Based on observation, record review, staff and family interviews, record review, and facility policy review the facility failed to identify a bed rail as a physical restraint, failed to accurately assess the resident for the use of a bed rail, and failed to ensure that the bed rail did not pose a risk of injury from falls for one (1) of 18 sampled residents. Resident #35Findings Include: Review of the facility policy titled Physical Restraints revealed under, Physical Restraint Standards: The goal of this facility is to ensure that each resident attains and maintains his/her highest practical level of function and well-being in an environment that limits restraint use to circumstances in which the medical symptoms of the resident warrant the use of the least restrictive restraint . An observation of Resident #35 on 9/2/25 at 2:45 PM revealed she was lying in bed with her eyes closed, and the bed was against the wall on her left side, with a full-length bed rail that was located on her right side, and a bed alarm was also in use. The resident was lying on a concave with raised edges mattress. Record review of Resident #35's Bed Rail Use Screening Form dated 6/23/25 revealed under, Recommended Type Bedrail 1/4 (one-quarter) length side rails were indicated. An interview with the Assistant Director of Nursing (ADON) on 9/3/25 at 11:28 AM confirmed Resident #35's side rail assessment was not accurate. She explained that the resident had the full-length side rail already in place when she started working at the facility several months ago. The ADON stated the resident had the bed rail because a family member requested it to prevent the resident from falling. She revealed the resident tried to get out of the bed and sometimes scooted to the end of the bed trying to get up. Record review of Resident #35's Bed Rails Informed Consent for Use dated 5/3/24 revealed under, Reason Bed Rail(s) Being Considered: Resident/Resident representative (RR) requested for safety. Also revealed under, Type of Rails: Right upper and lower. An interview with the Director of Nursing (DON) on 9/3/25 at 3:48 PM revealed Resident #35's bed rail was applied because a family member was adamant about applying it due to frequent falls. She stated the family member signed the consent and understood the risk and that it could pose harm to the resident. An interview with a family member for Resident #35 on 9/4/25 at 10:36 AM revealed she knew the bed rail was a restraint and stated that was the purpose of the rail, to keep her mother in bed. She revealed a couple weeks ago the resident fell from the bed while trying to climb over the bed rail but was not hurt. Record review of Resident #35's Fall with Injury Report dated 8/13/2025 revealed under, Incident Description: Resident was hollering out Momma this Nurse and CNA (certified nurse aide) headed to room, resident was falling to the floor. Also revealed under, Immediate Action Taken: Head to toe assessment performed with abrasion noted to center of the back. An interview with the DON on 9/4/25 at 11:02 AM revealed Resident #35 did fall while trying to crawl over the bed rail and acknowledged the rail posed a greater risk for injures to the resident. She confirmed a restraint assessment was not done and acknowledged that positioning the bed against the wall, using a concave mattress along with a bed alarm and bed rail was restraining the resident from getting up easily. She confirmed this was done for family convenience related to falls rather than the safety of the resident and that the resident had not been screened properly for the restraints. Record review of the admission Record revealed the facility admitted Resident #35 on 9/21/24 with a medical diagnosis of Chronic Diastolic (Congestive) Heart Failure. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/10/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 3, which indicated Resident #35 was severely cognitively impaired.

Based on record review, staff interviews, and facility policy review, the facility failed to timely complete quarterly minimum data sets (MDS) within the time frame specified by Centers for Medicare and Medicaid Services (CMS) for three (3) of 21 minimum data sets reviewed. Resident #20, #41, #53Findings Include: Review of the facility policy titled “MDS/RAI (Resident Assessment Instrument) Standard” unrevised, revealed under, “Standard: This facility makes a comprehensive assessment of each resident’s needs, strengths, goals, life history and preferences using the RAI specified by CMS.” Resident #20 Record review of Resident #20’s Quarterly MDS with an Assessment Reference Date (ARD) of 7/26/25 revealed under section Z0500, the assessment had not been completed. Record review of the admission Record revealed the facility admitted Resident #20 on 7/10/25 with a medical diagnosis of hyperkalemia. Resident #41 Record review of Resident #41’s Quarterly MDS with an ARD of 8/2/25, revealed under section Z0500, the assessment had not been completed. Record review of the admission Record revealed the facility admitted Resident #41 on 11/15/24, with a medical diagnosis of Disorder of Bone Density and Structure, Anemia, and Peripheral Vascular Disease. Resident #53 Record review of Resident #53’s Quarterly MDS with an ARD of 7/27/25 revealed under section Z0500, the assessment was not completed. Record review of the admission Record revealed the facility admitted Resident #53 on 7/08/25 with medical diagnoses that included Severe Sepsis with Septic Shock. An interview with the MDS Nurse on 9/3/25 at 3:15 PM confirmed Resident #20, #41, and #53’s quarterly assessments were completed late. She explained that she had been out sick and fell behind in getting the assessment completed. The MDS Nurse stated the assessments should be closed and submitted timely to have accurate information on the residents and for payment purposes. An interview with the DON on 9/3/25 at 3:23 PM revealed her expectations were for the MDS assessment to be completed and submitted within the designated timeframe specified by CMS. She explained that she did not review the assessment to ensure they were completed timely.

Based on record review, staff interviews, and facility policy review, the facility failed to timely encode and transmit a discharge Minimum Data Set (MDS) as required by the Centers for Medicare and Medicaid Services (CMS) guidelines for one (1) of twenty-one (21) MDS reviewed. Resident #58.Findings Include:Review of the facility policy titled MDS/RAI (Resident Assessment Instrument) Standard unrevised, revealed under, Standard: This facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences using the resident assessment instrument (RAI) specified by CMS.Record review of Resident #58's Discharge MDS with an Assessment Reference Data (ARD) of 6/6/25 revealed under section Z0500, an assessment completion date of 8/6/25, which indicated the assessment was completed late.Record review of the MDS Final Validation Report revealed Resident #58's Discharge MDS was accepted by CMS on 8/20/25 with a warning message that read, Assessment completed late: Z0500B (assessment completion date) is more than 14 days after A2300 ARD. An interview with the MDS Nurse on 9/3/25 at 3:15 PM confirmed Resident #58's discharge assessment was completed late. She explained that she had been out sick and fell behind in getting the assessment completed. The MDS Nurse stated the assessments should be closed and submitted timely to have accurate information on the residents and for payment purposes. An interview with the Director of Nursing (DON) on 9/3/25 at 3:23 PM revealed her expectations were for the MDS assessment to be completed and submitted within the designated timeframe specified by CMS. She explained that she did not review the assessment to ensure they were completed timely. Record review of the admission Record revealed the facility admitted Resident #58 on 1/22/25 with medical diagnoses that included Anorexia and Repeated Falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review and facility policy review, the facility failed to ensure the residents' environment was maintained in a homelike and sanitary manner as evidenced by the presence of a black substance in the grout lines of the shower stall wall tile, missing wall paint behind beds (Resident #17 and Resident #27) and torn bathroom flooring (Resident #4) for four (4) of 35 resident and facility rooms observed. The facility received F584 on the last annual survey therefore the scope and severity was raised to E. Findings Include: Review of the facility policy titled “Shower and Tub Room Cleaning” revised 1/16 revealed under, “Procedure Description: This procedure will remove soap scum, dirt and debris from these areas providing a safe and sanitary place for the residents to bathe.” Also revealed under, “Procedure: … 2. Shower stall walls need to be cleaned daily using cloth and spray bottle of disinfectant solution. It may be necessary to use a scrub brush and diluted all purpose cleaner or tub/tile cleaner on walls monthly to remove residue from grout and corners.” Review of the facility policy titled Homelike Environment revised 5/22 revealed under, Standard: Residents are provided a safe, clean, comfortable and homelike environment.On 9/2/25 at 10:23 AM, an observation of the shower room revealed that the lower shower wall tiles in the left stall were covered with a thick black substance along the grout lines and extended approximately five (5) to six (6) tiles up from the floor, reaching higher in the back two corners. The right shower wall tiles were the same and covered with a black substance in the crevices of the grout lines and extended approximately four (4) tiles up from the floor. Shower Room An observation of the shower stalls with Housekeeping Staff #2 on 9/2/25 at 10:28 AM confirmed the black substance in the grout lines of the tile. She stated, It looks like mold, and revealed that a member of housekeeping was responsible for cleaning the showers and acknowledged that the condition was not a sanitary environment for residents. She confirmed that she cleaned the showers every evening at the end of the day with Clorox and water. She stated she did not have any products to clean the tile thoroughly to remove the buildup and stated, It looked like that when I came here, and acknowledged she had not tried to clean the walls with a scrub brush to remove the buildup and the black substance. An observation and interview with the Administrator on 9/2/25 at 10:39 AM confirmed the showers should be cleaned thoroughly each day, including the walls, to remove any buildup and mold. He revealed that residents should have a clean, sanitary environment so infections do not spread. Resident #4 During an observation on 9/2/25, at 12:22 PM, it was noted that the linoleum flooring in Resident #4's bathroom had a torn area measuring approximately four (4) inches by five (5) inches, which exposed the concrete floor beneath. During an observation and interview on 9/4/25, at 8:55 AM, with the Maintenance Director and Director of Nursing (DON), both confirmed the presence of the torn area and acknowledged that it constituted a potential fall risk for residents, stating they were unaware of the damage prior to the observation. Record review of Resident #4’s “admission Record” revealed the resident was admitted to the facility on [DATE], with a medical diagnosis that included Chronic Obstructive Pulmonary Disease (COPD). Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/9/25, revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating Resident #4 is moderately cognitively impaired. Resident #17 During an observation on 9/2/25, at 1:48 PM, it was noted that there was a large area on the wall behind the headboard of Resident #17’s bed that measured approximately three (3) feet by four (4) feet, exhibiting scratched and damaged paint. On 9/4/25, at 8:43 AM, an observation and interview with the Maintenance Director and DON, both individuals confirmed that the damaged area on the wall should have already been repainted, acknowledging that it detracts from the quality of the living environment for the resident. Record review of Resident #17 ’s “admission Record” revealed the resident was admitted to the facility on [DATE], with a medical diagnosis that included Other Seizures. Record review of the MDS with an ARD of 8/13/25, revealed a BIMS score of 14, indicating Resident #17 is cognitively intact. Resident #27 During an observation on 9/2/25, at 12:22 PM, it was noted that there was a large area on the wall behind the headboard of Resident #27’s bed that measured approximately three (3) feet by four (4) feet, exhibiting scratched and damaged paint. On 9/4/25, at 8:53 AM, an observation and interview with the Maintenance Director and DON, both individuals confirmed that the damaged area on the wall should have already been repainted, acknowledging that it detracts from the quality of the living environment for the resident. Record review of Resident #27 ’s “admission Record” revealed the resident was admitted to the facility on [DATE], with a medical diagnosis that included Parkinson’s Disease. Record review of the MDS with an ARD of 5/30/25, revealed a BIMS score of 14, indicating Resident #27 is cognitively intact.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to develop the comprehensive care plan for one (1) of 18 sampled residents. (Resident #17) F656 was cited during the last annual survey, therefore the scope and severity was raised to E. Findings include:Review of the facility policy titled, Resident Centered Care Planning: Baseline Care Plan, dated 4/2025 outlines the standard: The facility shall develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Record review of Resident #17's Activities of Daily Living (ADLs) Care Plan date initiated 11/30/23 revealed, Interventions/Tasks did not include nail care.An observation and interview on 9/2/25 at 10:53 AM, with Resident # 17 revealed her fingernails were one-half inch in length, jagged, and had a brown substance underneath. Resident #17 expressed a desire to have her nails trimmed, stating she preferred them to be trimmed short. An interview on 9/3/25 at 11:09 AM, with Licensed Practical Nurse (LPN) #1 stated Resident #17's fingernails should have been trimmed by the nursing staff. She further verbalized the resident was at an increased risk for infection and skin tears due to having long, dirty jagged fingernails. An interview on 9/3/2025 at 11:35 AM, with the Minimum Data Set (MDS) Coordinator, she confirmed that the ADL care plan did not include nail care and was not fully developed. She verbalized that the care plan should have been developed to direct the care needed for the resident.Record review of the admission Record indicated that the facility admitted Resident #17 on 2/28/2023, with a medical diagnosis that included Other Seizures. A record review of the MDS with an Assessment Reference Date (ARD) of 8/13/25, revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 14 which indicated Resident #17 was cognitively intact.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide Activities of Daily Living (ADL) care to maintain personal hygiene for one (1) of 18 sampled residents. (Resident #17) F677 was cited during the last annual survey, therefore the scope/severity was raised to E. Findings include:Review of the facility policy titled, Resident Hygiene: Care of Fingernails/Toenails, with a review date of 6/22 outlines the purpose of providing nail care: To clean the nail bed, to keep nails trimmed and to prevent infections. During an observation and interview on 9/2/25 at 10:53 AM, Resident # 17 revealed her fingernails were one-half inch in length, jagged, and had a brown substance underneath. Resident #17 expressed a desire to have her nails trimmed, stating she preferred them to be trimmed short. During an interview on 9/3/25 at 11:09 AM, Licensed Practical Nurse (LPN) #1 stated Resident #17's fingernails should have been trimmed by the nursing staff. She further verbalized the resident was at an increased risk for infection and skin tears due to having long, dirty jagged fingernails. During an interview on 9/3/2025 at 11:16 AM, with the Director of Nursing (DON), she confirmed that usually nailcare is performed during bath time by the Certified Nursing Assistants (CNAs) for non-diabetic residents. She acknowledged that long, dirty, jagged fingernails increased the risk of infections. The DON expressed her expectations that residents' nails should be kept clean and trimmed as necessary. Record review of the admission Record indicated that the facility admitted Resident #17 on 2/28/2023, with a medical diagnosis that included Other Seizures. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/13/25, revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 14 which indicated Resident #17 was cognitively intact.

Based on observation, record review, facility policy review and staff interview, the facility failed to implement Enhanced Barrier Precautions (EBPs) as per Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines for one (1) of one (1) resident (Resident #16) observed during Percutaneous Endoscopic Gastrostomy (PEG) medication administration. The nurse did not don appropriate personal protective equipment (PPE) before handling the PEG tube, creating the potential for cross-contamination and infection spread. F880 was cited during the last annual survey, therefore the scope and severity was raised to E. Findings Include:Review of facility policy titled Enhanced Barrier Precautions, with a revision date of 5/2024, revealed, Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a multi-drug resistant organism (MDRO) as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). On 9/3/25 at 9:10 AM, an observation of medication administration via (by) PEG tube with Resident #16, observed Licensed Practical Nurse (LPN) #1 not using Enhanced Barrier Precautions and the nurse did not wear a gown while administering medications to a resident at high risk for infections. An interview on 9/3/25, at 9:30 AM with LPN#1, she stated she forgot to wear her gown and that PPE was available and accessible to staff. She was able to verbalize that the purpose of wearing a gown would be to reduce infection risk when coming in and out of the resident's room. An interview with the Director of Nursing (DON) on 9/3/25 at 11:00 AM, regarding EBP, stated that LPN#1 usually wears her gown and was probably nervous. She confirmed that she should have worn a gown to administer peg medications. She stated that the policy on EBP was in place and education was provided for staff and that an EBP sign was posted at resident's door to remind the staff to wear PPE. Record review of the admission Record revealed that the facility admitted Resident #16 on 8/07/25 with a medical diagnosis that included Pneumonia unspecified organism and Gastrostomy Status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview, record review, and facility policy review, the facility failed to ensure each resident was treated with dignity and respect for seven (7) of 16 residents sampled. Residents #3, #4, #5, #6, #7, #9, and #10. Findings include: Record review of facility policy titled, Resident Rights and Dignity Management - Dignity dated 5/22, revealed, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality. 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights at all times. 5. When interacting with a resident, pay attention to the resident as an individual. 9. Speak respectfully to residents . 10. Respect the resident's living space and personal possessions. 14. 'Treated with dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. 15. Staff shall speak respectfully to the residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his room number, diagnosis or care needs. 20. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed. 21. Staff shall treat cognitively impaired residents with dignity and sensitivity. Record review of facility policy titled, Resident Rights and Dignity Management - Resident Rights dated 5/2022, revealed, Employees shall treat all residents with kindness, respect and dignity. Record review revealed that the State Agency (SA) received an anonymous complaint that stated that Certified Nursing Assistant (CNA) #1 was verbally and mentally abusing residents and the staff had reported it many times to the Administrator but nothing had been done. Resident #3 An interview with Resident #3 on 11/18/24 at 10:30 AM, revealed CNA #1 had a bad attitude problem. She stated several weeks ago, CNA #1 came into her room and had pushed the lift towards her and she had to stop it with her foot to keep it from hitting her. She stated she told the CNA to be careful, but she acted like she did not even care. She stated the facility was her home and she had the right to feel cared for and to not have to deal with a grumpy worker with a mean attitude. She stated she had talked to the Social Worker and the Administrator about this. Record review of the admission Record revealed the facility admitted Resident #3 on 7/20/17. Record review of Resident #3's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/22/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Resident #4 An interview on 11/18/24 at 10:45 AM, with Resident #4 revealed, We have one CNA here that is a wild one and her name is (proper name for CNA #1). She stated when she has asked her to do things for her that she would often ignore her or make rude comments like What do you want now. She stated she did not feel that it was at the level of abuse and was not afraid of here, but she felt that her rights as a resident to be treated with dignity and respect were not honored by this CNA. She stated she had talked with the Social Worker in the past about these concerns with CNA#1. Record review of the admission Record revealed the facility admitted Resident #4 on 7/26/23. Record review of Resident #4's MDS with ARD of 11/5/24 revealed a BIMS score of 15 which indicated the resident was cognitively intact. Resident #5 During an interview on 11/18/24 at 10:48 AM, Resident #5 stated CNA #1 had a bad attitude and had been rude and disrespectful to her. She stated, It might just be her way, but I don't like to be talked to like that. She also stated that Respect was not in (proper name removed) CNA #1's repertoire. She stated, I tell the staff that I might be old but there is not a damn thing wrong with my mind. She stated that she did not feel that this was verbal abuse but being treated disrespectfully in her own home did go against her rights as a resident of the facility. Record review of admission Record revealed the facility admitted Resident #5 on 3/25/16. Record review of Resident #5's MDS with ARD of 10/28/24 revealed a BIMS score of 15 which indicated the resident was cognitively intact. Resident #6 During an interview on 11/18/24 at 11:15 AM, Resident #6 revealed some staff are just awful and will not listen to him. He stated, They just do what they want to do. He stated he told them to Give me their ear and listen to what I'm trying to tell them instead of doing what you want to do for me. He stated he had told CNA #1 and others that I'm going to the boss and tell him, and they tell him to go ahead and tell him and they will tell on me too. He also stated that CNA #1 told him he needed to go somewhere else since he could do some of his own care, and he told her this was his home, and he had the right to be there. He stated he had mentioned these concerns to the Social Worker and to the Administrator. He stated he did not feel abused, but he did feel very disrespected by CNA #1. Record review of admission Record revealed Resident #6 was admitted to the facility on [DATE]. Record review of Resident #6's MDS with ARD of 10/21/24 revealed a BIMS score of 13 which indicated the resident was cognitively intact. Resident #7 During an interview on 11/18/24 at 11:30 AM, Resident #7 revealed that CNA #1 Smarts off to me all the time. He stated he did not remember what was said each time, but did know she was very rude and mean, not abusive, but definitely not nice. He stated she also put his meal tray down roughly and it fell on him. He stated that she also complained a lot about having to reposition him and adjust his bed with the manual crank. Record review of admission Record revealed the facility admitted Resident #7 on 4/17/24. Record review of Resident #7's MDS with ARD of 10/4/24 revealed a BIMS score of 8 which indicated the resident had moderate cognitive impairment. Resident #9 During an interview on 11/19/24 at 2:00 PM, Resident #9 revealed some of the staff had been disrespectful to her. She stated she had pressed the call light for assistance and a staff member came in and asked what she needed now in a rude and mean way and then made comments about how the room smelled awful. She stated she could not help that she could not control her bowels or bladder and for the staff to say that was very disrespectful to her and it was not treating her with dignity. She stated she had the right to be treated with dignity and respect and making comments like that was not acceptable. Record review of admission Record revealed the facility admitted Resident #9 on 2/12/18. Record review of Resident #9's MDS with ARD of 9/13/24 revealed a BIMS score of 15 which indicated the resident was cognitively intact. Resident #10 An interview on 11/19/24 at 2:10 PM, with Resident #10 revealed some of the staff had bad attitudes and treated him and other residents disrespectfully. He stated one nurse was rude and he felt that she always questioned what he said he needed. He stated he received the care needed but at times it was with attitude and those with bad attitudes either need to be respectful or go home. Record review of admission Record revealed the facility admitted Resident #10 on 7/25/24. Record review of Resident #10's MDS with ARD of 9/27/24 revealed a BIMS score of 12 which indicated the resident had moderate cognitive impairment. Record review of the Grievance Log for the past six (6) months did not reveal any of the concerns voiced by these residents. Interview on 11/18/24 at 11:45 AM, with CNA # 2 stated CNA #1 was loud and her voice carried. Interview on 11/18/24 at 11:55 AM, with the Registered Nurse (RN) supervisor, stated she works both rotations, so she is aware of most of the staff and CNA #1 is thorough and gets the job done but she is loud and sounds blunt when talking and does not have a friendly tone. Interview on 11/18/24 at 1:40 PM, with CNA #3, stated at one time, CNA #1 was kinda shaky with the way she would talk, not abusive, but rude. She stated she is loud and rough and sounds mean and disrespectful but she had been trying to talk softer and kinder and she has made a complete turnaround. CNA #3 stated that CNA #1 would do good care for her residents but not with a friendly attitude. Interview on 11/18/24 at 1:48 PM, with Licensed Practical Nurse (LPN) #1 stated she works with CNA #1 almost every shift since they are on the same rotation and she had never heard her say anything that was mean or disrespectful to a resident, but that she does have a higher volume of speech. Interview on 11/19/24 at 10:50 AM, with CNA #1 confirmed that she has a loud voice, and it carries and she knows she sometimes sounds grumpy, but that is the way her voice is. She stated that she takes care of her residents and tries to do what she can for them to meet their needs. She acknowledged that she may appear rough and loud, but she tries to do her job in a good way and that she just thinks her voice is loud. During an interview on 11/19/24 at 3:00 PM, the Director of Nursing (DON) confirmed that each resident has the right to be treated with dignity and respect and the facility failed to ensure that each resident's rights were honored. During an interview on 11/19/24 at 4:00 PM, the Administrator stated each resident deserves to be treated with dignity and respect and he confirmed that there were several residents that were not treated with dignity and respect and the facility failed to honor each of these resident's rights. He stated that the facility had recently investigated an allegation of abuse with CNA #1 but was not able to substantiate the allegation and it had been reported to the State Agency. He stated that the CNA was suspended while the investigation was going on but it was not related to these concerns. He confirmed that there was a witness to this recent allegation and that it just didn't occur after the statements were gathered.

Based on observation and staff and resident interviews the facility failed to provide a safe clean environment as evidenced by a wheelchair with a torn armrest, a dirty oxygen concentrator, an overbed table with tattered and torn edging and overbed tables with a thick black substance on the metal base for three (3) of 44 residents rooms observed. Resident #13, Resident #31, and Resident #39 Findings include: An interview with the Administrator on 4/25/24 at 9:23 AM, revealed the facility did not have a policy addressing repairing and cleaning equipment. Resident #13 An observation and interview on 4/23/24 at 6:50 AM, revealed Resident #13 lying in bed with her overbed table pulled up to her. The overbed table edging was off around the table with exposed chipped wood. The metal base of the overbed table had a thick black substance. Resident #13 stated, I need a new table. It's been like this for a long time. During an interview and observation on 4/24/24 at 9:00 AM, Licensed Practical Nurse (LPN) #3 confirmed Resident #13's overbed table needed to be replaced because the edging around the table was tattered and torn and revealed the torn edging could cause a skin tear. Resident #31 An observation on 4/23/24 at 7:25 AM and again at 3:45 PM, revealed Resident #31's oxygen concentrator sitting by her bed with a brown and gray substance down the front and on top of the oxygen concentrator. Resident #31's overbed table had a thick brown and black substance on the metal base. During an observation and interview on 4/24/24 at 9:05 AM, LPN #3 revealed the cleaning of the oxygen concentrators is the responsibility of the nursing department but stated, really anyone who sees it can clean it. She confirmed that the oxygen concentrator was dirty and needed to be cleaned and that the metal base on the overbed table needed to be cleaned and revealed housekeeping usually does that. She revealed the metal base looks like it has rust, but it does need cleaning. Resident #39 Observation on 4/23/24 at 8:05 AM, revealed Resident #39 sitting in the dining room in a wheelchair with the left side armrest vinyl tattered and torn with jagged edges exposed where the resident's arm rested on the armrest Observation on 4/23/24 at 9:44 AM, revealed Resident #39's overbed table had a thick black substance scattered on the metal base. An interview and observation on 4/24/24 at 9:25 AM, Certified Nurse Aide (CNA) #1 revealed it is the CNA's responsibility to report any wheelchairs that are in disrepair to the Maintenance Director. She confirmed Resident #39's left armrest on his wheelchair needed to be repaired and revealed she had not reported the wheelchair to anyone. She confirmed the metal base on his overbed table was dirty and needed to be cleaned. She revealed housekeeping is responsible for cleaning the rooms. An observation and interview on 4/24/24 at 9:30 AM the Housekeeping Supervisor revealed that the nursing department is usually responsible for cleaning the oxygen concentrators and the housekeeping department is responsible for cleaning the overbed tables. She confirmed that the overbed tables for Resident #13, Resident #31, and Resident #39 had a thick substance on the metal base and the edging on Resident #13's overbed tabletop was torn and needed to be replaced. She revealed we can try and clean the metal bases on the overbed tables, but I think it's thick rust or old paint peeling. She confirmed the overbed tables looked bad and she would see what she could do to clean them. An observation and interview on 4/24/24 at 10:09 AM, the Administrator confirmed the left armrest on Resident #39's wheelchair was torn and tattered and needed to be repaired. He confirmed the overbed tables for Resident #13, Resident #31 and Resident #39 were in disrepair and needed to be either be cleaned, resurfaced, or replaced. He confirmed the tables did not look good.

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for a resident with an elopement bracelet (Resident #1) and a resident requiring nail care (Resident #24) for two (2) of 15 sampled residents reviewed during survey. Findings Include: Review of the facility policy titled Comprehensive Care Plan with a revision date of 3/2019 revealed under, Standard: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Record review of Resident #1's Care Plans, undated revealed Focus: (Proper name of Resident #1) is an elopement risk/wanderer .Interventions .Wanderguard at all times for safety . The care plan did not include any interventions to monitor the residents wanderguard bracelet. An observation on 04/23/24 at 12:49 PM revealed Resident #1 was wearing a wander guard bracelet on his left wrist. Record review of Resident #1's Elopement Evaluation dated 3/11/24 revealed the resident has a history of elopement or attempted elopement and wanders. Record review revealed that there was not any monitoring of the wander guard each shift on the Treatment Administration Record (TAR) or Medication Administration Record (MAR). Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/11/24 revealed in Section P the resident was coded for a wander/elopement alarm that was used daily. During an interview on 4/23/24 at 1:30 PM, with Registered Nurse (RN) #1 revealed Resident #1 wears a wanderguard because he has dementia and gets confused sometimes. She stated he says he wants to go home and does wander, but he has never eloped. During an interview on 4/25/24 at 8:20 AM, with the Director of Nurses (DON) revealed that it was her expectation that Resident #1's care plan would be implemented correctly because the purpose of the care plan was for staff to know what care the resident needs. She stated that the resident had gone out to the hospital and had returned and she thinks that the monitoring of the wander guard just got left off of his TAR. An interview on 4/25/24 at 9:00 AM, with Registered Nurse #1 confirmed Resident #1's care plan was not followed because the wander guard was not being monitored. Resident #24 Record review of Resident #24's care plan with an initiated date of 2/9/24 revealed Focus The resident has an ADL (Activities of Daily Living) self care performance deficit r/t (related to Dementia .Interventions . Personal Hygiene/Oral Care: The Resident requires (1) staff participation with personal hygiene and oral care . During an observation of Resident #24, on 4/23/2024 at 9:50 AM, revealed long thick discolored fingernails on the left hand that measured approximately three-eights (3/8) inch in length from the tip of the fingers. Also observed, the right fingernails measured approximately one-fourth (1/4) inch in length. During an observation and interview on 4/23/2024 at 2:39 PM, with Registered Nurse (RN) #1, confirmed Resident #24's nails were long and needed cutting. During an interview with the Director of Nursing (DON) on 4/25/2024 at 8:16 AM, revealed the purpose of the care plan was for the staff to know how to care for the resident. She revealed the personal hygiene care plan covered nail care and confirmed it was not done.

Based on observation, resident and staff interview, and facility policy review, the facility failed to perform nail care for a resident that needed assistance, as evidence by long thick fingernails for one (1) of two (2) residents reviewed for activities of daily living (ADLs). Resident #24 Findings Include: Review of the facility policy titled Care of Fingernails/Toenails with a revision date of 06/2022 revealed under, Purpose: The purpose of this procedure is to clean the nail bed, to keep nails trimmed and to prevent infections. Nail care includes cleaning and trimming as needed. Proper nail care can aid in the prevention of skin problems around the nail bed. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his/her skin (unless medically contraindicated). Resident #24 An observation and interview on 4/23/2024 at 9:50 AM, with Resident #24, revealed long thick discolored fingernails on the left hand that measured approximately three-eights (3/8) inch in length from the tip of the fingers. The nails on the right hand measured approximately one-fourth (1/4) inch in length. The resident expressed he would like his nails cut. An observation and interview with Licensed Practical Nurse (LPN) #6 on 4/23/2024 at 2:20 PM, confirmed Resident #24's nails needed cutting. She revealed a Registered Nurse (RN) must cut his nails because he was a diabetic. An observation and interview with Registered Nurse (RN) #1 on 4/23/2024 at 2:39 PM, revealed she was responsible for trimming the diabetic nails. She confirmed Resident #24's nails were long, and he could scratch himself and cause skin concerns. An interview with the Director of Nursing (DON) on 4/24/2024 at 8:14 AM revealed the Registered Nurse (RN) on duty was responsible for doing nail care for the diabetics every Tuesday, and it should be documented on the Medication Administration Record (MAR). She confirmed Resident #24 did not have this task on his MAR. She confirmed that the long nails were an infection and a personal hygiene concern.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide appropriate care and services for respiratory care, as evidenced by, failing to label and store an aerosol nebulizer mask device for one (1) of three (3) nebulizers in the facility. Resident #28 Findings Include: This citation is cross reference to: F867 Record review of the facility policy titled Respiratory System Management with a revision date of 1/2003 revealed Procedure, In Order: . 17. Rinse the nebulizer and mouthpiece. Shake to air dry and store in a plastic bag that is labeled with the resident's name and room number. Nebulizer and mouth piece may also be stored in the machine if storage shelf is available. 18. Change nebulizer set up-weekly. An observation and interview with Resident #28 on 4/23/2024 at 9:04 AM, revealed he was sitting on the edge of the bed. A nebulizer machine was sitting on a bedside table, with the nebulizer mask lying across the lower bed. The tubing and mask were undated, and the mask was unbagged. The resident revealed he used the nebulizer mask every day for his breathing and was not aware of a storage bag for the nebulizer mask. An observation of Resident #28's room on 4/23/2024 at 2:10 PM, revealed a nebulizer machine sitting on top of a bedside table with the nebulizer mask secured in an upright position on the side. The mask was not bagged, and the tubing had a piece of tape attached with a date of 4/23/2024. Record review of the Order Summary Report with active orders as of 4/24/24 revealed orders dated 3/21/24 for Arformoterol Tartrate Inhalation Nebulization Solution and Ipratropium Bromide Inhalation Solution for Chronic obstructive pulmonary disease. An observation and interview with Licensed Practical Nurse (LPN) #6 on 4/23/2024 at 2:25 PM, confirmed the nebulizer mask did not have a cover to protect it. She revealed the mask should be placed in a bag to prevent it from getting contaminated. She revealed she just changed out the nebulizer set-up and dated it. An interview with Registered Nurse (RN) #1 on 4/23/2024 at 2:42 PM, revealed the nebulizer mask should be stored in a plastic bag to prevent the formation of bacteria in the mask and the bag, mask and tubing should be changed out weekly and dated. An interview with the Director of Nursing (DON) on 4/24/2024 at 8:12 AM, revealed the nebulizer mask was to be placed in a bag when not in use to prevent infection. She revealed the bag, tubing, and mask were changed out weekly on the night shift and her expectation was for staff to do this and apply the date. Record review of the admission Record revealed the facility admitted Resident #28 on 1/27/23 with medical diagnoses that included Chronic obstructive pulmonary disease and Schizophrenia.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to ensure medications were stored appropriately and not left in the resident's room for one (1) of 15 sampled residents. Resident #31 Findings include: A review of the facility policy, titled 4.1 Storage of Medication with a date of 01/23 revealed, 4.1 STORAGE OF MEDICATION Policy: .The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . Procedures . 1. Medications are to remain in these containers and stored in a controlled environment. This may include such containers as medication carts, medication rooms, medication cabinets, or other suitable containers An observation and interview on 4/23/24 at 7:00 AM, revealed a prescription-labeled box of Latanoprost Solution eye drops and a prescription-labeled box of Cosopt Ophthalmic solution with medications inside of boxes sitting on Resident #31's overbed table. Licensed Practical Nurse (LPN) #1 entered the room and asked the resident, Why are these medications lying on your bedside table? Resident #31 revealed someone left them there. LPN #1 confirmed the medications were supposed to be locked up in the medication cart because the residents are not supposed to have medications in their rooms and revealed, the eye drop medication was given last night and should have been locked back up in the medication cart. An interview on 4/23/24 at 7:20 AM, Resident #31 revealed the nurse left the eye drops in here last night. In an interview on 4/23/24 at 2:22 PM, the Director of Nurses (DON) confirmed she was made aware of the eye medication left on the overbed table and revealed that is a no no. The DON stated, the nurses know that is not supposed to happen, all medication is to be kept locked up in the medication cart. She revealed a wandering resident could enter a resident's room and take the medications. A record review of Resident #31's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Heart Failure and Chronic Kidney Disease, Stage 3. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/14/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #31 was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and facility policy review, the facility failed to prevent the possibility of the spread of infection as evidenced by failing to utilize proper hand hygiene and maintaining a clean barrier for one (1) of five (5) care observations. Resident #13 Findings include: Review of the facility policy titled, Infection Control Standard with a revised date of 05-2023 revealed, STANDARD It is our standard to assume that patients are potentially infected or colonized with an organism that could be transmitted during the course of providing patient care services and therefore our facility applies the Standard Precautions infection control practices . 1. Hand Hygiene: a. During the delivery of patient care services, avoid unnecessary touching of surfaces in close proximity to the resident to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces . e. Staff must perform hand hygiene (even if gloves are used): iii .After contact with .nonintact skin, or wound dressing, visibly contaminated surfaces or after contact with objects in the resident's room . v . If hands shall be moving from a contaminated-body site to a clean-body site during resident care . Observation of wound care treatment for Resident #13 on 4/23/24 at 2:45 PM revealed Licensed Practical Nurse (LPN) #4 washed her hands applied clean gloves and assisted Certified Nurse Aide (CNA) #2 with turning Resident #13 to her left side. LPN #4 began removing the resident's brief and then cleaned the wound to her right buttock with wound cleanser and then applied the wound treatment without changing out her gloves and washing her hands. When the wound treatment to the right buttock was completed two unopened packages of abdominal (ABD) pads fell off the overbed table onto the floor, LPN #4 retrieved the unopened ABD packages off the floor while wearing her soiled gloves and placed the unopened ABD pads back on the clean barrier tray contaminating the clean barrier tray. LPN #4 then removed her gloves, washed her hands, and applied clean gloves. LPN #4 assisted CNA #2 with turning Resident #13 to her right-side, LPN #4 did not change her soiled gloves and proceeded to administer wound treatment to Resident #13's left outer thigh. An interview on 4/23/24 at 3:10 PM, LPN #4 confirmed she did not practice infection control measures by failing to change her gloves during wound treatment to both of the resident's wounds. She confirmed when she picked up the ABD packages from the floor while wearing her soiled gloves and laying them on the clean barrier that she contaminated her clean barrier. She confirmed that not practicing proper infection control measures could potentially cause an infection in the wound. During an interview on 4/23/24 at 3:45 PM, the Director of Nurses (DON) with LPN #4 present confirmed their policy regarding wound treatment is to make sure and change gloves and wash hands between soiled dressing and clean dressing care and confirmed by not doing so is an infection control issue and could delay healing. A record review of Resident #13's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Pressure ulcer of right buttock and Type 2 Diabetes Mellitus with Hyperglycemia.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review the facility failed to prevent the possibility of accidents and hazards for a resident who was an elopement risk by failing to monitor placement and function of a wander guard (Resident #1) and failure to secure smoking supplies for one (1) of three (3) days of survey. Findings Include Record review of the facility policy titled, Wandering/Elopement Risk with a revision date of 11/2017 revealed STANDARD It is the standard of this facility to identify those residents at risk for wandering/elopement and to take the appropriate steps to minimize the risk of elopement . The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering . of 10/2017 revealed STANDARD This facility provides a safe and healthy environment for residents .including safety as related to smoking. Safety protections apply to smoking and non-smoking residents .Standard Explanation and Compliance Guidelines .13. Smoking material will be maintained and secured by nursing staff . Resident #1 An observation on 04/23/24 at 12:49 PM, revealed Resident #1 was wearing a wander guard bracelet on his left wrist. Record review of Resident #1's Elopement Evaluation dated 3/11/24 revealed the resident has a history of elopement or attempted elopement and wanders. Record review of Resident #1's Order Summary Report with active orders as of 4/24/24 revealed there was not an order for a wander guard bracelet. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/11/24 revealed in Section P the resident was coded for a wander/elopement alarm that was used daily. An interview on 4/23/24 at 1:30 PM, with Registered Nurse (RN) #1 revealed that Resident #1 wears a wander guard because he has dementia and gets confused sometimes. She stated he says he wants to go home and does wander, but he has never eloped. An interview, observation, and record review on 4/24/24 at 4:30 PM, with Licensed Practical Nurse (LPN) #7 confirmed that Resident #1 had a wander guard bracelet on his left wrist. She stated he had worn it for a long time. She stated that anyone that has a wander guard bracelet should have an order and then it will show on either the Electronic Medication Administration Record (EMAR) or Electronic Treatment Administration Record (ETAR) to monitor it every shift. A record review of the resident's physician's orders with LPN #7 confirmed that Resident #1 did not have an order for a wander guard, and it was not triggered on the residents EMAR or ETAR to check for functioning or placement of the wander guard bracelet each shift. An interview and record review on 4/24/24 at 4:40 PM, with LPN #3 confirmed that Resident #1's wander guard bracelet had not been monitored each shift to make sure it was still on the resident and functioning. An interview on 4/25/24 at 8:20 AM with the Director of Nurses (DON), revealed it was her expectation that Resident #1's physicians order would have been put in the resident's record and triggered for the staff to monitor the resident's wander guard placement and function. She stated the residents order for a wander guard dropped off in December 2023 after he returned from a hospital stay. She confirmed a residents wander guard needs to be monitored for placement and function to prevent an elopement. Record review of Resident #1's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Schizoaffective Disorder, Bipolar Type. Smoking: An observation on 4/23/24 at 6:38 AM, revealed the smoking supply closet on the resident hall that held residents smoking supplies was unlocked. Observed a sign on the smoking supply closet door Keep this door locked at all times. An interview and observation on 4/23/24 at 6:45 AM, with Housekeeping Staff #2 confirmed the smoking supply closet was unlocked and stated they are supposed to keep that door locked at all times. Housekeeping Staff #2 stated the key is kept behind the nurse's desk. An interview and observation on 4/23/24 at 6:50 AM, with Licensed Practical Nurse (LPN) #6 confirmed that the resident smoking supply closet was unlocked, held resident's smoking supplies including at least one lighter and that it was supposed to always be locked for safety. An interview on 4/23/24 at 6:55 AM, with Registered Nurse (RN) #1 confirmed that the residents smoking supply closet was supposed to be locked at all times and the key is kept behind the nurse's station. She revealed that the purpose of keeping the smoking supply closet locked was to prevent residents from having access to the smoking supplies and the lighter. She stated there is at least one lighter in there. If the residents got a hold of the supplies they'd be smoking in the rooms and we have oxygen in the building, so it's a safety issue. Record review of the List of Resident on Designated Smoking list undated, revealed there were 9 active smokers listed. An interview with Administrator on 4/25/24 at 11:00 AM, confirmed that the smoking supplies should always be locked up to prevent the residents from having access to the smoking supplies including the lighter for safety issues and that was the facilities policy.

Based on record review and staff interview, the facility's Quality Assessment and Assurance Committee (QAA) failed to maintain implemented procedures and monitor the interventions the committee put in place following the recertification survey of 2/2/2023. This was for a deficiency recited during a recertification and complaint survey on 4/23/2024 in the area of F695 Respiratory/Tracheostomy Care and Suctioning. The continued failure of the facility during two State Surveys of record shows a pattern of the facility to sustain an effective QAA program. This was for one (1) of eight (8) deficient practice citations. Findings Included: This citation is cross-referenced to: F695 Review of the facility policy titled Quality Assurance and Performance Improvement with a revision date of 8/2023 revealed Standard: It is the standard of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Focused Rounds: Focused Rounds are intended to discover areas of concern before they become a problem for the facility. Focused Rounds take the form of short checklist devoted to specific practices and concerns and are conducted on a regular basis . An interview with the Administrator (ADM) on 4/25/2024 at 9:05 AM, revealed he was not aware that the nebulizer mask was not being stored appropriately and was a concern for the facility again. He revealed the interdisciplinary team (IDT) did discuss this in QAPI (Quality Assurance and Performance Improvement) after the facility was cited on this in February 2023. He revealed they implemented measures to ensure this did not happen again. The ADM explained that they made rounds to ensure all the nebulizers were stored in a bag, and they did in-services with the staff. He revealed the plan failed because they have a lot of new staff. He revealed the nurses should have been trained on hire that respiratory equipment was to be placed in a bag. The ADM revealed his expectation was for that information to be relayed to the new staff, but he stated, it must have fallen through. Record review of the Facility's Plan of Correction (POC) dated 3/10/2023 revealed under, 3. Education on Respiratory Management was provided to Nursing staff in person by our Nurse Educator on 2/03/2023 and assigned via (proper name) on 2/03/2023 with a completion date of 2/10/2023. Education on Infection Control was provided to clinical staff in person on 2/03/2023 by Nurse Educator and Via (proper name) on 2/03/2023 with a completion date of 2/10/2023. 4. Unit Manager/register nurse Supervisors to make daily audits using the Oxygen/Nebulizer audit form for 30 days beginning 2/03/2023 to ensure of proper storage of respiratory equipment. The Director of nursing /Nurse Educator will complete 5 audits using the Oxygen/Nebulizer audit form weekly x 4 weeks beginning 2/10/2023 then 5 audits biweekly for 60 days to ensure proper storage of respiratory equipment. The monitoring we have in place for this deficiency will be discussed at our monthly Quality Assurance and Performance Improvement meeting on 3/9/23 and then monthly for 2 months completing on 5/9/23. Review of the facility's Quality Assurance and Performance Improvement (QAPI) Meeting Notes dated 3/9/2023 revealed . Conclusions and Recommendations: . Plan of correction discussed with audit tools in place to monitor with no issues noted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, record review and facility policy review, the facility failed to resolve resident's grievances regarding allegations of verbal abuse from the staff for five (5) of 10 residents reviewed for unresolved grievances. Residents #1, Resident #2, Resident #5, Resident #6 and Resident #7. Findings Include: Review of the facility policy titled Grievance/Concern/Comments with a revision date of 12/2021 revealed under Standard .Residents and their family members may voice grievances to the facility or other agency/entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal The facility will make prompt efforts to resolve grievances. Resident #1 During an observation and interview on 2/7/24 at 7:40 PM, with Resident #1 revealed there was one Certified Nurse Assistant (CNA) that had talked ugly to her and other residents. She stated one night recently she was sleeping, and her arm hit the top of her overbed table and knocked a drink off and spilled it on the floor. She revealed that when she used her call light and CNA #1 came to her room. She told her what had happened and the CNA told her that she told her she wasn't cleaning that up. CNA #1 went and got a towel and brought it back and told her to get up and clean it up. She stated that she could not get herself out of bed to do that and that made her cry. She revealed CNA #1 did end up cleaning the spill. She stated she reported this incident to the Administrator and the Director of Nurses (DON). Record review of Resident #1 admission Record revealed the resident was admitted to the facility on [DATE] with a medical diagnosis that included Urinary Tract Infection. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/17/24 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicates the resident is cognitively intact. Resident #2 During an interview and observation on 2/8/24 at 8:45 AM, with Resident #2 he stated the only problem he has had was with CNA #1 on the night shift, is that she is young. Resident #2 stated , I just don't think she knows how to talk to people, because she talks short and ugly to people at times. He revealed that normally the day shift makes his bed, but one day they forgot, and he was trying to make it up around 6:30 PM that night and had asked CNA #1 to help him. He stated that she told him she was passing snacks, and it would have to wait. He stated that he asked her if passing snacks was more important than helping him get his bed made so he could lay down and as she walked out of his room she said, Make it yourself. Record review of Resident #2's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure. Record review of Resident #2's MDS with an ARD of 11/14/23 revealed in Section C a BIMS score of 15, which indicates the resident is cognitively intact. Resident #5 During an interview and observation on 2/8/24 at 8:30 AM, with Resident #5 revealed some of the CNA's talk ugly to her and one time they cussed at her. Resident #5 stated but I don't remember their names. Record review of Resident #5 admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Acute or Chronic Systolic (Congestive) Heart Failure. Record review of Resident #5's MDS with an ARD of 10/30/23 revealed in Section C a BIMS score of 14, which indicates the resident is cognitively intact. Resident #6 During an interview on 2/8/24 at 10:50 AM, with Registered Nurse (RN) #2 revealed that Resident #6 had reported to her last week that CNA #1, the aide on the night shift talks ugly and treats her ugly and that she reported this to the DON and informed the resident that she could talk with the Social Worker about it the next day. During an interview on 2/8/24 at 12:00 PM, with Resident #6 she stated that her only issue has been with CNA #1 on the night shift and that she talks ugly to her and tells her to stay off her call light so much at night. She stated that CNA #1 threatens her and says they will send her to behavioral health if she does not do what they tell her to do. She stated that she has reported this issue to the DON and RN #2 and stated, Please tell me you are going to do something about this. Record review of a note dated 2/3/24 at 15:26 (3:26 PM) revealed Type: eMAR-Medication Administration Note revealed (Proper name of CNA #1) and the other girl that works with her. They are thick as thieves, and they always threaten they are gonna get me sent off to behavioral. I don't know why they treat me like they do .DON was aware . Record review of Resident #6's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus with other Diabetic Neurological Complications. Record review of Resident #6's MDS with an ARD of 1/18/24 revealed in Section C a BIMS score of 13, which indicates the resident is cognitively intact. Resident #7 During an observation and interview on 2/7/24 at 7:50 PM, with CNA #1, CNA #2 and CNA #3 revealed that they were the three CNA's working the night shift and they revealed they have had in-services on abuse. During this interview while in the hallway, Resident #7 was self-propelling her wheelchair and when she passed, she stated to the CNA's, I need to go to the bathroom. CNA #1 responded quickly to the resident, Well you're gonna have to wait until I get done talking. During an interview on 2/7/24 at 8:00 PM, with RN #1, was informed of the manner and tone that CNA #1 had used in response to Resident #7. RN #1 confirmed that could be verbal abuse to a resident. She stated That is not an appropriate way to talk to residents. During an interview on 2/7/24 at 8:05 PM, with CNA #1 she confirmed that she had told Resident #7 she would have to wait until she was done talking when the resident asked to be helped to the bathroom. She stated that she did not mean it to sound rude and admits that she has been in-serviced on verbal abuse. She revealed that she had only had one complaint from a resident about her and that one complaint was from Resident #1. She had complained that I had knocked a drink off of her table, but I did not do that. She did it, but I did cleaned it up and I told the Director of Nursing (DON) that I cleaned it up. During an interview on 2/8/24 at 11:40 AM, with Licensed Practical Nurse (LPN)/Social Services confirmed that she had some complaints on CNA #1 talking ugly to the residents and that Resident #7 filed a formal grievance around the first of January that CNA #1 had refused to get her up that morning and talked ugly to her. She stated that on 1/7/24 Resident #2 came to her office to complain about CNA #1, and she asked him if he could wait to let her get the DON and the Administrator in there so they could hear, and he agreed. She revealed that the DON and the Administrator came to her office and the resident revealed that CNA #1 was passing snacks around 6:30 PM and when he asked her to help him make his bed, she told him she was busy passing snacks. She stated that the resident told them that he asked her if passing snacks that early was as important as helping him make his bed and then as she walked out of the room, she rudely told the resident to make it up himself. She revealed that Resident #1 complained to her on 2/6/24 about CNA #1 and that the resident complained that she had accidentally spilled her drink and CNA #1 told her You going to get that up. She stated that she asked the resident if she wanted to talk with the DON or the Administrator and the resident stated no that she already had, and they were going to take care of it. During an interview on 2/8/24 at 12:30 PM, with Resident #7 confirmed that CNA #1 told her she would Have to wait until she was done talking when she told her she needed to go to the bathroom last night. She stated that CNA #1 was rude but that wasn't the first time, and she is used to it from her. She revealed that she had complained about it to a lot of people, but it does no good; nothing gets done. She revealed she just don't say anything anymore. She stated that she is supposed to go to the bathroom every 2 hours and usually goes at 4:30,and she has told CNA #1 this. CNA #1 told her that she was not coming straight to her as soon as she came on duty to take her to the bathroom, so she knows to not even ask until around the time she ask last night (around 8 PM). She confirmed that she filed a formal grievance back in January of this year, because the night CNAs that included CNA #1 came in her room around 4 AM and told her if she did not get up right then, then she would have to wait until day shift got there to get up. She stated that she was supposed to get up around 5:30 AM and they never came back to get her up. She confirmed that this had been reported to the Social Worker, Administrator, the DON, and some of the other nursing staff but could not remember their names. Record review of Resident #7 admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus without Complications. Record review of Resident #7's MDS with an ARD of 10/30/23 revealed in Section C a BIMS score of 15, which indicates the resident is cognitively intact. Record review of the Grievance/Concern/Comment Report dated 1/2/24 revealed a formal grievance was filed regarding CNAs on the night shift not getting Resident #7 out of bed as requested. During an interview on 2/8/24 at 9:30 AM, with the CNA Supervisor revealed there has been one complaint from a resident back in November 2023 or December about night shift CNA #1 being rude to a resident and that she reported it to the DON and she took care of it. During an interview on 2/8/24 at 10:00 AM, with CNA #4 and CNA #5 revealed that they normally work day shift but sometimes they have to help and work night shift and that some of the residents complain about a CNA on the night shift that is rude to them but would rather not mention any names. She stated that she thinks that everyone knows it and is sure it has been reported to the DON and the Administrator. During an interview on 2/8/24 at 1:40 PM, with the DON confirmed that all staff receive abuse in services on hire and annually unless there is an issue and then we can do one anytime in our computer in-service system. She revealed that as far as she knows there has not been an issue in order to have to do an additional abuse in-service. She admitted that she had received a complaint on CNA #1 on 2/6/24, but that was the first complaint she had on the staff member, and she is not aware of any more complaints on other staff regarding talking disrespectfully. She stated that Resident #1 reported an issue to her on 2/6/24 that CNA #1 talked disrespectfully to her. The DON stated she came in last night and talked to CNA #1 about that issue around 6 PM. During an interview on 2/8/24 at 2:00 PM, with the Administrator, DON, and LPN/Social Services confirmed they had complaints about CNA #1 talking inappropriately to some of the residents. The Administrator stated that the reports he had from Resident # 1 and Resident #2 just did not seem like verbal abuse to him. Both agreed that the reports of how the CNA spoke to Resident #7 last night and how she said it was inappropriate and disrespectful. The DON confirmed at this time that she had known about the report from Resident #1 and Resident #2. When the State Agency (SA) inquired about Resident #6 and her complaint, the DON stated yes, she came into the office and also had a complaint. The DON verified that she had three (3) residents complain about how CNA #1 talked to them. The Administrator stated that CNA #1 had been talked to last night about the complaint that came in on 2/6/24 with Resident #1. The Administrator stated he was not aware that CNA #1 had told Resident #2 to make his own bed as she walked out of his room, but LPN/Social Services confirmed that he did report that to them. The Administrator confirmed that he was aware of the grievance that Resident #7 had filed about them not getting her up when she wanted to but was not aware that either one of them had told her that if she did not get up now, then she would not get up until day shift got there. He admitted that they would have to do an investigation and more than likely let CNA #1 go. During an interview on 2/8/24 at 2:20 PM, with LPN/Social Services confirmed that Resident #1 complained on 2/6/24, Resident #2 complained on 1/7/24 and Resident #7 filed a formal complaint on 1/3/24. Record review of the facility in-services from the last 6 months revealed there was an abuse in-service held in 1/2024 for all staff but was not attended by CNA #1. Record review of CNA#1 employee file revealed that she completed in-services on abuse on 9/25/23 and 12/11/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, record review and facility policy review, the facility failed to ensure residents were free from verbal abuse for five (5) of 10 residents reviewed for abuse. Residents #1, Resident #2, Resident #5, Resident #6 and Resident #7. Findings Include Review of the facility policy titled, Freedom of Abuse, Neglect and Exploitation with a revision date of 11/2019 revealed .Standard Statement : This facility shall not condone any acts of resident mistreatment, neglect, verbal, .or mental abuse . Resident #1 An observation and interview on 2/7/24 at 7:40 PM, with Resident #1 revealed there was one Certified Nurse Assistant (CNA) that had talked ugly to her and other residents. She stated one night recently she was sleeping, and her arm hit the top of her overbed table and knocked a drink off and spilled it on the floor. She revealed that when she used her call light and CNA #1 came to her room. She told her what had happened and the CNA told her that she told her she wasn't cleaning that up. CNA #1 went and got a towel and brought it back and told her to get up and clean it up. She stated that she could not get herself out of bed to do that and that made her cry. She revealed CNA #1 did end up cleaning the spill. She stated she reported this incident to the Administrator and the Director of Nurses (DON). Record review of Resident #1 admission Record revealed the resident was admitted to the facility on [DATE] with a medical diagnosis that included Urinary Tract Infection. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/17/24 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicates the resident is cognitively intact. Resident #2 An interview and observation on 2/8/24 at 8:45 AM, with Resident #2 he stated the only problem he has had was with CNA #1 on the night shift, is that she is young. Resident #2 stated , I just don't think she knows how to talk to people, because she talks short and ugly to people at times. He revealed that normally the day shift makes his bed, but one day they forgot, and he was trying to make it up around 6:30 PM that night and had asked CNA #1 to help him. He stated that she told him she was passing snacks, and it would have to wait. He stated that he asked her if passing snacks was more important than helping him get his bed made so he could lay down and as she walked out of his room she said, Make it yourself. Record review of Resident #2's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure. Record review of Resident #2's MDS with an ARD of 11/14/23 revealed in Section C a BIMS score of 15, which indicates the resident is cognitively intact. Resident #5 An interview and observation on 2/8/24 at 8:30 AM, with Resident #5 revealed some of the CNA's talk ugly to her and one time they cussed at her. Resident #5 stated but I don't remember their names. Record review of Resident #5 admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Acute or Chronic Systolic (Congestive) Heart Failure. Record review of Resident #5's MDS with an ARD of 10/30/23 revealed in Section C a BIMS score of 14, which indicates the resident is cognitively intact. Resident #6 An interview on 2/8/24 at 10:50 AM, with Registered Nurse (RN) #2 revealed that Resident #6 had reported to her last week that CNA #1, the aide on the night shift talks ugly and treats her ugly and that she reported this to the DON and informed the resident that she could talk with the Social Worker about it the next day. An interview on 2/8/24 at 12:00 PM, with Resident #6 she stated that her only issue has been with CNA #1 on the night shift and that she talks ugly to her and tells her to stay off her call light so much at night. She stated that CNA #1 threatens her and says they will send her to behavioral health if she does not do what they tell her to do. She stated that she has reported this issue to the DON and RN #2 and stated, Please tell me you are going to do something about this. Record review of a note dated 2/3/24 at 15:26 (3:26 PM) revealed Type: eMAR-Medication Administration Note revealed (Proper name of CNA #1) and the other girl that works with her. They are thick as thieves, and they always threaten they are gonna get me sent off to behavioral. I don't know why they treat me like they do .DON was aware . Record review of Resident #6's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus with other Diabetic Neurological Complications. Record review of Resident #6's MDS with an ARD of 1/18/24 revealed in Section C a BIMS score of 13, which indicates the resident is cognitively intact. Resident #7 An observation and interview on 2/7/24 at 7:50 PM, with CNA #1, CNA #2 and CNA #3 revealed that they were the three CNA's working the night shift and they revealed they have had in-services on abuse. During this interview while in the hallway, Resident #7 was self-propelling her wheelchair and when she passed, she stated to the CNA's, I need to go to the bathroom. CNA #1 responded quickly to the resident, Well you're gonna have to wait until I get done talking. An interview on 2/7/24 at 8:00 PM, with RN #1, was informed of the manner and tone that CNA #1 had used in response to Resident #7. RN #1 confirmed that could be verbal abuse to a resident. She stated That is not an appropriate way to talk to residents. An interview on 2/7/24 at 8:05 PM, with CNA #1 she confirmed that she had told Resident #7 she would have to wait until she was done talking when the resident asked to be helped to the bathroom. She stated that she did not mean it to sound rude and admits that she has been in-serviced on verbal abuse. She revealed that she had only had one complaint from a resident about her and that one complaint was from Resident #1. She had complained that I had knocked a drink off of her table, but I did not do that. She did it, but I did cleaned it up and I told the Director of Nursing (DON) that I cleaned it up. An interview on 2/8/24 at 11:40 AM, with Licensed Practical Nurse (LPN)/Social Services confirmed that she had some complaints on CNA #1 talking ugly to the residents and that Resident #7 filed a formal grievance around the first of January that CNA #1 had refused to get her up that morning and talked ugly to her. She stated that on 1/7/24 Resident #2 came to her office to complain about CNA #1, and she asked him if he could wait to let her get the DON and the Administrator in there so they could hear, and he agreed. She revealed that the DON and the Administrator came to her office and the resident revealed that CNA #1 was passing snacks around 6:30 PM and when he asked her to help him make his bed, she told him she was busy passing snacks. She stated that the resident told them that he asked her if passing snacks that early was as important as helping him make his bed and then as she walked out of the room, she rudely told the resident to make it up himself. She revealed that Resident #1 complained to her on 2/6/24 about CNA #1 and that the resident complained that she had accidentally spilled her drink and CNA #1 told her You going to get that up. She stated that she asked the resident if she wanted to talk with the DON or the Administrator and the resident stated no that she already had, and they were going to take care of it. An interview on 2/8/24 at 12:30 PM, with Resident #7 confirmed that CNA #1 told her she would Have to wait until she was done talking when she told her she needed to go to the bathroom last night. She stated that CNA #1 was rude but that wasn't the first time, and she is used to it from her. She revealed that she had complained about it to a lot of people, but it does no good; nothing gets done. She revealed she just don't say anything anymore. She stated that she is supposed to go to the bathroom every 2 hours and usually goes at 4:30,and she has told CNA #1 this. CNA #1 told her that she was not coming straight to her as soon as she came on duty to take her to the bathroom, so she knows to not even ask until around the time she ask last night (around 8 PM). She confirmed that she filed a formal grievance back in January of this year, because the night CNAs that included CNA #1 came in her room around 4 AM and told her if she did not get up right then, then she would have to wait until day shift got there to get up. She stated that she was supposed to get up around 5:30 AM and they never came back to get her up. She confirmed that this had been reported to the Social Worker, Administrator, the DON, and some of the other nursing staff but could not remember their names. Record review of Resident #7 admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus without Complications. Record review of Resident #7's MDS with an ARD of 10/30/23 revealed in Section C a BIMS score of 15, which indicates the resident is cognitively intact. Record review of the Grievance/Concern/Comment Report dated 1/2/24 revealed a formal grievance was filed regarding CNAs on the night shift not getting Resident #7 out of bed as requested. An interview on 2/8/24 at 9:30 AM, with the CNA Supervisor revealed there has been one complaint from a resident back in November 2023 or December about night shift CNA #1 being rude to a resident and that she reported it to the DON and she took care of it. An interview on 2/8/24 at 10:00 AM, with CNA #4 and CNA #5 revealed that they normally work day shift but sometimes they have to help and work night shift and that some of the residents complain about a CNA on the night shift that is rude to them but would rather not mention any names. She stated that she thinks that everyone knows it and is sure it has been reported to the DON and the Administrator. An interview on 2/8/24 at 1:40 PM, with the DON confirmed that all staff receive abuse in services on hire and annually unless there is an issue and then we can do one anytime in our computer in-service system. She revealed that as far as she knows there has not been an issue in order to have to do an additional abuse in-service. She admitted that she had received a complaint on CNA #1 on 2/6/24, but that was the first complaint she had on the staff member, and she is not aware of any more complaints on other staff regarding talking disrespectfully. She stated that Resident #1 reported an issue to her on 2/6/24 that CNA #1 talked disrespectfully to her. The DON stated she came in last night and talked to CNA #1 about that issue around 6 PM. An interview on 2/8/24 at 2:00 PM, with the Administrator, DON, and LPN/Social Services confirmed they had complaints about CNA #1 talking inappropriately to some of the residents. The Administrator stated that the reports he had from Resident # 1 and Resident #2 just did not seem like verbal abuse to him. Both agreed that the reports of how the CNA spoke to Resident #7 last night and how she said it was inappropriate and disrespectful. The DON confirmed at this time that she had known about the report from Resident #1 and Resident #2. When the State Agency (SA) inquired about Resident #6 and her complaint, the DON stated yes, she came into the office and also had a complaint. The DON verified that she had three (3) residents complain about how CNA #1 talked to them. The Administrator stated that CNA #1 had been talked to last night about the complaint that came in on 2/6/24 with Resident #1. The Administrator stated he was not aware that CNA #1 had told Resident #2 to make his own bed as she walked out of his room, but LPN/Social Services confirmed that he did report that to them. The Administrator confirmed that he was aware of the grievance that Resident #7 had filed about them not getting her up when she wanted to but was not aware that either one of them had told her that if she did not get up now, then she would not get up until day shift got there. He admitted that they would have to do an investigation and more than likely let CNA #1 go. An interview on 2/8/24 at 2:20 PM, with LPN/Social Services confirmed that Resident #1 complained on 2/6/24, Resident #2 complained on 1/7/24 and Resident #7 filed a formal complaint on 1/3/24. Record review of the facility in-services from the last 6 months revealed there was an abuse in-service held in 1/2024 for all staff but was not attended by CNA #1. Record review of CNA#1 employee file revealed that she completed in-services on abuse on 9/25/23 and 12/11/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility policy review the facility failed to report an allegation of sexual abuse within the required two-hour time frame for one (1) of nine residents sampled for potential abuse. Resident #1 Findings include: Record review of the facility policy titled, Freedom of Abuse, Neglect and Exploitation Standard, dated November 2019, revealed, .Report allegations or suspected abuse, neglect or exploitation immediately to: Administrator, Other officials in accordance with State Law, State Survey and Certification agency through established procedures. VI Reporting/Response A. The facility will have written procedures that include: 1. Reporting all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . Reporting . Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . Record review of the investigation dated 06/12/23 revealed that Resident #5 called Certified Nursing Assistant (CNA) #1 and a Housekeeper into her room around 10:30 AM and stated, (Proper name RN# 1) came in the room and pulled the curtain and started playing with (Resident #1). CNA #1 immediately went and told the Administrator and the Director of Nursing (DON) of the allegation of sexual abuse on 6/12/23 and that Resident #1's roommate (Resident #5) had called them in her room and reported the allegation of sexual abuse at 10:30 AM. Resident #5 was later interviewed by the Administrator that same day on 06/12/23, with no time documented on the written interview and stated, (Proper name RN#1) came into our room around 1:30 AM this morning. He pulled the curtain. He was playing with Resident #1 sexually. Resident #1 was interviewed by the DON, Social Services Director, and the Administrator on 06/12/23 with no time indicated on the written interview and Resident #1 stated that approximately 1:30 AM that RN#1 came into her room and offered her a honey bun and then proceeded to have sex with her. She stated that he did not get undressed or in her bed that they had sex through her diaper. Record review of a physician's order dated 06/12/23 at 1:34 PM revealed a physician's order to send resident to the (Proper name of hospital) for a vaginal exam related to pain. Record review of the hospital Emergency Department (ED) visit stated, This is a [AGE] year-old female patient who presented to the ED on June 12th, 2023, around 2:00 PM brought in by a nursing home worker with patient complaining of vaginal pain. The patient was not cooperative for history of exam according to ED records. The patient finally reported that she was dreaming like she was itching, and a male nurse came in to relieve the itching. She thought she might be pregnant. Patient had a pelvic exam, and no bleeding, injury or discharge was noted. Patient was admitted to observation until recommendations from Adult Protective Services and mental health evaluation can be made. Record review of an interview dated 06/12/23 conducted by the Administrator with the transport driver that took Resident #1 to the local ED stated, I was told to take Resident #1 through the emergency room (ER) by a nurse. So, when we arrive at ER, I gave the paperwork to front desk when they ask why we were there I never said anything. They call us back; the nurse came in and asked what was wrong. I encourage Resident #1 to tell them what she had told them. Resident #1 said she was itching for sex. He was too. The nurse left out and the doctor came in. Resident #1 told them the same story. She wanted sex, he want sex. It was consensual. So, the doctor came back in and said he have to call DHS (Department of Human Services) and the police. I then notified the Administrator. Police officer then came in and she told the police that they had consensual sex. When he asked who, she said RN #1. Interview with the Administrator on 7/20/23 at 1:00 PM, confirmed the facility failed to report the allegation of sexual abuse to the required entities within a two-hour time frame. He stated after the initial allegation the resident changed her statement several times and the immediate investigation, he did within the first two hours revealed the allegation was not credible in his mind. He stated around 1:30 PM, the resident was sent to the hospital and changed her statement several times but that the hospital was unable to note any trauma on her exam. He stated it was after sending resident to the hospital that he notified the State Agency (SA) after the police called him and wanted to get a statement. The Administrator stated that the hospital had notified SA, Adult Protective Services (APS), and the police. The Administrator stated that the police came to the facility to get a statement on the events that occurred after the resident had spoken with the police while in the hospital. The Administrator confirmed that the allegation was not reported to the Attorney General's Office (AGO) by the facility until 7/19/23 and the facility failed to notify the State Agency, Attorney General's Office, and the Local Police Department within a two-hour time frame of when the allegation was made. He confirmed the allegation was made on 6/12/23 at approximately 10:30 AM and the resident was transferred to the hospital on 6/12/23 approximately 1:30 PM, and the facility did not report to the State Agency until after that time. Interview with DON on 7/20/23 at 1:00 PM, she confirmed the facility failed to submit the allegation of abuse to the required entities within the two-hour time frame and stated that she thought since they considered it a false allegation from early on, they did not report timely. Record review of Resident #1's admission Record revealed the resident was originally admitted to the facility on [DATE]. Diagnoses included Bipolar Disorder, Major Depressive Disorder, Generalized Anxiety Disorder, and Auditory Hallucinations. Record review of Resident#1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Record review of Resident #5's admission Record revealed that the resident was originally admitted to the facility on [DATE] and had diagnosis which included Diabetes and Heart Disease. Record review of Resident#5's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for 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 observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure the accommodation of a resident's needs were met as evidenced by the absence of a full lift sling pad to utilize in a transfer of a resident from bed to chair for one (1) of five (5) residents that required full lift sling pads. Resident #8 Findings include: Record review of facility policy titled, Resident Rights and Dignity Management: Accommodation of Needs, dated May 2022, revealed, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being. 1. The resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. 2. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis. 3. In order to accommodate individual resident needs and preferences, staff attitudes and behaviors must be directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible and in accordance with the resident's wishes. An observation and interview with Resident #8 on 1/31/23 at 11:00 AM, revealed the resident was awake and alert and lying in bed with the head of his bed elevated. His wheelchair was observed in his room near his bed. Resident #8 stated that he likes to get up in his wheelchair, but he is still in the bed because the facility does not have a lift sling pad available to get him out of his bed and into his wheelchair. He stated the facility is a sling short and if the slings are already in use, he has to wait until one becomes available. He stated that the staff asked him earlier about getting up, but he is limited with the amount of time he can sit up in the wheelchair and he prefers to use his wheelchair time to eat lunch in the dining room. An interview on 1/31/23 at 11:30 AM, with Registered Nurse (RN) #3 revealed the facility only has a certain number of total lift sling pads, and this resident needs the extra-large size and all the slings that size are in use for other residents. She stated that the resident did not want to get up earlier and the slings were used on other residents and that Resident #8 had asked her about getting up and she told him they would get him up when a sling became available, and that would be when one of the residents using the sling was put back to bed. An observation and interview with Resident #8 on 1/31/23 at 2:30 PM, revealed the resident lying in bed with the head of his bed elevated. Resident #8 stated that he has not been assisted to his wheelchair yet and he had to eat his lunch in his room today because they were not able to get him up to go to the dining room because there were not any sling pads available. An observation and interview with Resident #8 on 2/1/23 at 9:00 AM, revealed the resident was lying in bed with the head of the bed elevated. The resident stated he was not able to get up at all yesterday, but he was hopeful that he would be able to get up for lunch today. On observation and interview with Resident #8 on 2/1/23 at 2:30 PM, revealed the resident lying in bed. He stated that he was able to go to lunch in the dining room and he was able to sit up for about an hour. An interview with the Certified Nursing Assistant (CNA) Supervisor on 2/1/23 at 3:20 PM, revealed that last week an extra-large sling had a tear in it, and it was discarded due to safety concerns. She stated a replacement sling was ordered, but it had not come in yet. She stated that an extra-large full body sling was used for Resident #8, and since one was discarded, the facility was one short of the extra-large slings. The facility does have a cross body size large sling that crosses between the resident's legs, but most residents do not like it because it hurts their legs and prefer the full body sling and prefer to wait until it is available. The CNA Supervisor confirmed that Resident #8 requires the extra-large sling. She stated that yesterday morning, the resident was not ready to get up and apparently, when he wanted to get up, there were no slings available since they were all in use on other residents. A sling was not available until after lunch when another resident was placed back in the bed. She confirmed that she was unaware that Resident #8 had changed his mind and had wanted to get up for lunch. An interview on 2/2/23 at 9:20 AM, with the Nurse Educator who was filling in for the Director of Nursing (DON), revealed there were four residents that required the extra-large full body sling (including Resident #8) and the facility had three extra-large slings for the full body lift and they were waiting for the replacement to be received. She confirmed that Resident #8 uses an extra-large full body sling and that the facility failed to provide an adequate number of needed slings for the lift and therefore was unable to accommodate Resident #8's needs. She confirmed the resident had a right to eat lunch in the dining room as desired, and he was unable to do so. An interview on 2/2/23 at 12:05 PM, with the Administrator revealed he was aware that one of the full body lift slings had to be removed from use due to having a tear in it and the replacement was on order and should arrive today or tomorrow. He revealed he was unaware of an incident that occurred when Resident #8 was unable to get out of his bed and into his wheelchair due to a lack of slings and stated, This should have never happened. He stated this is not a usual occurrence since Resident #8 is often up in his chair and propelling around the facility. He revealed that as far as he knew, a sling could be removed from underneath the resident once the resident was in the chair and could be cleaned and used on another resident and confirmed that a resident having to remain in bed due to a lack of slings is not acceptable. The Administrator confirmed the facility failed to provide Resident #8 with the accommodations needed for transfer from the bed to the wheelchair. Record review of Resident #8's admission Record revealed he was admitted to the facility on [DATE] with diagnoses of Reduced Mobility, Paraplegia, and Seizures. Record review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/3/22, revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and facility policy review, the facility failed to prevent possible contamination as evidenced by failure to properly store nebulizer and oxygen cannula in a manner to prevent bacteria growth for four (4) of ten (10) residents receiving respiratory services. Resident #3, Resident #4, Resident #12, Resident#30. Findings include: Review of the facility policy titled, Oxygen, Administration - Delivery Device with revision date 01/2023 revealed, Purpose To provide oxygen support when indicated via appropriate delivery device to achieve or maintain adequate oxygenation to the respiratory compromised resident. Review of the policy titled, Aerosolized Medication (Neb Med) Under Procedure, 17. Rinse the nebulizer and mouthpiece. Shake to air dry and store in a plastic bag that is labeled with the resident's name and room number. Resident #3 An observation on 01/31/23 at 9:35 AM and again at 11:35 AM revealed Resident #3 lying in bed with a nebulizer machine sitting on top of the bedside table. The nebulizer mask was attached to the machine and laying exposed and not in a plastic bag. A record review of Resident #3's face sheet revealed the resident was admitted to the facility on [DATE] with diagnoses that included, Chronic Obstructive Pulmonary Disease and Heart Failure. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/8/2022 revealed Resident #3 with a Brief Interview for Mental Status (BIMS) score of 02, which indicated the resident has a severe cognitive impairment. Resident #4 On 01/31/23 at 9:35 AM, an observation of Resident # 4's room revealed that her nebulizer face mask was on her nightstand and was not in a plastic bag. It was observed that her oxygen nasal cannula tubing was on the floor under the left edge of her bed. On 01/31/23 at 11:10 AM, observed Resident #4's nebulizer on the nightstand at the left side of her bed with the inner part of the face mask touching the top surface of the nightstand. On 02/02/23 at 10:15 AM, observed Resident #4 sitting up in her wheelchair in her room and observed the nebulizer on top of her three-drawer nightstand with the interior part of the face mask touching the surface of the table. On 02/02/23 at 10:20 AM, Registered Nurse (RN) #2 confirmed that Resident #4's nebulizer face mask was located on top of the nightstand and that it was supposed to be in a plastic bag. She revealed that the face mask or nasal cannula left open to air could cause infection for the resident. Record review of Resident #4's admission Record revealed her original admission date of 07/07/2017 with the following diagnoses to include: Chronic Obstructive Pulmonary Disease, Stage 4 Chronic Kidney Disease, Type 2 Diabetes, Heart Failure, Dementia. Record review of Resident #4's Minimum Data Set (MDS) dated [DATE] revealed Brief Interview for BIMS score of 08 which indicated moderate cognitive deficit. Resident #12 On 01/31/23 at 9:15 AM, an observation revealed Resident #12 lying in his bed with oxygen in use at 3 Liters by nasal cannula (BNC). An observation of the resident's nebulizer machine on top of the three-drawer nightstand to the right of his bed with his face mask open to air and not placed in a plastic bag. On 01/31/23 at 11:00 AM, observed Resident #12's nebulizer on the nightstand with the facemask open to air and not in clear plastic bag. Record review of Resident #12's admission Record revealed that he was admitted on [DATE] with the following diagnoses to include Chronic Obstructive Pulmonary Disease. Record review of the MDS with an ARD of 01/26/2023 revealed a BIMS score of 11 which indicated moderate cognitive deficit. Resident #30 On 01/31/23 at 9:20 AM, an observation and interview with Resident #30 revealed that he received breathing treatments for his lung issues. An observation was made of the resident's nebulizer machine on top of his nightstand with privacy curtain brushing up against the face mask which was left open to air and not placed in a plastic bag. On 01/31/23 at 11:05 AM, observed Resident #30's nebulizer on the nightstand at the distal end of his bed with face mask open to air and not in a plastic bag. Record review of Resident #30's admission Record revealed that he was originally admitted on [DATE] with the following diagnoses to include Unspecified Atrial Fibrillation. Record review of Resident #30's MDS with an ARD of 12/30/2022 revealed his BIMS score of 12 which indicated that he was cognitively intact. On 01/31/23 at 3:16 PM, an interview with the Infection Control Nurse revealed that the nebulizer mask and tubing were to be changed out weekly per their policy and when not in use, the items were to be placed in a plastic bag. She also revealed that a nurse had asked that morning for some plastic bags from the kitchen; and she was told that they were out of plastic bags and she did not know how long they had been without the bags in the resident rooms. The Infection Control Nurse confirmed that leaving the oxygen device/tubing open to air could cause bacteria to enter the respiratory tract and cause infection. On 01/31/23 at 4:00 PM, an interview with Licensed Practical Nurse (LPN) #1 revealed that face masks, oxygen, and nebulizer tubing were changed, initialed, and dated once a week on Sundays on the evening shift. LPN #1 revealed that she came in at 12:00 PM today and while making rounds, she realized that there were no plastic bags covering the oxygen nasal cannulas or face masks and that she did not know how long they had been like that. LPN #1 revealed that the nasal cannulas and face masks were to stay covered when not in use to help prevent infection.

Based on observations, staff interviews, record review and facility policy review, the facility failed to ensure items in the kitchen refrigerator and freezer were dated and labeled for one (1) of three (3) dietary observations. Findings include: Review of the facility policy titled, Sanitation and Infection Control Storage of Refrigerated Food, revision date 10-2019, revealed, .4. Food taken out of original containers is put in a clean sanitized container with a tight-fitting lid. No food is left uncovered. 5. All non-hazardous, opened foods are labeled with name of food, date stored and use-by date. 6. All hazardous foods are labeled with name of food and date to be discarded or the date stored. Cooked foods should be held longer than forty-eight (48) hours . An observation and interview during the initial tour of the kitchen on 01/31/23 at 9:05 AM, with the Dietary Manager (DM), revealed in Refrigerator #2 a white plastic container with a manufactured label of cheese spread. The container's seal was broken, and the container was undated. The DM revealed I think it was opened yesterday but I'm not sure. She confirmed that it is supposed to have the date on it when it is first opened. Nine (9) wrapped sandwiches were inside Refrigerator #2, which DM revealed were bologna sandwiches with no dates or labels. Refrigerator #5 revealed a rectangular metal container with red liquid and vegetables, with plastic wrap on top, without a label, a date of 1/28/23 was marked through with a date of 1/30/23 written below it. The DM revealed it is vegetable soup; she thinks it was from last night but not sure. Freezer #5 revealed nine (9) chicken tenders confirmed by the DM in a bag not labeled with food content or the date it was opened. A white chest freezer revealed a large blue opened bag which DM confirmed was mixed vegetables. The bag was not dated nor labeled. The DM revealed it is our policy to make sure the food is dated when opened and all food items are to be labeled. She confirmed it had not been done and should have been labeled and dated. An interview on 02/02/23 at 8:30 AM, the DM revealed it is everyone's responsibility to ensure that the food is labeled and dated in the refrigerator and freezers but ultimately it was her responsibility. She confirmed that the foods not being dated and labeled could possibly cause a resident to become sick.