed he did sign off on a disciplinary action form for Certified Nurse Aide (CNA) #7 regarding the incident that occurred on 5/17/23 He stated, She should have been suspended immediately until an investigation was done. On 7/27/23 at 10:10 AM, interview with Registered Nurse (RN) #1 revealed that she was summoned to the room of Resident # 84 on 5/18/23, which was the next day after the incident occurred, after being notified of the incident. She revealed that she spoke with Resident #84 regarding the incident and after speaking with her, she tried to find out who the assigned aide was. She revealed she identified Certified Nurse Aide (CNA) #7 as the assigned aide for Resident #84 on 5/17/23 3PM-11PM shift. She confirmed that a nurse overheard CNA #7 make the alleged statements and identified the nurse who witnessed the incident to be Licensed Practical Nurse (LPN) # 1. RN #1 stated that CNA # 7 was called into the conference room and given a verbal disciplinary action on 5/18/23, of which the CNA did sign. She revealed that CNA # 7 denied making the statements to the resident. RN #1 confirmed that she called and notified Resident #84's daughter of the disciplinary action taken regarding the CNA. On 7/27/23 at 10:35 AM, an interview with Licensed Practical Nurse (LPN) #1 revealed she was working 3PM-11PM shift on 5/17/23 and was assigned to Resident #84. She revealed the resident pushed her call light and she told Certified Nurse Aide (CNA) # 7 that Resident #84's call light was on. She stated that CNA # 7 replied, I went down there, and she didn't want nothing. She revealed that later, the resident propelled herself in the wheelchair down to the nurse's station and stated she wanted to be changed and to go to bed. She revealed that CNA # 7 stated, You can get back in bed the same way you got out. She revealed that Resident #84 stated, I'm wet and CNA # 7 replied, I'm going to change you when I make my next round. LPN # confirmed the alleged statements were made to Resident # 84 and stated, Yes, she made those statements to Resident # 84. LPN # 1 revealed that she took the resident back to her room and helped her back into bed that night. LPN # 1 stated that she notified the charge nurse the next day of the incident, and the CNA was written up. LPN #1 revealed the Administrator (ADM) and the Assistant Director of Nursing (ADON) were called and notified by Registered Nurse (RN) #1. LPN #1 confirmed that she did not notify anyone until the next day about the incident. On 7/27/23 at 10: 50 AM, an interview with the Social Worker (SW) revealed that she started the Record of Concern form for the incident that occurred on 5/17/23 for Resident #84. She revealed that Resident #84's daughter called in the concern to her, and she filled out the necessary form and took it to the morning meeting to discuss with the Administration. On 7/27/23 at 11:00 AM, an interview with Resident #84's daughter revealed that her mother called her on 5/17/23 and told her of the incident that occurred. She revealed she called and spoke with the Social Worker (SW) the following day and filed a grievance related to statements made to her mother. The daughter stated, Those aides need to realize that they can leave the facility, my mother is helpless, and she relies on them for everything. On 7/27/23 at 11:25 AM, an interview with the ADM revealed that CNA # 7 was in his office on 5/22/23 where she was spoken to by him and the ADON regarding the incident. He revealed that he directed her to go and apologize to Resident # 84 and stated that the CNA was upset and stated she did not make the alleged statements. He confirmed that the CNA wanted to leave work, and he asked her to gather herself and go apologize. On 7/27/23 at 12:52 PM, a telephone interview with CNA # 7 revealed that she did recall Resident #84 and the incident that occurred on 5/17/23. She stated that she only worked with the resident that one time. She revealed that on that night, the resident came to the desk in her wheelchair and asked to speak to someone. She stated there were about 4-5 staff members at the desk at the time. She stated she had just completed hall rounds and changed everyone, and she told the resident, You shouldn't get out of your bed, sweetheart; You could have fallen. She revealed that she did not recall making the alleged statements. CNA # 7 stated, I was written up, and I told the ADON and the Administrator that I didn't say that; I don't know why they put that on me. CNA # 7 revealed that she did not quit working at the facility and that she only worked PRN (as needed), and they just took her off the schedule after 06/27/23. Record review of Certified Nurse Aide (CNA) # 7's Timecard revealed the CNA worked 17 days at the facility following the alleged incident on 5/17/23. CNA # 7 worked 5/18/23, 5/22/23, 5/23/23, 5/24/23, 5/25/23, 5/29/23, 6/2/23, 6/3/23, 6/5/23, 6/6/23, 6/7/23, 6/8/23, 6/12/23, 6/13/23, 6/21/23, 6/22/23, and 6/27/23. On 7/27/23 at 3:30 PM, an interview with the Administrator revealed CNA # 7 was no longer employed at the facility due to no call, no show which resulted in termination. Record review of documentation on facility letterhead dated July 27, 2023, revealed, Certified Nurse Aide (CNA) # 7's last day working at the facility June 27, 2023. Record review of CNA # 7's personnel file revealed a Criminal History Record Check dated March 13, 2023, that found no violations. Also revealed CNA received and signed policy and in-services for, Resident's Right under Federal Law, Abuse of a Resident, and Abuse, Neglect, Exploitation, and the Vulnerable Adults Act dated 3/13/23. The Survey Agency (SA) did not find any further disciplinary actions in the employee file. Record review of the Face Sheet revealed that Resident #84 was admitted to the facility on [DATE] with diagnosis which included Diabetes, Anxiety Disorder and Depression. Record review of the most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/29/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating full cognitive ability.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, record review, and facility policy review, the facility failed to report an allegation of abuse to the appropriate state agencies for one (1) of 32 residents reviewed. Resident #84 Findings Include: Record review of the facility policy titled Abuse, Neglect, Exploitation, and the Vulnerable Adults Act Policy with a revision date of 2/6/23 revealed, It is the policy of this facility that residents and patients are to be treated with dignity and respect at all times under any circumstance. Mistreatment in the form of verbal or physical abuse of any nature will not be tolerated. Also revealed under, Procedure: . b. Who is responsible for reporting abuse? i. Any care facility employee, or health care professional, working in connection with the facility who has knowledge or reasonable cause to believe that a patient or resident of a care facility has been the victim of abuse, exploitation, or neglect. The employee must immediately report all alleged violations to their supervisor then he/she will notify Administrator and Director of nursing immediately i. The employee or healthcare professional is to report knowledge or reasonable cause to believe that any patient or resident of a care facility has been the victim of abuse, neglect, or exploitations . Record review of the Record of Concern dated 5/18/23 revealed resident #84's daughter called the facility and spoke with the Social Worker (SW) on 5/18/2023 at 1:53 PM to report an incident that occurred on 5/17/2023 around 8/8:30 PM. The residents' daughter stated that Resident # 84 had pushed her call light to be changed. The resident waited for a while, and no one ever responded to her call light. The resident transferred herself into the wheelchair and propelled herself to the nurse's station, where she reported several staff members standing around. Resident #84 asked if someone would change her and put her in bed, and a staff member responded, You got yourself in the wheelchair, so you can get back in bed; We aren't coming to your room. Resident # 84 stated, I need changed. The staff member responded, I already changed you and I will change you during my last rounds. Record of Concern revealed under, Action taken at time of concern; Reported to the Charge Nurse. Revealed under, Investigation Activity if needed; Upon investigation resident was assisted back to bed and changed. Also revealed under, Action taken/Findings; Verbal counseling attached to the Record of Concerns provided to the State Agency (SA) was a Disciplinary Report that was signed by the Administrator (ADM) and Director of Nursing (DON) with a date of 5/23/23 and under Offense warrants suspension or discharge: Yes; No was left blank. An interview with Resident #84 on 7/27/23 at 9:20 AM, revealed she recalled the incident. She stated, I was told by someone behind the desk that I could put myself back to bed; I'm not coming down to your room. She revealed that she did not recall the name of the staff member and described her as an African American female. The resident stated, I reported it to Registered Nurse (RN) # 1. An interview with the Director of Nursing (DON) on 7/27/23 at 9:30 AM revealed she was aware of the incident that occurred to Resident #84 on 5/17/23. She confirmed that she did sign off on a disciplinary action form on 5/23/23 for Certified Nurse Aide (CNA) # 7, and she was given a verbal counseling by the Registered Nurse (RN) supervisor. She revealed that the CNA no longer worked at the facility and that she quit shortly after the incident. She stated that the RN supervisor on the floor was responsible for the investigation and the required action for the Record of Concerns and then they came to her and the Administrator for review and further action. She revealed she had not received any other complaints on CNA #7 before, and she didn't think any further action was warranted and the DON confirmed that she did not report the allegation of abuse to the appropriate state agencies. An interview with the ADM on 7/27/23 at 9:45 AM, revealed he did sign off on a disciplinary action form for Certified Nurse Aide (CNA) #7 regarding the incident that occurred on 5/17/23 He stated, She should have been suspended immediately until an investigation was done, and we should have reported it to the state. He stated, I should have told them to get some interviews from other residents to see if there were other residents with concerns and reported it. An interview with Licensed Practical Nurse (LPN) #1 on 7/27/23 at 10:35 AM, revealed she was working 3PM-11PM shift on 5/17/23 and was the nurse for Resident #84. The Resident propelled herself in the wheelchair down to the nurse's station and stated she wanted to be changed and to go to bed. She revealed that CNA # 7 stated, You can get back in bed the same way you got out. She revealed that Resident #84 stated, I'm wet and CNA # 7 replied, I'm going to change you when I make my next round. LPN # confirmed the alleged statements were made to Resident # 84 and stated, Yes, she made those statements to Resident # 84. LPN # 1 stated that she notified the charge nurse the next day of the incident. An interview with the Administrator (ADM) on 7/27/23 at 11:25 AM, revealed that Certified Nurse Aide (CNA) # 7 was in his office on 5/22/23 where she was spoken to by him and the Assistant Director of Nursing (ADON) regarding the incident. He confirmed that he didn't write any kind of statement or put anything on paper after speaking with her and confirmed that the allegation of Resident #84's mistreatment was never reported to the state agency. He stated, Any further investigation that was not completed was on me; I should have further investigated and reported the incident. Record review of the Face Sheet revealed that Resident #84 was admitted to the facility on [DATE] with diagnosis which included Diabetes, Anxiety Disorder and Depression. Record review of the most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/29/23 revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating full cognitive ability.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to complete a through investigation of alleged abuse for one (1) of 32 residents in initial pool. Resident #84. Findings include: Record review of the facility policy Abuse of a Resident Policy dated 3/6/15, revealed, It is the policy of this facility to strictly prohibit abuse, mistreatment, neglect, or exploitation of all residents .All allegations reported to the facility will be thoroughly investigated and handled in accordance with guidelines in this policy .6. Investigation-It is the policy of this facility to investigate, and report alleged incidents of abuse .The investigation will be completed by, but not limited to, the key staff responsible for that department and the Administrator . Record review of the Record of Concern dated 5/18/23 revealed Resident #84's daughter called the facility and spoke with the Social Worker (SW) on 5/18/2023 at 1:53 PM to report an incident that occurred on 5/17/2023 around 8/8:30 PM. The residents' daughter stated that Resident # 84 had pushed her call light to be changed. The resident waited for a while, and no one ever responded to her call light. The resident transferred herself into the wheelchair and propelled herself to the nurse's station, where she reported several staff members standing around. Resident #84 asked if someone would change her and put her in bed, and a staff member responded, You got yourself in the wheelchair, so you can get back in bed; We aren't coming to your room. Resident # 84 stated, I need changed. The staff member responded, I already changed you and I will change you during my last rounds. Record of Concern revealed under, Action taken at time of concern; Reported to the Charge Nurse. Revealed under, Investigation Activity if needed; Upon investigation resident was assisted back to bed and changed. Also revealed under, Action taken/Findings; Verbal counseling attached to the Record of Concerns provided to the State Agency (SA) was a Disciplinary Report that was signed by the Administrator (ADM) and Director of Nursing (DON) with a date of 5/23/23 and under Offense warrants suspension or discharge: Yes; No was left blank. During an interview with on 7/27/23 at 9:20 AM,Resident #84 revealed she recalled the incident. She stated, I was told by someone behind the desk that I could put myself back to bed; I'm not coming down to your room. She revealed that she did not recall the name of the staff member and described her as an African American female. The resident stated, I reported it to Registered Nurse (RN) # 1. During an interview with the Director of Nursing (DON) on 7/27/23 at 9:30 AM, revealed she was aware of the incident that occurred to Resident #84 on 5/17/23. She confirmed that she did sign off on a disciplinary action form on 5/23/23 for Certified Nurse Aide (CNA) # 7, and she was given a verbal counseling by the Registered Nurse (RN) supervisor. She confirmed that no further investigation was completed. She stated that the RN supervisor on the floor was responsible for the investigation and the required action for the Record of Concerns and then they came to her and the Administrator for review and further action. During an interview on 7/27/23 at 9:45 AM, with the ADM revealed he did sign off on a disciplinary action form for CNA #7 regarding the incident that occurred on 5/17/23 He confirmed that a thorough investigation was not conducted into the incident. He stated, She should have been suspended immediately until an investigation was done. He stated, I should have told them to get some interviews from other residents to see if there were other residents with concerns. In an interview on 7/27/23 at 10:35 AM, with Licensed Practical Nurse (LPN) #1, she revealed she was working 3-11 shift on 5/17/23 and was the nurse for Resident #84. The resident pushed her call light, and she told CNA # 7 that Resident #84's call light was on. She stated that CNA # 7 replied, I went down there, and she didn't want nothing. She revealed that later on, the resident propelled herself in the wheelchair down to the nurse's station and stated she wanted to be changed and to go to bed. She revealed that CNA # 7 stated, You can get back in bed the same way you got out. She revealed that Resident #84 stated, I'm wet and CNA # 7 replied, I'm going to change you when I make my next round. LPN # confirmed the alleged statements were made to Resident # 84 and stated, Yes, she made those statements to Resident # 84. LPN # 1 revealed that she took the resident back to her room and helped her back into bed that night. LPN # 1 stated she notified the charge nurse the next day of the incident, and the CNA was written up. LPN #1 revealed the Administrator (ADM) and the Assistant Director of Nursing (ADON) were called and notified by Registered Nurse (RN) #1. During an interview on 7/27/23 at 10: 50 AM, with the Social Worker (SW) revealed that she started the Record of Concern form for the incident that occurred on 5/17/23 for Resident #84. She revealed that Resident #84's daughter called in the concern to her, and she filled out the necessary form and took it to the morning meeting to discuss with administration. She revealed that she did not recall if the Administrator or Director of Nursing was in the meeting that day. She revealed following the meeting, she gave the Record of Concern to the charge nurse. During an interview with Resident #84's daughter on 7/27/23 at 11:00 AM, revealed that her mother called her on 5/17/23 and told her of the incident that occurred. She revealed she called and spoke with the Social Worker (SW) the following day and filed a grievance related to statements made to her mother. The daughter stated, Those aides need to realize that they can leave the facility, my mother is helpless, and she relies on them for everything. An interview with the ADM on 7/27/23 at 11:25 AM, revealed that CNA # 7 was in his office on 5/22/23 where she was spoken to by him and the ADON regarding the incident. He confirmed that he didn't write any kind of statement or put anything on paper after speaking with her, and confirmed that a thorough investigation of Resident #84's allegations was never conducted. He stated, Any further investigation that was not completed was on me; I should have further investigated. An interview with the Administrator on 7/27/23 at 3:30 PM, revealed CNA # 7 was no longer employed at the facility due to no call, no show which resulted in termination. He confirmed that he should have done a more in-depth facility investigation into Resident #84's allegations and stated, It's nobody's fault but my own. The facility provided documentation on letterhead dated July 27, 2023, that read, After initial investigation at time of incident regarding Resident # 84 and Certified Nurse Aide (CNA) # 7, CNA was written up for her behavior and directed to apologize to Resident # 84. A follow-up thorough investigation was not conducted afterwards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to maintain adequate staffing to assist residents in getting the care needed for seven (7) of 109 residents upon initial tour. Resident # 14, #64, #84, #87, #96, #98, and #101. Findings include: The facility provided documentation on letterhead dated July 27, 2023, The Windsor Place does not currently have a written general policy as related to staffing. Resident #14 During the resident council meeting on 07/25/23 at 2:30 PM, Resident #14 revealed that they were sometimes late on getting her showers and she sometimes had to wait awhile when she pushed her call light because of not having enough people to work the halls. Record review of Resident #14's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 07/06/23 under Section C documented her Brief Interview for Mental Status (BIMS) Score of 15 which indicated resident was cognitively intact. Resident #64 On 7/25/23 at 2:30 PM, during Resident Council, Resident #64 revealed that he felt like the Certified Nursing Assistants (CNAs) got their training and then they just didn't come back to work. He stated that he sometimes had to wait awhile for his call light to be answered and it was mainly on the 11PM - 7AM shifts that they were so shorthanded. He revealed that so many people just don't come in and it happens often. Record review of Resident #64's MDS with ARD 06/19/23 under Section C documented BIMS Score of 15 which indicated resident was cognitively intact. Resident #96 An interview on 07/24/23 at 03:55 PM, Resident #96 revealed, sometimes they will tell us on the weekend they can't get us up because they don't have enough help. She revealed the staff is really good but there is just not enough help. I don't know why they they have so many people calling in on the weekends. Record review of the MDS with an ARD of 5/26/23 revealed a BIMS score of 15 which indicated Resident #96 was cognitively intact. Resident #98 An interview on 07/24/23 at 11:21 AM, Resident #98 revealed, I have to wait a while to be changed. The aides come sit in the room on their phone. Sometimes it takes an hour. They are running around now because they know y'all are here. Resident #98 revealed, I don't get up everyday because it's hard to get put back to bed, and it hurts sitting in the wheelchair for a long time. She revealed it happens during the week and weekend because they don't have enough help. On 07/26/23 at 10:35 AM, interview with Resident # 98 revealed I would like to get up more often but I don't because it's so hard to be put back to bed, She revealed they will tell us they are short and I have to wait so I choose to just stay in the bed to avoid that. She revealed that she has told staff about this before but nothing gets done. Observation and interview on 07/27/23 at 1:45 PM, SA heard and observed a call light when entering the hall going off for Resident #98's room. SA spoke to Resident #98 briefly and observed call light going off. SA mentioned call light and Resident #98 revealed she hadn't pushed it not sure why it was on. SA observed room-mate squirming around with covers, call light noted on her covers. SA exited the room and walked to nurses desk. Observed the Registered Nurse (RN) supervisor at the desk on the computer and Certified Nursing Assistant (CNA) #6 sitting at a desk with head down looking at a cell phone on her lap. SA inquired what the sound was that was beeping, CNA #6 looked up from the cell phone and said that's a call light and got up. The nurse at the desk said, I'm sorry I was working on an admission. An interview with CNA #6 revealed she usually works in medical records but comes over at times to help answer call lights. An interview 07/27/23 2:00 PM, the SA spoke with the DON regarding CNA #6, the DON revealed, that aide normally works in medical records and I'm not sure why she was over here but she shouldn't have been on her phone. The DON revealed she may have been called over to assist with answering call lights during lunch breaks. She confirmed that she shouldn't have been on her phone and she should have answered the call-light. An interview on 07/27/23 02:38 PM the Administrator revealed that CNA #6 works PRN (as needed) and works mainly in medical records, he revealed she can answer the call lights to see what the residents may need but is not able to render care at this time. He confirmed that she could have answered the call light instead of being on her phone. Record review of Resident #98's MDS with an ARD of 6/12/23 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Resident #87 An interview on 07/24/23 02:45 PM Resident # 87 revealed, Sometimes I have to wait 30 minutes or more for help. I like to lay down about 3:30 for a nap before dinner. He revealed I've sat in this chair before up to 5:00. He revealed last night there were only two (2) CNAs on shift for 3-11. I just wish I didn't have to wait so long. When they come in late they always say well you know we are short handed. On 07/26/23 at 09:05 AM, an interview with Resident # 87 revealed to SA that he has been told several times when I asked about laying down for my nap that I would have to wait until the aide got here. He revealed the problem is really bad on the 3-11 shift and weekends also. Record review of Resident #87's MDS with an ARD of 6/6/23 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Resident #84 An interview on 07/25/23 at 10:15 AM, with Resident # 84 revealed that when she pushed her call light for assistance with changing her brief, the staff would come in and tell her, It's going to be a while. She revealed it takes a long time to get changed. SA (Survey Agent) inquired about an estimate of the time that she usually waits, and she stated, Sometimes an hour. She stated, When they come into my room, they tell me that it's only 2 or 3 of them working, and you're going to have to wait. Resident revealed she doesn't think the facility had enough staff to care for the residents at the facility. An interview with the Registered Nurse #1 on 7/27/23 at 9:15 AM revealed that Resident #84 was totally incontinent of bowel and bladder. She revealed that the resident would push her call light and let the staff know when she was wet or had a bowel movement and needed to be changed. An interview with Resident # 84's daughter on 7/27/23 at 10:55 AM, revealed the facility had staffing issues, especially on the weekend. She revealed the weekends were so short-staffed, and it's nothing like during the week. She stated the call lights take a lot longer to be answered. She stated, They need help. Record review of the Face Sheet for Resident #84 revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Psychosis, Cardiac Arrhythmia, Hyperlipidemia, Major Depressive Disorder, Anxiety Disorder and Type 2 Diabetes Mellitus. Record Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/29/23 revealed under section C a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #84 is cognitively intact. Section H revealed that Resident #84 is always incontinent of bladder and bowel. Resident #101 During the resident council meeting on 07/25/23 at 2:30 PM, Resident #101 revealed that she felt like they needed more hall keepers (Nurse Aides). She confirmed that staffing was worse on weekends and sometimes during the week. She also revealed that sometimes they only had two Certified Nursing Assistants (CNAs) on the halls and the facility would have to send one to another hall (B-Hall) to help out and then sometimes they had to request one to be pulled to this side (A-Hall) to help. She stated that they were supposed to have four or five aides working the halls and they don't. She confirmed that not having enough to work the halls caused a longer wait time to get call lights answered. Record review of Resident #101's MDS with ARD of 07/24/23 under Section C documented BIMS Score of 15 which indicated resident was cognitively intact. ******** On 07/26/23 at 08:37 AM, an interview with the Activity Director revealed the residents have voiced some concern in resident council about staffing. She revealed after the meeting I fill out a concern form and give it to the appropriate departments. She revealed for staffing I give it to the nursing department, we discuss the concerns that were voiced at the next morning meeting. She revealed a lot of the residents has voiced staffing issues in the past and the DON came to the June Resident council meeting and addressed staffing concerns. On 07/26/23 at 08:45 AM, an interview with DON revealed any issues or concerns that have been voiced during resident council the activities director fills out a concern form and gives it to the appropriate department and then we also discuss it in the morning meeting. State Agent inquired if there have been any issues voiced during resident council regarding staffing concerns. DON revealed, not as far as being short-staffed but rather not answering the call lights timely. She revealed she met with the resident council members last month. She revealed I didn't document any of the issues that were discussed and can't remember what exactly they were, the activities director should have documented the issues. She revealed I just don't recall discussing any staffing issues. In an interview on 07/26/23 at 2:35 PM, the Administrator confirmed that staffing is a constant issue and he has actually put a stop on admissions due to low staffing in the past but right now admissions are still being accepted. He confirmed that staffing the 3-11 shift was a challenge due to call ins and sometimes day shift staff will stay over and the 11PM-7AM shift would come in early. An interview with Certified Nurse Aide (CNA) # 8 on 7/26/23 at 9:02 AM, revealed she was working on B-hall, and they have a total of 3 CNAs' working 7-3 shift. She revealed she was assigned to care for 9 residents. She stated, We work short all the time. She revealed that working with only 2 aides on the hall makes caring for the residents difficult. She stated that to ensure that her assigned residents' needs were met, she had to stay over until 3:30 or 4:00 PM to complete all her documentation. She revealed that when she had multiple call lights alarming at once, she would step into the rooms and let the resident know she was tied up across the hall and would come back as soon as she could. She revealed that the facility frequently asked her to stay late or come in early, but she has only come in early once. An interview with CNA #10 on 7/26/23 at 9:40 AM, revealed that the facility does not have enough aides, and they frequently work short with only 4 aides (2 aides on each unit) on 3-11/11-7 shift. She stated, If I'm in another room and have other call lights going off, they will still be going off when I come out. She revealed the nurses do not help to answer any call lights. An interview with CNA #11 on 7/26/23 at 9:55 AM, revealed they do work short some days due to call ins. She stated we all have to work together to get things done and try to get the lights answered. An interview with the DON on 7/26/23 at 2:10 PM, revealed they had a nurse who handled staffing, but she would be working another shift tonight to fill a position. Survey Agent (SA) inquired from the DON how the facility ensured they met resident needs, and she replied, I'm not certain how she (the staffing nurse) handles that, but I know if we have a higher acuity on a hall we try to staff up. She revealed any call in was received at the nurse's desk and was then relayed to the staffing nurse who tried to fill the position. She revealed that she had not had any workload concerns brought to her attention by the CNA's or families. An interview with CNA #12 on 7/26/23 at 6:20 PM, revealed she worked 3-11 shift. She revealed they do sometimes work short-staffed, and it makes it hard on them because they have more residents to care for. An interview with CNA #13 on 7/26/23 at 6:30 PM, revealed she worked part-time. She stated that one day last week they worked with 2 aides on B hall and that the resident needs were met to the best of their ability. An interview with the ADM on 7/27/23 at 8:20 AM, confirmed that he was aware of the staffing issue. He confirmed that they do have a lot of call ins and that he had people in the office that would come out to help the CNA's.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and pharmacist interviews, record review, and facility policy review, the facility failed to ensure a resident on an as needed (PRN) psychotropic medication had a stop date for one (1) of six (6) medication reviews. Resident #17 Findings Include: Review of the facility policy titled Psychotropic Medication Policy and Procedure revealed under, Standards: 1. The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long-term care facility to include regular review for continued need, appropriate dosage, side effects, risk and /or benefits. Revealed under, Physician/NP/mental health NP (When available to a facility) . 3. Orders for PRN psychotropic medications will be time limited (i.e., times 2 weeks) and only for specific clearly documented circumstances. Also revealed under, Consultant pharmacist: 1. Monitors psychotropic drug use in the facility to ensure that medications are not used in excessive doses or for excessive duration. 2. Notifies the physician and the nursing unit if whenever a psychotropic medication is past due for review. Record review of Resident # 17's Medication Administration Record (MAR) for the month of July 2023 revealed an order dated 6/30/23, Ativan 1 mg (milligram) tablet take one tablet by mouth every 6 hours as needed related to agitation and anxiety with no stop date. Resident #17 received seven (7) doses from 7/1/23 - 7/25/23. An interview with the Assistant Director of Nursing (ADON) on 7/25/23 at 4:00 PM, confirmed that Resident #17 did not have a stop date for as needed (PRN) Ativan that was ordered on 6/30/23. The ADON stated, Yes, it should have one. An interview with the Pharmacy Consultant on 7/25/23 at 4:10 PM, confirmed that Resident #17 did not have a stop date for as needed (PRN) Ativan and acknowledged that it should have a stop date. An interview with the Director of Nursing (DON) on 7/26/23 at 8:40 AM, confirmed that all as need (PRN) orders for psychotropics medications should have a stop date so that the physician can re-evaluate and extend the order out if the medication was still needed. Record review of the Face Sheet for Resident #17 revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction, Schizoaffective Disorder, Unspecified Dementia, Generalized Anxiety Disorder and Type 2 Diabetes Mellitus.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and facility policy review, the facility failed to prevent the likelihood of the spread of infection as evidenced by staff not cleaning and disinfecting a multi-use resident device used to check vital signs between each resident use for one (1) of four (4) survey days. Findings include: A review of the facility's Clinical Equipment policy, undated, revealed, It is the policy of this facility to provide clean equipment and help promote a sanitary environment. For all clinical equipment, the manufacturer's recommendations for cleaning or disinfecting are followed for type of clean or disinfectant and how often to clean or disinfect .Procedure: 1. Clinical equipment includes the following equipment .e. Vital signs equipment . On 07/25/23 at 2:55 PM, an observation revealed Certified Nurse Aide (CNA) #2 pushed a vital sign machine down the hall and entered room [ROOM NUMBER], CNA #2 then exited the room and did not clean the vital sign machine and immediately entered room [ROOM NUMBER], CNA #2 exited the room and did not clean the vital sign machine and was stopped by the State Agent (SA) before proceeding into another room. An interview on 07/25/23 at 3:05 PM, CNA #2 revealed, we are supposed to clean the vital sign machine equipment by using alcohol wipes between each of the residents' rooms to sanitize it. She confirmed she had not cleaned it between the rooms and there were no alcohol wipes on her cart to do so. She revealed it is my responsibility to clean the equipment between each resident's room and by not cleaning it, it could possibly spread infection between the residents. An interview on 07/25/23 at 3:20 PM, the Infection Control Nurse revealed, the vital sign machines are to be cleaned after leaving a resident's room and before entering another resident room. She revealed the cleaner wipes are to be in the basket on the front of each machine and the cleaner is called Oxivir 1 wipes. She confirmed that not properly disinfecting the machines between resident rooms could transmit infections among the residents. An interview on 07/25/23 at 3:25 PM, Registered Nurse (RN) #1 revealed, the aides are supposed to be keeping alcohol wipes in the basket of the machines to wipe them down between resident rooms to prevent any spread of infection. An interview on 07/25/23 at 4:15 PM, the DON revealed all equipment that is used between the resident rooms is to be cleaned between each room. The staff is to use the germicidal disposable wipe. She confirmed that the vital sign machines not being cleaned between resident rooms could cause the spread of infection between residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to provide actions taken and resolutions of grievances filed with the facility for three (3) of five (5) residents reviewed. Resident (Res) #1, Resident #2 and Resident #5. Findings include: Record review of a typed document on facility letter, dated February 7, 2023, and signed by the Administrator, revealed Currently, (Name of Facility) does not have a general policy for grievance procedures, whether individual or group grievances. (Name of Facility) is currently working on implementing a grievance procedure. The grievance procedure is attached. Resident #1: Interview on [DATE] at 12:10 PM, with the facility Licensed Social Worker (LSW) revealed that Resident #1's niece had filed a grievance on [DATE] during a visit to the facility that Res #1's diamond cross necklace and two (2) diamond rings were missing from her room. The LSW stated that the staff searched Res #1's room and were unable to locate the missing diamond cross necklace and the missing diamond rings. The LSW confirmed that the facility posted a Lost notice on the facility bulletin board with a description of the missing jewelry with instructions to please help locate the missing jewelry. The LSW then confirmed that the diamond necklace and diamond rings were never located, and the facility had not replaced the missing items as to date. The LSW stated that the facility policy was that they were not responsible for missing jewelry or money in excess of $5.00 and that she was not aware of the items being listed on an inventory list for Resident #1's property on her admission. The LSW did confirm that Resident #1 was cognitively impaired and that her nephew was her Resident Representative (RR). In an interview on [DATE] at 12:25 PM, with the facility Administrator (ADM), he confirmed that he had located an inventory list for Resident #1 in the medical records department and confirmed that the diamond and gold jewelry of Resident #1 was listed on the inventory list and that the facility had not replaced the missing jewelry of Resident #1 because he was in hopes that the Attorney General Office (AGO) would get the jewelry back from the staff member, Certified Nursing Assistant (CNA) #1 that had taken it. The ADM stated that the AGO had told him that he had enough evidence against CNA #1 to make an arrest and that he was certain that CNA #1 had taken the jewelry of Resident #1. The ADM showed pictures of Resident #1 wearing the diamond cross necklace and had obtained pictures of CNA#1 wearing that same necklace and a diamond ring on a social media post. The ADM also confirmed that they had not replaced any of the items stolen nor had the facility followed up with the grievance resolutions with Resident #1's family. Interview on [DATE] at 4:00 PM, with the RR of Resident #1 revealed that he had not been to see his aunt since before Covid-19. He stated that he was told by his sister that Resident #1's jewelry was missing when she visited the resident on [DATE] and that she had reported it to the facility. The RR stated that his aunt was severely cognitively impaired and that he nor his sister he had been contacted by the facility other than just recently to tell them that a CNA had stolen the jewelry. In an interview on [DATE] at 4:10 PM with the niece of Resident #1, revealed that she came to the facility in [DATE] to visit Resident #1 and noticed that she was not wearing her jewelry that she had always worn. The niece also stated that she noticed that Res #1 had declined mentally and was not cognitively intact. The resident's niece reported to the LSW that the diamond cross necklace and two (2) diamond rings were missing. She confirmed that her brother, was the RR for Resident #1 because he lived in the state and she lived out of state. The niece stated that the facility had recently told her that a staff member had stolen the jewelry of Res #1. The facility had not contacted her with any information until [DATE]. The niece confirmed that she had reported the missing jewelry items to the facility in [DATE]. She stated that Resident #1 had wanted to keep her jewelry on her person and would not remove the jewelry upon admission in 2015 and that to her knowledge the facility had not done anything to locate Res #1's jewelry after she had reported it missing on [DATE]. Interview on [DATE] at 4:40 PM, with the police detective that completed the local police report confirmed that he had spoken to the ADM on [DATE] and he reported that the CNA #1 had taken jewelry from Resident #1 and a cell phone that belonged to Resident #2. Interview on [DATE] at 1:30 PM, with the AGO revealed that he was confident that CNA #1 had taken the property of Resident #1 and Resident #2. The AGO had not yet met with CNA #1 and had not charged anyone with the theft of the resident property. Record review of the (Formal Name of County) Sheriffs Office Investigative Report revealed that the ADM contacted the local police department on [DATE]. The ADM reported that CNA #1 was suspected of taking jewelry and a cell phone belonging to a couple of Residents at the facility. The local police department did not come to the facility and contacted the AGO. The AGO informed the police department that the AGO was handling the case. Record review of Resident #1's Face Sheet revealed that Resident #1 was admitted to the facility on [DATE] with diagnoses that included Unsp (Unspecified) Dementia and Anxiety Disorder. Record review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated Res #1 had severe cognitive impairment. Record review of a document titled Record of Concern dated [DATE], revealed Statement of Concern: Niece (Formal name of Niece) called this writer and reported reident diamnd cross necklance missing and (2) diamond clustered riengs. Niece indicated she has had the necklace on since admitting .Action Taken at Time of Concern: Reported the necklance missing to charge nurse. Room search included;searching drawers, closet, and under bed. Shower room searched. Asked staff if they had seen the cross.Hung a lost and ound note at desk w/ (with) description of cross . The sections titled Investigation Activity if Needed and Action Taken/Findings were blank. The document was not signed by the Administrator or Director of Nurses (DON). There was no documentation of the resident/family notified of outcome. The Resident Inventory List for Resident #1 dated [DATE] revealed a diamond cross necklace and three (3) diamond rings among other gold jewelry and a watch listed on the inventory form. Resident #2: Interview on [DATE] at 12:10 PM, with the facility Licensed Social Worker (LSW) revealed there was not a formal grievance documented in the grievance logs for Resident #2's grievance from the family stating that the resident had a missing cell phone. LSW stated that the facility Administrator (ADM) would have the investigation that was completed for the missing cell phone of Res #2. In an interview on [DATE] at 12:25 PM, with the facility ADM, confirmed that the family of Resident #2 had provided a cell phone call list with calls to and from CNA #1. The ADM stated that the facility terminated CNA #1 on [DATE] after she had been suspended on [DATE], pending the investigation. The ADM provided the termination documentation for CNA #1 dated [DATE] that outlined the reason for termination as cell phone missing and noted to have her phone number as receiving calls from the missing cell phone. The ADM stated that calls had been made on the cell phone after the death of Resident #2 and the ADM confirmed that Resident #2 expired in the facility on [DATE]. The ADM also confirmed that they had not replaced any of the items stolen nor had the facility followed up with the grievance resolutions with Resident #2's family. Interview on [DATE] at 3:45 PM, with Certified Nursing Assistant (CNA #1) revealed that she had no idea how the cell phone records of Res #2 contained her phone number, and she denied taking the cell phone of Resident #2. CNA #1 confirmed that she had an appointment to meet with the AGO on Wednesday [DATE] at 10:00 AM. CNA #1 confirmed that she was terminated from the facility for her phone number appearing on the cell phone records of Res #2. Record review of the Face Sheet for Resident #2 revealed that he was admitted to the facility on [DATE] and expired in the facility on [DATE]. Resident #2 had diagnoses that included Anxiety disorder and Chronic kidney disease, stage 4 (severe). Record review of the MDS dated [DATE], revealed a BIMS score of 00 indicating Resident #2 was unable to participate in the BIMS interview. Resident #5: Observation and interview on [DATE] at 3:30 PM, with Resident #5, revealed that she had $240.00 taken from her bedside table and that she had reported the money missing over a year ago. The facility had not offered to replace the money. She stated that she obtained the cash from her trust fund account and that she noticed the money was gone a couple of days after she had contacted her sister to come get the money to shop for her. Resident stated that she thought the facility should have replaced her money, especially since they were aware of her obtaining the cash from her trust fund and the facility assisted her with shopping for personal items. She was able to give an account of when her money was missing from her bedside table. Interview on [DATE] at 11:30 AM, with Social Services Designee (SSD) for Resident #5 revealed that she was not aware of the actions taken by the facility to resolve Resident #5's grievance. Interview on [DATE] at 12:50 PM, with the Activities Direct (AD) stated that she attended the resident council meetings with the residents and she would give the residents' concerns to the appropriate departments.She stated the following month the issues for the previous month would be discussed. The AD stated that she was not aware of a facility policy for formally handling and following up on Resident grievances. Interview on [DATE] at 3:30 PM, with the facility ADM he confirmed that the facility had no current policy for grievances and that he had been working on a policy and had not yet gotten it approved through the Quality Assurance (QA) committee. He stated that the Residents nor their RR's had not been educated on the facility's grievance processes and that he had not followed up with the RR's that had filed the grievances on behalf of Resident #1, Resident #2 or Resident #5. Interview on [DATE] at 5:30 PM, with the sister, who is the RR, of Resident #5 revealed that she was contacted by Resident #5 to come and get money to go purchase a refrigerator for her room and that she had gotten the money from her trust fund account.The RR was not able to come to get the money and shop for Resident #5 until several days later. The RR stated that Resident #5 reported to her at that time that someone had taken her money from her purse that was in her bedside table. The RR reported the missing money to the LSW on [DATE]. Record review of the Trust Fund Transaction List date ranges [DATE] through [DATE] revealed Resident #5 made multiple cash withdrawals ranging from $39.00 to $400.00. Record review of the Face Sheet revealed Resident #5 was admitted to the facility on [DATE] with diagnoses that included Pneumonia and Chronic Systolic (Congestive) Heart Failure. Record review of the MDS dated [DATE], revealed that Res #5 had a BIMS score of 15 which indicated that she was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, observations, and policy and procedure reviews the facility failed to ensure loss/theft of resident's personal property was prevented for three (3) of five (5) Residents reviewed for misappropriation. Resident #1, Resident #2 and Resident #5. Findings include: The facility policy and procedure titled: Code of Conduct revealed: Examples of conduct and behavior that are considered inappropriate and are therefore prohibited by this policy include, but are not limited to, the following: Misuse or abuse of nursing home funds, dishonesty, theft, misrepresentation, conflict of interest, or false statement in connection with any aspects of employment; The policy was signed by Certified Nursing Assistant (CNA #1) and dated [DATE]. The facility policy titled: Abuse Neglect, Exploitation, and the Vulnerable Adults Act Policy dated revised [DATE] read: Any employee guilty of abusing a resident or patient is subject to immediate dismissal and criminal charges may be filed against any employee guilty of abuse. Employees may be fined $5000.00 and sentenced to 3 years in prison. Record review of Resident's Rights under Federal Law signed by CNA #1 and dated [DATE] revealed, .7.The Resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident.8. The Resident has the right to .filing a grievance .concerning .misappropriation of Resident property in the facility .27.The Resident has a right to retain and use personal possessions . Resident #1: Interview on [DATE] at 12:10 PM, with the facility Licensed Social Worker (LSW) revealed that Resident #1's niece had filed a grievance on [DATE] during a visit to the facility that Res #1's diamond cross necklace and two (2) diamond rings were missing from her room. The LSW stated that the staff searched Res #1's room and were unable to locate the missing diamond cross necklace and the missing diamond rings. The LSW confirmed that the facility posted a Lost notice on the facility bulletin board with a description of the missing jewelry with instructions to please help locate the missing jewelry. The LSW then confirmed that the diamond necklace and diamond rings were never located, and the facility had not replaced the missing items as to date. The LSW stated that the facility policy was that they were not responsible for missing jewelry or money in excess of $5.00 and that she was not aware of the items being listed on an inventory list for Resident #1's property on her admission. The LSW did confirm that Resident #1 was cognitively impaired and that her nephew was her Resident Representative (RR). In an interview on [DATE] at 12:25 PM, with the facility Administrator (ADM), he confirmed that he had located an inventory list for Resident #1 in the medical records department and confirmed that the diamond and gold jewelry of Resident #1 was listed on the inventory list and that the facility had not replaced the missing jewelry of Resident #1 because he was in hopes that the Attorney General Office (AGO) would get the jewelry back from the staff member, Certified Nursing Assistant (CNA) #1 that had taken it. The ADM stated that the AGO had told him that he had enough evidence against CNA #1 to make an arrest and that he was certain that CNA #1 had taken the jewelry of Resident #1. and had also taken the cell phone of Resident #2. The ADM showed pictures of Resident #1 wearing the diamond cross necklace and had obtained pictures of CNA#1 wearing that same necklace and a diamond ring on a social media post. The ADM also confirmed that they had not replaced any of the items stolen. Interview on [DATE] at 4:00 PM, with the RR of Resident #1 revealed that he had not been to see his aunt since before Covid-19. He stated that he was told by his sister that Resident #1's jewelry was missing when she visited the resident on [DATE] and that she had reported it to the facility. In an interview on [DATE] at 4:10 PM, with the niece of Resident #1, revealed that she came to the facility in [DATE] to visit Resident #1 and noticed that she was not wearing her jewelry that she had always worn. The niece also stated that she noticed that Res #1 had declined mentally and was not cognitively intact. The resident's niece reported to the LSW that the diamond cross necklace and two (2) diamond rings were missing. She confirmed that her brother, was the RR for Resident #1 because he lived in the state and she lived out of state. The niece stated that the facility had recently told her that a staff member had stolen the jewelry of Res #1. The niece confirmed that she had reported the missing jewelry items to the facility in [DATE]. She stated that Resident #1 had wanted to keep her jewelry on her person and would not remove the jewelry upon admission in 2015 and that to her knowledge the facility had not done anything to locate Res #1's jewelry after she had reported it missing on [DATE]. Interview on [DATE] at 4:40 PM, with the police detective that completed the local police report confirmed that he had spoken to the ADM on [DATE] and he reported that the CNA #1 had taken jewelry from Resident #1 and a cell phone that belonged to Resident #2. Interview on [DATE] at 1:30 PM, with the AGO revealed that he was confident that CNA #1 had taken the property of Resident #1 and Resident #2. The AGO had not yet met with CNA #1 and had not charged anyone with the theft of the resident property. Record review of the (Formal Name of County) Sheriffs Office Investigative Report revealed that the ADM contacted the local police department on [DATE]. The ADM reported that CNA #1 was suspected of taking jewelry and a cell phone belonging to a couple of Residents at the facility. The local police department did not come to the facility and contacted the AGO. The AGO informed the police department that the AGO was handling the case. Record review of Resident #1's Face Sheet revealed that Resident #1 was admitted to the facility on [DATE] with diagnoses that included Unsp (Unspecified) Dementia and Anxiety Disorder. Record review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated Res #1 had severe cognitive impairment. Record review of a document titled Record of Concern dated [DATE], revealed Statement of Concern: Niece (Formal name of Niece) called this writer and reported reident diamnd cross necklance missing and (2) diamond clustered riengs. Niece indicated she has had the necklace on since admitting .Action Taken at Time of Concern: Reported the necklance missing to charge nurse. Room search included;searching drawers, closet, and under bed. Shower room searched. Asked staff if they had seen the cross.Hung a lost and ound note at desk w/ (with) description of cross . The sections titled Investigation Activity if Needed and Action Taken/Findings were blank. The document was not signed by the Administrator or Director of Nurses (DON). There was no documentation of the resident/family notified of outcome. The Resident Inventory List for Resident #1 dated [DATE] revealed a diamond cross necklace and three (3) diamond rings among other gold jewelry and a watch listed on the inventory form. Resident #2: Interview on [DATE] at 12:10 PM, with the facility Licensed Social Worker (LSW) revealed there was not a formal grievance documented in the grievance logs for Resident #2's grievance from the family stating that the resident had a missing cell phone. LSW stated that the facility Administrator (ADM) would have the investigation that was completed for the missing cell phone of Res #2. In an interview on [DATE] at 12:25 PM, the facility ADM confirmed that the family of Resident #2 had provided a cell phone call list with calls to and from CNA #1. The ADM stated that the facility terminated CNA #1 on [DATE] after she had been suspended on [DATE], pending the investigation. The ADM provided the termination documentation for CNA #1 dated [DATE] that outlined the reason for termination as cell phone missing and noted to have her phone number as receiving calls from the missing cell phone. The ADM stated that calls had been made on the cell phone after the death of Resident #2 and the ADM confirmed that Resident #2 expired in the facility on [DATE].The ADM also confirmed that they had not replaced any of the items stolen. Interview on [DATE] at 3:45 PM, with CNA #1 revealed that she had no idea how the cell phone records of Res #2 contained her phone number, and she denied taking the cell phone of Resident #2. CNA #1 confirmed that she had an appointment to meet with the AGO on Wednesday [DATE] at 10:00 AM. CNA #1 confirmed that she was terminated from the facility for her phone number appearing on the cell phone records of Res #2. Record review of the Face Sheet for Resident #2 revealed that he was admitted to the facility on [DATE] and expired in the facility on [DATE]. Resident #2 had diagnoses that included Anxiety disorder and Chronic kidney disease, stage 4 (severe). Record review of the MDS dated [DATE], evealed a BIMS score of 00 indicated Resident #2 was unable to participate in the BIMS interview. Resident #5: Observation and interview on [DATE] at 3:30 PM, with Resident #5, revealed that she had $240.00 taken from her bedside table and that she had reported the money missing over a year ago. The facility had not offered to replace the money. She stated that she obtained the cash from her trust fund account and that she noticed the money was gone a couple of days after she had contacted her sister to come get the money to shop for her. Resident stated that she thought the facility should have replaced her money, especially since they were aware of her obtaining the cash from her trust fund and the facility assisted her with shopping for personal items. She was able to give an account of when her money was missing from her bedside table. Interview on [DATE] at 11:30 AM, with Social Services Designee (SSD) for Resident #5 revealed that she was not aware of the actions taken by the facility to resolve Resident #5's missing money. Interview on [DATE] at 5:30 PM, with the sister, who is the RR, of Resident #5 revealed that she was contacted by Resident #5 to come and get money to go purchase a refrigerator for her room and that she had gotten the money from her trust fund account.The RR was not able to come to get the money and shop for Resident #5 until several days later. The RR stated that Resident #5 reported to her at that time that someone had taken her money from her purse that was in her bedside table. The RR reported the missing money to the LSW on [DATE]. Record review of the Trust Fund Transaction List date ranges [DATE] through [DATE] revealed Resident #5 made multiple cash withdrawals ranging from $39.00 to $400.00. Record review of the Face Sheet revealed Resident #5 was admitted to the facility on [DATE] with diagnoses that included Pneumonia and Chronic Systolic (Congestive) Heart Failure. Record review of the MDS dated [DATE] revealed that Res #5 had a BIMS score of 15 which indicated that she was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #111 Record review Physician's Orders revealed resident #111 was hospitalized on [DATE] due to fall and was readmitted to the facility on [DATE] Record review of Physician's Orders dated 10/03/21 revealed Resident #111 was transferred to the hospital due to a fall with right hip pain and was re-admitted to the facility on [DATE]. On 10/27/21 at 10:52 AM, an interview with Social Services (SS) #1 confirmed the facility is not sending a written notice when residents are transferred and admitted to the hospital. SS #1 revealed she interpreted the regulation requiring a written notification to be sent to the RR was only applicable when the resident was discharged from the facility and not expected to return to the facility. Based on staff interviews, resident interview and record review, the facility failed to notify the Resident Representatative in writing of a transfer to the hospital for two (2) of four(4) residents reviewed. Resident # 56 and Resident # 111. Findings include: Record review of the facility Policy and Procedure titled Notice of Facility Initiated Emergency Transfer dated 10/28/21 revealed upon a facility initiated emergency transfer, it is the policy to provide transfer notice as soon as practicable to resident and resident representative to include the reason for the transfer, the effective date of the transfer, and location to which the resident is transferred. On 10/25/21 at 02:11 PM, an interview with Resident # 56 revealed she had one recent hospital stay because she was having breathing problems. On 10/26/21 at 02:10 PM, an interview with Social Services (SS) #2 revealed the Bed Hold Form was being sent to families and a call is made to inform families of a resident being transferred to the hospital, but no written notification is given to the Resident Representatiave (RR) with notification of the hospital transfer or reason for the transfer. On 10/27/21 at 08:27 AM, an interview with the Director of Nursing (DON), when asked by the Surveyor for a copy of Resident #56's Transfer Notification Form, the DON revealed she was not aware of this form being completed by this facility, and she has not seen the form, but will provide information regarding it. Record review of the Physician's orders revealed orders to transfer Resident # 56 to the hospital on 6/6/21 and 7/21/21. Record review of Resident # 56's Minimum Data Set (MDS) for discharge and returns revealed a discharge MDS on 6/6/21, a return MDS on 6/11/21, a discharge MDS on 7/21/21 and a return MDS on 7/23/21. Record reviw of Resident #56's Face Sheet was admitted to the facility on [DATE] and has diagnoses that include Dysphagia, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure, Schizophrenia, Bipolar and Diabetes. Record review of Resident #56's quarterly MDS with an with an Assessment Reference Date (ARD) of 8/31/21 revealed Resident #56 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy review, the facility failed to complete a discharge assessment for the Minimum Data Set (MDS) for one ( 1) of two (2) residents identified for resident assessments. Resident 1. Findings include: Review of the facility policy titled, MDS 3.0 Completion revealed .Policy Explanation and Compliance Guidelines: . #2 .f. Discharge Assesssment- .completed using the discharge date as the Assessment Reference Date (ARD). Must be completed within 14 days of the discharge date /ARD. On 10/28/21 at 3:50 PM, an interview with Licensed Practical Nurse (LPN) #3 revealed that Resident #1 was admitted on [DATE] and discharged on 5/17/21. LPN #3 confirmed that Resident #1 did not have a Minimum Data Set (MDS) discharge assessment. On 10/28/21 at 3:55 PM, an interview with Licensed Practical Nurse (LPN) #1 revealed that Resident #1 did not have a discharge MDS assessment, and it was an oversight on her part. On 10/28/21 at 4:04 PM, an interview with the Administrator (ADM) confirmed he was responsible for the MDS staff. The ADM stated that the discharge MDS assessment should not have been missed. Record review of Resident #1's Face Sheet revealed Resident #1 was admitted to the facility on [DATE] and was discharged on 5/17/21 with return anticipated.

Based on staff interviews, record reviews and facility policy review the facility failed to maintain the appropriate staff at the quarterly Quality Assurance (QA) meetings for two( 2) of four(4) quarterly meetings reviewed. Findings include: Review of the facility policy titled, Quality Assurance/Assessment and Performance Improvement Plan, dated 01/29/20, stated, The QA committee consists of the Director of Nursing/Designee (DON), the Medical Director, Administrator, Dietary Manager, Social Services, Quality Assurance Nurse, plus 2 (two) non-licensed staff. Record review of the QA sign in sheets revealed on 10/28/21 at 11:30AM, the QA sign-in sheets were dated from October 2020 through July 2021. October 2020 QA sign in sheet stated, No QAPI meeting held. The January 27, 2021 QA sign in sheet did not have the Medical Director in attendance and stated, Elected to not attend meeting. The July 28, 2021 sign-in sheet revealed that the Medical Director was not in attendance for the QA meeting. Interview on 10/28/21 at 1:45PM, with the Director of Nurses (DON) confirmed that the facility did not have a QA meeting in September and have not had a QA meeting so far for the month of October. The DON confirmed that after she reviewed the monthly QA meeting sign-in sheets that the facility either did not have the appropriate staff at the meetings or either they missed the monthly meeting and the facility did not have the required quarterly meetings with the required staff present at the meetings and that the facility was not in compliance with federal requirements. Interview with the current QA nurse on 10/28/21 at 2:25PM, stated, I began this job about the second week of October. We are going to get with the Medical Director and plan a meeting for November. The Medical Director is here in the building a lot. He wouldn't have a problem attending.

Based on observation, staff interviews and facility policy reviews the facility failed to store food to prevent the likelihood of foodborne illness as evidenced by opened items with no open date and unlabeled food items in the refrigerator for one (1) of two (2) kitchen tours. Findings include: Record review of the facility policy titled Food Storage Policy with a revised date of 4/23/19 under Food Storage Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminates. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination . Procedure: .13. leftover food will be stored in covered or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. Leftover food is used within 7 days or discarded as per the 2013 Federal Food Code . Check state regulations as state regulations as state regulations may allow shorter time frames for use of leftovers. On 10/25/21 at 1:40 PM, during the initial kitchen tour the State Agency (SA) observed in the four (4) door refrigerator a white container with of pimento and cheese spread with approximately a cup leftover in the bottom with no open date, a white container of chicken salad approximately three fourths full with no open date, a white container with tuna salad approximately half full with no open date, a white container with cucumber salad and onion approximately half full with no open date, a bowl with a lid that was dated 9/29/21 and chili written beside the date, and a glass of a tan colored milk like liquid covered with plastic wrap, with two (2) spots of a dark substance floating on top of the liquid. This glass was not labeled with the contents or a date. An interview on 10/25/21 at 1:55 PM, with the Dietary Supervisor revealed that all opened items placed in the refrigerator should be covered and dated with the open date. She revealed that they do not have a specific schedule for checking opened items for dates and that everyone knows that they should be dated. In the presence of the SA, the dietary supervisor removed each item from the four (4) door refrigerator and she confirmed that the pimento and cheese, the chicken salad, the tuna salad, and the cucumber and onion salad were opened and not dated and she confirmed that the bowl with the lid had a date of 9/29/21 and chili written by the date and that the milk like liquid was honey thickened milk and that there were 2 dark spots that looked like mold to her and it was not dated. She confirmed that opened items without dates could cause the food to spoil and cause a foodborne illness. An interview on 10/25/21 at 2:05 PM, with the Dietary Manager revealed that all opened items should be dated when placed in the refrigerator and that food not dated could definitely cause issues and cause a foodborne illness. She revealed that the head cook and assistant cook are responsible to check the refrigerators daily for opened items to ensure that they are dated and she confirmed that they do not have a log for this. She revealed that this is in their job description to check the refrigerators and that they know to do this. She revealed that she spot checks the refrigerators herself and that she checked them about 2 weeks ago but she guessed that she had overlooked the bowl of chili dated 9/29/21. She revealed that the last in-service for food storage which included labeling and dating of food items was on 4/28/21 that was given by the Registered Dietician (RD). Record review of the in-service dated 4/28/21 conducted by the RD revealed that all items should be covered, labeled and dated. Leftovers thrown out after 72 hours. An interview on 10/28/21 at 8:50 AM, with the Administrator revealed that if opened food items are placed in the refrigerator without being dated that they could spoil and cause someone to get sick.