**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview and document review, the facility failed to ensure the accuracy of Minimum Data Set 3.0 (MDS) assessments for 2 of 12 sampled residents (Resident #1 and #9). This deficient practice had the potential to deprive the residents of person-centered care plans and the associated interventions relative to their current health management needs. Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of major depressive disorder, recurrent, unspecified. Resident #1's quarterly MDS assessment dated [DATE], Section N0415 (Medications-High-risk Drug Classes: Use and Indication, C. Antidepressant), documented Resident #1 had been administered an antidepressant medication within the prior seven-day look-back period. A physician's order dated 04/22/2024, documented SEROquel oral tablet 25 milligrams (mg), give 25 mg by mouth at bedtime for anxiety, paranoid ideation, agitation related to major depressive disorder, recurrent, unspecified. The medication had a discontinue date of 09/10/2024. Resident #1's physician orders lacked documentation an antidepressant medication was currently ordered. Resident #9 Resident #9 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including aphasia following cerebral infarction, unspecified intellectual disabilities, other abnormalities of gait and mobility, and a history of falling. Resident #9's quarterly MDS assessment dated [DATE], Section P0200 (Restraints and Alarms: Alarms, C. Floor mat alarm), documented a floor mat alarm had been used daily within the prior seven-day look-back period. Resident #9's physician orders lacked documentation a floor mat alarm had been ordered. On 04/16/2025 at 1:51 PM, Resident #9 was in bed with the bed in a low position. The floor and area around the bed was absent of any floor mats or floor mat alarms. On 04/16/2025 at 2:04 PM, the Director of Nursing (DON) confirmed Resident #1 had not been currently ordered or administered an antidepressant. The DON confirmed Resident #9 did not have a floor mat alarm, and verbalized the facility did not have any, nor had they every used floor mat alarms. The DON confirmed the MDS entries for each resident's last quarterly assessment had been coded incorrectly and the facility followed the Resident Assessment Instrument Manual to complete the assessment process. The facility policy titled, Comprehensive Assessment and Reassessment, reviewed 10/30/2024, documented assessments would be individualized to meet the needs of the resident and must accurately reflect the resident's status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, interview and document review the facility failed to ensure 1) an order was obtained for the application of pressure redistribution/heel protector boots (heel boots) prior to applying heel boots and 2) failed to ensure the heel boots were correctly applied with the potential to cause a pressure injury (PI) or deep tissue injury (DTI) to the resident's heels for 1 of 12 sampled residents (Resident #14). Findings include: Resident #14 Resident #14 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, and anxiety, foot drop, unspecified foot, and pain in left lower leg. On 04/14/2025 at 1:52 PM, Resident #14 was resting in bed with a pair of heel boots placed under the resident's feet. The heel boots were not fastened to help ensure appropriate placement and the resident's heels were resting on the inner surface of the heel boots and were not positioned over the pressure redistribution opening in the heel of the boot. On 04/16/2025 at 3:41 PM, Resident #14 was resting in bed with a pair of heel boots placed under the resident's feet. The heel boots were not fastened and the resident's heels were not aligned with the pressure redistribution opening in the heel of the boots. Resident #14's clinical record did not include an order for the use and monitoring of heel boots. The resident's Treatment Administration Record (TAR) did not include monitoring for the use of heel boots and the resident's clinical record lacked documented evidence the resident's heels had been assessed/monitored for PI/DTI related to the use of the heel boots. On 04/16/2025 at 3:44 PM, a Registered Nurse (RN) verbalized due to a past trauma Resident #14's feet were very sensitive and the resident could not tolerate anything touching the tops of the resident's feet and did not like to have the heel boots fastened. The RN explained the heel boots were used prophylactically to prevent PI/DTI due to the resident was in bed most of the time. On 04/16/2025 at 3:46 PM, The RN verbalized both nurses and Certified Nursing Assistants applied the heel boots. The RN explained to apply the boots staff raised up the resident's leg and place the heel boots under the resident's feet. The heel boots were left unstrapped because the resident did not like to have the heel boots fastened due to sensitivity in the resident's feet. The RN verbalized the use of the pressure redistribution heel boots required a physician's order and confirmed Resident #14's clinical record lacked documented evidence of an order for the use of the heel boots. On 04/16/2025 at 3:53 PM, the Director of Nursing (DON) verbalized the facility required orders for all equipment used for resident care including the heel boots. The DON confirmed Resident #14's clinical record did not include an order for the use of pressure redistribution boots and confirmed an order should have been in place prior to the application of the heel boots. On 04/16/2025 at 3:58 PM, the DON explained heel boots were generally used when residents were in bed to protect the resident's heels from skin break down including PI and DTI. The DON confirmed when heel boots were applied, the resident's heel were to be positioned over the opening in the heel of the boot. On 04/16/2025 at 4:19 PM, Resident #14 was resting in bed with heel boots placed under the resident's feet, the boots were not fastened, and the resident's heels were not resting within the opening of the heel boots. The resident's heel and foot was resting on the inner surface of the boots. The DON confirmed the heel boots were not correctly applied. On 04/16/2025 at 4:28 PM, the DON confirmed Resident #14's clinical record did not include an order for the use of heel boots and confirmed a physician's order should have been obtained prior to the use of the heel boots. The DON verbalized the correct application of the boots required the resident's heels to be placed in the opening of the heel of the boots. The DON confirmed the heel boots had not been correctly applied for Resident #14. The DON confirmed when a resident's heels were not correctly aligned within the opening of the heel of the boots, pressure was being applied to the resident's heels and had the potential to cause the resident to develop a PI or DTI. The facility policy titled Skin Integrity and Injury Prevention, dated 03/15/2022, documented pressure injury prevention included managing pressure. Pressure was managed by providing appropriate support surfaces an off-loading heels by using pillows or positioning boots. The facility policy titled Written, Verbal, Electronic Physician Orders, reviewed 10/28/2024, documented orders for resident treatment were carried out only when given by a qualified physician or other duly licensed person authorized to prescribe. All orders for treatment included the type of treatment, specific requirements, and frequency of the treatment. The healthcare professional implementing the order documented the order was implemented in the appropriate section of the resident's clinical record.

Based on personnel record review, interview and document review, the facility failed to ensure initial behavioral health care training was completed timely per facility policy for 1 of 20 sampled employees (Employee #9). This deficient practice had the potential to prevent residents with behavioral health care needs from attaining or maintaining their highest practicable physical, mental and psychosocial well-being. Findings include Employee #9 Employee #9 was hired as the Minimum Data Set 3.0 Registered Nurse on 02/25/2025. Employee #9's personnel record lacked documented evidence of behavioral health care training. On 04/16/2025 at 11:05 AM, the Human Resources Director confirmed Employee #9's start date of 02/25/2025, and Employee #9 had not yet completed behavioral health care training. The Human Resources Director verbalized all employees were to have completed the training per the facility's policy. On 04/16/2025 at 11:41 AM, the Administrator verbalized not having been aware Employee #9 was required to complete the training. The facility policy titled, Employee Compliance, revised 06/28/2023, documented new employees were required to complete behavioral health training within 40 hours of the candidate's start date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure a care plan was developed to address side effects and necessary monitoring for a resident with bilateral lower extremity edema for 1 of 12 sampled residents (Resident #5). This deficient practice had the potential for the resident to suffer adverse health outcomes because of staff caring for the resident being unaware of the need to monitor for signs of leg swelling. Findings include: Resident #5 Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of bilateral primary osteoarthritis of knee. On 10/15/2024 at 11:48 AM, Resident #5 verbalized Resident #5 had swelling in both legs. Resident #5 verbalized Resident #5 was not wearing compression stockings. Resident #5's clinical record lacked documented evidence a care plan had been developed for the resident's diagnosis of bilateral primary osteoarthritis of knee and the management of the resident's bilateral leg edema. A physician's order dated 06/06/2024, documented compression stockings to bilateral limbs as needed for occasional swelling associated with bilateral primary osteoarthritis of knee. On 10/17/2024 at 11:51 AM, the Director of Nursing (DON) confirmed Resident #5's clinical record did not include a care plan for the resident's bilateral primary osteoarthritis of knee and the management of the resident's edema. The DON verbalized the compression stockings should be care planned as an intervention for the diagnosis since the hose were being placed on the resident to provide an intervention for the bilateral leg edema. The facility policy titled Baseline and Comprehensive Care Plan, revised 04/13/2023, documented the facility shall provide an individualized, interdisciplinary plan of care for all residents appropriate to the resident's needs, strengths, rules of diagnostic testing limitations and goals. The care plan shall describe the services to be furnished to attain or maintain the resident's highest practical physical well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure comprehensive care plans were revised to include the physician identified behaviors for the administration of a psychotropic medication for 1 of 12 sampled residents (Resident #2) and new interventions for the prevention of falls for 2 of 12 sampled residents (Resident #23 and #25). Findings include: Resident #2 Resident #2 was admitted on [DATE], and readmitted on [DATE], with diagnoses including major depressive disorder, recurrent, unspecified and vascular dementia, moderate with mood disturbances. Resident #2's psychotropic physician's orders dated 02/15/2024, documented the following: -Seroquel Oral Tablet 25 milligrams (mg), give one tablet by mouth in the afternoon for low mood, anxiety, paranoid ideation related to major depressive disorder, recurrent, unspecified. -Cymbalta Oral Capsule Delayed Release Particles 30 mg, give one capsule by mouth two times a day for low mood, anxiety, paranoid ideation related to major depressive disorder, recurrent, unspecified. Resident #2's care plans documented the following focus areas related to psychotropic medications: -Resident #2 had a behavior history of self-isolation, sense of doom, crying/tearful episodes, anxious related to (r/t) major depressive disorder, initiated 03/05/2023 and revised 10/09/2024. -Resident #2 used psychotropic medications r/t major depressive disorder with behaviors. Resident #2 had a history of fearfulness, crying, tearfulness, anxious, self isolation, sense of doom and agitation, initiated 09/13/2023 and revised 10/09/2024. Resident #2's care plans lacked evidence of the paranoid ideation indicated in the physician ordered psychotropic medications. On 10/17/2024 at 3:45 PM, the Director of Nursing (DON) confirmed the behaviors indicated by the physician on the psychotropic medication orders did not match the behaviors documented by the nurses on the care plan for Resident #2 and the care plans lacked paranoid ideation as a behavior exhibited by the resident. The facility policy titled Baseline and Comprehensive Care Plan, last reviewed 04/13/2023, documented any resident receiving any type of psychotropic medication shall have a resident specific care plan which includes identification of resident specific targeted behaviors Cross reference F tag 758 Resident #23 Resident #23 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbances and major depressive disorder, single episode, severe without psychotic features. On 10/15/2024 at 10:50 AM, Resident #23 recalled having fell off the bed and the resident's knees hurt from the fall. On 10/16/2024 at 2:15 PM, Resident #23 stood up from the resident's bed, physically moved a wheelchair out of the way, walked around the bed from the left side to the right side while bracing self with right hand on the bed, retrieved the resident's walker and ambulated to the bathroom. Resident #23's Progress Notes documented the following: -10/08/2024 The resident was impulsive and forgetful and had poor safety awareness. The resident was on the edge of the bed, moved forward and slid from the bed with no injury . consistent reminders offered to resident to ask for assistance. -10/09/2024 Interdisciplinary Team (IDT) and Root Cause analysis, resident was in room and slid from bed, no injury, all parties notified. Root cause resident was impulsive and had intermittent confusion and was ambulatory but overestimates abilities at times. Resident was educated and verbalized understanding of call light use and safety but was non-compliant. Will attempt to discuss grip strips with maintenance as resident at times had slipper socks on but the grip did not prevent sliding, care plan would be reviewed, no injury or pain noted. On 10/18/2024 at 8:50 AM, Resident #23's room lacked grip strips on the floor as indicated in the IDT progress notes. Resident #23's comprehensive care plan initiated and revised on 09/17/2024, documented a focus area for high risk for falls r/t confusion, conditioning, gait/balance problems, poor communication/comprehension, unaware of safety needs and history of falling. On 10/18/2024 at 9:12 AM, the DON explained Resident #23 had attempted to self transfer out of bed when the resident fell. The resident had leaned forward and slipped because the grip on the resident's socks was not enough to prevent sliding. The resident had difficulty with safety awareness. The facility had not applied grip tape as indicated by the IDT as a possible intervention and confirmed the tape was not available at the facility and had not been ordered. On 10/18/2024 at 9:19 AM , the DON verbalized the facility should have updated Resident #23's care plan with new interventions or revised past interventions after the fall on 10/08/2024. The DON confirmed new interventions had not been initiated or revised on the care plan to prevent future falls. Resident #25 Resident #25 was admitted to the facility on [DATE], with a diagnosis of major depressive disorder, recurrent, unspecified. Resident #25's Progress Notes documented the following: -09/14/2024 Post Fall Evaluation Fall Details: Date / Time of Fall: 09/14/2024 2:20 PM, Fall was not witnessed. Fall occurred in the resident's room. Activity at the time of fall: Resident cannot recall activity at time of fall. The reason for the fall was not evident .Resident was heard screaming down the hall and was found laying next to the resident's bed, on the ground, with head towards foot of the bed. Resident with no visible injuries. Denied hitting head but cannot recall how the resident fell or what the resident was doing . Bed alarm was not going off and call light was not on. New bed alarm placed. Resident returned to bed, educated and reminded to use the call light for assistance .Resident was not using cane/walker as instructed. Resident was not wearing oxygen as prescribed at time of fall . -09/25/2024 Post Fall Evaluation Fall Details: Date / Time of Fall: 09/25/2024 2:05 PM, Fall was not witnessed. Fall occurred in the resident's room. Resident was attempting to self toilet at time of the fall. The reason for the fall was not evident .Fall Details Note: Resident with unwitnessed fall in room. Resident found face down on the ground, head towards foot of the bed. Resident was assessed by Registered Nurse (RN) and DON for injures or any deformities. No visual sign of injury. Resident assisted back into bed by RN and Certified Nursing Assistant (CNA.) Resident denied hitting head. Reported no pain. Resident attempted to self-transfer out of bed and admitted to needing to use the restroom. Vital signs within defined limits. Bed alarm in place. Contributing Factors: .Footwear at time of fall: Socks. Resident was not using cane/walker as instructed. Resident was not wearing oxygen as prescribed at time of fall .-10/06/2024 Post Fall Evaluation Late Entry: Date / Time of Fall: 10/06/2024 6:30 PM, Fall was not witnessed. Fall occurred in the resident's room. Activity at the time of fall: Resident stated was trying to get self back to bed from sitting at side of bed eating dinner. Reason for the fall was evident. Reason for fall: Resident tried to get self back into bed. Resident denied utilizing call light for assistance . Contributing factors note: Patient denied utilizing call light for staff assistance when they were finished with meal. -10/07/2024 Fall Root cause analysis and IDT: Resident was impulsive and had poor safety awareness .The resident overestimated abilities and often became anxious and impatient during care provision .The resident denied any pain related to fall and stated the resident will attempt to be more patient and ask for assistance due to cognitive decline related to resident's condition, staff will continue to offer frequent reminders on safety past fall follow up indicated this fall was not the result of abuse or neglect. The care plan had been reviewed and updated to reflect interventions to assist in fall prevention for the resident. Resident #25's comprehensive care plan initiated on 04/30/2024 and revised on 07/02/2024, documented a focus area for high risk for falls r/t gait/balance problems and history of falling. The care plan contained one intervention post falls in September, initiated 09/17/2024: Physical Therapy/Occupational Therapy (PT/ OT) evaluate and treat as ordered or as needed (PRN.) Resident #25's Alert Note dated 10/09/2024, documented the prior Director of Nursing initiated potential to utilize trapeze as an intervention for the resident related to falls, upon reviewing this with therapy and nursing staff and the resident, it had been determined this was an ineffective intervention and the resident would not receive any benefit related to bed mobility with a trapeze, this is an ineffective intervention. Therapy did not have a suggestion for equipment related to fall intervention, to assist in fall will have staff provide frequent checks and encourage resident to be in visual areas while awake to assist in fall prevention at this time. On 10/18/24 at 9:28 AM, the DON explained Resident #25 had impulse control problems and had quite a few falls. It was almost behavioral, the resident gets impatient and tries to get out of bed. On 10/18/2024 at 9:35 AM, the DON confirmed implementing new interventions after the 10/06/2024 fall. The previous DON wanted to do a trapeze as an intervention after one of the falls in September but did not get an evaluation from PT/OT. The current DON had a verbal meeting with PT/OT and they said no, the trapeze was not approriate and had no other interventions. The intervention for the trapeze was not on the care plan. The care plan did not reflect interventions post falls from 09/14/2024 and 09/25/2024 to prevent future falls. The PT/OT eval, post fall, did not derive new interventions. The facility policy titled Falls and Fall Prevention, last revised 05/2024, documented extra measures were to be on the care plan for fall prevention. The facility policy titled Baseline and Comprehensive Care Plan, last reviewed 04/13/2023, documented all staff using the plan of care shall be responsible for interdisciplinary collaboration to establish goals and appropriate interventions as well as ongoing evaluation and revisions. Cross reference F tag 689

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and document review, the facility failed to ensure fall prevention interventions were initiated post-fall as a result of the root cause analysis of the falls for 2 of 12 sampled residents (Resident #23 and #25). This deficient practice had the potential for a resident to fall with serious injury. Findings include: Resident #23 Resident #23 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbances and major depressive disorder, single episode, severe without psychotic features. On 10/15/2024 at 10:50 AM, Resident #23 recalled having fell off the bed and the resident's knees hurt from the fall. On 10/16/2024 at 2:15 PM, Resident #23 stood up from the resident's bed, physically moved a wheelchair out of the way, walked around the bed from the left side to the right side while bracing self with right hand on the bed, retrieved the resident's walker and ambulated to the bathroom. Resident #23's Progress Notes documented the following: -10/08/2024 The resident was impulsive and forgetful and had poor safety awareness. The resident was on the edge of the bed, moved forward and slid from the bed with no injury . consistent reminders offered to resident to ask for assistance. -10/09/2024 Interdisciplinary Team (IDT) and Root Cause analysis, resident was in room and slid from bed, no injury, all parties notified. Root cause resident was impulsive and had intermittent confusion and was ambulatory but overestimates abilities at times. Resident was educated and verbalized understanding of call light use and safety but was non-compliant. Will attempt to discuss grip strips with maintenance as resident at times had slipper socks on but the grip did not prevent sliding, care plan would be reviewed, no injury or pain noted. On 10/18/2024 at 8:50 AM, Resident #23's room lacked grip strips on the floor as indicated in the IDT progress notes. Resident #23's comprehensive care plan initiated and revised on 09/17/2024, documented a focus area for high risk for falls related to (r/t) confusion, conditioning, gait/balance problems, poor communication/comprehension, unaware of safety needs and history of falling. On 10/18/2024 at 9:12 AM, the Director of Nursing (DON) explained Resident #23 had attempted to self transfer out of bed when the resident fell. The resident had leaned forward and slipped because the grip on the resident's socks was not enough to prevent sliding. The resident had difficulty with safety awareness. The facility had not applied grip tape as indicated by the IDT as a possible intervention and confirmed the tape was not available at the facility and had not been ordered. On 10/18/2024 at 9:19 AM , the DON verbalized the facility should have updated Resident #23's care plan with new interventions or revised past interventions after the fall on 10/08/2024. The DON confirmed new interventions had not been initiated or revised on the care plan to prevent future falls. On 10/18/2024 at 9:21 AM, the DON confirmed the Morse scale evaluation had not been completed post fall for Resident #23. The DON explained the Morse scale evaluation would be used to determine if the resident had a decline and why the resident had fallen. The facility would complete another evaluation quarterly to determine if increase in functionality had occurred and to ensure no functional issue or decline had occurred. The Morse scale evaluation was required to be completed post fall. Resident #25 Resident #25 was admitted to the facility on [DATE], with a diagnosis of major depressive disorder, recurrent, unspecified. Resident #25's Progress Notes documented the following: -09/14/2024 Post Fall Evaluation Fall Details: Date / Time of Fall: 09/14/2024 2:20 PM, Fall was not witnessed. Fall occurred in the resident's room. Activity at the time of fall: Resident cannot recall activity at time of fall. The reason for the fall was not evident .Resident was heard screaming down the hall and was found laying next to the resident's bed, on the ground, with head towards foot of the bed. Resident with no visible injuries. Denied hitting head but cannot recall how the resident fell or what the resident was doing . Bed alarm was not going off and call light was not on. New bed alarm placed. Resident returned to bed, educated and reminded to use the call light for assistance .Resident was not using cane/walker as instructed. Resident was not wearing oxygen as prescribed at time of fall . -09/25/2024 Post Fall Evaluation Fall Details: Date / Time of Fall: 09/25/2024 2:05 PM, Fall was not witnessed. Fall occurred in the resident's room. Resident was attempting to self toilet at time of the fall. The reason for the fall was not evident .Fall Details Note: Resident with unwitnessed fall in room. Resident found face down on the ground, head towards foot of the bed. Resident was assessed by Registered Nurse (RN) and DON for injures or any deformities. No visual sign of injury. Resident assisted back into bed by RN and Certified Nursing Assistant (CNA.) Resident denied hitting head. Reported no pain. Resident attempted to self-transfer out of bed and admitted to needing to use the restroom. Vital signs within defined limits. Bed alarm in place. Contributing Factors: .Footwear at time of fall: Socks. Resident was not using cane/walker as instructed. Resident was not wearing oxygen as prescribed at time of fall . -10/06/2024 Post Fall Evaluation Late Entry: Date / Time of Fall: 10/06/2024 6:30 PM, Fall was not witnessed. Fall occurred in the resident's room. Activity at the time of fall: Resident stated was trying to get self back to bed from sitting at side of bed eating dinner. Reason for the fall was evident. Reason for fall: Resident tried to get self back into bed. Resident denied utilizing call light for assistance . Contributing factors note: Patient denied utilizing call light for staff assistance when they were finished with meal. -10/07/2024 Fall Root cause analysis and IDT: Resident was impulsive and had poor safety awareness .The resident overestimated abilities and often became anxious and impatient during care provision .The resident denied any pain related to fall and stated the resident will attempt to be more patient and ask for assistance due to cognitive decline related to resident's condition, staff will continue to offer frequent reminders on safety past fall follow up indicated this fall was not the result of abuse or neglect. The care plan had been reviewed and updated to reflect interventions to assist in fall prevention for the resident. Resident #25's comprehensive care plan initiated on 04/30/2024 and revised on 07/02/2024, documented a focus area for high risk for falls r/t gait/balance problems and history of falling. The care plan contained one intervention post falls in September, initiated 09/17/2024: Physical Therapy/Occupational Therapy (PT/ OT) evaluate and treat as ordered or as needed (PRN.) Resident #25's Alert Note dated 10/09/2024, documented the prior Director of Nursing initiated potential to utilize trapeze as an intervention for the resident related to falls, upon reviewing this with therapy and nursing staff and the resident, it had been determined this was an ineffective intervention and the resident would not receive any benefit related to bed mobility with a trapeze, this is an ineffective intervention. Therapy did not have a suggestion for equipment related to fall intervention, to assist in fall will have staff provide frequent checks and encourage resident to be in visual areas while awake to assist in fall prevention at this time. On 10/18/2024 at 9:28 AM, the DON explained Resident #25 had impulse control problems and had quite a few falls. It was almost behavioral, the resident gets impatient and tries to get out of bed. On 10/18/2024 at 9:35 AM, the DON confirmed implementing new interventions after the 10/06/2024 fall. The previous DON wanted to do a trapeze as an intervention after one of the falls in September but did not get an evaluation from PT/OT. The current DON had a verbal meeting with PT/OT and they said no, the trapeze was not approriate and had no other interventions. The intervention for the trapeze was not on the care plan. The care plan did not reflect interventions post falls from 09/14/2024 and 09/25/2024 to prevent future falls. The PT/OT eval, post fall, did not derive new interventions. The facility policy titled Falls and Fall Prevention, last revised 05/2024, documented extra measures were to be on the care plan for fall prevention and Morse scale completed post fall. Cross reference F tag 657

Based on interview and personnel record review, the facility failed to ensure a Certified Nursing Assistant (CNA) had an annual performance evaluation completed timely for 3 of 4 CNAs employed greater than one year, sampled for personnel record review (Employee #3, #8 and #9). Findings include: Employee #3 Employee #3 was hired as the Activity Director/CNA with a start date of 02/08/2018. Employee #3's personnel record documented the CNA had an annual performance evaluation last completed on 05/22/2023. Employee #3's personnel record lacked documented evidence a performance evaluation was completed in May 2024. Employee #8 Employee #8 was hired as a CNA with a start date of 07/20/2022. Employee #8's personnel record documented the CNA had an annual performance evaluation last completed on 04/28/2023. Employee #8's personnel record lacked documented evidence a performance evaluation was completed in April 2024. Employee #9 Employee #9 was hired as a CNA with a start date of 04/17/2013. Employee #9's personnel record documented the CNA had an annual performance evaluation last completed on 06/03/2023. Employee #9's personnel record lacked documented evidence a performance evaluation was completed in June 2024. On 10/16/2024 at 11:32 AM, the Human Resources Director was unable to provide evidence Employee #3, #8 and #9 had an annual performance evaluation completed for 2024 and verbalized the CNA annual performance evaluations were to be completed annually by the anniversary date of hire. The Human Resources Director confirmed the CNA annual performance evaluations were not completed for Employee #3, #8 and #9 annually for 2024. The facility policy titled Long Term Care Staff Continuing Education, last reviewed 04/13/2024, documented CNAs would receive annual evaluation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review the facility failed to ensure ordered medications were available for 1 of 5 residents observed for medication administration (Resident #6) and have a procedure in place for the safe procurement of drugs and biologicals. Findings include: Resident #6 Resident #6 was admitted to the facility on [DATE], with diagnoses including dry eye syndrome of bilateral lacrimal glands and abnormal results of other function studies of the eye. Resident #6's October 2024 Medication Administration Record (MAR) documented Restasis Ophthalmic Emulsion, instill one drop in both eyes two times a day for cataract inflammation. The order date was 09/10/2024. The medication was documented as 9 on the following dates for the 8:00 AM medication pass: -10/11/2024 -10/16/2024 -10/17/2024 The medication was documented as 9 on the following dates for the 8:00 PM medication pass: -10/10/2024 -10/12/2024 -10/13/2024 -10/14/2024 -10/15/2024 -10/16/2024 The MAR chart code documented a 9 equated to other, see progress notes. Resident #6's Orders Administration Notes documented the following: -Effective date 10/10/2024, Restasis Ophthalmic Emulsion, instill one drop in both eyes two times a day. On order. -Effective date 10/11/2024, Restasis Ophthalmic Emulsion, instill one drop in both eyes two times a day. Awaiting medication delivery. -Effective date 10/12/2024, Restasis Ophthalmic Emulsion, instill one drop in both eyes two times a day. On order, awaiting delivery. -Effective date 10/13/2024, Restasis Ophthalmic Emulsion, instill one drop in both eyes two times a day. Awaiting delivery. -Effective date 10/14/2024, Restasis Ophthalmic Emulsion, instill one drop in both eyes two times a day. Still awaiting pharmacy delivery. -Effective date 10/15/2024, Restasis Ophthalmic Emulsion, instill one drop in both eyes two times a day. On order. -Effective date 10/16/2024, Restasis Ophthalmic Emulsion, instill one drop in both eyes two times a day. Awaiting medication delivery. -Effective date 10/17/2024, Restasis Ophthalmic Emulsion, instill one drop in both eyes two times a day. Awaiting pharmacy delivery. On 10/18/2024 at 8:30 AM, during an interview with the Director of Nursing (DON) and a Registered Nurse (RN), the DON confirmed Resident #6 had not received ordered doses of Restasis Ophthalmic Emulsion eye drops due to the medication being unavailable in the facility and on order from the pharmacy. The DON explained the DON was aware the Restasis eye drops were not available in the facility and had contacted the facility's pharmacy multiple times to request a refill of the medication. The RN reviewed Resident #6's clinical record and explained the medication had been unavailable in the facility since 10/10/2024. On 10/18/2024 at 11:40 AM, during an interview with the Administrator and the DON, the Administrator explained the facility did not have a documented policy or procedure in place for the safe procurement of drugs and biologicals for residents. The facility document titled Consultant Pharmacist Agreement, effective 10/01/2024, documented the consultant pharmacist was to assist the facility with the implementation of policies and procedures for the safe procurement of drugs and biologicals. Cross reference F tag 759

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #24 Resident #24 was admitted to the facility on [DATE], with a diagnosis of major depressive disorder, recurrent, unspecified. Resident #24's psychotropic physician's order dated 01/22/2024, documented Fluoxetine HCl oral capsule 40 mg, give 40 mg by mouth at bedtime related to major depressive disorder, recurrent, unspecified. On 10/17/2024 at 3:23 PM, the Director of Nursing (DON) explained physician orders for psychotropic medications were required to include the specific behaviors and/or symptoms the medication was ordered for. On 10/17/2024 at 3:45 PM, the DON confirmed the physician had not been identifying specific behaviors related to the administration of the psychotropic medications. Nurses were entering behaviors on care plans however, the physician had not indicated the targeted behaviors identified for the need for the specific psychotropic medications. The facility policy titled Psychotropics Medications, reviewed 04/14/2023, documented psychotropic medications were drugs effecting brain activities associated with mental processes and behavior. The interdisciplinary team would determine the lowest possible effective dose in managing identified behaviors. The provider's order would include the reason for the psychotropic being ordered. Resident #5 Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of depressive disorder, recurrent, unspecified. Resident #5's psychotropic physician's order dated 10/05/2024, documented Mirtazapine 15 mg oral tablet, give 15 mg by mouth at bedtime related to depressive disorder, recurrent, unspecified. Resident #12 Resident #12 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of unspecified psychosis not due to a substance or known physiological condition. Resident #12's psychotropic physician's order dated 07/23/2024, documented Olanzapine 2.5 mg oral tablet, give 2.5 mg by mouth at bedtime related to unspecified psychosis not due to a substance or known physiological condition. Based on interview, clinical record review, and document review, the facility failed to ensure behaviors monitored were associated with the specific condition indicated by the physician for the use of psychotropic medications for 1 of 12 sampled residents (Resident #2) and physician ordered psychotropic medications had a specific condition documented for indication of use associated with the diagnoses for 5 of 12 sampled residents (Resident #23, #25, #5, #12, and #24). Findings include: Resident #2 Resident #2 was admitted on [DATE], and readmitted on [DATE], with diagnoses including major depressive disorder, recurrent, unspecified and vascular dementia, moderate with mood disturbances. Resident #2's psychotropic physician's orders, dated 02/15/2024, documented the following: -Seroquel oral tablet 25 milligrams (mg), give one tablet by mouth in the afternoon for low mood, anxiety, paranoid ideation related to major depressive disorder, recurrent, unspecified. -Cymbalta oral capsule delayed release particles 30 mg, give one capsule by mouth two times a day for low mood, anxiety, paranoid ideation related to major depressive disorder, recurrent, unspecified. Resident #2's care plans documented the following focus areas related to psychotropic medications: -Resident #2 had a behavior history of self-isolation, sense of doom, crying/tearful episodes, anxious related to (r/t) major depressive disorder, initiated 03/05/2023 and revised 10/09/2024. -Resident #2 used psychotropic medications r/t major depressive disorder with behaviors. Resident #2 had a history of fearfulness, crying, tearfulness, anxious, self isolation, sense of doom and agitation, initiated 09/13/2023 and revised 10/09/2024. An intervention included to monitor for effectiveness by charting every shift behavior monitoring in Point of Care (POC) and/or additional behavior monitoring in progress notes of electronic Medication Administration Record (eMAR). Resident #2's behavior monitoring in the eMAR instructed the nurse to document behavior monitoring every day and night shift related to major depressive disorder, recurrent, unspecified. On 10/15/2024, the resident had behaviors twice on the day shift. The documentation was indicated with yes. On 10/17/2024 at 2:29 PM, the Director of Nursing (DON) verbalized the behavior monitoring on the eMAR was not personalized to each resident for the specific psychotropic medication. On 10/17/2024 at 3:45 PM, the DON confirmed Resident #2 did not have any documented evidence of the behaviors exhibited on 10/15/2024 or the behaviors monitored were related to the behaviors identified for the administration of the psychotropic medications. The behavior monitoring was entered by nurses in the eMAR and the physician signed after it was entered. The nurses had been using the diagnosis on the psychotropic medication as the behavior to be monitored and did not add specific behaviors related to the medication, as identified by the physician. The facility policy titled Psychotropics Medications, reviewed 04/14/2023, documented daily monitoring of psychotropic medications were to include the presence and frequency of resident-specific targeted behaviors. Resident #23 Resident #23 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbances and major depressive disorder, single episode, severe without psychotic features. Resident #23's psychotropic physician's order dated 09/12/2024, documented the following: -Venlafaxine Hydrochloric Acid (HCl) extended release oral tablet 24 hour 75 mg, give 75 mg by mouth, one time a day related to major depressive disorder, single episode, severe without psychotic features. -Divalproex Sodium oral tablet delayed release 250 mg, give 250 mg by mouth, two times a day related to other headache syndrome and major depressive disorder, single episode, severe without psychotic features. Resident #25 Resident #25 was admitted to the facility on [DATE], with a diagnosis of major depressive disorder, recurrent, unspecified. Resident #25's psychotropic physician's order dated 05/01/2024, documented Citalopram Hydrobromide oral tablet 20 mg, give 20 mg by mouth, one time a day related to major depressive disorder, recurrent, unspecified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review the facility failed to ensure medications were administered with an error rate of less than five percent (%). There were 29 opportunities and two medication errors. The medication error rate was 6.9%. Findings include: Resident #6 Resident #6 was admitted to the facility on [DATE], with diagnoses including heart failure, unspecified, dry eye syndrome of bilateral lacrimal glands, and abnormal results of other function studies of the eye. On 10/17/2024 at 8:08 AM, a Registered Nurse (RN) began preparing medications for Resident #6. The RN verbalized the physician ordered Restasis Ophthalmic Emulsion eye drops were not available in the facility and were on order from the pharmacy. The RN verbalized Resident #6's physician ordered medications for the morning medication pass included Metoprolol 12.5 milligrams (mg). The RN compared the bubble pack containing Metoprolol to the physician order on the Medication Administration Record (MAR) then placed the bubble pack back in the medication cart. The RN did not remove the medication from the bubble pack. On 10/17/2024 at 8:14 AM, the RN locked the medication cart, grabbed the medication cup containing Resident #6's prepared medications, and began to move toward Resident #6 to administer the medications. The RN was asked to verify the number of tablets in the medication cup. After counting the number of tablets in the medication cup, the RN verbalized Resident #6's Metoprolol was not in the cup. The RN then retrieved the Metoprolol from the medication cart, placed the medication in the medication cup and administered the medications to Resident #6. On 10/17/2024 at 8:27 AM, the RN explained the RN's usual process when administering medications to residents was to retrieve the medication from the medication cart, compare it to the order on the resident's MAR, remove the medication from the medication card, and placed the medication in a medication cup. The RN verbalized the RN forgot to place Resident #6's Metoprolol in the medication cup during the morning medication pass because the RN was nervous about being observed during medication administration. Resident #6's MAR documented the following: -Restasis Ophthalmic Emulsion, instill one drop in both eyes two times a day for cataract inflammation. The order date was 09/10/2024. -Metoprolol Tartrate oral tablet 25 milligrams (mg), give one half tablet by mouth two times a day related to heart failure, unspecified and tachycardia unspecified. The order date was 09/10/2024. On 10/18/2024 at 8:30 AM, the DON explained the DON's expectation of nursing staff when administering medications to residents was to check the physician's order, verify the medication against the order, assure the resident was within parameters if applicable, punch/remove the tablet from the medication card (bubble pack), administer the medication, and document the administration. The DON confirmed medication errors included failure to administer an ordered medication (omission). The facility policy titled Medication Error Prevention and Investigation, Adverse Drug Reactions, dated 09/27/2007, documented all medications were to be administered to residents in a safe manner, according to physician's orders. Medication errors included omitting a prescribed medication. Cross reference F tag 760

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review the facility failed to ensure 1 of 5 residents reviewed for medication administration were free from significant medication errors (Resident #6). This deficient practice had the potential to cause worsening of the resident's diagnosed heart failure. Findings include: Resident #6 Resident #6 was admitted to the facility on [DATE], with a diagnosis of heart failure, unspecified. Resident #6's MAR documented Metoprolol Tartrate oral tablet 25 milligrams (mg), give one half tablet by mouth two times a day related to heart failure, unspecified and tachycardia unspecified. Nurse to hold medication if blood pressure is lower than 90/50 and/or heart rate is lower than 50. The order date was 09/10/2024. On 10/17/2024 at 8:08 AM, during medication pass observation, a Registered Nurse (RN) began preparing medications for Resident #6. The RN verbalized Resident #6's physician ordered medications for the morning medication pass included Metoprolol 12.5 milligrams (mg). The RN compared the bubble pack containing Metoprolol to the Medication Administration Record (MAR), then placed the bubble pack back in the medication cart. The RN did not remove the medication from the bubble pack. The RN explained it was safe to administer the Metoprolol as the resident's blood pressure was 96/55 and the physician's parameters indicated to hold the medication if the resident's blood pressure was less than 90/50. On 10/17/2024 at 8:14 AM, the RN locked the medication cart, grabbed the medication cup containing Resident #6's prepared medications, and began to move toward Resident #6 to administer the medications. The RN was asked to verify the number of tablets in the medications cup. After counting the number of tablets in the medication cup, the RN verbalized Resident #6's Metoprolol was not in the cup. The RN then retrieved the Metoprolol from the medication cart, placed the medication in the medication cup and administered the medications to Resident #6. On 10/17/2024 at 8:27 AM, the RN explained the RN's usual process when administering medications to residents was to retrieve the medication from the medication cart, compare it to the order on the resident's MAR, remove the medication from the medication card, and placed the medication in a medication cup. The RN verbalized the RN forgot to place Resident #6's Metoprolol in the medication cup during the morning medication pass because the RN was nervous about being observed during medication administration. The RN explained if a resident did not receive the resident's physician ordered Metoprolol, the resident's blood pressure could elevate and the resident could suffer a cerebrovascular accident (stroke). On 10/18/2024 at 8:30 AM, the DON explained the DON's expectation of nursing staff when administering medications to residents was to check the physician's order, verify the medication against the order, punch/remove the tablet from the medication card (bubble pack), administer the medication, and document the administration. The DON explained it was important to assure the resident was within parameters if applicable, such as with blood pressure medications, to assure it was safe to administer the medication. The DON confirmed medication errors included failure to administer an ordered medication (omission). Epocrates (online drug database) - Metoprolol Tartrate, version 19.01, revised 08/09/2023, documented Metoprolol Tartrate was used to treat hypertension (high blood pressure) and to lower risk of death or needing to be hospitalized for heart failure. Anyone taking Metroprolol Tartrate was to follow all directions on the prescription label and use the medication exactly as directed. Metoprolol Tartrate should not be stopped suddenly as stopping the medication suddenly could make the condition for which it was prescribed worse. The facility policy titled Medication Error Prevention and Investigation, Adverse Drug Reactions dated 09/27/2007, documented all medications were to be administered to residents in a safe manner, according to physician's orders. Medication errors included omitting a prescribed medication. Cross reference F tag 759

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure psychotropic behavior monitoring was documented on the Behavioral Health (BH) Record for 6 of 12 sampled residents (Resident #2, #5, #11, #12, #24, and #25) and records were accurate for 1 of 5 residents observed during medication administration (Resident #6). Findings include: Incomplete Records Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of major depressive disorder, recurrent, unspecified. A physician order dated 02/18/2024, documented behavior monitoring every day and night shift related to major depressive disorder, recurrent, unspecified. Resident #2's October 2024 BH Record documented behavior monitoring every day and night shift related to major depressive disorder, recurrent, unspecified. The BH record had blank spaces for behavioral monitoring during the day shift on 10/03/2024 and 10/13/2024. Resident #2's clinical record lacked documented evidence behavioral monitoring was completed during the day shift on 10/03/2024 and 10/13/2024. Resident #5 Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of major depressive disorder, recurrent, unspecified. A physician order dated 02/04/2024, documented monitor behaviors every shift: verbal outbursts, tearfulness, social isolation, and negative statements every day and night shift for behavior monitoring. Resident #5's October 2024 BH Record documented monitor behaviors every shift: verbal outbursts, tearfulness, social isolation, and negative statements every day and night shift for behavior monitoring. The BH record had blank spaces for behavioral monitoring during the day shift on 10/13/2024. Resident #5's clinical record lacked documented evidence behavioral monitoring was completed during the day shift on 10/13/2024. Resident #11 Resident #11 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of unspecified dementia, unspecified severity, with other behavioral disturbance. A physician order dated 09/10/2024, documented behavior monitoring every day and night shift. Resident #11's October 2024 BH Record documented behavior monitoring every day and night shift. The BH record had blank spaces for behavioral monitoring during the day shift on 10/03/2024 and 10/13/2024. Resident #11's clinical record lacked documented evidence behavioral monitoring was completed during the day shift on 10/03/2024 and 10/13/2024. Resident #12 Resident #12 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of personal history of traumatic brain injury and mood disorder due to known physiological condition with mixed features. A physician order dated 09/10/2024, documented behavior monitoring every day and night shift related to personal history of traumatic brain injury and mood disorder due to known physiological condition with mixed features. Resident #12's October 2024 BH Record documented behavior monitoring every day and night shift related to personal history of traumatic brain injury and mood disorder due to known physiological condition with mixed features. The BH record had blank spaces for behavioral monitoring during the day shift on 10/03/2024 and 10/13/2024. Resident #12's clinical record lacked documented evidence behavioral monitoring was completed during the day shift on 10/03/2024 and 10/13/2024. Resident #24 Resident #24 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, unspecified, generalized anxiety disorder, and major depressive disorder, recurrent, unspecified. A physician order dated 09/10/2024, documented behavior monitoring every day and night shift related to Alzheimer's disease, unspecified, generalized anxiety disorder, and major depressive disorder. Resident #24's October 2024 BH Record documented behavior monitoring every day and night shift related to Alzheimer's disease, unspecified, generalized anxiety disorder, and major depressive disorder. The BH record had blank spaces for behavioral monitoring during the day shift on 10/03/2024 and 10/13/2024. Resident #24's clinical record lacked documented evidence behavioral monitoring was completed during the day shift on 10/03/2024 and 10/13/2024. Resident #25 Resident #25 was admitted to the facility on [DATE], with a diagnosis of major depressive disorder, recurrent, unspecified. A physician order dated 04/30/2024, documented every shift behavioral monitoring. Every day and night shift related to major depressive disorder, recurrent, unspecified. Resident #25's October 2024 BH Record documented every shift behavioral monitoring. Every day and night shift related to major depressive disorder, recurrent, unspecified. The BH record had blank spaces for behavioral monitoring during the day shift on 10/03/2024 and 10/13/2024. Resident #25's clinical record lacked documented evidence behavioral monitoring was completed during the day shift on 10/03/2024 and 10/13/2024. On 10/17/2024 at 2:29 PM, the Director of Nursing (DON) confirmed spaces were left blank during the day shift on 10/03/2024 and 10/13/2024 and verbalized the nurse may have forgotten to document monitoring on 10/03/2024 and 10/13/2024. On 10/18/2024 at 11:10 AM, the DON verbalized behavior monitoring should be documented immediately after observation.Inaccurate Records Resident #6 Resident #6 was admitted to the facility on [DATE], with diagnoses including dry eye syndrome of bilateral lacrimal glands, and abnormal results of other function studies of the eye. Resident #6's MAR documented Restasis Ophthalmic Emulsion eyes drops were administered to Resident #6 during the 8:00 AM medication pass from 10/12/2024 through 10/15/2024. Orders Administration notes dated 10/10/2024 through 10/17/2024 documented Resident #6's Restasis Ophthalmic Emulsion eye drops were on order, awaiting delivery from the pharmacy. On 10/18/2024 at 8:30 AM, during an interview with the DON and a Registered Nurse (RN), the DON verbalized Resident #6 had not received ordered doses of Restasis Ophthalmic Emulsion eye drops due to the medication being unavailable in the facility and on order from the pharmacy. The DON explained the DON was aware the Restasis eye drops were not available in the facility and had contacted the facility's pharmacy multiple times to request a refill of the medication. The RN reviewed Resident #6's clinical record and explained the medication had been unavailable in the facility since 10/10/2024. The DON explained the DON had administered medications to Resident #6 during the 8:00 AM medication pass from 10/12/2024 through 10/14/2024. The DON verbalized the Restasis eye drops were not available, and the DON documented the medication as administered in error. The facility policy titled Medication Administration, reviewed 04/13/2023, documented facility staff would ensure safe resident medication administration by using the seven rights for medication administration. The seven rights for medication administration included right documentation. Documentation of medication administration would be completed after administering the medication to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and document review, the facility failed to ensure a resident's right to be treated with respect and dignity was protected when a care plan was updated to include sexual behaviors of the resident, as the facility response to the resident experiencing abuse. A cognitively impaired, non-verbal resident without previously identified behaviors had a care plan initiated as part of their clinical record without evidence or assessment of a change in the resident's baseline, after facility staff observed physical and verbal abuse by a Certified Nursing Assistant (CNA1) toward the resident for 1 of 13 sampled residents (Resident #3). Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified intracranial injury with loss of consciousness of unspecified duration, initial encounter, dysphagia, unspecified, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and quadriplegia, unspecified. A Facility Reported Incident (FRI) dated 03/21/2024, and concluded on 03/25/2024, documented a Dietary Aide (Food Services Supervisor) had overheard a CNA tell Resident #3 I told you I would slap you if you did that again and alleged the resident was touching the CNA's breasts. The FRI was unsubstantiated by the facility. A letter from a Behavioral Health Advanced Practice Registered Nurse (APRN), dated 03/21/2024, documented Resident #3 had been living in the facility since 2005, due to inability to care for self, related to a traumatic brain injury following an accident. During the resident's time at the facility, the resident had not shown a significant change to the resident's cognitive status. The resident had limited fine motor skills and was non-verbal which made traditional cognitive testing difficult. The resident was able to express approval or enjoyment by smiling, eye-tracking subjects and was able to answer yes or no questions about immediate needs with blinking, nodding or waiving of a hand response. The resident was unreliable with yes or no responses when approached with complex communication attempts. On 04/08/2024 at 2:34 PM, Resident #3's Guardian verbalized the facility had informed the Guardian there was an investigation into an abuse allegation toward Resident #3. The allegation included a staff member telling Resident #3 to shut up. It was alleged Resident #3 had reached out to a staff member and was touching the staff member inappropriately. The Guardian verbalized not understanding how Resident #3 could have touched an employee inappropriately because the resident had limited mobility and was non-verbal. The Guardian explained having been Resident #3's Guardian for nine years and had not been aware of the resident having any previous behaviors of touching anyone inappropriately and verbalized it was really disheartening staff would talk to a resident with limited cognition, in an abusive way. The resident also could not open hands due to contractures with limited mobility. The Guardian questioned the ability of the resident to be able to touch staff inappropriately. An Incident Progress Note dated 03/21/2024, documented Dietary staff had witnessed a CNA slap Resident #3 on the hand and verbalized to the resident I told you if you did that again that I would smack you. The incident was reported to the Chief Nursing Officer (CNO) and Chief Executive Officer (CEO) and alleged after breakfast on 03/21/2024, a CNA was assisting Resident #3 with feeding the resident when the resident had brushed the hand against the staff member's breast. The resident was spoken to about the behavior and explained to the resident the touching was unwelcome and inappropriate. A Care Plan initiated on 03/25/2024, documented Resident #3 had a behavior problem related to inappropriate sexual behaviors. The Behavior Monitoring Flow Sheet dated from 03/10/2024, through 04/09/2024, documented Resident #3 had only shown a behavioral issue on the afternoon of 03/21/2024, by projecting Public Sexual Acts. No other behaviors were documented within the 30-day timeframe. A Social Service assessment dated [DATE], documented Resident #3 did not have any mood or behavior diagnoses, however, had a diagnosis of dementia. The annual Minimum Data Set (MDS) 3.0 dated 04/01/2024, documented the resident did not exhibit behaviors, such as, hitting, kicking, pushing, scratching, grabbing, or abusing others sexually. On 04/10/2024 at 8:24 AM, the Food Services Supervisor recalled observing the incident on 03/21/2024. The resident had lifted a fist up, which was a common occurrence because the resident often gave fist bumps to staff, and the CNA slapped Resident #3's hand. The CNA told the resident you better stop or I am going to smack you and smacked his hand. On 04/10/2024 at 8:41 AM, CNA2 explained Resident #3 was non-verbal and could communicate with staff by touching with the resident's right hand. CNA2 could not explain the difference between Resident #3 attempting to communicate with staff and inappropriate touching because the resident could only move the right hand with limitation. The facility's Investigation Packet dated 03/21/2024, documented Dietary staff's recollection of observed verbal and physical abuse toward Resident #3. The Dietary Aide (Food Services Supervisor) had overheard CNA1 tell Resident #3 I told you I was going to smack you if you did that again. An immediate assessment of the resident lacked observations of redness, bruising, signs and symptoms of pain, grimacing withdrawal, and skin integrity issues. Included in the packet were statements from staff, statements from residents, and abuse trainings completed by CNA1. A witness statement from the Administrator dated 03/21/2024, documented the Administrator had removed CNA1 from being in the same vicinity as Resident #3. A witness statement from CNA3 dated 03/21/2024, documented CNA3 heard CNA1, who was assigned to feed Resident #3, verbalize to the resident to stop touching CNA1's breasts. A witness statement from the Food Services Supervisor dated 03/21/2024, documented the Food Services Supervisor was serving drinks to residents in the dining room and overheard CNA1 tell Resident #3 you had better stop doing that right now or I am going to smack you next time. The Food Services Supervisor observed CNA1 smack Resident #3 and verbalized I told you I would smack you if you did it again. It appeared to the Food Services Supervisor, Resident #3 was attempting to fist bump CNA1 and CNA1 was irritated by Resident #3. The observation was reported to the Charge Nurse right away. A witness statement from CNA4 dated 03/21/2024, documented CNA4 overheard CNA1 verbalize to Resident #3 to not touch CNA1's breasts. CNA4 observed CNA1 put Resident #3's hand down in a non-aggressive way. CNA1's statement dated 03/21/2024, documented CNA1 verbalized Resident #3 was touching CNA1 inappropriately and warned the resident to stop. CNA1 explained telling the resident the touching would not be tolerated. CNA1 then tapped the resident on the resident's right hand and then held the right hand to prevent the resident from moving the right hand. On 04/10/2024 at 10:16 AM, the Licensed Social Worker (LSW) verbalized on 03/21/2024, a report was submitted regarding a CNA verbally and physically abusing Resident #3. The LSW immediately went to speak to Resident #3 to determine a baseline for potential negative psychosocial outcome, behavioral changes and patterns as a result of the abuse. The resident was monitored for three days by the LSW, however, the LSW determined no further monitoring was necessary because the resident was acting normally, as the resident had not exhibited any sexual behaviors prior to this incident. On 04/10/2024 at 3:03 PM, the Administrator verbalized on 03/21/2024, the Food Services Supervisor notified a Charge Nurse of abuse against Resident #3 by a CNA. The CNA deflected Resident #3's hand because the resident was touching the CNA inappropriately and told the resident I told you I would slap your hand if you did that again. The Administrator defined abuse as willful injury and confinement resulting in physical harm or anguish, including deprivation. The Administrator described Resident #3 as non-verbal and communicated with staff with right hand gestures to indicate a 'yes' or a 'no' to questions asked and could not demonstrate if the resident was trying to communicate to CNA1 regarding the resident needing something or if the touching was inappropriate. The Administrator acknowledged the care plan was not accurate related to the resident exhibiting sexual behaviors toward others. On 04/11/2024 at 12:27 PM, MDS Coordinator confirmed job duties included creating and revising care plans. That CP came from the FRI that was The care plan for Resident #3's behavior problem related to inappropriate sexual behaviors came from the FRI investigation and was contacted by the abuse investigation team to initiate it. The MDS Coordinator confirmed the APRN indicated cognitive difficulties and non-verbal state but nothing specifically regarding behaviors, and confirmed mental and physical abilities remained unchanged. Based on the evaluation of the APRN, it could not be definitively said the resident's touching was inappropriate. No further assessments were completed. The facility policy titled Abuse Prevention and Prohibition, last reviewed 08/25/2023, documented each resident had a right to a dignified existence and to be free of physical, sexual, psychological abuse, and neglect. The facility would protect and promote the rights of each resident, including the right to be free from all forms of abuse or neglect, including verbal and mental abuse. The facility policy titled Baseline and Comprehensive Care Plan, reviewed 04/13/2023, documented care, treatment, and services shall be planned to ensure all were individualized to the resident's needs and goals. The planning for care, treatment, and services included regularly reviewing and revising the care plan and determining how the planned care, treatment, and services would be provided. Care planning would be implemented through the integration of assessment findings. The facility policy titled Resident [NAME] of Rights, last revised 05/29/2003, documented the resident had a right to be treated with consideration, respect, dignity, and individuality, including privacy and care of personal needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and document review, the facility failed to ensure a resident's Guardian gave informed consent prior to placing an air mattress on top of a resident's bariatric bed for 1 of 13 sampled residents (Resident #3). Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified intracranial injury with loss of consciousness of unspecified duration, initial encounter, dysphagia, unspecified, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and quadriplegia, unspecified. On 04/08/2024 at 11:05 AM, Resident #3 was in a geri-chair next to the bed. The bed was a bariatric bed with an air mattress on the top of the bed. Resident #3's clinical record lacked a care plan addressing the air mattress on the top of the bariatric bed. Resident #3's clinical record lacked documented evidence the risk and benefits were explained to the resident's Guardian and the resident had been assessed for the risk of entrapment and restraint. A physician's order dated 06/06/2023, documented bariatric air mattress to bed to prevent skin breakdown. On 04/09/2024 at 2:21 PM, the air mattress had air barriers on each side of the mattress. Two Certified Nursing Assistants (CNAs) were providing care to the resident and explained Resident #3 had an air mattress on the top of the bariatric bed frame to prevent bed sores from developing or getting worse. The CNA explained the barriers would fill up with air at the same time the mattress would inflate with air. The barriers would act as a fall deterrent so as the bed would tilt to rotate the resident, the barrier would prevent the resident from falling out of the bed. On 04/10/2024 at 1:35 PM, the Director of Nursing (DON) explained Resident #3 was a quadriplegic and needed help with all Activities of Daily Living (ADL). The facility acquired a bariatric bed for the resident. The bed tilted from side to side to help rotate the resident. The mattress on top of the bed frame was an air mattress, with air borders lining each side of the mattress. Staff were able to inflate or deflate the mattress, to include the barriers, as needed, to help prevent the resident from acquiring a pressure sore. The DON verbalized since the resident could not turn themselves, if the resident rolled into the air barriers on the mattress, the resident could suffocate. The DON verbalized the air mattress was considered a restraint for the resident. As a requirement of a potential restraint, the facility needed to attempt and document interventions attempted prior to applying the air mattress to the bed, assess the resident for risk of entrapment and review the risks and benefits with the resident's Guardian. The DON confirmed an informed consent from the resident's guardian was not obtained prior to placing the air mattress on the resident's bariatric bed. On 04/10/2024 at 2:02 PM, the Minimum Data Set (MDS) Coordinator explained the MDS Coordinator was responsible for completing assessments for risk of entrapment. A consent to use the air mattress should be obtained, a physician's order should be written and the risks and benefits should be explained to the Guardian. The MDS Coordinator confirmed an informed consent was not obtained from the resident's Guardian prior to placing the air mattress on the resident's bariatric bed. The facility policy titled Mobility Devices and Physical Restraints, last reviewed 04/13/2023, documented all residents would be assessed for physical mobility. Every resident had the right to be free from any physical restraint and a restraint would only be used to treat a specific medical condition. Prior to the using physical devices or physical restraints, an assessment would be completed, the resident would be monitored, a physician's order would be obtained, consents would be obtained, the risks and benefits of a restraint would be obtained, and a care plan would be developed. Cross Reference Tags F656 and F689

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and document review, the facility failed to protect a resident's right to be free from verbal and physical abuse by a Certified Nursing Assistant (CNA) for 1 of 13 sampled residents (Resident #3). Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified intracranial injury with loss of consciousness of unspecified duration, initial encounter, dysphagia, unspecified, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and quadriplegia, unspecified. A Facility Reported Incident (FRI) dated 03/21/2024, and concluded on 03/25/2024, documented a Dietary Aid (Food Services Supervisor) had overheard a CNA1 tell Resident #3 I told you I would slap you if you did that again. The FRI was unsubstantiated by the facility for failure to prove Resident #3 experienced a negative psychosocial outcome. A letter from a Behavioral Health Advanced Practice Registered Nurse (APRN), dated 03/21/2024, documented Resident #3 had been living in the facility since 2005, due to inability to care for self, related to a traumatic brain injury following an accident. During the resident's time at the facility, the resident had not shown a significant change to the resident's cognitive status. The resident had limited fine motor skills and was non-verbal which made traditional cognitive testing difficult. The resident was able to express approval or enjoyment by smiling, eye-tracking subjects and was able to answer yes or no questions about immediate needs with blinking, nodding or waiving of a hand response. The resident was unreliable with yes or no responses when approached with complex communication attempts. On 04/08/2024 at 2:34 PM, Resident #3's Guardian verbalized the facility had informed the Guardian there was an investigation into abuse toward Resident #3. The allegation included a staff member telling Resident #3 to shut up. It was alleged Resident #3 had reached out to a staff member and was touching the staff member inappropriately. The Guardian verbalized not understanding how Resident #3 could have touched an employee inappropriately because the resident had limited mobility and was non-verbal. The Guardian explained being Resident #3's Guardian for nine years and had not had any previous behaviors of touching anyone inappropriately and verbalized it was really disheartening staff would talk to a resident with limited cognition, in an abusive way. The Resident also could not open hands due to contractures and had limited mobility. The Guardian questioned the ability of the resident to be able to touch staff inappropriately. An Incident Progress Note dated 03/21/2024, documented Dietary staff (Food Services Superviser) had witnessed a CNA1 slap Resident #3 on the hand and verbalized to the resident I told you if you did that again that I would smack you. The incident was reported to the CNO and CEO and alleged after breakfast on 03/21/2024, a CNA was assisting Resident #3 with feeding the resident when the resident had brushed the hand against the staff members breast. The resident was spoken to about the behavior and explained to the resident the touching was unwelcomed and inappropriate. A Care Plan initiated on 01/10/2024, and revised on 03/25/2024, documented Resident #3 was at risk for alteration in wellbeing secondary to risk of experiencing victimization of verbal/physical/emotional abuse related to cognitive impairment, communication barriers and physical limitations (paralysis). The Behavior Monitoring Flow Sheet dated from 03/10/2024, through 04/09/2024, documented Resident #3 had only shown a behavioral issue on the afternoon of 03/21/2024, by projecting Public Sexual Acts. No other behaviors were documented within the 30-day timeframe. A Social Service assessment dated [DATE], documented Resident #3 did not have any mood or behavior diagnoses, however, had a diagnosis of dementia. The annual Minimum Data Set (MDS) 3.0 dated 04/01/2024, documented the resident did not exhibit behaviors, such as, hitting, kicking, pushing, scratching, grabbing, or abusing others sexually. On 04/10/2024 at 8:24 AM, the Food Services Supervisor explained the facility had trained on abuse prior to employment with the facility and had received at least five trainings on abuse and neglect since hire. The trainings covered all types of abuse, procedures on what to do if an individual suspected or witnessed abuse, who to report the abuse to and exact timeframes to report the abuse. The Food Services Supervisor verbalized on 03/21/2024, while helping to serve residents beverages, the door to the kitchen was open to the resident dining room with a view of where Resident #3 was seated. There was a CNA with Resident #3 and the CNA had an attitude. The CNA's attitude was full of frustration because Resident #3 kept moving the right arm. The resident had lifted a fist up, which was a common occurrence because the resident often gave fist bumps to staff, and the CNA slapped Resident #3's hand. The CNA told the resident you better stop or I am going to smack you and smacked his hand. The Food Services Supervisor demonstrated the force on the slap on the resident's hand. The slap on the hand provided some discomfort. The Food Services Supervisor retrieved the Charge Nurse and reported the verbal and physical abuse toward Resident #3. The CNO was notified and assigned a different CNA to help Resident #3 with the rest of the breakfast. The Food Services Supervisor explained the way Resident #3 was treated was demeaning to an individual who was non-verbal and expressed the CNA knew it was abuse toward the resident, especially because the CNA had completed abuse training the day prior. On 04/10/2024 at 8:41 AM, CNA2 recalled overhearing a CNA1 tell Resident #3 to stop touching the CNA1's breasts. CNA2 did not report the incident to any staff members. CNA2 verbalized Resident #3 was non-verbal and could communicate with staff by touching with the resident's right hand. CNA2 could not explain the difference between Resident #3 attempting to communicate with staff and inappropriate touching because the resident could only move the right hand with limitation. On 04/10/2024 at 9:45 AM, the Administrator explained there was an allegation of abuse against CNA1 on 03/21/2024, however, there was no disciplinary action toward CNA1 and would provide the investigation into the allegations. The Investigation Packet dated 03/21/2024, documented Dietary staff's recollection of observed verbal and physical abuse toward Resident #3. The Dietary Aid (Food Services Supervisor) had overheard CNA1 tell Resident #3 I told you I was going to smack you if you did that again. An immediate assessment of the resident lacked observations of redness, bruising, signs and symptoms of pain, grimacing withdrawal, and skin integrity issues. Included in the packet were statements from staff, statements from residents, and the abuse trainings completed by CNA1. A witness statement from the Administrator dated 03/21/2024, documented the Administrator had removed CNA1 from being in the same vicinity as Resident #3. A visual check was done on the resident and did not identify any redness to the resident's hand, arm, or face area. A witness statement from CNA3 dated 03/21/2024, documented CNA3 heard CNA1, who was assigned to feed Resident #3, verbalize to the resident to stop touching CNA1's breasts. A witness statement from the Food Services Supervisor dated 03/21/2024, documented the Food Services Supervisor was serving drinks to residents in the dining room and heard CNA1 tell Resident #3 you had better stop doing that right now or I am going to smack you next time. The Food Services Supervisor observed CNA1 smack Resident #3 and verbalized I told you I would smack you if you did it again. It appeared to the Food Services Supervisor, Resident #3 was attempting to fist bump CNA1 and CNA1 was irritated by Resident #3. The observation was reported to the Charge Nurse right away. A witness statement from CNA4 dated 03/21/2024, documented CNA4 overheard CNA1 verbalize to Resident #3 to not touch CNA1's breasts. CNA4 observed CNA1 put Resident #3's hand down in a non-aggressive way. CNA1's statement dated 03/21/2024, documented CNA1 verbalized Resident #3 was touching CNA1 inappropriately and warned the resident to stop. CNA1 explained telling the resident the touching would not be tolerated. CNA1 then tapped the resident on the resident's right hand and then held the right hand to prevent the resident from moving the right hand. On 04/10/2024 at 10:16 AM, the Licensed Social Worker (LSW) explained the definition of abuse was non-accidental injuries, physical damage and mental anguish of a resident to include willful action and unjustified injury. Abuse did not need to leave an obvious physical injury on an individual to prove abuse occurred. The LSW verbalized on 03/21/2024, a report was submitted regarding a CNA verbally and physically abusing Resident #3. The LSW immediately went to speak to Resident #3 to determine a baseline for potential negative psychosocial outcome, behavioral changes and patterns as a result of the abuse. The resident was monitored for three days by the LSW, however, the LSW determined no further monitoring was necessary because the resident was acting normally. The LSW described a negative psychosocial outcome and behaviors associated would not necessarily be obvious within three days. A negative psychosocial outcome could develop a year later or even ten years after an incident had occurred. On 04/10/2024 at 1:35 PM, the DON explained there were five different types of abuse and abuse was any intentional or unintentional act toward another individual whether the abuse was psychological, physical, entrapment, verbal or sexual. Furthermore, an individual would not need to have obvious signs of physical injury for abuse to occur. The DON verbalized on 03/21/2024, the Administrator informed the DON there was an incident in the dining room between a CNA1 and Resident #3. The DON arrived at the facility and escorted CNA1 off of the facility premises. The DON explained Resident #3 was non-verbal and was a quadriplegic. The resident could not care for themselves and relied on staff for all activities of daily living, making the resident vulnerable. On 04/10/2024 at 3:03 PM, the Administrator verbalized on 03/21/2024, the Food Services Supervisor notified a Charge Nurse of abuse against Resident #3 by a CNA. The CNA deflected Resident #3's hand because the resident was touching the CNA inappropriately and told the resident I told you I would slap your hand if you did that again. The Administrator defined abuse as willful injury and confinement resulting in physical harm or anguish, including deprivation. The Administrator described Resident #3 as non-verbal and communicated with staff with right hand gestures to indicate a 'yes' or a 'no' to questions asked and could not demonstrate if the resident was trying to communicate to CNA1 regarding the resident needing something or if the touching was inappropriate. The Administrator verbalized CNA1 made a statement regarding the abuse. The statement documented CNA1 had asked the resident to stop touching CNA1 and had smacked the resident's hand as a result of frustration with the resident. The Administrator admitted CNA1 had completed abuse training the day prior to the incident and stated maybe the CNA1 was not paying attention to the training. The Administrator verbalized this was not abuse toward Resident #3 because the resident did not have any physical signs of injury, such as, a cut, scrape, red mark, or bruise. The Administrator referred to the State Operations Manual (SOM) abuse grid for pathways regarding resident-to-resident abuse and determined, based off of the grid in the SOM, abuse criteria was not met and the incident was unsubstantiated by the facility. The Administrator made no attempt to refer CNA1 to the Board of Nursing, nor investigate the allegation any further. On 04/10/2024 at 5:38 PM, during a joint interview with the DON and Administrator, the DON verbalized the CNAs actions against Resident #3 on 03/21/2024, did not meet the facility's definition of abuse and would have been discouraged. The facility policy titled Abuse Prevention and Prohibition, last reviewed 08/25/2023, documented each resident had a right to a dignified existence and to be free of physical, sexual, psychological abuse, and neglect. The facility would protect and promote the rights of each resident, including the right to be free from all forms of abuse or neglect, including verbal and mental abuse. The facility policy titled Resident [NAME] of Rights, last revised 05/29/2003, documented the resident had a right to be free from mental and physical abuse. The resident had a right to be treated with consideration, respect, dignity, and individuality, including privacy and care of personal needs. The facility policy titled Psychosocial Needs, last reviewed 04/14/2023, documented all residents would have psychosocial needs met on a continuum of growth and development. All available services would be utilized to give the best quality of care. Residents would be assured a safe environment, both mentally and physically. FRI #NV00070753 Cross Reference with tags F607, F656, and F726

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, document review, and interview, the facility failed to implement the facility's Abuse policies regarding identification, investigation, protection and reporting for an allegation of verbal and physical abuse toward a resident by a Certified Nursing Assistant (CNA) for 1 of 13 sampled residents (Resident #3). Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including unspecified intracranial injury with loss of consciousness of unspecified duration, initial encounter, dysphagia, unspecified, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and quadriplegia, unspecified. A Facility Reported Incident (FRI) dated 03/21/2024, and concluded on 03/25/2024, documented a Dietary Aid (Food Services Supervisor) had overheard a CNA tell Resident #3 I told you I would slap you if you did that again. The FRI was unsubstantiated by the facility for failure to prove Resident #3 experienced a negative psychosocial outcome. An Incident Progress Note dated 03/21/2024, documented Dietary staff (Food Services Supervisor) had witnessed a CNA slap Resident #3 on the hand and verbalized to the resident I told you if you did that again that I would smack you. The incident was reported to the Chief Nursing Officer (CNO) and Chief Executive Officer (CEO) and alleged after breakfast on 03/21/2024, a CNA was assisting Resident #3 with feeding the resident when the resident had brushed the hand against the staff member's breast. The resident was spoken to about the behavior and explained to the resident the touching was unwelcomed and inappropriate. A Care Plan initiated on 01/10/2024, and revised on 03/25/2024, documented Resident #3 was at risk for alteration in wellbeing secondary to risk of experiencing victimization of verbal/physical/emotional abuse related to cognitive impairment, communication barriers and physical limitations (paralysis). On 04/10/2024 at 8:24 AM, the Food Services Supervisor explained the facility had trained on abuse prior to employment with the facility and had received at least five trainings on abuse and neglect. The training covered all types of abuse, procedures on what to do if an individual suspected or witnessed abuse, who to report the abuse to and exact timeframes to report the abuse. The Food Services Supervisor verbalized on 03/21/2024, while helping to serve residents beverages, the door to the kitchen was open to the resident dining room with a view of where Resident #3 was seated. There was a CNA with Resident #3 and the CNA had an attitude. The CNAs attitude was full of frustration because Resident #3 kept moving the right arm. The resident had lifted a fist up, which was a common occurrence because the resident often gave fist bumps to staff, and the CNA slapped Resident #3's hand. The CNA told the resident you better stop or I am going to smack you and smacked his hand. The Food Services Supervisor demonstrated the force on the slap on the resident's hand. The slap on the hand provided some discomfort. The Food Services Supervisor retrieved the Charge Nurse and reported the verbal and physical abuse toward Resident #3. A different CNA was assigned to help Resident #3 with the rest of the breakfast. The Food Services Supervisor explained the way Resident #3 was treated was demeaning to an individual who was non-verbal and expressed the CNA knew it was abuse toward the resident, especially because the CNA had completed abuse training the day prior. On 04/10/2024 at 8:41 AM, CNA2 explained overhearing a CNA1 tell Resident #3 to stop touching the CNA1s breasts. CNA2 did not report the incident to any staff members. CNA2 verbalized Resident #3 was non-verbal and could communicate with staff by touching with the resident's right hand. CNA2 could not explain the difference between Resident #3 attempting to communicate with staff and inappropriate touching because the resident could only move the right hand with limitation. On 04/10/2024 at 9:45 AM, the Administrator explained there was an allegation of abuse against CNA1 on 03/21/2024, however, there was no disciplinary action toward CNA1 and the Administrator would provide the investigation the Administrator completed into the abuse allegations. The Investigation Packet dated 03/21/2024, documented Dietary staff's recollection of observed verbal and physical abuse toward Resident #3. The Dietary Aid (Food Services Supervisor) had overheard CNA1 tell Resident #3 I told you I was going to smack you if you did that again. An immediate assessment of the resident lacked observations of redness, bruising, signs and symptoms of pain, grimacing withdrawal, and skin integrity issues. Included in the packet were statements from staff, statements from residents, and the CNA1's trainings. A witness statement from the Administrator dated 03/21/2024, documented the Administrator had removed CNA1 from being in the same vicinity as Resident #3. A visual check was done on the resident and did not identify any redness to the resident's hand, arm, or face area. A witness statement from CNA3 dated 03/21/2024, documented CNA3 heard CNA1, who was assigned to feed Resident #3, verbalize to the resident to stop touching CNA1's breasts. A witness statement from the Food Services Supervisor dated 03/21/2024, documented the Food Services Supervisor was serving drinks to residents in the dining room and heard CNA1 tell Resident #3 you had better stop doing that right now or I am going to smack you next time. The Food Services Supervisor observed CNA1 smack Resident #3 and verbalized I told you I would smack you if you did it again. It appeared to the Food Services Supervisor, Resident #3 was attempting to fist bump CNA1 and CNA1 was irritated by Resident #3. The observation was reported to the Charge Nurse right away. A witness statement from CNA4 dated 03/21/2024, documented CNA4 overheard CNA1 verbalize to Resident #3 to not touch CNA1's breasts. CNA4 observed CNA1 put Resident #3's hand down in a non-aggressive way. CNA1's statement dated 03/21/2024, documented CNA1 verbalized Resident #3 was touching CNA1 inappropriately and warned the resident to stop. CNA1 explained telling the resident the touching would not be tolerated. CNA1 then tapped the resident on the resident's right hand and then held the right hand to prevent the resident from moving the right hand. On 04/10/2024 at 10:16 AM, the Licensed Social Worker (LSW) explained the definition of abuse was non-accidental injuries, physical damage and mental anguish of a resident to include willful action and unjustified injury. Abuse did not need to leave an obvious physical injury on an individual to prove abuse occurred. The LSW verbalized on 03/21/2024, a report was submitted regarding a CNA1 verbally and physically abusing Resident #3. The LSW immediately went to speak to Resident #3 to determine a baseline for potential negative psychosocial outcome, behavioral changes and patterns as a result of the abuse. The resident was monitored for three days by the LSW, however, the LSW determined no further monitoring was necessary because the resident was acting normally. The LSW described a negative psychosocial outcome and behaviors associated would not necessarily be obvious within three days. A negative psychosocial outcome could develop a year later or even ten years after an incident had occurred. On 04/10/2024 at 1:35 PM, the Director of Nursing (DON) explained there were five different types of abuse and abuse was any intentional or unintentional act toward another individual whether the abuse was psychological, physical, entrapment, verbal or sexual. Furthermore, an individual would not need to have obvious signs of physical injury for abuse to occur. The DON verbalized on 03/21/2024, the Administrator informed the DON there was an incident in the dining room between a CNA and Resident #3. The DON arrived at the facility and escorted CNA1 off of the facility premises. The DON explained Resident #3 was non-verbal and was a quadriplegic. The resident could not care for themselves and relied on staff for all activities of daily living, making the resident vulnerable. On 04/10/2024 at 3:03 PM, the Administrator verbalized on 03/21/2024, the Food Services Supervisor notified a Charge Nurse of abuse against Resident #3 by a CNA. The CNA deflected Resident #3's hand because the resident was touching the CNA inappropriately and told the resident I told you I would slap your hand if you did that again. The Administrator defined abuse as willful injury and confinement resulting in physical harm or anguish, including deprivation. The Administrator described Resident #3 as non-verbal and communicated with staff with right hand gestures to indicate a 'yes' or a 'no' to questions asked and could not demonstrate if the resident was trying to communicate to CNA1 regarding the resident needing something or if the touching was inappropriate. The Administrator verbalized CNA1 made a statement regarding the abuse. The statement documented CNA1 had asked the resident to stop touching CNA1 and had smacked the resident's hand as a result of frustration with the resident. The Administrator admitted CNA1 had completed abuse training the day prior to the incident and stated maybe the CNA1 was not paying attention to the training. The Administrator verbalized this was not abuse toward Resident #3 because the resident did not have any physical signs of injury, such as, a cut, scrape, red mark, or bruise. The Administrator referred to the State Operations Manual (SOM) abuse grid for pathways regarding resident-to-resident abuse and determined, based off of the grid in the SOM, abuse criteria was not met and the incident was unsubstantiated by the facility. The Administrator made no attempt to refer CNA1 to the Board of Nursing, nor investigate the allegation any further. The facility policy titled Abuse Prevention and Prohibition, last reviewed 08/25/2023, documented each resident had a to be free of physical, sexual, psychological abuse, and neglect. The facility would protect and promote the rights of each resident, including the right to be free from all forms of abuse or neglect, including verbal and mental abuse. The facility utilized an Abuse Investigation Team consisting of Social Services, Human Resources, a department head, other than the accused employee's director supervisor, and other staff or administration as deemed necessary to assist in the investigative process. The team would interview witnesses, including residents, staff and the alleged abuser, obtain statements from all witnesses, coordinate and act as the liaison between the State Agencies and other authorities, make a recommendation based off of the information gathered to determine in the alleged abuse was substantiated and send the final report of the abuse investigation to the Quality Assurance and Performance Improvement (QAPI) Committee for review. Once an allegation was substantiated, based off of interviews, statements made by witnesses and the alleged perpetrator, the CNO would report the findings to the State Nurse Aide Registry, indicating the employee was unfit for service. FRI #NV00070753 Cross Reference with F Tags 600, 656, and 726

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review the facility failed to ensure a fall resulting in serious bodily injury was reported the State Agency (SA) for 1of 13 sampled residents (Resident #7). Findings include: Resident #7 Resident #7 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbance and wandering in diseases classified elsewhere. A Post Fall Evaluation dated 01/21/2024, documented Resident #7 fell in the facility's dining area. Resident #7 fell backward and struck the back of the resident's head on a door frame. Resident #7 lost consciousness for five seconds and was transferred to the emergency room (ER) for further assessment. On 04/11/2024 at 1:10 PM, the Administrator explained falls resulting in serious bodily injury were required to be reported to the SA. The Administrator verbalized the Administrator's understanding was a fall including the resident striking the resident's head with subsequent loss of consciousness, and requiring transfer to the ER did not meet the definition of serious bodily injury. The Administrator confirmed a fall with strike to the head, subsequent loss of consciousness and transfer to the ER would not have been reported to the SA. On 04/15/2024 at 11:05 AM, the Director of Nursing (DON) explained any fall with serious injury was required to be reported to the SA. The DON confirmed loss of consciousness after a fall in which a resident struck the resident's head was a serious bodily injury. The DON confirmed Resident #7 fell on [DATE], the resident's head was struck during the fall, the resident lost consciousness and was transferred to the ER for further assessment. The DON explained the DON had the capability to report incidents to the SA. The DON confirmed the DON did not report Resident #7's fall which occurred on 01/21/2024, to the SA. The facility policy titled Falls and Fall Prevention, reviewed 04/13/2023, documented if a fall was associated with patient injury, an initial report would be filed by the nurse with the Nevada state reporting system. The facility policy titled Abuse Prevention and Prohibition, reviewed 08/25/2023, documented any falls with significant injury were required to be reported the SA. A significant injury was one which required the resident to be sent to the ER, clinic, or x-ray department for medical attention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview, and document review, the facility failed to provide a discharge notification to the State Long Term Care Ombudsman for 1 of 3 discharged residents (Resident #26). Findings include: Resident #26 Resident #26 was admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus with other specified complications and chronic obstructive pulmonary disease, unspecified. A Nurse's Note dated 03/03/2024, documented the resident was found to have slurred speech and altered mental status. The resident was transferred to the hospital for consultation. The resident was discharged from the facility on 03/04/2024. Resident #26's clinical record lacked documented evidence a notification of discharge was provided to the State Long Term Care Ombudsman's office. On 04/09/2024 at 10:08 AM, the Minimum Data Set (MDS) Registered Nurse (RN) confirmed the MDS RN was responsible for notifying the State Long Term Care Ombudsman's office of discharges. The MDS RN confirmed notification of Resident #26's discharge had not been submitted to the State Long Term Care Ombudsman's office but should have been as the resident was discharged after having been transferred to the hospital. The facility policy titled, Transfer of Resident, reviewed 04/13/2023, documented the facility was to send a copy of the discharge notice to the State Long Term Care Ombudsman's office.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #15 Resident #15 was admitted to the facility on [DATE], with diagnoses including other sequelae of cerebral infarction and vascular dementia, moderate, with other behavioral disturbance. Resident #15's last quarterly MDS assessment dated [DATE], section N0415 (Medications - High-Risk Drug Classes: Use and Indication) documented the resident was taking an antipsychotic and the indication was noted. Section N0450 (Medications - Antipsychotic Medication Review) documented antipsychotics were received on a routine basis. Resident #15's clinical record lacked documentation the resident was receiving an antipsychotic. A physician's order dated 03/27/2024, and started 03/29/2024, documented Depakote oral tablet delayed release 250 milligrams (mg). Give one tablet by mouth two times a day for irritable/disruptive behaviors related to vascular dementia, moderate, with other behavioral disturbance. On 04/11/2024 at 12:14 PM, the MDS Coordinator verbalized the resident received Depakote as a response to the resident's behavior related to vascular dementia. The MDS Coordinator explained Depakote was classified as an anticonvulsant but was used as an antipsychotic. The MDS Coordinator admitted the medication should not have been documented as an antipsychotic on the MDS assessment. Resident #15's last quarterly MDS assessment dated [DATE], section P0100 (Restraints and Alarms - Physical Restraints) documented the resident used bed rails daily as a physical restraint that could not be removed easily which restricts freedom of movement or normal access to one's body. On 04/08/2024 at 10:01 AM, Resident #15 had half bed rails up, one on each side of the upper part of the bed. On 04/08/2024 at 1:11 PM, the resident verbalized the resident felt safer with bed rails up. Resident #15's comprehensive care plan initiated 09/26/2022, and revised 10/05/2022, documented a focus on the utilization of left and right upper bed rails with a goal of utilization for safety, transfers, bed mobility, and to maintain current level of independence, and an intervention bed rails were not used as a restraint. A physician's order dated 04/09/2024, documented upper left and right side rail - continuous usage - other sequelae of cerebral infarction. Side rail utilization was for safety, transfers, bed mobility, and to maintain current level of independence. Resident #15's clinical record lacked documentation the resident used bed rails as a restraint. On 04/11/2024 at 12:23 PM, the MDS Coordinator verbalized Resident #15 used bed rails for mobility and to self-transfer, so the bed rails were not used as a restraint. On 04/15/2024 at 10:44 AM, the MDS Coordinator admitted the bed rails for Resident #15 should not have been documented as restraints on the MDS assessment. Resident #17 Resident #17 was admitted to the facility on [DATE], with a diagnosis of other sequelae of cerebral infarction. Resident #17's last quarterly MDS assessment dated [DATE], section N0415 (Medications - High-Risk Drug Classes: Use and Indication) documented the resident was taking an anticoagulant and the indication was noted. A physician's order dated 05/24/2023, and started 05/25/2023, documented Clopidogrel Bisulfate (Clopidogrel) oral tablet 75 milligrams (mg) give one tablet by mouth one time a day related to unspecified sequelae of cerebral infarction; other sequelae of cerebral infarction. Resident #17's clinical record lacked documentation the resident was receiving an anticoagulant. On 04/15/2024 at 10:50 AM, the MDS Coordinator verbalized Resident #17 was on Clopidogrel. The MDS Coordinator admitted Clopidogrel was classified as a hematological agent, not an anticoagulant, and should have been documented as an antiplatelet on the MDS assessment according to the Resident Assessment Instrument (RAI) Manual. The facility policy titled Comprehensive Assessment and Reassessment, last reviewed 04/13/2023, documented an individualized assessment of the care or treatment required to meet resident needs would be completed throughout the resident's stay. The assessment would accurately document the care needs of each resident, to include any devices used by the resident based on ability to perform Activities of Daily Living (ADL) care. Based on clinical record review, interview, and document review the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 3 of 13 sampled residents (Resident #2, #15 and #17). Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic respiratory failure with hypoxia and vascular dementia, moderate, with mood disturbance. On 04/08/2024 at 1:06 PM, Resident #2 denied having an indwelling catheter in place currently or recently. Resident #2's MDS Section H - Bowel and Bladder, dated 03/11/2024, documented Resident #2 had an indwelling catheter. Resident #2's clinical record lacked any other documented evidence of the presence of an indwelling catheter. On 04/10/2024 at 3:35 PM, the MDS Coordinator confirmed Resident #2 did not have an indwelling catheter in place at the time the MDS dated [DATE], was completed and the indwelling catheter was marked in error.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview, and document review the facility failed to ensure a care plan was developed and implemented related to 1) a resident's indwelling catheter (Resident #19), 2) a resident's end-of-life/comfort care (Resident #24), and 3) a resident's air mattress (Resident #3) for 3 of 13 sampled residents. Findings include: Resident #19 Resident #19 was admitted to the facility on [DATE], with diagnoses including unspecified sequelae of cerebral infarction and schizoaffective disorder, unspecified. A physician's order dated 04/07/2024, documented indwelling catheter. Resident #19's clinical record lacked a care plan related to the presence or care of the resident's indwelling catheter. On 04/10/2024 at 3:31 PM, the Minimum Data Set (MDS) Coordinator verbalized catheters and catheter care should be included in a resident's care plan when the resident had an indwelling catheter. The MDS Coordinator explained the care plan would include interventions such as signs and symptoms to monitor for, checking the tubing for kinks and keeping the drainage bag below the level of the bladder. The MDS Coordinator confirmed Resident #19 did not have a care plan related to the indwelling catheter. Resident #24 Resident #24 was admitted to the facility on [DATE], with diagnoses including arthropathy, unspecified and anemia, unspecified. A progress note dated 02/05/2024, documented a nurse spoke with Resident #24's family regarding comfort medications. A physician's order dated 02/06/2024, documented morphine sulfate oral solution 20 milligrams (mg)/milliliter (ml), give 0.5 ml by mouth every 30 minutes as needed for pain. A physician's order dated 02/06/2024, documented Ativan solution two mg/ml, give one ml orally every two hours as needed for agitation/anxiety. A progress note dated 02/06/2024, documented the Physician ordered morphine and Ativan liquid, oral solutions. Hold oral medications if the resident was not alert. The Physician would call the resident's family to discuss the ordered medications and the resident's condition. A progress note dated 02/06/2024, documented the Physician spoke with Resident #24's family regarding the resident's change in condition. The end-of-life care plan was reviewed. A progress note dated 02/07/2024, documented Resident #24 was on comfort measures. Resident #24's clinical record lacked a care plan related to end-of-life/comfort care. On 04/15/2024 at 12:45 PM, the MDS Coordinator verbalized the MDS Coordinator did not update Resident #24's care plan to include end-of-life/comfort care. The MDS Coordinator explained the electronic medical record had a focus, goals, and interventions available to implement for residents receiving end-of-life/comfort care. The MDS Coordinator verbalized all care being provided for Resident #24 should have been added to the resident's care plan. Resident #3 Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified intracranial injury with loss of consciousness of unspecified duration, initial encounter, dysphagia, unspecified, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and quadriplegia, unspecified. On 04/08/2024 at 11:05 AM, Resident #3 was in a geri-chair next to the bed. The bed was a bariatric bed with an air mattress on the top of the bed. Resident #3's clinical record lacked a care plan addressing the air mattress on the top of the bariatric bed. A physician's order dated 06/06/2023, documented bariatric air mattress to bed to prevent skin breakdown. On 04/10/2024 at 2:02 PM, the MDS Coordinator explained an air mattress needed to be care planned to include the risk for entrapment, montoring of the resident, and resident abilities.The care plan interventions would help ensure the resident's safety while in bed and confirmed the air mattress for Resident #3 was not created nor completed. The facility policy titled Mobility Devices and Physical Restraints, last reviewed 04/13/2023, documented all residents would be assessed for physical mobility. Every resident had the right to be free from any physical restraint and a restraint would only be used to treat a specific medical condition. A care plan would be developed. The facility policy titled Baseline and Comprehensive Care Plan, reviewed 04/13/2023, documented care, treatment, and services shall be planned to ensure all were individualized to the resident's needs and goals. The planning for care, treatment, and services included regularly reviewing and revising the plan and determining how the planned care, treatment, and services would be provided. The facility policy titled Standards of Care, reviewed 04/13/2023, documented care plans were updated at least every quarter, with a new intervention, significant change in condition, new or change in medication. Cross reference with tags F690, F689, and F842

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview, and document review, the facility failed to follow physician's orders for insulin therapy for 2 of 13 sampled residents (Resident #9 and #13). Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE], with a diagnosis of type II diabetes mellitus with unspecified complications. A physician's order dated 10/10/2023, documented NovoLOG Insulin FlexPen subcutaneous solution pen-injector 100 unit/milliliters (ml), (Insulin Aspart). Inject as per sliding scale subcutaneously before meals and at bedtime related to type II diabetes mellitus with unspecified complications: - if blood sugar was between 150 - 200, inject two units; - 201 - 250 = four units; - 251 - 300 = six units; - 301 - 350 = eight units; - 351 - 400 = ten units; - 401 - 450 = 12 units. Give insulin as directed and call provider. Resident #9's Medication Administration Record (MAR) dated February 2024, documented the resident's blood sugar was over 400 on the following dates: -02/03/2024 at 8:00 PM, the resident's blood sugar was 446 and 12 units of insulin was administered. -02/08/2024 at 8:00 PM, the resident's blood sugar was 413 and 12 units of insulin was administered. The resident's clinical record lacked documented evidence the physician was notified of the resident's blood sugar level over 400 on 02/03/2024 and 02/08/2024. Resident #13 Resident #13 was admitted to the facility on [DATE], with a diagnosis of type II diabetes mellitus with hyperglycemia. A physician's order dated 09/16/2023, documented HumaLOG Insulin KwikPen subcutaneous solution pen-injector 100 unit/ml, (Insulin Lispro). Inject as per sliding scale subcutaneously before meals related to type II diabetes mellitus with hyperglycemia: - if blood sugar was between 0 - 250, inject zero units; - 251 - 300 = two units; - 300 - 350 = four units; - 351 - 400 = six units; - 401 - 450 = eight units; - 451 and over = ten units. Give insulin and notify provider with any blood sugar levels above 400. The order was discontinued on 02/27/2024. Resident #13's MAR dated January 2024, and February 2024, documented the resident's blood sugar was over 400 on the following dates: -01/28/2024 at 11:30 AM, the resident's blood sugar was 411 and eight units of insulin was administered. -01/30/2024 at 11:30 AM, the resident's blood sugar was 481 and ten units of insulin was administered. -02/06/2024 at 11:30 AM, the resident's blood sugar was 483 and ten units of insulin was administered. -02/15/2024 at 11:30 AM, the resident's blood sugar was 439 and eight units of insulin was administered. -02/16/2024 at 11:30 AM, the resident's blood sugar was 434 and eight units of insulin was administered. -02/16/2024 at 4:30 PM, the resident's blood sugar was 454 and ten units of insulin was administered. -02/17/2024 at 11:30 AM, the resident's blood sugar was 458 and ten units of insulin was administered. -02/23/2024 at 4:30 PM, the resident's blood sugar was 495 and ten units of insulin was administered. -02/24/2024 at 11:30 AM, the resident's blood sugar was 403 and eight units of insulin was administered. -02/24/2024 at 4:30 PM, the resident's blood sugar was 454 and ten units of insulin was administered. -02/27/2024 at 11:30 AM, the resident's blood sugar was 404 and eight units of insulin was administered. A physician's order dated 02/27/2024, documented HumaLOG Insulin KwikPen subcutaneous solution pen-injector 100 unit/ml, (Insulin Lispro). Inject as per sliding scale subcutaneously before meals related to type II diabetes mellitus with hyperglycemia: - if blood sugar was between 0 - 200, inject zero units; - 201 - 250 = two units; - 251 - 300 = four units; - 301 - 350 = six units; - 351 - 400 = eight units; - 401 - 450 = ten units. Give insulin and advise provider of blood sugar levels above 400. The order was discontinued on 03/05/2024. Resident #13's MAR dated February 2024, and March 2024, documented the resident's blood sugar was over 400 on the following dates: -02/28/2024 at 11:30 AM, the resident's blood sugar was 432 and ten units of insulin was administered. -03/01/2024 at 11:30 AM, the resident's blood sugar was 403 and ten units of insulin was administered. A physician's order dated 03/05/2024, documented HumaLOG Insulin KwikPen subcutaneous solution pen-injector 100 unit/ml, (Insulin Lispro). Inject as per sliding scale subcutaneously before meals related to type II diabetes mellitus with hyperglycemia: - if blood sugar was between 0 - 200, inject zero units; - 201 - 250 = three units; - 251 - 300 = four units; - 301 - 350 = five units; - 351 - 400 = six units; - 401 - 450 = seven units; - 451 - 500 = eight units; - 500 and over = nine units. Give insulin and advise provider of blood sugar levels above 400. Resident #13's MAR dated March 2024, documented the resident's blood sugar was over 400 on the following dates: -03/22/2024 at 11:30 AM, the resident's blood sugar was 464 and eight units of insulin was administered. -03/22/2024 at 4:30 PM, the resident's blood sugar was 441 and seven units of insulin was administered. The resident's clinical record lacked documented evidence the physician had been notified of the resident's blood sugar level over 400 on 01/28/2024, 01/30/2024, 02/06/2024, 02/15/2024, 02/16/2024, 02/17/2024, 02/23/2024, 02/24/2024, 02/27/2024, 02/28/2024, 03/01/2024, and 03/22/2024. On 4/15/2024 at 12:00 PM, the Director of Nursing (DON) confirmed Resident #9 and #13's clinical records lacked documented evidence the physician had been notified of Resident #9's blood sugar level over 400 on 02/03/2024 and 02/08/2024, and Resident #13's blood sugar level over 400 on 01/28/2024, 01/30/2024, 02/06/2024, 02/15/2024, 02/16/2024, 02/17/2024, 02/23/2024, 02/24/2024, 02/27/2024, 02/28/2024, 03/01/2024, and 03/22/2024. The DON verbalized it was the DON's expectation for the nurse to notify the physician if the resident's blood sugar was over 400, per the physician's orders, and to have documented the notification in the resident's record. The DON verbalized the importance of notifying the physician as the resident could have been experiencing diabetic ketoacidosis or if a consistent [NAME] emerged, as to allow the physician to make changes or provide additional directions as needed. The facility policy titled, Standing Protocol for Treatment of Hypo and Hyper-Glycemia, reviewed 05/11/2023, documented if the resident had orders for sliding scale insulin, the nurse would notify the physician per the physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, interview and document review, the facility failed to assess an air mattress for entrapment and restraint for 1 of 13 sampled residents (Resident #3). Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified intracranial injury with loss of consciousness of unspecified duration, initial encounter, dysphagia, unspecified, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and quadriplegia, unspecified. On 04/08/2024 at 11:05 AM, Resident #3 was in a geri-chair next to the bed. The bed was a bariatric bed with an air mattress on the top of the bed. Resident #3's clinical record lacked a care plan addressing the air mattress on the top of the bariatric bed. Resident #3's clinical record lacked documented evidence the risk and benefits were explained to the resident's Guardian and the resident had been assessed for the risk of entrapment and restraint. A physician's order dated 06/06/2023, documented bariatric air mattress to bed to prevent skin breakdown. On 04/09/2024 at 2:21 PM, the air mattress had air barriers on each side of the mattress. Two Certified Nursing Assistants (CNAs) were providing care to the resident and explained Resident #3 had an air mattress on the top of the bariatric bed frame to prevent bed sores from developing or getting worse. The CNA explained the barriers would fill up with air at the same time the mattress would inflate with air. The barriers would act as a fall deterrent when the bed would tilt to rotate the resident; the barrier would prevent the resident from falling out of the bed. On 04/10/2024 at 1:35 PM, the Director of Nursing (DON) explained Resident #3 was a quadriplegic and needed help with all Activities of Daily Living (ADL). The facility acquired a bariatric bed for the resident that would tilt from side to side to help rotate the resident. The mattress on top of the bed frame was an air mattress, with air borders lining each side of the mattress. Staff were able to inflate or deflate the mattress, to include the barriers, as needed, to help prevent the resident from acquiring a pressure sore. The DON verbalized since the resident could not turn themself, if the resident rolled into the air barriers on the mattress, the resident could suffocate. The DON verbalized the air mattress was considered a restraint for the resident. As a requirement of a potential restraint, the facility needed to attempt and document interventions attempted prior to applying the air mattress to the bed, assess the resident for risk of entrapment and review the risks and benefits with the resident's guardian. The DON confirmed the risks and benefits were not reviewed with the resident's guardian, an assessment was not completed nor was a consent signed to be able to utilize an air mattress on top of the residents bariatric bed. On 04/10/2024 at 2:02 PM, the Minimum Data Set (MDS) Coordinator explained the MDS Coordinator was responsible to complete assessments for risk of entrapment and if a resident had an air mattress. A consent to use the air mattress would be obtained, a physician's order would be written and the risks and benefits would be explained to the Guardian. The MDS Coordinator verbalized Resident #3 would require a head to toe assessment be completed, consents would be obtained for the air mattress and all factors included to explain the risks and benefits to the resident's Guardian to be completed. It was important for Resident #3 to have all components in place because the air mattress would be over inflated or underinflated, creating a cradle situation, which could suffocate the resident. The MDS Coordinator confirmed the risks and benefits were not reviewed with the resident's guardian, an assessment was not completed for the air mattress, nor was a consent signed to be able to utilize the air mattress on top of Resident #3's bariatric bed. The facility policy titled Mobility Devices and Physical Restraints, last reviewed 04/13/2023, documented all residents would be assessed for physical mobility. Every resident had the right to be free from any physical restraint and a restraint would only be used to treat a specific medical condition. Prior to using physical devises or physical restraints, an assessment would be completed, the resident would be monitored, a physician's order would be obtained, consents would be obtained, the risks and benefits of a restraint would be obtained, and a care plan would be developed. Cross Reference with tag F656

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review the facility failed to ensure 1) a resident with an indwelling catheter had orders in place for ongoing care of the catheter, 2) catheter care provided to a resident was documented in the resident's clinical record, and 3) a care plan was developed and implemented related to an indwelling catheter for 1 of 13 sampled residents (Resident #19). Findings include: Resident #19 Resident #19 was admitted to the facility on [DATE], with diagnoses including unspecified sequelae of cerebral infarction and schizoaffective disorder, unspecified. Resident #19's admission Record documented on 04/04/2024, the onset of the diagnoses of other symptoms and signs involving the genitourinary system and retention of urine, unspecified. A physician's order dated 04/07/2024, documented indwelling catheter. On 04/10/2024 at 3:11 PM, a Certified Nursing Assistant (CNA) verbalized the catheter care CNAs provided to residents included emptying the catheter bag, recording urinary output, cleansing of the catheter and cleansing around the insertion site. The CNA explained the CNA knew care needed to be provided for residents' catheters when the electronic medical record informed staff catheter care was needed and when the information was shared during shift change. The CNA confirmed Resident #19 had an indwelling catheter. The CNA verbalized the CNA did not believe Resident #19 had a catheter care task to be completed in the resident's clinical record. On 04/10/2024 at 3:23 PM, a Registered Nurse (RN) verbalized nurses and CNAs were responsible for catheter care. The RN explained nurses were alerted of the need for catheter care by a task on the Treatment Administration Record (TAR) and the TAR was populated by physician orders. The RN confirmed Resident #19 did not have physician orders for catheter care. Resident #19's clinical record lacked documented evidence of physician orders for catheter care or a care plan related to the resident's indwelling catheter. On 04/10/2024 at 3:31 PM, the Minimum Data Set (MDS) Coordinator explained staff knew a resident required catheter care by verbally reporting at shift change and later by physician orders placed in the resident's electronic medical record. The MDS Coordinator verbalized orders would include the placement of the catheter, when the catheter was to be changed, and catheter care. Catheter care included checking the leg strap, cleansing of the catheter and cleansing of the insertion site. The MDS coordinator explained physician orders triggered tasks to appear on the TAR so nurses or CNAs would know to complete the tasks daily. The MDS Coordinator verbalized it was discovered in the afternoon of 04/10/2024, Resident #19 had not had physician orders for catheter care. The MDS Coordinator verbalized the orders should have been placed when the catheter was ordered and inserted on 04/07/2024. The MDS Coordinator verbalized catheters and catheter care should be included in a resident's care plan when the resident had an indwelling catheter. The MDS Coordinator explained the care plan would include interventions such as signs and symptoms to monitor for, checking the tubing for kinks and keeping the drainage bag below the level of the bladder. The MDS Coordinator confirmed Resident #19 did not have a care plan related to the indwelling catheter. On 04/11/2024 at 12:01 PM, an RN confirmed the RN provided catheter care to Resident #19 on 04/10/2024. The RN verbalized any catheter care provided to Resident #19 prior to 04/11/2024, was not documented due to the task not populating on the TAR until the morning of 04/11/2024. The facility policy titled Indwelling Urinary Catheter and Maintenance, reviewed 04/13/2023, documented maintenance of indwelling catheters included emptying of urine drainage bags at least once per shift. Perineal and catheter care included: cleansing of the catheter and perineum at least once per shift and as needed with incontinence of stool, cleansing of the perineum and meatus at least once per day. Daily documentation included: time of catheter care and perineal care and nursing assessment of catheter and meatus. The facility policy titled Standards of Care, reviewed 04/13/2023, documented care plans were updated at least every quarter, with a new intervention, significant change in condition, new or change in medication. Each shift documentation would include care, treatment, and interventions provided. Cross reference with Tag F656 and F842.

Based on observation, interview, clinical record review, and document review the facility failed to ensure 1) a multidose vial was discarded by the use by date, 2) discontinued medications were disposed of timely and 3) the temperature of a refrigerator containing medications was logged daily for 1 of 1 sampled medication rooms. Findings include: Multidose Vial On 04/09/2024 at 4:23 PM, during an inspection of the medication storage room in the presence of a Registered Nurse (RN), a vial of tuberculin purified protein derivative, diluted aplisol 5 tuberculin units (TU)/0.1 milliliters (ml) was located in a refrigerator. The vial was inside the manufacturer box, 11/28 was written on the box. The box contained the following instruction: Once entered, vial should be discarded after 30 days. The RN confirmed the date written on the box was 11/28 and the vial should have been discarded prior to 04/09/2024. On 04/10/2024 at 10:05 AM, the Director of Nursing (DON) explained the expectation of nursing staff when a multidose vial was opened was to write the date opened on the vial. The vial was to be discarded on or before 28 days after the open date. The DON confirmed a multidose vial with an open date of 11/28 should have been discarded prior to 04/09/2024. The DON explained potential outcomes from the use of a multidose vial past the use by date were adverse reactions and infection. The facility policy titled Medication Storage, reviewed 05/12/2023, documented multidose vials of injectable medications were to be dated and initialed when opened. The vial would be destroyed within 28 days of opening. Medication Disposal On 04/09/2024 at 4:23 PM, during an inspection of the medication storage room in the presence of an RN, an unopened box containing a suprep bowel preparation kit was located in a cabinet. The box had a resident label attached, indicating the medication belonged to Resident #24. The RN verbalized the medication should have been destroyed due to the resident no longer residing in the facility. A physician's order dated 06/16/2023, documented suprep bowel preparation kit oral solution 15.5-3.13-1.6 grams (GM)/177 ml (sodium sulfate - potassium sulfate - magnesium sulfate). Give six ounces (oz) by mouth one time only related to gastrointestinal hemorrhage. Discontinue date 06/19/2023, resident refused procedure, procedure cancelled per resident request. On 04/10/2024 at 10:05 AM, the DON explained the process when a resident expired or was discharged from the facility was to place the resident's medications in a bin in the medication storage room, remove any resident labels and shred the labels, then use a prescription (rx) destroyer to destroy the medication. The DON verbalized the destruction/disposal of medications should be completed at the time of discharge or on the date the resident expired. The DON confirmed Resident #24 expired on 02/08/2024, and the bowel preparation kit should have been destroyed. The facility policy titled Disposal of Drugs, reviewed 04/27/2023, documented discontinued drugs should be returned to the pharmacy for proper disposition. Refrigerator Temperatures On 04/09/2024 at 4:23 PM, during an inspection of the medication storage room in the presence of a Registered Nurse (RN), the log titled Refrigerator Temperature Log for Medications was reviewed and lacked documented evidence the temperature was monitored and recorded as follows: -The Refrigerator Temperature Log for Medications (Temperature Log) for January 2024, did not document a temperature for 2 of 31 days. -The Temperature Log for March 2024, did not document a temperature for 1 of 31 days. The Temperature Log instructions documented in case of abnormal temperature values: -Remove and discard all foods or biologicals. -Do incremental adjustments to the refrigerator temperature to correct the temperature. -Recheck temperature in two hours, if no changes call maintenance or the individual on call. -Complete QRR (incident report). On 04/09/2024 at 4:37 PM, the RN verbalized refrigerator temperatures were to be checked once daily. The RN confirmed the Temperature Logs lacked documentation of a temperature reading on 01/24/2024, 01/31/2024, and 03/28/2024. On 04/10/2024 at 10:05 AM, the DON verbalized medications were stored in the refrigerator in the medication storage room. The DON verbalized the floor nurse was responsible to check the temperature of the medication refrigerator each day and write the temperature on the log. The DON confirmed the Temperature Logs for the refrigerator in the medication storage room lacked documented evidence the temperature was monitored on 01/24/2024, 01/31/2024, and 03/28/2024. The DON explained the importance of monitoring medication refrigerator temperatures was if the temperature was out of range medications could go bad. The facility policy titled Medication Storage, reviewed 05/12/2023, documented all drugs and biologicals would be stored in a way to ensure safety of all medications. Refrigerators containing drugs were maintained between two degrees Celsius (36 degrees Fahrenheit) and eight degrees Celsius (46 degrees Fahrenheit). A daily log of temperatures would be kept.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and document review the facility failed to assist a resident in obtaining dental services after a resident experienced bleeding gums for 1 of 13 sampled residents (Resident #10). Findings include: Resident #10 Resident #10 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of cerebellar stroke syndrome. On 04/08/2024 at 2:36 PM, Resident #10's Guardian explained the resident had dental issues in the past and there was supposed to be a follow-up appointment but the Guardian did not know if a dental appointment was made. A physician's order dated 11/22/2021, documented the facility may arrange for podiatry, dental, psychiatric, audiology and vision consultations as needed. A care plan initiated 04/07/2023, and revised 10/12/2023, documented the resident had oral/dental health problems related to poor oral hygiene, needing supervision with oral care, and history of cavities. The care plan documented an intervention to coordinate arrangements for dental care and dental care transportation as needed. Resident #10's progress notes documented the following: -Effective date 01/10/2024, Certified Nursing Assistant (CNA) entered resident's room and observed the resident was uncomfortable. The resident indicated the resident was experiencing oral pain. -Effective date 01/10/2024, an attempt was made to inform the Guardian of the resident's wishes to schedule a dentist appointment. An email dated 01/10/2024 to the Guardian by the Unit Secretary requested an appointment. -Effective date 02/20/2024, the resident was given oral care due to a large amount of plaque noted. While cleaning, the resident had a large amount of blood from gums. On 04/10/2024 at 2:35 PM, a CNA verbalized the CNA provided oral care to Resident #10 every morning but a few months prior, the resident had a gum bleeding issue causing the resident pain. The CNA verbalized the CNA hoped there was a dentist appointment made to address the dental issues experienced by the resident. On 04/10/2024 at 3:15 PM, the Social Worker (SW) verbalized the last known attempt made to notify the Guardian of a request for a dentist appointment was on 01/10/2024, but the Guardian did not respond. On 04/10/2024 at 03:28 PM, a Registered Nurse (RN) explained the Guardian returned the phone call to the facility on [DATE], and asked for the resident to receive a follow-up dentist appointment. Following the guardian's failure to respond to the last known contact attempt on 01/10/2024 until 04/10/2024, no further documented attempts were made to schedule a dentist appointment. The facility policy titled Dental Services in LTC (Long Term Care) & (and) Swing Bed dated 11/28/2007, and reviewed 04/13/2023, documented the facility would assist residents on obtaining routine and emergency dental care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and document review the facility failed to ensure a resident's allergy restrictions were accommodated related to lactose intolerance for 1 of 13 sampled residents (Resident #17). Findings include: Resident #17 Resident #17 was admitted to the facility on [DATE], with a diagnosis of lactose intolerance, unspecified. On 04/08/2024 at 10:28 AM, Resident #17 verbalized the resident could not eat cheese because the resident was lactose intolerant. The resident explained the resident sometimes received cheese with the resident's meals and the resident was served eggs with cheese on top for the resident's breakfast on the morning of 04/08/2024. Resident #17's physician's orders documented the following: -Order date 05/31/2023, resident to dairy-free products as a replacement for whole milk. -Order date 02/18/2024, regular diet, regular texture, thin consistency, related to lactose intolerance, unspecified. Resident #17's comprehensive care plan initiated 08/10/2023, documented the resident had episodes of diarrhea related to lactose intolerance. A diet order and communication form dated 04/01/2024, documented a food allergy to milk. A diet type report dated 04/10/2024, documented a regular diet type, regular texture, thin consistency. There were no additional directions for Resident #17. On 04/10/2024 at 3:40 PM, the Dietary Manager (DM) verbalized the breakfast menu for 04/08/2024, documented an egg and sausage bake with cheese. The DM recalled speaking with Resident #17 after breakfast on 04/08/2024 and the resident informed the DM the resident received cheese on the resident's egg and sausage bake. The DM explained the diet type report the kitchen used to ensure therapeutic diets and preferences were adhered to did not document the resident's allergies. The DM confirmed the DM had a diet order and communication form documenting milk as an allergy for the resident. On 04/15/2024 at 1:36 PM, the Minimum Data Set (MDS) Coordinator confirmed Resident #17 was lactose intolerant and verbalized the diet order and communication form was inaccurate. The MDS Coordinator explained the diet order and communication form indicated no milk when the form should have indicated no milk products to accurately reflect the resident's diagnosis and physician's orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #19 Resident #19 was admitted to the facility on [DATE], with diagnoses including unspecified sequelae of cerebral infarction and schizoaffective disorder, unspecified. A physician's order dated 04/07/2024, documented indwelling catheter. Resident #19's clinical record lacked documented evidence of catheter care being provided or ordered. On 04/10/2024 at 3:11 PM, a Certified Nursing Assistant (CNA) verbalized the catheter care CNAs provided to residents included emptying of the catheter bag, recording urinary output, cleansing of the catheter and cleansing around the insertion site. The CNA explained the CNA knew care needed to be provided for residents' catheters when the electronic medical record informed staff catheter care was needed and when the information was shared during shift change. On 04/10/2024 at 3:23 PM, a Registered Nurse (RN) verbalized nurses and CNAs were responsible for catheter care. The RN explained the task indicating the need for catheter care was populated for nurses on the Treatment Administration Record (TAR). On 04/10/2024 at 3:31 PM, the MDS Coordinator explained staff knew a resident required catheter care by verbally reporting at shift change and later by physician orders placed in the resident's electronic medical record. The MDS Coordinator verbalized physician orders would include the placement of the catheter, when the catheter was to be changed, and catheter care. Catheter care included checking the leg strap, cleansing the catheter and cleansing the insertion site. The MDS coordinator explained physician orders triggered tasks to appear on the TAR so nurses or CNAs would know to complete the tasks daily. The MDS coordinator verbalized physician orders for catheter care for Resident #19 were placed in the afternoon of 04/10/2024, and should have been placed when the catheter was ordered. On 04/11/2024 at 12:01 PM, the RN verbalized the task indicating the need for catheter care for Resident #19 did not populate on the TAR until the morning of 04/11/2024. The RN confirmed the RN provided catheter care for Resident #19 on 04/10/2024. The RN verbalized any catheter care provided to Resident #19 prior to 04/11/2024, was not documented due to the task not populating on the TAR until the morning of 04/11/2024. The facility policy titled Indwelling Urinary Catheter and Maintenance, reviewed 04/13/2023, documented required daily documentation included: time of catheter care and perineal care, nursing assessment of catheter and meatus, and urinary output. The facility policy titled Standards of Care, reviewed 04/13/2023, documented each shift documentation would include care, treatment, and interventions provided. The facility policy titled Comprehensive Assessment and Reassessment, reviewed 04/13/2023, documented the facility must be capable of transmitting MDS data to the Internet Quality Improvement and Evaluation System within seven days of a discharge event (the date of death or discharge). All resident assessments completed in the previous 15 months would be maintained in the resident's record including discharge records. The facility policy titled Medical Records - Content of Health Record, reviewed 03/14/2024, documented the medical record must be completed within 30 days post patient discharge from the facility. Cross reference with F Tags 640, 656 and 690. Based on interview, clinical record review and document review, the facility failed to ensure a resident's clinical record was complete when an Minimum Data Set 3.0 (MDS) assessment was not completed for a resident upon discharge from the facility for 1 of 1 resident selected for Resident Assessment (Resident #22) and care provided related to a resident's indwelling catheter was documented in the resident's clinical record for 1 of 13 sampled residents (Resident #19). Findings include: Resident #22 Resident #22 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy and major depressive disorder, recurrent, unspecified. A Transfer/Discharge Report documented Resident #22 was discharged from the facility on 11/20/2023. Resident #22's clinical record lacked a discharge MDS assessment. On 04/09/2024 at 9:26 AM, the MDS Coordinator verbalized the facility was required to complete MDS assessments upon a resident's entry to the facility, with any changes in condition, and upon discharge from the facility. The MDS Coordinator explained the MDS Coordinator was required to submit a final validation report to the Centers for Medicare and Medicaid Services (CMS) within two weeks of a resident's discharge from the facility. The MDS Coordinator verbalized the validation report for Resident #22's discharge was due to CMS by 12/04/2023, was not submitted, and was over 120 days late. The MDS Coordinator confirmed Resident #22's clinical record was incomplete and inaccurate due to the lack of a discharge MDS assessment. On 04/09/2024 at 2:07 PM, facility staff verbalized the facility lacked a policy related to MDS final validation reporting.

Based on interview, personnel record review and document review, the facility failed to ensure infection control training was provided timely to 1 of 20 sampled employees (Employee #9). Findings include: Employee #9 Employee #9 was hired as the Minimum Data Set (MDS) Coordinator on 08/16/2021. Employee #9's personnel record documented infection control training was last completed on 01/25/2023. The employee's personnel record lacked documented evidence infection control training had been completed for 2024. On 04/15/2024 at 3:17 PM, the Human Resources (HR) Generalist verbalized infection control training was required to be completed upon hire and annually. The HR Generalist confirmed Employee #9 had not completed infection control training timely. The facility policy titled Long-Term Care Staff Continuing Education, reviewed 04/13/2023, documented all permanent nursing department employees shall receive infection control educational programs yearly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review the facility failed to ensure the Restorative Nursing Program (RNP) was provided to 13 of 13 residents in need of restorative nursing services (Resident #1, #2, #3, #7, #10, #11, #12, #15, #16, #17, #20, #21, and #23). Findings include: On 04/09/2024 at 2:48 PM, the Restorative Nursing Aide (RNA) verbalized the facility's RNP had not been active since January 2024, when the Licensed Practical Nurse (LPN) providing restorative nursing care changed job duties due to short staffing. The RNA explained the RNP started back up when the RNA was hired on 04/08/2024. The RNA verbalized the RNA briefly spoke with the Physical Therapist (PT) on 04/08/2024, and referred to the restorative nursing binder for activities to do with the residents. The RNA verbalized the RNA was supposed to document RNP after working with the residents but had not had the opportunity to do so. On 04/09/2024 at 3:01 PM, the Director of Nursing (DON) verbalized the LPN providing restorative nursing care to residents changed job duties the week of 01/08/2024, due to short staffing. The DON explained the RNA was hired on 04/08/2024, and immediately the RNA began the Walk to Dine (WTD) program. The DON confirmed from 01/08/2024, to 04/08/2024, the nursing staff did not provide restorative care to residents. The DON explained the purpose of the RNP was to prevent residents from losing their baseline physical abilities. The DON verbalized the Passive Range of Motion (PROM) program helped to maintain and get to baseline physical functioning because the program prevented stiffness, helped blood flow, and had other muscular and psychosocial benefits. The DON described one resident who did not often walk, but since working with the RNA, was able to walk for meals. The DON verbalized the RNA was expected to document how far residents ambulated, but the DON was not sure where the information was documented. Resident #1 Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including generalized anxiety disorder, contracture of muscle, unspecified lower leg, feeding difficulties, unspecified, and other specified congenital deformities of hip. Resident #1's Minimum Data Set 3.0 (MDS) Assessment, Section O0500, dated 02/26/2024, lacked documented evidence the resident was participating in a RNP. On 04/09/2024 at 3:35 PM, a RNA explained the facility did not have an official list of residents participating in the RNP, but the RNA made a (handwritten) list of the residents the RNA planned to work with. Resident #1 was listed as a PROM resident. An email from the DON to the PT and edited by the PT dated 04/10/2024 at 7:49 AM, documented Resident #1 was a PROM resident. Resident #1's comprehensive care plan lacked documented evidence of a RNP to include PROM. Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of chronic respiratory failure with hypoxia. Resident #2's MDS, Section O0500, dated 03/11/2024, lacked documented evidence the resident was participating in a RNP. On 04/09/2024 at 3:35 PM, the RNA explained the facility did not have an official list of residents participating in the RNP, but the RNA made a list of the residents the RNA planned to work with. Resident #2 was listed as a WTD resident. An email from the PT to the DON dated 03/12/2024 at 12:54 PM, documented Resident #2 as a WTD resident. An email from the DON to the PT and edited by the PT dated 04/10/2024 at 7:49 AM, documented Resident #2 as a PROM resident. Resident #2's comprehensive care plan initiated 02/20/2021, and revised 09/12/2023, documented the resident was evaluated for the RNP with recommendations and plan of care from physical therapy. Suggestions initiated on 12/11/2023 were as follows: -ADL locomotion off unit. -ADL transferring. -ADL walk in corridor. -ADL walk in room. Resident #3 Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified intracranial injury with loss of consciousness of unspecified duration, initial encounter and contracture of muscle, unspecified lower leg. On 04/09/2024 at 3:35 PM, the RNA explained the facility did not have an official list of residents participating in the RNP, but the RNA made a list of the residents the RNA planned to work with. Resident #3 was listed as a PROM resident. An email from the DON to the PT and edited by the PT dated 04/10/2024 at 7:49 AM, documented Resident #3 as a PROM resident. Resident #3's comprehensive care plan initiated 07/27/2011, and revised 07/19/2023, documented an intervention for RNP to maintain range of motion. Resident #7 Resident #7 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, with other behavioral, wandering in diseases classified elsewhere and scoliosis, unspecified. Resident #7's MDS, Section O0500, dated 01/15/2024, lacked documented evidence the resident was participating in a RNP. On 04/09/2024 at 3:35 PM, the RNA explained the facility did not have an official list of residents participating in the RNP, but the RNA made a list of the residents the RNA planned to work with. Resident #7 was listed as a WTD resident. An email from the PT to the DON dated 03/12/2024 at 12:54 PM, documented Resident #7 as a WTD resident. Resident #7's comprehensive care plan lacked documented evidence of a RNP to include WTD. Resident #10 Resident #10 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnosis including unspecified intellectual disabilities, muscle weakness, contracture of muscle, right hand, and other abnormalities of gait and mobility. Resident #10's MDS, Section O0500, dated 02/26/2024, lacked documented evidence the resident was participating in a RNP. On 04/09/24 at 3:35 PM, the RNA explained the facility did not have an official list of residents participating in the RNP, but the RNA made a list of the residents the RNA planned to work with. Resident #10 was listed as a WTD resident. An email from the PT to the DON dated 03/12/2024 at 12:54 PM, documented Resident #10 as a WTD resident. An email from the DON to the PT and edited by the PT dated 04/10/2024 at 7:49 AM, documented Resident #10 as a PROM resident. Resident #10's comprehensive care plan lacked documented evidence of a RNP to include WTD and PROM. Resident #11 Resident #11 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of dementia in other diseases classified elsewhere, severe, with other behavioral disturbance. Resident #11's MDS, Section O0500, dated 03/04/2024, lacked documented evidence the resident was participating in a RNP. On 04/09/2024 at 3:35 PM, the RNA explained the facility did not have an official list of residents participating in the RNP, but the RNA made a list of the residents the RNA planned to work with. Resident #11 was not on the list for the RNP. An email from the PT to the DON dated 03/12/2024 at 12:54 PM, documented Resident #11 as a WTD resident. Resident #11's comprehensive care plan lacked documented evidence of a RNP to include WTD. Resident #12 Resident #12 was admitted to the facility on [DATE], with diagnoses including personal history of traumatic brain injury, history of falling, scoliosis unspecified, and weakness. Resident #12's MDS, Section O0500, dated 02/26/2024, lacked documented evidence the resident was participating in a RNP. On 04/09/2024 at 3:35 PM, the RNA explained the facility did not have an official list of residents participating in the RNP, but the RNA made a list of the residents the RNA planned to work with. Resident #12 was not on the list for the RNP. An email from the PT to the DON dated 03/12/2024 at 12:54 PM, documented Resident #12 as a WTD resident. An email from the DON to the PT and edited by the PT dated 04/10/2024 at 7:49 AM, documented Resident #12 as a PROM resident. Resident #12's comprehensive care plan lacked documented evidence of a RNP to include Walk to Dine and PROM. Resident #15 Resident #15 was admitted to the facility on [DATE], with diagnoses including primary osteoarthritis, right shoulder, other sequelae of cerebral infarction, primary osteoarthritis, left shoulder, and low back pain, unspecified. Resident #15's MDS, Section O0500, dated 02/26/2024, lacked documented evidence the resident was participating in a RNP. On 04/09/2024 at 3:35 PM, the RNA explained the facility did not have an official list of residents participating in the RNP, but the RNA made a list of the residents the RNA planned to work with. Resident #15 was listed as a WTD resident. An email from the PT to the DON dated 03/12/2024 at 12:54 PM, documented Resident #15 as a WTD resident. Resident #15's comprehensive care plan lacked documented evidence of a RNP to include WTD. Resident #16 Resident #16 was admitted to the facility on [DATE], with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery and hemiplegia and hemiparesis after a stroke affecting the right side of the brain. Resident #16's MDS, Section O0500, dated 02/05/2024, lacked documented evidence the resident was participating in a RNP. On 04/09/2024 at 3:35 PM, the RNA explained the facility did not have an official list of residents participating in the RNP, but the RNA made a list of the residents the RNA planned to work with. Resident #16 was listed as a WTD resident. An email from the PT to the DON dated 03/12/2024 at 12:54 PM, documented Resident #16 as a WTD resident. Resident #16's comprehensive care plan initiated 02/26/2023, documented an intervention of restorative care walking program for staff to assist the resident in ambulation around the unit a minimum of one time per day on days off from physical therapy treatment or as needed. There was no documented evidence of a RNP to include WTD. Resident #17 Resident #17 was admitted to the facility on [DATE], with diagnoses including other sequelae of cerebral infarction, contracture of muscle multiple sites, and pain in unspecified knee. On 04/08/2024 at 10:16 AM, Resident #17 verbalized the resident used to receive restorative nursing care until a Licensed Practical Nurse (LPN) who provided restorative nursing care changed job duties. Resident #17's MDS, Section O0500, dated 03/11/2024, lacked documented evidence the resident was participating in a RNP. On 04/09/2024 at 3:35 PM, the RNA explained the facility did not have an official list of residents participating in the RNP, but the RNA made a list of the residents the RNA planned to work with. Resident #17 was listed as a PROM resident. Resident #17's comprehensive care plan lacked documented evidence of a RNP to include PROM. Resident #20 Resident #20 was admitted to the facility on [DATE], with diagnoses including cerebral palsy unspecified, and history of falling. Resident #20's MDS, Section O0500, dated 02/12/2024, lacked documented evidence the resident was participating in a RNP. On 04/09/2024 at 3:35 PM, the RNA explained the facility did not have an official list of residents participating in the RNP, but the RNA made a list of the residents the RNA planned to work with. Resident #20 was listed as a WTD resident. An email from the PT to the DON dated 03/12/2024 at 12:54 PM, documented Resident #20 as a WTD resident. Resident #20's comprehensive care plan lacked documented evidence of a RNP to include WTD. Resident #21 Resident #21 was admitted to the facility on [DATE], with a diagnosis of unspecified dementia, unspecified severity, with other behavioral disturbance. Resident #21's MDS, Section O0500, dated 03/04/2024, lacked documented evidence the resident was participating in a RNP. On 04/09/2024 at 3:35 PM, the RNA explained the facility did not have an official list of residents participating in the RNP, but the RNA made a list of the residents the RNA planned to work with. Resident #21 was listed as a WTD resident. Resident #21's comprehensive care plan lacked documented evidence of a RNP to include WTD. Resident #23 Resident #23 was admitted to the facility on [DATE], with a diagnosis of Alzheimer's disease, unspecified. Resident #23's MDS, Section O0500, dated 01/29/2024, lacked documented evidence the resident was participating in a RNP. On 04/09/2024 at 3:35 PM, the RNA explained the facility did not have an official list of residents participating in the RNP, but the RNA made a list of the residents the RNA planned to work with. Resident #23 was listed as a WTD resident. An email from the PT to the DON dated 03/12/2024 at 12:54 PM, documented Resident #23 as a WTD resident. Resident #23's comprehensive care plan lacked documented evidence of a RNP to include WTD. On 04/09/2024 at 3:35 PM, the RNA explained the facility did not have an official list of residents participating in the RNP, but the RNA made a list of the residents the RNA planned to work with. The RNA verbalized the RNA was instructed by the PT to create a list of residents who were supposed to participate in the RNP, not active in physical therapy. The RNA then created a list of residents to work with on RNP, not active in physical therapy. On 04/09/2024 at 4:45 PM, the DON verbalized the DON read the restorative nursing policy and admitted the DON was mistaken as to what was considered restorative nursing. According to the policy, restorative nursing included showering, brace assistance and dressing, all of which the facility had provided. The clinical record of the residents who required RNP services lacked documented evidence showering, brace assistance, and dressing were related to the RNP. On 04/11/2024 at 2:58 PM, the RNA verbalized the RNA did provide restorative nursing to some residents active in physical therapy as the RNA tried to work with all residents if they were willing to participate. On 04/15/2024 at 4:18 PM, the Administrator verbalized the facility failed to execute the plan to have more than one person oversee the RNP when the LPN left the position on 01/08/2024, and it somehow got missed. The facility policy titled Restorative Nursing Program dated 01/10/2008, and reviewed 04/14/2023, documented the following: -The RNP focused on restoring or compensating for skills lost, seeking to maximize and prolong abilities with individualized, progressive restorative programs. -The RNPs were expected to include a range of motion and ambulation. -Daily documentation of care delivery was to be completed on each participating resident's restorative nursing Flowsheet. -The restorative nurse Coordinator, DON or Minimum Data Set Coordinator was obliged to document on the resident's care plan when the resident entered the program, identified resident specific goals for the program, and when the resident was discharged from the program. Cross Reference with Tag F726.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Restorative Nursing Program (RNP) On 04/09/2024 at 3:01 PM, the Director of Nursing (DON) verbalized the Licensed Practical Nurse (LPN) providing restorative nursing care to residents changed job duties the week of 01/08/2024, due to short staffing. The DON explained the Restorative Nursing Aide (RNA) was hired on 04/08/2024, and immediately the RNA began the Walk to Dine (WTD) program. The DON confirmed from 01/08/2024, to 04/08/2024, the nursing staff did not provide restorative care to residents. The DON explained the purpose of the RNP was to prevent residents from losing their baseline physical abilities. The DON verbalized the PROM program helped to maintain and get to baseline physical functioning because the program prevented stiffness, helped blood flow, and had other muscular and psychosocial benefits. The DON described one resident who did not often walk, but since working with the RNA, was able to walk for meals. The DON verbalized the DON did not know who was expected to be on the RNP. The DON verbalized the RNA was expected to document how far residents ambulated, but the DON was not sure where the information was documented. The DON also verbalized not knowing where to access physical therapy notes related to RNP. On 04/09/2024 at 3:35 PM, the RNA explained the facility did not have an official list of residents participating in the RNP, but the RNA made a list of the residents the RNA planned to work with. The RNA verbalized the RNA was instructed by the PT to create a list of residents who were supposed to participate in the RNP, not active in physical therapy. The RNA then created a list of residents to work with on RNP, not active in physical therapy. On 04/09/2024 at 04:45 PM, the DON verbalized the DON read the restorative nursing policy and admitted the DON was mistaken as to what was considered restorative nursing. According to the policy, restorative nursing included showering, brace assistance and dressing, all of which the facility had provided. The clinical record of the residents who required RNP services lacked documented evidence showering, brace assistance, and dressing were related to the RNP. On 04/11/2024 at 2:58 PM, the RNA verbalized the RNA did provide restorative nursing to some residents active in physical therapy as the RNA tried to work with all residents if they were willing to participate. On 04/15/2024 at 4:18 PM, the Administrator verbalized the facility failed to execute the plan to have more than one person oversee the RNP when the LPN left the position on 01/08/2024, and it somehow got missed. The facility policy titled Restorative Nursing Program dated 01/10/2008, and reviewed 04/14/2023, documented the following: -The RNP focused on restoring or compensating for skills lost, seeking to maximize and prolong abilities with individualized, progressive restorative programs. -The RNPs were expected to include a range of motion and ambulation. -Daily documentation of care delivery was to be completed on each participating resident's restorative nursing Flowsheet. -The restorative nurse Coordinator, DON or Minimum Data Set Coordinator was obliged to document on the resident's care plan when the resident entered the program, identified resident specific goals for the program, and when the resident was discharged from the program. Cross Reference with Tag F688. Based on clinical record review, document review, and interview, the facility's Abuse Committee, to include the Director of Nursing, failed to understand and identify actual employee to resident verbal and physical abuse had occurred toward a resident for 1 of 13 sampled residents (Resident #3) and 2) the facility failed to ensure the Director of Nursing (DON) in charge of the facility's Restorative Nursing Program (RNP), had the knowledge and skills needed to manage the program. Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including unspecified intracranial injury with loss of consciousness of unspecified duration, initial encounter, dysphagia, unspecified, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and quadriplegia, unspecified. A Facility Reported Incident (FRI) dated 03/21/2024, and concluded on 03/25/2024, documented a Dietary Aid had overheard a Certified Nursing Assistant (CNA) tell Resident #3 I told you I would slap you if you did that again. The FRI was unsubstantiated by the facility for failure to prove Resident #3 experienced a negative psychosocial outcome. An Incident Progress Note dated 03/21/2024, documented Dietary staff had witnessed a CNA slap Resident #3 on the hand and verbalized to the resident I told you if you did that again that I would smack you. The incident was reported to the Chief Nursing Officer (CNO) and Chief Executive Officer (CEO) and alleged after breakfast on 03/21/2024, a CNA was assisting Resident #3 with feeding the resident when the resident had brushed the hand against the staff members breast. The resident was spoken to about the behavior and explained to the resident the touching was unwelcomed and inappropriate. On 04/10/2024 at 8:24 AM, the Food Services Supervisor explained the facility had trained on abuse prior to employment with the facility and had received at least five trainings on abuse and neglect. The training covered all types of abuse, procedures on what to do if an individual suspected or witnessed abuse, who to report the abuse to and exact timeframes to report the abuse. The Food Services Supervisor verbalized on 03/21/2024, while helping to serve residents beverages, the door to the kitchen was open to the resident dining room with a view of where Resident #3 was seated. There was a CNA with Resident #3 and the CNA had an attitude. The CNAs attitude was full of frustration because Resident #3 kept moving the right arm. The resident had lifted a fist up, which was a common occurrence because the resident often gave fist bumps to staff, and the CNA slapped Resident #3's hand. The CNA told the resident you better stop or I am going to smack you and smacked his hand. The Food Services Supervisor demonstrated the force on the slap on the resident's hand. The slap on the hand provided some discomfort. The Food Services Supervisor retrieved the Charge Nurse and reported the verbal and physical abuse toward Resident #3. The CNO retrieved the CNA and assigned a different CNA to help Resident #3 with the rest of the breakfast. The Food Services Supervisor explained the way Resident #3 was treated was demeaning to an individual who was non-verbal and expressed the CNA knew it was abuse toward the resident, especially because the CNA had completed abuse training the day prior. On 04/10/2024 at 8:41 AM, CNA2 explained overhearing a CNA1 tell Resident #3 to stop touching the CNA1s breasts. CNA2 did not report the incident to any staff members. CNA2 verbalized Resident #3 was non-verbal and could communicate with staff by touching with the resident's right hand. CNA2 could not explain the difference between Resident #3 attempting to communicate with staff and inappropriate touching because the resident could only move the right hand with limitation. On 04/10/2024 at 9:45 AM, the Administrator explained there was an allegation of abuse against CNA1 on 03/21/2024, however, there was no disciplinary action toward CNA1 and would provide the investigation into the allegations. The Investigation Packet dated 03/21/2024, documented Dietary staff's (Food Services Supervisor) recollection of observed verbal and physical abuse toward Resident #3. The Dietary Aid had overheard CNA1 tell Resident #3 I told you I was going to smack you if you did that again. An immediate assessment of the resident lacked observations of redness, bruising, signs and symptoms of pain, grimacing withdrawal, and skin integrity issues. Included in the packet were statements from staff, statements from residents, and the abuse trainings completed by CNA1. A witness statement from the Administrator dated 03/21/2024, documented the Administrator had removed CNA1 from being in the same vicinity as Resident #3. A visual check was done on the resident and did not identify any redness to the resident's hand, arm, or face area. A witness statement from CNA3 dated 03/21/2024, documented CNA3 heard CNA1, who was assigned to feed Resident #3, verbalize to the resident to stop touching CNA1's breasts. A witness statement from the Food Services Supervisor dated 03/21/2024, documented the Food Services Supervisor was serving drinks to residents in the dining room and heard CNA1 tell Resident #3 you had better stop doing that right now or I am going to smack you next time. The Food Services Supervisor observed CNA1 smack Resident #3 and verbalized I told you I would smack you if you did it again. It appeared to the Food Services Supervisor, Resident #3 was attempting to fist bump CNA1 and CNA1 was irritated by Resident #3. The observation was reported to the Charge Nurse right away. A witness statement from CNA4 dated 03/21/2024, documented CNA4 overheard CNA1 verbalize to Resident #3 to not touch CNA1's breasts. CNA4 observed CNA1 put Resident #3's hand down in a non-aggressive way. CNA1's statement dated 03/21/2024, documented CNA1 verbalized Resident #3 was touching CNA1 inappropriately and warned the resident to stop. CNA1 explained telling the resident the touching would not be tolerated. CNA1 then tapped the resident on the resident's right hand and then held the right hand to prevent the resident from moving the right hand. On 04/10/2024 at 10:16 AM, the Licensed Social Worker (LSW) explained the definition of abuse was non-accidental injuries, physical damage and mental anguish of a resident to include willful action and unjustified injury. Abuse did not need to leave an obvious physical injury on an individual to prove abuse occurred. On 04/10/2024 at 1:35 PM, the Director of Nursing (DON) explained there were five different types of abuse and abuse was any intentional or unintentional act toward another individual whether the abuse was psychological, physical, entrapment, verbal or sexual. Furthermore, an individual would not need to have obvious signs of physical injury for abuse to occur. The DON explained Resident #3 was non-verbal and was a quadriplegic. The resident could not care for themselves and relied on staff for all activities of daily living, making the resident vulnerable. On 04/10/2024 at 3:03 PM, the Administrator verbalized on 03/21/2024, the Food Services Supervisor notified a Charge Nurse of abuse against Resident #3 by a CNA. The CNA deflected Resident #3's hand because the resident was touching the CNA inappropriately and told the resident I told you I would slap your hand if you did that again. The Administrator defined abuse as willful injury and confinement resulting in physical harm or anguish, including deprivation. The Administrator described Resident #3 as non-verbal and communicated with staff with right hand gestures to indicate a 'yes' or a 'no' to questions asked and could not demonstrate if the resident was trying to communicate to CNA1 regarding the resident needing something or if the touching was inappropriate. The Administrator verbalized CNA1 made a statement regarding the abuse. The statement documented CNA1 had asked the resident to stop touching CNA1 and had smacked the resident's hand as a result of frustration with the resident. The Administrator admitted CNA1 had completed abuse training the day prior to the incident and stated maybe the CNA1 was not paying attention to the training. The Administrator explained the facility did not have an Abuse Coordinator to handle allegations of abuse but rather an Abuse Committee. The Abuse Committee consisted of the Administrator, the Chief Nursing Officer, and the Risk Manager. Whoever received an allegation of abuse, was the individual in charge of investigating and following abuse policies and procedures. The Administrator verbalized this was not abuse toward Resident #3 because the resident did not have any physical signs of injury, such as, a cut, scrape, red mark, or bruise. The Administrator referred to the State Operations Manual (SOM) abuse grid for pathways regarding resident-to-resident abuse and determined, based off of the grid in the SOM, abuse criteria was not met and the incident was unsubstantiated by the facility. The Administrator admitted CNA1 confessed to verbally and physically abusing Resident #3, however unsubstantiated the allegation of abuse, because the Administrator verbalized the allegation did not meet the definition of abuse. The Administrator made no attempt to refer CNA1 to the Board of Nursing, nor investigate the allegation any further. On 04/10/2024 at 5:38 PM, during a joint interview with the DON and Administrator, the DON verbalized the CNA's actions against Resident #3 on 03/21/2024, did not meet the facility's definition of abuse and would have been discouraged. The facility policy titled Abuse Prevention and Prohibition, last reviewed 08/25/23, documented each resident had a right to a dignified existence and to be free of physical, sexual, psychological abuse, and neglect. The facility would protect and promote the rights of each resident, including the right to be free from all forms of abuse or neglect, including verbal and mental abuse. Assessments were to be completed to monitor for important prevention tools used to identify residents with needs and behaviors which may lead to conflict or neglect. Residents with communication disorders and those who were completely dependent on staff were at a greater risk for abuse and neglect. The processes for abuse investigation were as follows: -The Caregiver would be suspended and removed from the facility pending the investigation. -The family and/or guardian would be notified. -The facility would promote protection of the resident. -An alleged abuse allegation violation would be reported to law enforcement. -The CNO or designee would report to the State Nurse Aide Registry or licensing authorities for acts of abuse. -The CNO would analyze events of abuse, neglect, mistreatment or misappropriation of resident property to determine what changes were needed, if any, to policies and procedures to prevent further occurrences. The Risk Manager would maintain a record of all abuse events. -The Abuse Team would investigate the allegation of abuse with interviews, obtaining statements, make recommendations based on the information gathered, and forward the report to QAPI for review. Failure to comply with the procedures outlined would result in disciplinary action, up to and including terminating employment. The facility policy titled Resident [NAME] of Rights, last revised 05/29/03, documented the resident had a right to be free from mental and physical abuse. The resident had a right to be treated with consideration, respect, dignity, and individuality, including privacy and care of personal needs. FRI #NV00070753 Cross Reference with Tags F600 and F607

Based on clinical record review, interview and document review, the Administrator failed to ensure a Restorative Nursing Program (RNP) was maintained for residents with the potential to participate in the program and failed to ensure the Abuse Committee investigated allegations of employee to resident abuse by applying the current definition of abuse as per 42 CFR Chapter IV, Part 483, Section 12, Freedom from Abuse, Neglect, and Exploitation. Findings include: Restorative Nursing Program On 04/09/2024 at 2:48 PM, the Restorative Nursing Aide (RNA) verbalized the facility's RNP had not been active since January of 2024, when the Licensed Practical Nurse (LPN) providing restorative nursing care changed job duties due to short staffing. On 04/09/2024 at 3:01 PM, the Director of Nursing (DON) verbalized the LPN providing restorative nursing care changed job duties the week of 01/08/2024, due to short staffing. The DON confirmed from 01/08/2024, to 04/08/2024, nursing staff did not provide restorative care. On 04/15/2024 at 4:18 PM, the Administrator verbalized the facility failed to execute the plan to have more than one person oversee the RNP and it somehow got missed. Abuse Committee The Facility Reported Incident (FRI) NV00070753, with the allegation an employee verbally and physically abused a resident was investigated by the facility and was unsubstantiated. The FRI's final report dated 03/25/2024, documented the investigation included reports of witnesses, the employee of concern's documented statements regarding the incident and the employee of concern admitting responsibility to the allegations. The report documented the facility unsubstantiated the incident due to the resident not having shown signs of any psychosocial impact. On 04/11/2024 at 2:34 PM, the Administrator verbalized the Administrator was a part of the Abuse Committee. The Administrator verbalized an employee hitting a resident or telling a resident they would hit the resident was only considered abuse if resulting in injury, harm, pain or mental anguish to the resident. On 04/15/2024 at 4:38 PM, the Administrator verbalized the Abuse Committee's understanding of the definition of abuse by an employee to a resident, at the time of the investigation, was only substantiated as abuse if the resident experienced injury, harm, pain or mental anguish from the abuse. The Administrator confirmed employee to resident abuse allegations had not been investigated appropriately as the definition of abuse had not been applied correctly. Cross Reference Tags F600, F607 and F688

Based on personnel record review, interview and document review, the facility failed to ensure 10 of 20 facility staff received training on the facility's Quality Assurance and Performance Improvement (QAPI) program. Findings include: The following employee records lacked documented evidence QAPI training had been completed: -Employee #2, with a title of Director of Nursing and a start date of 12/05/2023. -Employee #4, with a title of Registered Dietitian and a start date of 06/28/2017. -Employee #8, with a title of Certified Nursing Assistant and a start date of 06/03/2003. -Employee #16, with a title of Certified Nursing Assistant and a start date of 01/23/2024. -Employee #13, with a title of Registered Nurse and a start date of 12/13/2023. -Employee #15, with a title of Licensed Practical Nurse and a start date of 12/20/2021. -Employee #18, with a title of Dietary Aide/Cook and a start date of 11/20/2023. -Employee #19, with a title of Dietary Aide/Cook and a start date of 06/16/2017. -Employee #20, with a title of Housekeeper and a start date of 01/24/2023. -Employee #21, with a title of Certified Nursing Assistant and a start date of 01/19/2015. On 04/15/2024 at 2:41 PM, the Administrator verbalized the issue with QAPI training had been identified, a couple of surveys ago, and staff were assigned but some had not yet completed the training. The Administrator verbalized the facility had not previously made it part of their onboarding employee orientation but would do so moving forward. On 04/15/2024 at 4:27 PM, the Risk Manager confirmed it was the Risk Manager's responsibility to ensure QAPI training had been completed. The Risk Manager confirmed the 10 of 20 sampled employees had not yet completed the required training. The facility policy titled, Quality Assurance and Performance Improvement Plan (QAPI) for Pershing General Hospital Long-Term Care Facility, reviewed 10/11/2023, documented facility-wide training would be conducted to inform all employees in the facility about the QAPI plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and document review, the facility failed to ensure residents were treated with dignity when residents felt bother, annoyed, or harassed by other residents' comments and behaviors for 2 of 15 Facility Reported Incident (FRI) residents (Resident #2 and #3). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus with unspecified complications and acquired absence of right leg above knee. Resident #2 Resident #2 was admitted to the facility on [DATE], with a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. FRI #NV00069712 documented on 10/23/23, Resident #1 was in the dining room getting coffee when Resident #2 walked by and stated you guys need to get Resident #1 black glasses, so I don't have to see them looking at me. A staff member encouraged Resident #1 to keep walking. Within hearing of Resident #2, Resident #1 stated Resident #4 is nothing but a piece of <expletive>, they think they are a man because they have a <expletive>. On 02/27/24 at 12:35 PM, Resident #2 verbalized they can not stand how Resident #1 stared at the resident. The resident explained Resident #1 did it on purpose because Resident #1 knew Resident #2 did not like it. On 02/28/24 at 10:21 AM, a Certified Nursing Assistant (CNA) explained Resident #1 would sit in the hallway and stare at the female staff and residents. In the dining room, some female residents have asked for the double doors to be closed so Resident #1 could not look at them. The staff attempted to redirect Resident #1 and told them staring was rude and made the other residents uncomfortable. Residents have complained to staff and have asked to have Resident #1 moved to a different area in the dining room or have the resident look out the window. On 02/28/24 at 11:31 AM, a License Practical Nurse (LPN) verbalized some of the female residents have complained about Resident #1's staring, including Resident #2. Administration has spoken with Resident #1 several times about their inappropriate behaviors. When staff saw Resident #1 staring inappropriately, they redirected the resident and asked the resident to quit staring. A Psychosocial Note dated 10/24/23, documented the Licensed Social Worker (LSW) met with Resident #1 to discuss the reported altercation that occurred on 10/23/23. Resident #1 reported Resident #2 was upset with the resident for an unknown reason and Resident #2 tried to make Resident #1 feel bad. On 02/28/24 at 1:06 PM, the LSW verbalized they interviewed Resident #1 regarding the incident and Resident #1 expressed they did not want to be around Resident #2. The LSW verbalized the LSW was unsure when they became aware Resident #1 stared at Resident #2. When the LSW interviewed Resident #2 regarding the incident, Resident #2 explained Resident #1 made them uncomfortable with the way Resident #1 stared and due to past trauma Resident #2 has experienced. The LSW explained Resident #1 was considered the victim of the incident because Resident #2 lashed out at Resident #1 and it was witnessed. Resident #2 was sent to an inpatient behavioral health facility due to their behaviors. The LSW verbalized Resident #2 was not investigated as a potential victim. On 02/28/24 at 2:46 PM, the Chief Nursing Officer (CNO) verbalized Resident #2 was walking down the hallway and made a comment to Resident #1 about getting glasses so Resident #2 did not have to see Resident #1 looking at them. Resident #1 was interviewed and stated they felt safe. The CNO verbalized they did not recall speaking with Resident #2. The CNO explained the LSW interviewed Resident #2. Resident #2 was sent to an inpatient behavioral health facility due to their recent outburst, to include this situation. On 02/28/23 at 2:59 PM, the Administrator verbalized the administration was not aware of concerns with Resident #1 leering at Resident #2. The FRI was not substantiated as abuse because there was not psychosocial harm to Resident #1. Resident #2 was not assessed for psychosocial harm related to the incident; however the resident was sent to an outpatient behavioral facility because Resident #2 appeared to be off baseline at the time of the incident. The Administrator verbalized they spoke with Resident #2 in the past week and the resident did not have any concerns. The Administrator admitted the Administrator did not ask Resident #2 about Resident #1's staring. Resident #3 Resident #3 was admitted to the facility on [DATE], with diagnoses including personal history of traumatic brain injury, anterograde amnesia, and mood disorder due to known physiological condition with mixed features. Resident #4 Resident #4 was admitted to the facility on [DATE], with a diagnosis of vascular dementia, unspecified severity, with other behavioral disturbance. FRI #NV000069781 documented on 11/06/23, Resident #3 and Resident #4 were sitting in the dining room together when Resident #3 left the table looking upset. A Certified Nursing Assistant (CNA) followed Resident #3 and Resident #3 informed the CNA Resident #4 said some not nice things to the resident and the resident felt isolated in their room. On 02/28/24 at 11:40 AM, a CNA verbalized Resident #3 and Resident #4 were roommates. The CNA recalled Resident #3 would get frustrated with Resident #4 because Resident #4 would turn off the lights when Resident #3 was reading in the evening (around 7 PM). Resident #4 would leave the bathroom door open when using the bathroom and refuse to shut it when asked. The CNA verbalized witnessing Resident #3 leaving the table appearing upset. The CNA walked with the resident to their room and spoke with them privately. When asked what was wrong, the resident verbalized they were tired of Resident #4 instigating - leaving the light on, leaving the bathroom door open. Resident #4 would throw their clothing on Resident #3's side of the room. Resident #3 would close their curtain between Resident #3 and Resident #4's bed, however Resident #4 would open the curtains. The CNA recalled Resident #3 explained Resident #3 felt isolated in their own room. Resident #3 verbalized to the CNA the resident just wanted the behavior to stop. On 02/28/24 at 11:58 AM, a Licensed Practical Nurse (LPN) verbalized Resident #3 and Resident #4 were roommates. The LPN recalled Resident #4 would turn off the lights in the room. Resident #3 liked to read, and the facility got the resident a night light to accommodate both residents. Resident #4 would go on Resident #3's side of the room and turn off the night light. Resident #4 would leave the bathroom door open while using the bathroom and would refuse to shut it. Resident #3 felt they did not have privacy. Resident #3 was often tearful and felt Resident #4 was doing these things on purpose. Resident #3 was provided a room change. On 02/28/24 at 1:40 PM, the Licensed Social Worker (LSW) verbalized Resident #3 reported they felt uncomfortable with Resident #4 leaving the bathroom door open while using it and made Resident #3 feel like they did not have any privacy. Resident #3 reported that Resident #4 would make eye contact while using the bathroom. Resident #3 felt Resident #4 was intimidating them with the eye contact. Resident #3 liked to read and Resident #4 would turn off the lights while Resident #3 was reading. The residents were separated and a room change was provided. A Behavior Note dated 09/22/23, documented a Registered Nurse (RN) was attempting to give Resident #3 their medication when the resident yelled they were not going to take them. The RN asked the resident if something was bothering them, the resident replied they could not read because the lights were off so early in their room. The RN told the resident the resident could have the lamp on in their room and the resident responded they cannot because Resident #4 would complain about it. A Behavior Note dated 09/22/23, documented a CNA found Resident #3 in their room in tears stating they were tired of being treated badly by their roommate. A Physician Rounds note dated 09/24/23, documented nursing was concerned at Resident #3's episodes of anger toward staff and roommate had increased. The Provider recommended a medication change and a behavioral evaluation be completed. A Behavior Note dated 09/30/23, documented Resident #3 came out to the nurses station complaining I can't take it anymore! referring to their roommate, Resident #4 and their difficulty communicating and compromising to live together. Director of Nursing (DON) made aware. A Behavior Note dated 10/02/23, a CNA noticed Resident #3 left the dining room table during lunch. The CNA asked the resident where they were going and if they were ok and the resident responded no, I am going back to my room, and I am not hungry. The CNA went to check on Resident #3. Resident #3 stated they were not ok due to everything with their roommate. The resident explained Resident #4 will not shut the bathroom door when they use the toilet. Resident #3 has asked Resident #4 to shut the door and Resident #4 says no. The resident does not feel like going down for meals anymore because Resident #4 pushes their food on Resident #3's side of the table and Resident #4 talks about how Resident #3 wants the light on to read before bed, and Resident #4 wants it off. Resident #3 informed the CNA they do not want to sit with Resident #4 at meals anymore. The CNA told the resident the resident can sit wherever they want and offered to move the resident's plate to another table for the remainder of lunch. Resident #3 asked why they had to change where they sit. A CNA Note dated 10/14/23, documented Resident #3 was walking toward the nurses station in tears. When asked what was wrong, the resident replied I don't know why Resident #4 is so mean to me. They keep turning off the light when I am trying to read my book. The CNA told Resident #3 they would speak to Resident #4 and Resident #3 could come read their book at the nurses station. A Progress Note dated 11/06/23, documented Resident #3's Power of Attorney was contacted and advised that Resident #3 reported their roommate said not nice things and expressed their discomfort with being a roommate with Resident #4. The Power of Attorney (POA) gave approval for the room change. A Behavior Note dated 11/07/23, documented while giving Resident #3 their morning medication, the RN asked Resident #3 if they slept well. The resident responded not particularly and added their nerves are just shot. They did not know Resident #4 could be so weird. A Behavior Note dated 11/07/23, documented Resident #3 left the dining room during dinner. The CNA went to the resident's room to see if the resident was ok. The resident stated I'm fine. The CNA could tell something was wrong. The CNA repeated their question. Resident #3 then responded they were not coming back for dinner because they were mad. During follow up, Resident #3 stated they were fine, but Resident #4 keeps closing the drapes when Resident #3 wants them open, makes phone calls at 4:00 AM, which wakes up Resident #3. When Resident #3 turns on the light, Resident #4 turns the light off. Resident #4 throws their clothes on Resident #3's side of the room and when the resident throws them back, Resident #4 throws them back to Resident #3's side again. When Resident #3 is trying to sleep, Resident #4 turns on the lights. When Resident #4 goes poop or pee in the bathroom, the resident leaves the door wide open and did not close it when asked. Resident #3 tried to talk to Resident #4, however Resident #4 ignored them. Resident #3 felt isolated in their own room. Administration was notified. Roommate temporarily removed to prevent further problems at this time. A Psychosocial Note dated 11/07/23, documented the LSW met with Resident #3 to discuss the recent situations that had occurred in the past 24 hours. The resident expressed concerns with Resident #4. On 02/28/24 at 3:28 PM, the Chief Nursing Officer (CNO) verbalized the FRI was not substantiated by the facility as there was no outcome of psychosocial harm for Resident #3. Resident #3 was interviewed by the Minimum Data Set 3.0 (MDS) Coordinator and the LSW and was provided with a room change. The CNO confirmed the resident's clinical record documented the resident was having problems with their roommate dating back to 09/22/23, and the DON was notified of the concerns on 09/30/23. The CNO verbalized the clinical record documented the resident was upset by the roommate's behavior. The CNO was not sure why the FRI was not substantiated. The facility policy titled Resident [NAME] of Rights, last revised 05/29/03, documented the resident had a right to be treated with consideration, respect, dignity, and individuality, including privacy and care of personal needs. NV00069781

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure a non-verbal resident was not verbally abused by a staff member for 1 of 15 Facility Reported Incident (FRI) residents (Resident #12). Findings include: Resident #12 Resident #12 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including diffuse traumatic brain injury with loss of consciousness of unspecified duration, sequela, quadriplegia, unspecified, paraplegia, unspecified, and aphasia following unspecified cerebrovascular disease. FRI #NV00070158 dated 01/03/24, documented Resident #12 was receiving a beverage in the dining room on the morning of 12/28/23, when a Dietary Aide (DA) overheard a Certified Nursing Assistant (CNA1) say shut the (expletive) up to the resident. The DA reported the incident to the Dietary Manager on 01/03/24, and an investigation was initiated. Resident #12's clinical record lacked any documentation of the incident. Resident #12's Minimum Data Set 3.0 Assessment (MDS), Section C0500-Cognitive Patterns dated 10/02/23, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 00. The BIMS scoring method was as follows: 00-07: Severe cognitive impairment 08-11: Moderate cognitive impairment 12-15: Cognitively intact A BIMS Quarterly assessment dated [DATE], documented Resident #12 had severe cognitive impairment. Resident #12's MDS dated [DATE], documented the resident was unable to be interviewed because the resident was rarely/never understood. The staff assessment of the resident's mental status in Sections C0700-C0800 documented the resident had short term and long term memory loss. On 02/28/24 at 10:22 AM, the Social Worker (SW) explained a BIMS of 00 meant the resident had severe cognitive impairment. The SW had asked Resident #12 about the incident on 12/28/23, however the resident did not seem to remember. The SW could not provide documentation of the interview or explain how the resident would have answered the question. On 02/28/24 at 10:30 AM, the SW explained staff had noticed Resident #12 was experiencing increasing issues with the understanding of staff communication. The SW had requested the Psychiatric Nurse to evaluate Resident #12 for cognition capacity on 1/17/24 and 2/21/24, and it had not yet been completed. On 02/28/24 at 11:39 AM, the Administrator explained the investigation into the incident consisted of Resident #12's interview, the CNA1 interview, the Dietary Aide (DA) interview, and two other staff interviews. The Administrator verbalized the incident was unsubstantiated by the facility based on the lack of corroboration of multiple staff, communication with the resident, and CNA1's denial of the incident. CNA1 was suspended during the investigation and was terminated on 01/03/24, the same day as the investigation. On 02/28/24 at 11:42 AM, the Administrator communicated the Abuse Team was unable to ascertain if Resident #12 understood the investigative questions because the resident did not always accurately use the same signs for communication such as blinking one or two eyes, raising a hand, or shaking the head side to side for no. On 02/28/24 at 12:09 PM, the Chief Nursing Officer (CNO) explained Resident #12 was unable to inform staff if someone had shown abusive behavior towards the resident and staff had no way of knowing if the resident understood what was asked with a BIMS of 00. The CNO communicated the allegation of abuse was unsubstantiated based on the CNO's judgement of CNA1's denial of the allegation, the CNO did not feel CNA1 had behaved in the reported manner, even though the DA had witnessed CNA1's interaction with Resident #12. On 02/28/24 at 2:02 PM, the Dietary Manager confirmed the DA had reported overhearing CNA1 tell Resident #12 to shut the (expletive) up while the DA was serving the resident chocomoco (a hot chocolate drink) at breakfast. The Dietary Manager explained the DA felt CNA1 had directed the statement to the resident and believed the DA as the DA had never said anything negative about a CNA before. On 02/28/24 at 2:33 PM, the Dietary Aide confirmed serving Resident #12 chocomoco on the morning of 12/28/23. The resident was making noises of excitement while receiving a favorite breakfast drink when CNA1 told the resident to shut the (expletive) up. The DA confirmed CNA1 directed the statement at Resident #12. The DA explained the DA was directed to speak to Risk Management by the Dietary Manager. On 02/28/24 at 2:40 PM, the DA confirmed a discussion with the Risk Management Director (RMD) regarding what the DA overheard CNA1 say to Resident #12. The RMD told the DA no one had the right to speak to someone that way and it should have been reported right away. On 02/28/24 at 2:47 PM, CNA2 recalled an interview with the CNO about the statement made to Resident #12 by CNA1. CNA2 explained CNA2 was in the dining room the morning of 12/28/23, but was not sitting close enough to hear the conversation and could not say whether or not it happened. On 02/28/24 at 3:19 PM, the RMD explained Resident #12 was a difficult resident to get direct answers from and the resident would get flustered when asked too many questions at one time. The RMD could not explain how the resident was interviewed when the resident was non-verbal. The RMD recalled the incident was substantiated because CNA1's statement was a very inappropriate thing to say to a resident. The RMD communicated CNA1 was suspended and then dismissed by not renewing CNA1's agency contract because of the inappropriate actions towards Resident #12. On 02/28/24 at 3:57 PM, the Administrator explained the incident was not substantiated because two CNA's in the dining room that morning did not hear CNA1 make the statement to Resident #12, even though the DA reported witnessing the incident. The Administrator confirmed the two CNAs may not have heard what CNA1 said to Resident #12 if they were not sitting close enough to the resident. The Administrator verbalized the lack of more than one witness to the conversation did not mean CNA1 did not tell Resident #12 to shut the (expletive) up. The facility policy titled Abuse Prevention and Prohibition, last reviewed 08/25/23, documented each resident had a right to a dignified existence and to be free of physical, sexual, psychological abuse, and neglect. The facility would protect and promote the rights of each resident, including the right to be free from all forms of abuse or neglect, including verbal and mental abuse. The facility policy titled Resident [NAME] of Rights, last revised 05/29/03, documented the resident had a right to be free from mental abuse. The resident had a right to be treated with consideration, respect, dignity, and individuality, including privacy and care of personal needs. NV00070158

Based on interview, record review and document review, the facility failed to ensure a Facility Reported Incident (FRI) was completed and submitted timely to the State Agency (SA) for allegations of abuse for 1 of 15 FRIs. Findings include: FRI #NV00069839 with the allegation of resident to resident abuse was submitted to the SA on 11/14/23. The allegation was made on 11/12/23. On 02/28/24 at 4:19 PM, the Chief Nursing Officer confirmed the FRI was submitted late and outside of the required timeframes. On 2/28/24 at 2:41 PM, the Administrator verbalized allegations of abuse and neglect were to be reported to the SA within two hours if bodily harm occurred, 24 hours for all other allegations of abuse and neglect, and the final report was to be submitted within five working days of the incident. The facility policy titled Abuse Prevention and Prohibition, last revised 08/25/23, documented the abuse investigation team would report suspected abuse via the Facility Reported Incident form for all alleged violations of abuse, neglect, exploitation, mistreatment, and misappropriation of resident property. All alleged violations would be reported immediately but not later than two hours if the alleged violation involves abuse or results in serious bodily injury. Alleged violations not involving abuse or serious injury would be reported within 24 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to 1) ensure an allegation of employee to resident verbal abuse was thoroughly investigated and documented for 1 of 15 Facility Reported Incident (FRI) residents (Resident #12) and 2) report investigation results within five working days of the for 2 of 15 FRIs (NV00070209 and NV00070124). Findings include: Employee to Resident Altercation Resident #12 Resident #12 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including diffuse traumatic brain injury with loss of consciousness of unspecified duration, sequela, quadriplegia, unspecified, paraplegia, unspecified, and aphasia following unspecified cerebrovascular disease. FRI #NV00070158 dated 01/03/24, documented Resident #12 was receiving a beverage in the dining room on the morning of 12/28/23, when a Dietary Aide (DA) overheard a Certified Nursing Assistant (CNA) say shut the (expletive) up to the resident. The DA reported the incident to the Dietary Manager on 01/03/24 and an investigation was initiated seven days after the witnessed altercation. Resident #12's clinical record lacked documentation of the incident or investigation. Resident #12's care plan, undated, lacked documentation of the incident and did not include methods and interventions to prevent further abuse or monitoring for signs and symptoms of abuse or psychosocial effects. On 02/28/24 at 11:39 AM, the Administrator explained the investigation into the employee to resident verbal abuse consisted of Resident #12's interview, the accused staff interview, the Dietary Aide (DA) interview, and two other staff witness interviews. The Administrator verbalized the investigation was completed and unsubstantiated based on the interviews of staff present in the dining room, communication with the resident, and the CNA's denial of the incident. On 02/28/24 at 12:09 PM, the Chief Nursing Officer (CNO) explained Resident #12 was unable to inform staff if someone had shown abusive behavior towards the resident and staff were unable to ascertain if the resident understood what was asked. The CNO communicated the allegation of abuse was unsubstantiated based on the CNO's judgement, as the CNO did not feel the CNA had behaved in the reported manner, even though the conversation was witnessed by staff. The CNO could not provide documentation of the investigation, a statement from the CNA, or a statement from the DA witness. The CNO confirmed Resident #12's care plan was not updated with the incident and did not include interventions to implement or monitor related to the incident. On 02/28/24 at 1:35 PM, the CNO confirmed Resident #12 was interviewed by the CNO and the Risk Management Director (RMD) regarding the incident and when the resident did not answer the questions regarding the allegation, it was taken as a no answer. The CNO explained there was no documentation regarding the resident interview or the incident in the clinical record. On 02/28/24 at 3:19 PM, the RMD explained Resident #12 was difficult to get direct answers from and could not explain how the resident was interviewed when the resident was non-verbal. The facility policy titled Abuse Prevention and Prohibition, last revised 08/25/23, documented it was the policy of the facility to report and investigate all allegations of actual or suspected abuse. The facility had a zero tolerance policy for any type of elder abuse or neglect, or the failure to report alleged abuse or neglect. Without exception, the person identifying potential abuse would immediately report to nurse leadership. The abuse investigation team would be notified of the facts giving rise to the concern and would investigate the matter. The Risk Manager would maintain a record of all incidents and reportable events. Timely Reporting FRI #NV00070209 with the allegation of an injury of unknown source for Resident #10 was submitted to the State Agency on 01/11/24. The final report was submitted on 01/17/24, one day late. On 02/28/24 at 12:22 PM, the Administrator confirmed the FRI final report was not submitted within the required five day timeframe.FRI #NV00070124 with the allegation of resident to resident abuse was submitted to the SA on 12/27/23. The final report was submitted to the SA on 01/03/24. On 02/28/24 at 4:30 PM, the Chief Nursing Officer confirmed the final FRI report was submitted late and outside of the required timeframes. On 2/28/24 at 2:41 PM, the Administrator verbalized the final report was to be submitted within five working days of the incident. The facility policy titled Abuse Prevention and Prohibition, last revised 08/25/23, documented final reports were to be submitted within five working days of the facility's awareness of the event.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure a care plan was developed and implemented related to 1) post-traumatic stress disorder and psychotic disorder with hallucinations for 1 of 15 Facility Reported Incident (FRI) investigated residents (Resident #14), 2) following an investigation for employee to resident verbal abuse for 1 of 15 FRI investigated residents (Resident #12), and 3) inappropriate behaviors for 2 of 15 FRI investgated residents (Resident #1 and #4). Findings include: Resident #14 Resident #14 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including post-traumatic stress disorder (PTSD), chronic, altered mental status, unspecified, and psychotic disorder with hallucinations due to known physiological condition. Resident #14's physician order dated 04/18/23, documented the following: Cymbalta oral capsule delayed release particles 60 milligrams (mg), give one capsule by mouth one time a day for anxiety and neuropathic pain related to PTSD. Resident #14's physician order dated 01/12/23, documented the following: Seroquel oral tablet 50 mg, give one tablet by mouth at bedtime for hallucinations/anxiety/sleeplessness related to PTSD. Resident #14's physician order dated 03/07/23, documented the following: Zyprexa oral tablet 10 mg, give one tablet by mouth at bedtime related to psychotic disorder with hallucinations due to known physiological condition. Resident #14's physician order dated 07/05/23, documented the following: Zyprexa oral tablet 7.5 mg, give one tablet by mouth at bedtime for paranoia and agitation related to psychotic disorder with hallucinations due to known physiological condition. Resident #14's clinical record lacked a care plan for the resident's diagnosis and treatment of PTSD and psychotic disorder with hallucinations to include problem areas, goals, and interventions. Resident #14's Minimum Data Set Assessment 3.0 (MDS) dated [DATE], Section E: Behavior, documented the resident had delusions (misconceptions or beliefs that are firmly held, contrary to reality). The resident had verbal behaviors toward others, physical behaviors towards themself, rejection of care, and wandering. On 02/28/24 at 10:50 AM, the Social Worker (SW) confirmed Resident #14's care plan did not document post-traumatic stress disorder and psychotic disorder with hallucinations. The SW explained a psychiatric diagnosis should 100 percent be included in the care plan. The SW verbalized the purpose of the care plan was to give everyone a full picture and idea of how to care for the resident. On 02/28/24 at 1:22 PM, the Chief Nursing Officer (CNO) confirmed the expectation of a diagnosis of PTSD and psychotic disorder with hallucinations was to be care planned for a resident. The CNO confirmed the diagnoses were not care planned for Resident #14. The CNO verbalized a care plan was used to provide the best nursing ad ancillary care for the best outcome of the resident. The CNO explained a consequence to not including a psychiatric diagnosis or PTSD as triggers for the diagnoses could occur unintentionally and unknowingly. Resident #12 Resident #12 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including diffuse traumatic brain injury with loss of consciousness of unspecified duration, sequela, quadriplegia, unspecified, paraplegia, unspecified, and aphasia following unspecified cerebrovascular disease. FRI #NV00070158 dated 01/03/24, documented Resident #12 was receiving a beverage in the dining room on the morning of 12/28/23, when a Dietary Aide overheard a Certified Nursing Assistant (CNA) say shut the (expletive) up to the resident. The Dietary Aide reported the incident to the Dietary Manager on 01/03/24 and an investigation was initiated. Resident #12's MDS dated [DATE], documented the resident was unable to be interviewed because the resident was rarely/never understood. Resident #12's care plan, undated, lacked documentation of the incident and did not include methods and interventions to prevent further abuse or monitoring for signs and symptoms of abuse or psychosocial effects. On 02/28/24 at 2:33 PM, the Dietary Aide confirmed serving Resident #12 a breakfast drink on the morning of 12/28/23, when a CNA told the resident to shut the (expletive) up. The Dietary Aide confirmed the CNA directed the statement at Resident #12 as the resident was making excited noises about the drink. On 02/28/24 at 1:35 PM, the Chief Nursing Officer (CNO) confirmed Resident #12 did not have a care plan created or implemented for the incident on 12/28/23. Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus with unspecified complications and acquired absence of right leg above knee. On 02/28/24 at 11:31 AM, a License Practical Nurse (LPN) verbalized Resident #1 had inappropriate behaviors with staff and residents. Some of the female residents have complained about Resident #1's staring. Administration has spoken with Resident #1 several times about their inappropriate behaviors. When staff see Resident #1 staring inappropriately, they redirect the resident and tell the resident to quit staring. A Behavior Note dated 04/04/23 documented when Nurse Apprentices were walking down the hall, Resident #1 proceeded to lift the phone camera to take pictures of staff. The resident was educated to not take pictures of staff. A Behavior Note dated 04/06/23, documented a CNA reported Resident #1 was sitting in the hallway staring at staff. Staff noticed the resident had a chux on their lap and the resident's hand was under the chux and was moving up and down. It appeared the resident was masturbating in the hallway. Staff noticed the resident moving their hand in their private area while peeking around the corner at staff and when staff approached the resident, the resident stopped and started massaging their leg. The nurse educated the resident regarding sexual behavior and encouraged the resident to have the behavior in the privacy of their room. A Behavior Note dated 04/29/23, documented the DON received a message from a staff member stating Resident #1 was trying to get the staff member to tell them their age and proceeded to talk about the staff members body and gave the staff member compliments on their body. The staff member ignored the resident, but the resident kept going. Afterwards, the resident began being inappropriate in front of them. The staff member informed the DON the resident would sit in their wheelchair and touch themselves in their groin area repetitively. The DON advised the staff member to write a progress note and stated they would educate Resident #1 on the facility's intolerance to sexually inappropriate behaviors towards staff and other residents. A Behavior Note dated 05/20/23, documented an aide asked Resident #1 to move to a different table in the lunch room after a new plan was made following reports from staff the resident was watching the female staff inappropriately and making inappropriate comments to them during meal times. A Behavior Note dated 08/10/23, documented an Activity Aide reported to the a CNA Resident #1 was being inappropriate on an outing on 08/05/23, and reported more inappropriate behavior on an outing at the senior center on 08/10/23. A QRR report was submitted by the Activity Aide and documentation was submitted to the MDS Coordinator to submit to the DON on night shift. A QRR Report dated 08/10/23, documented Resident #1 was being inappropriate during an outing. The following comments were added to the report: - 08/10/23 - staff member was at the park with Resident #1 when towards the end of the day the resident made inappropriate comments, to include do you want to be my girlfriend? - 08/10/23 - the Risk Management Director documented the LSW was told about the incident and had a conversation with Resident #1. The LSW was informed this was not the first time Resident #1 had done this to younger girls. - 08/14/23 - the Risk Management Director documented the LSW reported Resident #1 denied saying anything inappropriate. - 08/16/23 the DON documented Resident #1 was educated on inappropriate behaviors. An email was sent to the Ombudsman (OMB) seeking guidance on prohibiting Resident #1 from attending outings due to behaviors. The OMB advised the resident be given the sexual harassment policy to further educate on expectations. The DON provided the resident with the policy. The resident continued to deny any inappropriateness. The report further stated the DON spoke with Resident #1 about inappropriate behavior toward staff, especially underaged staff. The resident verbalized understanding however the DON was hesitant to believe the resident would not continue the behavior. A Behavior Note dated 01/20/24, documented Resident #1 said an inappropriate comment while a CNA was walking by. The CNA did not address the comment with the resident. The resident denied making inappropriate comments. Education was provided to the resident on respectful conversation with the staff. Resident #1's Comprehensive Care Plan lacked a care plan specific to inappropriate sexual behaviors. On 02/28/24 at 2:26 PM, the CNO confirmed Resident #1's care plan lacked a care plan for Resident #1's inappropriate sexual behaviors. Resident #3 Resident #3 was admitted to the facility on [DATE], with diagnoses including personal history of traumatic brain injury, anterograde amnesia, and mood disorder due to known physiological condition with mixed features. Resident #4 Resident #4 was admitted to the facility on [DATE], with a diagnosis of vascular dementia, unspecified severity, with other behavioral disturbance. On 02/28/24 at 11:40 AM, a CNA verbalized that Resident #3 and Resident #4 were roommates. The CNA recalled Resident #3 would get frustrated with Resident #4 because Resident #4 would turn off the lights when Resident #3 was reading in the evening (around 7 PM). Resident #4 would leave the bathroom door open when using the bathroom and refuse to shut it when asked. Resident #4 would throw their clothing on Resident #3's side of the room. Resident #3 would close their curtain between Resident #3 and Resident #4's bed, however Resident #4 would open the curtains. On 02/28/24 at 11:58 AM, a Licensed Practical Nurse (LPN) verbalized Resident #3 and Resident #4 were roommates. The LPN recalled Resident #4 would turn off the lights in the room. Resident #3 liked to read, and the facility got the resident a night light to accommodate both residents. Resident #4 would go on Resident #3's side of the room and turn off the night light. Resident #4 would leave the bathroom door open while using the bathroom and would refuse to shut it. A Behavior Note for Resident #4 dated 09/21/23, documented at around 830 PM, Resident #3 was sitting in the dark room with the bathroom door open, using the lights to be able to read their book. Resident #4 was asked if the light could be turned turn on so Resident #3 could read a little before bed and Resident #4 said, No, I want to sleep. Resident #4 was told it was only 8:30 PM and Resident #3 would like to read before bed. The nurse was notified about the incident. A Behavior Note for Resident #4 dated 09/30/23, documented Resident #4 was rummaging through their roommate's personal belongings on the table and bed area. Resident was asked if they needed anything and the resident quickly walked away from their roommates living area and walked to their own bed and sat down and said no. A Behavior Note for Resident #4 dated 10/02/23 documented roommate Resident #3 reported Resident #4 poops and pees with door open. When Resident #4 was asked to shut bathroom door the replied no. Resident #4 opens roommates privacy curtains and ignores requests to please don't do that, per roommate. During meals CNAs and roommate also reported Resident #4 moved other resident's plates of food. Resident #4 has been educated on respect for other resident's space and privacy wishes. Staff will continue to attempt to redirect Resident #4's behaviors. A Behavior Note for Resident #4 dated 02/18/24, documented Resident #4 was observed running from their roommate's side of the room with something in their hand then jumped into their bed. Resident #4 was trying to open a packet of chocolate [NAME]. The nurse was notified, and it was confirmed the chocolate [NAME] belonged to Resident #4's roommate, Resident #3, who was out of the room. Resident #4's Comprehensive Care Plan lacked a care plan for the resident's behaviors. On 02/28/24 at 3:28 PM, the Chief Nursing Officer (CNO) confirmed Resident #4 had behaviors documented by the facility and those behaviors should have been care planned. On 02/28/23 at 2:59 PM, the Administrator verbalized a resident with inappropriate behaviors should be care planned for the behaviors. The facility policy titled, Baseline and Comprehensive Care Plan, reviewed on 04/13/23, documented the services provided or arranged by the facility, as outlined in the comprehensive care plan, would meet professional standards and quality. The comprehensive care plan would be provided by qualified persons in accordance with each resident's written plan of care, and would be culturally competent and trauma informed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #20 Resident #20 was admitted to the facility on [DATE], with diagnoses including unspecified sequelae of cerebral infarction, contracture of muscle and mild cognitive impairment of uncertain or unknown etiology. A FRI dated 08/24/23, documented Resident #20 had complained a Certified Nursing Assistant (CNA) forcefully pushed Resident #20 to roll to the edge of the bed to provide peri-care. On 10/16/23 at 1:38 PM, Resident #20 explained having an issue with one CNA staff member. Resident #20 verbalized needing peri-care after a bowel movement on the morning of 08/24/23. Two CNAs came into the room to perform peri-care, CNA1 was facing the resident and CNA2 was behind the resident when performing peri-care. CNA 2 instructed the resident to roll over, then began to aggressively shove Resident #20 to the edge of the bed. Resident #20 recalled being afraid of falling off the bed, and the only thing stopping the resident from falling out of the bed was CNA1. On 10/18/23 at 3:40 PM, CNA1 verbalized abuse was anything mental, sexual, physical, or exploitation. Physical abuse was putting your hands on someone aggressively, or roughly. CNA1 explained on the date of incident two CNAs went to do vitals in the morning, when the resident asked if the night CNA was still on shift as the resident had a bowel movement and needed to be cleaned up. CNA2 verbalized you (profainity) yourself and didn't clean yourself? CNA1 and CNA2 went in to change the resident and CNA2 proceeded to tell the resident to roll over. CNA2 began to push the resident further over to the edge of the bed and the resident's legs were pushed up against CNA1. On 10/18/23 at 5:23 PM, the DON explained abuse was any physical, mental, sexual and any action intentionally or unintentionally causing harm to another person. Physical abuse was considered unwanted touching with or without force resulting in injury. The DON verbalized having received a report of CNA2 being verbally aggressive and was rough when providing peri-care to Resident #20. The DON explained Resident #20 was fearful of falling off the bed and CNA1 was there to ensure the resident did not fall off the bed. The DON confirmed CNA2 used physical force on Resident #20. On 10/19/23 at 9:39 AM, the SW explained abuse was verbal, physical, neglect, and exploitation. The SW verbalized physical abuse would be any physical action such as a hit, slap, or forceful actions. The SW conducted an interview with theResident #20. Resident #20 complained one of the CNAs had been physically and verbally aggressive with the resident. The SW explained Resident #20 filed a grievance, and the SW notified the Abuse Invesitgation Team. On 10/19/23 at 10:59 AM, the Administrator explained when the facility was aware of abuse the staff was to report to the charge nurse. The original allegation was shared from the SW as the resident had spoken with the SW and filed a grievance. There were two CNAs in the room when the incident occurred, and CNA1 advised the resident to file a grievance. CNA2 was put on administrative leave the evening of 08/24/23. The investigation included interviewing the resident and CNA2. The facility substantiated the abuse allegation. The facility policy titled Abuse Prevention and Prohibition, reviewed 08/25/23, documented each resident has the right to be free from physical, sexual, and psychological abuse and neglect. Cross reference Tag F656 FRI #NV00069288 CPT #NV00069571 Based on clinical record review, interview, observation, and document review, the facility failed to protect a resident from abuse and harassment by another resident and prevent further abuse and harassment for 2 of 12 sampled residents (Resident #2 and Resident #6) and ensure a resident was not verbally and physically abused by a Certified Nursing Assistant (CNA) when providing peri-care for 1 of 12 sampled residents (Resident #20). Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], with diagnoses including major depressive disorder and mild cognitive impairment of uncertain etiology. Resident #2's Communication Note dated 10/09/23, documented by an Activities Aide, documented after a Resident Council meeting, Resident #2 went into the activity office for a personal conversation. Resident #2 started crying because after the Resident Council meeting, Resident #6 balled out Resident #2 for not telling the truth regarding meals being served in a timely manner. During the conversation with Resident #2, Resident #6 intruded on the conversation and stated, You need to tell the truth, you are always complaining at the dinner table about the food. The Activities Aide looked at Resident #2, held the resident's hand and comforted the resident, stating, this was the resident's voice, and the resident could state whatever the resident would like. Resident #2 was still upset, but agreed and thanked the Activity Aide for comforting the resident, not sure if it was because Resident #6 was still around. Resident #2's Behavior Note dated 10/09/23, documented by an Activities Aide, documented the incident was reported to a Registered Nurse (RN). The RN would speak with Resident #2 regarding the situation. Resident #2's Nurses Note dated 10/09/23, documented after the Resident Council Meeting, Resident #2 was upset about the resident's roommate's reaction to one of Resident #2's answers in Resident Council. While Resident #2 was trying to explain the situation to the Activities Director, Resident #2's roommate, Resident #6, came in and interrupted the meeting and confronted Resident #2 again about the situation. The Registered Nurse (RN) and Activities Director consulted with Resident #2. Resident #2 stated the resident felt safe, just answered wrong. Resident #2 was educated on the importance of being able to report grievances. The resident was asked if the resident wanted to change rooms to relieve the situation. The resident declined. Administration was notified of the situation. Resident #6 Resident #6 was admitted to the facility on [DATE], with diagnoses including cerebral infarction, generalized anxiety disorder, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic mood disorder, and mood disorder. Resident #6's care plan dated 04/07/23, documented Resident #6 had a behavior problem to include verbal aggression. Interventions included: intervene as necessary to protect the rights and safety of others. On 10/17/23 at 11:09 AM, a Certified Nursing Assistant (CNA1) verbalized Resident #6 was outspoken and had a history of behaviors with other residents, including name calling. On 10/18/23 at 11:48 AM, a Licensed Practical Nurse (LPN) verbalized Resident #2 and Resident #6 were roommates. Resident #6 had a short attention span and could be verbally aggressive. Resident #6 would get upset when they had to repeat themselves or other residents took too long. The LPN explained the LPN had heard there was an incident between the residents in Resident Council and the Director of Nursing (DON) was involved. The LPN verbalized Resident #2 had been more tearful since the interaction with Resident #6. Both residents were offered a room change and both declined. Resident #2 followed Resident #6 around and did not want to leave Resident #6 as a roommate. The LPN verbalized the LPN considered Resident #6's verbal aggressiveness to Resident #2 to be abuse. On 10/18/23 at 1:37 PM, the DON verbalized Resident #6 had behaviors. The most recent situation was Resident #6 was very upset with Resident #2 as a roommate. Resident #6 informed the DON they were tired of living with the living dead. Resident #6 felt Resident #2 was not giving Resident #6 privacy. Resident #2 would go everywhere Resident #6 was going and would complain of pain. Resident #6 felt Resident #2 would interrogate Resident #6 whenever Resident #6 went out without Resident #2. Resident #6 informed the DON the resident did not want to live with Resident #2. The DON verbalized Resident #6 had been verbally aggressive with Resident #2. The DON explained Resident #2 told the DON and a floor nurse Resident #6 was being mean and used the word bullied. Resident #2 was offered a room change and the resident declined. The DON verbalized Resident #6 would be snappy and short with Resident #2 and used an aggressive/mean/frustrated tone with Resident #2. The DON explained verbal abuse would be negative statements with a negative inflection with intent, bullying. The DON confirmed Resident #2 was being bullied by Resident #6. Resident #6's frustration came out as bullying. The DON explained Resident #2 expressed their feelings in Resident Council about the food and Resident #6 snapped at Resident #2. Resident #2 went to the Activities Aide and a nurse after the incident happened. The DON was not in the facility the day of the incident, however when the DON spoke with Resident #2, the resident was still upset. The DON asked the resident if the resident wanted to move rooms and the resident declined. The DON verbalized the facility would have separated the residents but did not have an extra room and could not just move residents willy nilly. The DON confirmed Resident #2 had been more tearful since the incident on 10/09/23. The DON explained the facility was responsible for protecting residents from bullying, however, the facility could not move residents without guardian and Power of Attorney approval. The DON further explained the DON had addressed Resident #2 and Resident #6 when situations had happened, but because the residents had rights, the facility did not want to overrule their rights and move them when they did not want to be moved. The DON verbalized Resident #2 would be upset by Resident #6 and cry, however the resident would back track and say everything was fine. The DON verbalized the Resident Council incident was the escalation between Resident #2 and Resident #6. The DON explained the facility did not notify the facility's mental health provider of the incident between the residents because the provider would be in the facility for regular rounding on Monday, 10/23/23. The DON did not ask for an as needed visit from the mental health provider at the time of the incident because the provider was scheduled to come into the facility and Resident #2 would be seen by the mental health provider at that time. The DON confirmed Resident #2 was verbally abused and the abuse was not reported to the State Agency. The DON confirmed the interaction should have been reported to the State Agency. The DON confirmed the facility did not notify the mental health provider to have Resident #2 assessed for psychosocial harm and should have. On 10/18/23 at 2:23 PM, the Activities Coordinator (AC) verbalized Resident #2 and Resident #6 were sitting next to each other in Resident Council when Resident #6 looked over at Resident #2 and said, don't you have anything to add. Resident #2 said no, and Resident #6 got upset because a couple of days before, Resident #2 told Resident #6 the resident had a complaint. Resident #2 was adamant they did not remember the complaint. Resident #2 became upset Resident #6 was mad. Resident #2 cried and was upset. The AC explained when the AC started in the position last November, Resident #2 was often tearful, however the resident's medications changed, and the resident became less tearful. When Resident #2 cried about Resident #6, the AC knew it was a big deal for Resident #2 because the resident had not had episodes of tearfulness for a while. The AC verbalized Resident #6 did not want to be roommates with Resident #2 but Resident #2 did not want to change rooms. The AC had never seen Resident #2 cry the way they did at the time of the incident on 10/09/23. The AC explained Resident #2 would sit with Resident #6 at lunch and at Resident Council. Resident #2 was very sweet and tried to be friends with everyone. Resident #6 was feisty, and the AC would often have to intervene in situations involving Resident #6 and other residents. On 10/18/23 at 3:43 PM, Resident #2 was in bed and Resident #6 was sitting in a recliner a couple of feet from Resident #2's bed. While the surveyor was speaking with Resident #2, Resident #6 loudly whispered I can't stand being their roommate. On 10/18/23 at 3:45 PM, Resident #6 verbalized the resident had spoken with the DON about changing rooms. The resident explained Resident #2 was much older and complained of dying all the time and Resident #6 did not want to hear it. Resident #6 did not want to talk about death and being in pain and did not want to hear the roommate talking about those things. Resident #6 further explained Resident #2 had become reliant on Resident #6 for assistance and followed Resident #6 around all the time like a shadow. Resident #2 also used the bathroom with the door open often and Resident #6 did not like it for privacy reasons and because it stinks. Resident #6 verbalized the resident informed the DON the resident did not like these behaviors on 10/16/23. On 10/19/23 at 9:00 AM, the Risk Manager verbalized the Risk Manager would consider it verbal abuse if a resident stated they felt bullied. On 10/19/23 at 9:26 AM, the Administrator verbalized the Administrator did not feel this isolated incident between Resident #2 and Resident #6 was abuse. The Administrator explained they felt the incident was a disagreement between residents. Resident #2 wanted to stay with Resident #6 and the facility did not want to move the residents when they felt the residents had a relationship. The Administrator verbalized the residents liked to be together and even though Resident #6 may have been frustrated with Resident #2 following Resident #6 around, the residents interacted like siblings and had a close relationship. The Administrator confirmed the facility should have notified the mental health provider of the incident. The Administrator verbalized the facility Social Worker (SW) met with Resident #6 and did not have concerns. The Administrator verbalized the facility did not initiate an abuse investigation or report to the State Agency because the Administrator did not feel the isolated incident between Resident #2 and Resident #6 rose to the level of abuse. Resident #6's Annual Social Services assessment dated [DATE], documented Resident #6 recently reported the resident and the resident's roommate (Resident #2) were not getting along as well as before. The resident had many friends in the facility but often felt bored and alone and it had a lot to do with the negativity of my roommate. It's depressing. It seemed the resident had become somewhat more verbally aggressive towards the resident's roommate (Resident #2). On 10/19/23 at 10:36 AM, the SW verbalized the SW was not notified of the incident between Resident #2 and Resident #6. The SW would have expected to have been notified of the incident so the SW could have spoken with the residents involved. The SW read the communication note the AC documented and verbalized the SW would have expected someone to notify the SW Resident #2 was upset. Had the SW been notified, the SW would have met with the residents. The SW further explained since a grievance was mentioned to Resident #2, the SW would have followed up to see if the resident wanted to file a grievance, however the SW was not aware of the incident or of Resident #6's desire to change rooms until the SW asked a standard question on the assessment. The SW recalled the nurse and AC verbalizing during daily rounding, Resident #2 had felt down but the SW did not follow up with the resident regarding the concern. The SW explained the SW did not meet with Resident #6 as a result of the incident, but because the SW had a planned Social Services Assessment scheduled with the resident on 10/17/23. The SW verbalized during the assessment, Resident #6 reported the resident did not enjoy sharing a space with Resident #2, who was always in pain and complaining about it. The SW confirmed the SW did not meet with Resident #2 or Resident #6 regarding the incident 0n 10/09/23. On 10/19/23 at 11:50 AM, Resident #6 verbalized the resident was getting a new roommate. The resident explained the facility staff came in and stated they were moving Resident #2 and Resident #6 had been mean to Resident #2 and there were witnesses. Resident #6 was still happy Resident #2 was being moved and relieved the resident would not have to take care of Resident #2 any longer. On 10/19/23 at 2:25 PM, the Administrator verbalized the Administrator did not believe this was a case of abuse, Resident #2's family did not believe it was abuse, and the resident had the right to stay in the room with Resident #6. The Administrator explained Resident #2's family believed Resident #6 may have been jealous of Resident #2 because Resident #2's family visited often and brought baked goods. On 09/27/23, the facility held a facility wide training for Abuse and Neglect: Prevention and Prohibition. The training documented: -Bullying was also a form of abuse and may occur in a long-term care facility. Each bullying situation must be investigated to determine if it was abuse. -It was not your (facility staff) responsibility to prove abuse or make a determination on the validity of the claim. The staff role was to report so the Abuse Investigation Team could make a determination. -Signs and symptoms of abuse were often subtle. In addition, victims were reluctant to admit abuse was occurring. If you suspect abuse was occurring, report it. The facility policy titled Abuse Prevention and Prohibition, reviewed 08/25/23, documented it was the policy of the facility to protect and promote the rights of each resident, including the right be free from all forms of abuse or neglect. The policy defined psychological abuse as abuse that inflicted emotional pain and distress on the elderly individual. This included but was not limited to humiliation and harassment. If a resident was found to be abusive to another resident, the physician would be contacted, and action taken to curb such behavior. The facility policy titled Resident [NAME] of Rights, reviewed 05/29/23, documented the resident had the right to be free from mental and physical abuse, fear, pressure resistance, or forcing to do as others wished. Cross reference Tag F610

Based on interview, clinical record review, and document review, the facility failed to submit an initial Facility Incident Report to the State Agency within two hours for 1 of 1 Facility Reported Incidents (FRI). Findings include: On 10/18/23 at 3:40 PM, CNA1 confirmed witnessing CNA2 forcefully rolling a resident in bed to provide morning peri-care. CNA1 did notified the Director of Nursing of the incident until the afternoon of 08/24/23. The facility's documented timeline indicated the Social Worker received the allegation of employee to resident abuse on 08/24/23 at 3:30 PM. An initial FRI #NV00069288 was submitted to the State Survey Agency on 08/24/23 at 8:38 PM, with the allegation of employee to resident abuse, three hours late. On 10/19/23 at 10:59 AM, the Administrator verbalized the Administrator was part of the facility Abuse Prevention Team (Abuse Investigation Team). The Administrator confirmed the initial report for alleged employee to resident abuse was not reported to the State Agency within the two-hour required timeframe. The facility policy titled Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment, revised 10/2022, documented any resident presenting with any sign of possible physical or mental abuse the person identifying signs will immediately report to nurse leadership. The nurse leader upon receipt of this information will report to the Bureau of Licensure and Certification. The abuse investigation team would report suspected abuse via the Facility Reported Incident immediately but not later than two hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review the facility failed to ensure a care plan was developed following employee to resident abuse for 1 of 12 sampled residents (Resident #20). The failure had the potential to delay implementation of appropriate resident care interventions. Findings include: Resident #20 Resident #20 was admitted to the facility on [DATE], with diagnoses including unspecified sequelae of cerebral infarction, contracture of muscle and mild cognitive impairment of uncertain or unknown etiology. An initial Facility Reported Incident (FRI) dated 08/24/23, documented an employee to resident abuse on 08/24/23, at 3:30 PM. The FRI documented a Certified Nursing Assistant (CNA) witnessed another CNA forcefully push Resident #20 to the edge of the bed to provide peri-care. Resident #20 met with the Social Worker alleging employee to resident abuse. Resident #20's Comprehensive Care Plan lacked a care plan related to the employee to resident abuse. On 10/19/23 at 9:39 AM, the Social Worker verbalized the care plan should be updated to ensure the staff is aware of what to watch for after an abuse incident. On 10/19/23 at 9:53 AM, the Minimum Data Set (MDS) Coordinator confirmed the employee-to-resident abuse was not included on Resident #20's care plan. The MDS Coordinator explained being responsible to update the care plan and the incident was missed. The MDS Coordinator verbalized the purpose of the care plan was to identify a change in resident behaviors, notice similar patterns, and provide interventions for reassurance techniques with fear and anxiety. On 10/19/23 at 10:59 AM, the Administrator explained the facility substantiated the FRI allegation for employee to resident abuse. The facility policy titled Comprehensive Care Plan, reviewed 04/14/23, documented the Care Plan must be an ongoing reflection of the resident's current status and treatment plan. Cross reference Tag F600 FRI #NV00069288 CPT #NV00069571

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure a facility staff member did not endorse a check to themselves, from a resident's trust fund checking account for 1 of 4 Facility Reported Incidents (FRI) (Resident #26). Findings include: Resident #26 Resident #26 was admitted to the facility on [DATE], with diagnoses including unspecified protein-calorie malnutrition, muscle weakness and mild cognitive impairment of uncertain or unknown etiology. The resident expired on [DATE]. The FRI final report, documented on [DATE], Resident #26's Representative reported to the Chief of Nursing (CNO) there were three checks posted to Resident #26's trust fund checking account. Check #4557 dated [DATE], was made payable to Certified Nursing Assistant (CNA) 1 in the amount of $3100 and posted to Resident #26's trust fund checking account on [DATE]. The police were notified of the attempted theft and CNA 1's employee contract was terminated. A copy of check #4557 for the amount of $3100, documented CNA 1's name as the recipient and was signed on the endorsement line on the back of the check. On [DATE], CNA 2 provided a written statement. CNA 2's statement documented CNA 1 had contacted CNA 2 to see if anyone was talking in the facility about the suspected incident. CNA 1 admitted to CNA 2 having taken a check from Resident #26 to start up a cannabis farm. CNA 1 explained to CNA 2, Resident #26 had expired, and would not be able to say otherwise. On [DATE] at 2:37 PM, the Director of Nursing (DON) verbalized Resident #26's Representative had contacted the facility on [DATE] to inquire about the following checks; -4557 -4563 -4596 -4597 The DON explained only check #4557 was made out to CNA 1 and the other three checks were made out to someone the facility administration had reason to believe to be a friend of CNA 1 based on their invesigation of social media accounts.The DON verbalized CNA 1's employment contract was terminated on [DATE]. The facility policy titled Abuse Prohibition and Prevention, last reviewed [DATE], documented it was the policy of the facility for residents to be free from exploitation of person or property. Exploitation was defined as any act taken by a person having the trust or confidence of a resident to obtain control. FRI #NV00067777