Based on interview and record review, it was determined that the facility failed to keep residents apprised of the progress towards resolution, and maintain evidence demonstrating the response and rationale of the resident group grievance for the attendees of the Resident Council Meeting for 3 of 3 months of meeting minutes reviewed. Findings include: Interview on 5/22/25 at approximately 10:00 a.m. during Resident Council Meeting revealed that the complaints about LNA's (Licensed Nursing Assistance) discussing other residents and being loud is an on going issue. All 9 residents at this meeting stated they do not feel this concern was addressed and that no one had followed up to inform them of what if any actions had been taken since the initiation of the concerns. Review on 5/22/25 of the facility's Resident Council Meeting minutes revealed the following documented concerns under Nursing: February 11, 2025 minutes: LNA's talking about residents in front of other residents; March 25, 2025 minutes: LNA's talking about residents in front of other residents. Has gotten better; April 15,2025 minutes: LNA's talking about residents in front of other residents or in the hallways near rooms. Still ongoing (Birch Wing). Hollering of staff in hallways and at nurse's stations (All wings). Interview on 5/22/25 at approximately 11:00 a.m. with Staff K (Activities Director) confirmed the above concerns regarding the LNA's had been an ongoing issue at the Resident Council Meeting. Staff K stated that Social Services is given the resident concerns after the meeting. Staff K confirmed that there was no written follow up of actions taken in the meeting minutes the months following the continued concerns. Interview on 5/22/25 at approximately 10:30 am with Staff E (Social Services coordinator) stated that they do not write the concerns from Resident Council as separate Grievances. Staff E stated that they verbalize the Resident Council concerns to the Department heads at the managers meeting the following day so all managers can be aware of what concerns are brought up and for them to address. Review on 5/22/25 of facility policy titled Resident Council Meetings, revised 10/2022, revealed .7. The facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the Council .

Based on observation, interview and record review, it was determined that the facility failed to develop and update comprehensive care plans for 2 of 3 residents reviewed for pressure ulcers in a final sample of 16 residents. (Resident identifiers are #32 and #158). Findings include: Resident #32 Review on 5/22/25 of Resident #32's medical record revealed a provider note dated 5/19/25 written by Staff D (Advanced Practice Registered Nurse) that stated; Previously closed sacral ulcer now has one open area, mid-line, continue with medihoney and silicone border dressings to open area. Review on 5/22/25 of Resident #32's MAR (Medication Administration Record) revealed a physician's order with a start date of 4/21/25 to Cleanse sites on inner left and right buttock. Apply Medi honey and cover with silicone dressing. Change 3x [three times a] week in the morning every Mon, Wed, Fri [Monday, Wednesday, and Friday]. Interview on 5/23/25 at approximately 8:30 a.m. with Staff H (Unit Manager) confirmed that there were no new orders addressing the 5/19/25 wound note that identified the new area at mid-line. Interview on 5/23/25 at approximately 8:45 a.m. with Staff D confirmed that he/she saw Resident #32 on 5/19/25 and noted the new area at mid-line and did not write a new treatment order. Staff D further confirmed that the treatments had not been completed. Review on 5/23/25 of Resident #32's care plan for skin revealed that the last update to the care plan was on 3/27/25. Interview on 5/23/25 at approximately 9:00 a.m. with Staff H confirmed that Resident #32's care plan for skin had not been updated since 3/27/25.Resident #158 Review on 5/21/25 of Resident #158's progress notes revealed that on 3/27/25 there was an Unstageable pressure area to the right buttock and a stage 2 pressure ulcer to the left buttock. Further review revealed that on 4/12/25 there was a Deep Tissue Injury to the right heel. Observation on 5/23/25 at approximately 12:30 p.m. of Resident #158's wound care with Staff G (Infection Preventionist/Wound Care Nurse) and with Staff D revealed that Resident #158 has pressure areas to the right heel, left gluteal fold, and right coccyx area. Review on 5/23/25 of Resident #158's care plan initiated on 3/10/25 revealed, Resident at risk for skin breakdown related to impaired functional mobility and actual MASD [Moisture-associated skin damage]. Further review revealed that the care plan had not been updated to include interventions for the above pressure areas. Interview on 5/27/25 with Staff H confirmed that there was no care plan intervention for Resident #158's pressure ulcers that developed in March and April.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to follow physician orders for 1 of 3 residents reviewed for choices in a final sample of 16 residents (Resident Identifier is #21). Findings include: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .It is essential to verify the accuracy of every medication you give to your patients with the patient's order. If the medication order is incomplete, incorrect, or inappropriate, or if there is a discrepancy between the original order and the information on the MAR [Medication Administration Record]. consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication . [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th ed. St. Louis, Missouri: Mosby Elsevier, 2021. Chapter 31 Medication Administration Page 595, .Medications that are time critical most likely cause harm or have subtherapeutic effects if they are not administered in time (usually 30 minutes before and after the scheduled dose). Non-time-critical medications most likely do not cause harm if they are given within 1 hour to 2 hours before or after the schedule time. Thus, you need to administer time-critical medications at a precise time, within 30 minutes before and after a scheduled time. You administer non-time-critical medications within 1 to 2 hours of their scheduled times . Interview on 5/21/25 at 11:37 a.m. with Resident #21 revealed that his/her medications are often given late. He/she stated it has happened multiple times within the last month. Review on 5/22/25 of Resident #21's annual Minimum Data Set (MDS) with an assessment reference date of 3/18/25 revealed Resident #21 had a Basic Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Review on 5/22/25 of Resident #21's Medication Administration Audit Report for the last 30 days revealed the following medications were given past the scheduled time: On 4/21/25 Methylphenidate (central nervous system stimulant) HCI Oral Tablet 20 mg. Give 1 tablet by mouth one times a day for bipolar disorder, scheduled for 4:00 a.m., given at 6:13 a.m. On 4/22/25 Methylphenidate HCI Oral Tablet 20 mg. Give 1 tablet by mouth one times a day for bipolar disorder, scheduled for 4:00 a.m., given at 7:05 a.m. On 4/28/25 Olanzapine (antipsychotic) Oral Tablet. Give 10 mg by mouth at bedtime for bipolar disorder, scheduled for 7:00 p.m., given at 8:52 p.m. On 4/29/25 Olanzapine Oral Tablet. Give 10 mg by mouth at bedtime for bipolar disorder, scheduled for 7:00 p.m., given at 8:52 p.m. On 5/3/25 Methylphenidate HCI Oral Tablet 20 mg. Give 1 tablet by mouth one times a day for bipolar disorder, scheduled for 4:00 a.m., given at 6:17 a.m. On 5/4/25 Methylphenidate HCI Oral Tablet 20 mg. Give 1 tablet by mouth one times a day for bipolar disorder, scheduled for 4:00 a.m., given at 6:14 a.m. On 5/5/25 Methylphenidate HCI Oral Tablet 20 mg. Give 1 tablet by mouth one times a day for bipolar disorder, scheduled for 4:00 a.m., given at 6:35 a.m. Olanzapine Oral Tablet. Give 10 mg by mouth at bedtime for bipolar disorder, scheduled for 7:00 p.m., given at 8:53 p.m. On 5/7/25 Methylphenidate HCI Oral Tablet 20 mg. Give 1 tablet by mouth one times a day for bipolar disorder, scheduled for 4:00 a.m., given at 6:07 a.m. Olanzapine Oral Tablet. Give 10 mg by mouth at bedtime for bipolar disorder, scheduled for 7:00 p.m., given at 8:57 p.m. On 5/8/25 Valbenazine Tosylate (treat various movement disorder) Oral Capsule. Give 40 mg by mouth one time a day for Tardive Dyskinesia, scheduled for 7:00 a.m., given at 10:17 a.m. Valbenazine Tosylate Oral Capsule. Give 40 mg by mouth one time a day for Tardive Dyskinesia, scheduled for 4:00 p.m., given at 8:51 p.m. On 5/9/25 Valbenazine Tosylate Oral Capsule. Give 40 mg by mouth one time a day for Tardive Dyskinesia, scheduled for 4:00 p.m., given at 8:30 p.m. On 5/10/25 Valbenazine Tosylate Oral Capsule. Give 40 mg by mouth one time a day for Tardive Dyskinesia, scheduled for 4:00 p.m., given at 2:25 a.m. Olanzapine Oral Tablet. Give 10 mg by mouth at bedtime for bipolar disorder, scheduled for 7:00 p.m., given at 2:25 a.m. Gabapentin (nerve pain medication) Oral Capsule 300 mg. Give 1 capsule by mouth three times a day for polyneuropathy, scheduled for 8:00 p.m., given at 2:24 a.m. Bupropion (antidepressant) HCI ER Oral Tablet Extended Release 12 Hour 150 mg. Give 1 tablet by mouth two times a day for depression and anxiety, scheduled for 8:00 p.m., given at 2:24 a.m. On 5/11/25 Methylphenidate HCI Oral Tablet 20 mg. Give 1 tablet by mouth one times a day for bipolar disorder, scheduled for 4:00 a.m., given at 6:01 a.m. Valbenazine Tosylate Oral Capsule. Give 40 mg by mouth one time a day for Tardive Dyskinesia, scheduled for 4:00 p.m., given at 7:35 p.m. 5/12/25 Valbenazine Tosylate Oral Capsule. Give 40 mg by mouth one time a day for Tardive Dyskinesia, scheduled for 4:00 p.m., given at 8:15 p.m. On 5/13/25 Methylphenidate HCI Oral Tablet 20 mg. Give 1 tablet by mouth one times a day for bipolar disorder, scheduled for 4:00 a.m., given at 7:21 a.m. Valbenazine Tosylate Oral Capsule. Give 40 mg by mouth one time a day for Tardive Dyskinesia, scheduled for 4:00 p.m., given at 8:30 p.m. On 5/14/25 Methylphenidate HCI Oral Tablet 20 mg. Give 1 tablet by mouth one times a day for bipolar disorder, scheduled for 4:00 a.m., given at 7:09 a.m. Valbenazine Tosylate Oral Capsule. Give 40 mg by mouth one time a day for Tardive Dyskinesia, scheduled for 4:00 p.m., given at 8:05 p.m. On 5/15/25 Methylphenidate HCI Oral Tablet 20 mg. Give 1 tablet by mouth one times a day for bipolar disorder, scheduled for 4:00 a.m., given at 6:06 a.m. Valbenazine Tosylate Oral Capsule. Give 40 mg by mouth one time a day for Tardive Dyskinesia, scheduled for 4:00 p.m., given at 8:11 p.m. 5/16/25 Valbenazine Tosylate Oral Capsule. Give 40 mg by mouth one time a day for Tardive Dyskinesia, scheduled for 4:00 p.m., given at 8:24 p.m. 5/17/25 Valbenazine Tosylate Oral Capsule. Give 40 mg by mouth one time a day for Tardive Dyskinesia, scheduled for 4:00 p.m., given at 8:33 p.m. 5/18/25 Valbenazine Tosylate Oral Capsule. Give 40 mg by mouth one time a day for Tardive Dyskinesia, scheduled for 4:00 p.m., given at 8:35 p.m. On 5/21/25 Methylphenidate HCI Oral Tablet 20 mg. Give 1 tablet by mouth one times a day for bipolar disorder, scheduled for 4:00 a.m., given at 6:36 a.m. Interview on 5/23/25 at 8:51 a.m. with Staff D (Advanced Practice Registered Nurse) confirmed that the above medications were administered late. Review on 5/23/25 of the facility's policy titled Medication Administration revised on 3/25 revealed, .10. Ensure that the six rights of medication administration are followed: . e . right time .12b. Administer within 60 minutes prior to or after scheduled times unless otherwise ordered by physician .

Based on interview and record review, it was determined that the facility failed to assist a resident in gaining access to hearing services for 1 of 1 resident reviewed for communication in a final sample of 16 residents (Resident Identifier is #42). Findings include: Interview on 5/22/25 at 10:40 a.m. with Resident #42 revealed that he/she had requested to be seen by the audiologist. Resident #42 stated that he/she felt that his/her hearing was getting worse, and he/she was concerned. Review on 5/23/25 of Resident #42's medical record revealed that Resident #42 was admitted to the facility in 2023 and diagnosed with abnormal auditory perceptions in the left ear in 9/2024. Review on 5/23/25 of Resident #42's ambulatory clinic notes for a hearing evaluation dated 5/23/24 revealed that Resident #42 was a good candidate for bilateral hearing aides. Interview on 5/23/25 at approximately 1:00 p.m. with Resident #42's Durable Power of Attorney (DPOA) revealed that Resident #42 had difficulty communicating with family both in person and on the telephone. Interview on 5/23/25 at approximately 2:00 p.m. with Staff F (Medical Records/Central Supply coordinator) confirmed that Resident #42 had requested to be seen by the audiologist for a hearing consult and the facility did not make an appointment. Review on 5/23/25 of the facility's policy titled, Consultant Referrals dated 7/21 revealed, .1. Outside clinical services will be provided to the residents as ordered by the resident physician and as available by appointment from the outside provider .

Based on interview and record review, it was determined the facility failed to provide the necessary assistance in making transportation arrangements for a scheduled x-ray which resulted in a missed appointments for 1 of 1 resident reviewed for transportation assistance in a final sample of 16 residents. (Resident Identifier is #13.) Findings include: Review on 5/21/25 of Resident #13's medical record revealed that he/she was admitted to the facility on 12/2024. Interview on 5/21/25 at 10:42 a.m. with Resident #13 revealed that he/she was upset because they were supposed to have an x-ray of their knee at the orthopaedic clinic, but was told by Staff F (Medical Records/Central Supply coordinator), who sets up the transportation, that they did not know anything about an appointment and transportation had not been set up. Interview on 5/22/25 at 2:28 p.m. with Staff L (Certified Occupational Therapy Assistant) confirmed that they had seen paperwork at the nurses station for Resident #13 regarding an appointment for an x-ray of the knee on 5/21/25 and that they had reached out to Staff F to be sure they were aware of it. Interview on 5/22/25 at 2:35 p.m. with Staff F revealed that Staff L had told them that there had been paperwork at the nurses station regarding an appointment/x-ray for Resident #13. Interview on 5/23/25 at 9:55 a.m. with Staff F and with the orthopaedic clinic confirmed that Resident #13 had been seen at the clinic on 5/6/25 and given paperwork to Resident #13 that included an appointment for an x-ray and physician visit for 5/21/25 at 12:00 p.m. The clinic confirmed that Resident #13 did not go the appointment or have the x-ray.

Based on observation, interview, and record review, it was determined that the facility failed to implement policies and procedures for 2 of 2 residents observed for wound care and failed to develop a water management program to minimize the risk of Legionella that had the potential to effect the facility census of 56 residents who resided at the facility. (Resident Identifiers are #32 and #158). Findings include: Resident #32 Observation on 5/23/25 at approximately 12:00 p.m. with Staff G (Infection Preventionist/ Wound Care Nurse) and Staff D (Advanced Practice Registered Nurse) performing wound care for Resident #32 revealed the following: Staff G gathered their supplies outside of the room and placed them on a clip board without cleaning the clipboard or placing a clean field barrier. There was a sign indicating the resident needed EBP (Enhanced Barrier Precautions) hanging on the outside of Resident #32's door. Staff G entered Resident #32's room. Staff G did not don an isolation gown. Staff G removed Resident #32's dirty coccyx wound dressing. Resident #158 Observation on 5/23/25 at approximately 12:30 p.m. with Staff G and Staff D performing wound care for Resident #158 revealed the following: Staff G gathered their supplies outside of the room and placed them on a clip board without cleaning the clipboard or placing a clean field barrier. Staff G removed a pair of scissors that were stored on the top of the treatment cart and placed them on the clipboard. There was a sign indicating EBP hanging on the outside of Resident #158's door. Staff G and Staff D entered the room without putting on an isolation gown. Staff G placed the clipboard with the dressing change supplies directly on Resident #158's bed. Staff G cut Resident #158's right heel wound dressing off with the scissors and placed them back on to the clipboard. Staff G removed the left gluteal fold wound dressing. Staff G removed right coccyx wound dressing. When treatments were completed, Staff G brought the clip board and placed it on top of the treatment cart Staff G placed the dirty scissors back into the holder on the top of the cart. Interview on 5/23/25 at approximately 1:00 p.m. with Staff G confirmed the above observations. Review on 5/23/25 of facility policy titled Enhanced Barrier Precautions, revised 1/2024, revealed .3. Implementation of Enhanced Barrier Precautions .a. Make gowns and gloves available immediately near or outside of the resident's room . b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities .4. High-contact resident care activities include: .h. wound care: any skin opening requiring a dressing .10. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk . Review on 5/23/25 of the facility policy titled Clean Dressing Change, revised 5/2024, revealed .5. Set up clean field on the overbed table with needed supplies for wound cleansing and dressing application .12. Cleanse the wound as ordered . Review on 5/22/25 of the water management plan provided by the facility revealed that it contained a water system for a 4 story building [The facility is only one story]. Interview on 5/22/25 at approximately 11:40 a.m. with Staff I (Administrator) revealed the facility did not have a water management plan that describes the flow of the water system at the facility. Review on 5/23/25 of the facility policy titled Infection Prevention and Control Program, revised 1/2024, revealed .16. Water Management: a. A water management program has been established as part of the overall infection prevention and control program. b. Control measures and testing protocols are in place to address potential hazards associated with the facility's water systems. c. The Maintenance Director serves as the leader of the water management program.

Based on record review and interview it was determined that the facility failed to ensure that a resident was free from abuse for 1 of 3 residents reviewed for abuse (Resident Identifier #5). Findings include: Review on 8/7/24 of Resident #5's medical record revealed the following diagnosises: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Further review of the medical record that Resident #5 has a Brief Interview for Mental Status (BIMS) of 3. Review on 8/7/24 of a facility reported incident, dated 5/9/24, revealed that on 5/5/24, Resident #2 was observed by a staff member with his/her hand down the pants of Resident #5. Interview on 8/7/24 with Staff A (Activities Director) revealed on 5/5/24, Staff A observed Resident #2 with his/her hand down the pants of Resident #5. Further interview revealed that Staff A was aware of multiple incidents of Resident #2 being sexually inappropriate with residents who have cognitive issues. Interview on 8/7/24 at approximately 11:50 a.m. with Staff H (Licensed Nursing Assistant (LNA)) revealed that on 7/27/24, he/she observed Resident #5 lying in bed and Resident #2 was positioned with his/her right hand on Resident #5's left shoulder and Resident #2's other hand was rubbing back and forth on Resident #5's genital area. Interview on 8/16/24 at approximately 8:30 a.m. with Staff K (LNA) revealed that on 8/13/24 around dinner time, Staff K had witnessed Resident #1 touching Resident #5 at the top of their inner thigh near their genital area. Staff K stated that he/she immediately separated the residents and reported the incident to Staff M (Licensed Practical Nurse (LPN)) because it was inappropriate. Interview on 8/19/24 at approximately 1:20 p.m. with Staff L (LNA) revealed that Staff L witnessed Resident #1 run his/her hand up Resident #5's leg to where [pronoun omitted] leg meets [pronoun omitted] crotch. Staff L further revealed that he/she was not aware of any interventions in place for Resident #1 to prevent inappropriate behaviors. Review on 8/7/24 of Resident #2's medical record revealed that Resident #2 had a BIMS of 12 with no cognitive or mood related diagnosis. Review on 8/7/24 of Resident #2 care plan revealed a focus for potential to exhibit physical behaviors related to poor impulse control and adjustment disorder with depressed mood, created on 5/29/24, revealed the following interventions: Evaluate need for Psych/Behavioral Health consult, initiated on 5/29/24, Encourage resident/patient to seek staff support for distressed mood, initiated on 5/29/24, and Divert resident/patient by giving alternative objects or activities, created on 5/29/24. Further review Resident #2's care plan revealed a care plan for tendency to exhibit sexually inappropriate behavior related to: lack of disinhibition, created on 4/1/24 and revised on 5/6/24, with the following interventions: Evaluate need for Psych/Behavioral Health consult, initiated on 5/9/24, Provide psychosocial rehabilitation education regarding appropriate sexual behavior through use of Meditelecare, initiated on 5/9/24, When sexually inappropriate behaviors occur, approach [name omitted] in a calm, unhurried manner, reassure as necessary, initiated on 4/1/24 and revised on 5/9/24. Review on 8/7/24 of Resident #1's medical record revealed that Resident #2 had a BIMS of 3 and the following diagnsosises: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Review on 8/7/24 of Resident #1's care plan revealed a focus for the potential to demonstrate verbal/physical behaviors toward others related to ineffective coping skills, with an intervention to provide 1:1 care when up in wheel chair, created on 8/7/24.

Based on interview and record review, it was determined that the facility failed to ensure that alleged violations of abuse were reported immediately to the State Survey Agency (SSA) for 3 of 4 allegations of abuse reviewed (Resident Identifiers are #1, #2 and #3). Findings include: Review on 8/7/24 of the facility policy titled, Abuse, Neglect and Exploitation, revised on 01/2024, revealed: .VII Reporting/Response .1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframe's: a. Immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . Resident #2 Review on 8/7/24 of a facility reported incident, reported to the State Agency on 7/28/24 at 6:02 a.m., revealed that Resident #2 was observed by Staff H (Licensed Nursing Assistant (LNA)) with his/her right hand on Resident #5's left shoulder and his/her other hand placed on the genital area of Resident #5 on 7/27/24 at 8:30 a.m Interview on 8/7/24 at approximately 11:50 a.m. with Staff H (LNA) revealed that on 7/27/24, Staff H observed Resident #2 with his/her hands on the outside of Resident #5's clothing rubbing and squeezing his/her genital area. Staff H stated they immediately notified Staff I (Nurse). Interview on 8/7/24 at approximately 11:40 a.m. with Staff I revealed that on 7/27/24, Staff H reported to Staff I that Resident #2 was in Resident #5's room and was rubbing Resident #5's genital area. Staff I also revealed that he/she wrote a note for Staff J (Assistant Director of Nursing) about the incident and left it in their mailbox because Staff J was not in the facility. Interview on 8/7/24 at approximately 1:00 p.m. with Staff F (Director of Nursing) confirmed that the incident with Resident #2 and Resident #5 occurred on 7/27/24 and was reported to the SSA on 7/28/24, more than 2 hours after the incident. Resident #3 Review on 8/7/24 of a facility reported incident, reported to the State Agency on 8/6/24 at 1:38 p.m., revealed that Resident #4 had fallen, possibly due to an altercation with Resident #3. Interview on 8/7/24 at approximately 12:40 p.m. with Staff G (Social Services) revealed that on the morning of 8/1/24, Resident #4 had told Staff G that they were attacked by another resident the night before. Interview on 8/8/24 at approximately 7:25 a.m. with Staff C (Registered Nurse) revealed that on the evening of 7/31/24, Staff C had heard a commotion coming from Resident #4 room. Staff C had responded to the commotion and had seen Resident #3 exiting Resident #4's room. Resident #4 was on the floor inside the doorway when staff arrived. Resident #4 had stated that Resident #3 had hit them and caused them to fall. Interview on 8/7/24 at approximately 9:00 a.m. with Staff F confirmed that the incident with Resident #3 and Resident #4 had occurred on 7/31/24 was reported to the SSA on 8/6/24, more than 2 hours after the allegation was made. Resident #1 Interview on 8/16/24 at approximately 8:30 a.m. with Staff K (LNA) revealed that Staff K had witnessed an interaction between Resident #1 and Resident # 5 on 8/13/24 around dinner time. Interview further revealed that Resident #1 was seen touching Resident #5 on [pronoun omitted] inner thigh almost to [pronoun omitted [genital area]. Staff K stated that Resident #5 was visibly upset. Staff K stated that he/she immediately separated the residents and reported the incident to Staff M (Licensed Practical Nurse). Interview on 8/16/24 at approximately 10:00 a.m. with Staff E (Administrator) confirmed that the incident with Resident #1 and Resident #5 had occurred on 8/13/24 and had not been reported to the SSA.

Based on observation, interview, and record review, it was determined that the facility failed to revise care plans for 2 of 3 residents reviewed for abuse (Resident Identifiers are #1 and #3). Findings include: Resident #1 Review on 8/7/24 of a facility reported incident revealed that Resident #1 was observed by Staff B (Licensed Nursing Assistant) with his/her hand placed on the genital area of Resident #6 on 7/28/24 at 4:40 p.m. Review on 8/7/24 of Resident #1's medical record revealed a provider progress note, dated 7/30/24, that stated Resident #1 had been seen for increased sexual behaviors towards others and also indicated staff reported increased wandering behaviors with difficulty to redirect. Review on 8/7/24 of Resident #1's care plan revealed a care plan for the potential to demonstrate verbal/physical behaviors towards others related to ineffective coping skills, created on 7/1/24 and revised on 7/15/24. Resident #1's behavior care plan revealed the following interventions: Evaluate need/provide for Psych/Behavioral Health consultation, created on 7/15/24. Further review of Resident #1's care plan revealed no other interventions were added for behaviors. Resident #3 Interview on 8/7/24 at approximately 12:40 p.m. with Staff G (Social Services) revealed that on the morning of 8/1/24 that Resident #4 had informed Staff G that they were attacked by another resident the night before. Interview on 8/8/24 at approximately 7:25 a.m. with Staff C (Registered Nurse) revealed that on the evening of 7/31/24 Staff C had heard a commotion coming from Resident #4's room. Staff C had responded to the commotion and had seen Resident #3 exiting Resident #4's room. Resident #4 was on the floor inside the doorway of their room when staff arrived. Resident #4 had stated that Resident #3 had hit them and caused them to fall. Review on 8/7/24 of Resident #3's care plan revealed a care plan for potential to demonstrate verbal behaviors related to: Cognitive loss/ Dementia; and shaves head at times initiated on 8/23/23. Resident #3's behavior care plan identified the following interventions: If resident requests/attempts to shave head attempt to discourage from activity using calm, gentle approach and if unable to redirect, assure safety during activity, created on 8/23/23, Evaluate need/provide Psych/Behavioral Health consultation, created on 8/23/23, Explain all care, including procedures (one step at a time), and the reason for performing the care before initiating, created on 8/23/23, Provide consistent, trusted caregiver and structured daily routine, when possible, created 8/23/23, Remove resident/patient from environment, if needed. Gently guide the resident from the environment while speaking in a calm, reassuring voice, created on 8/23/23, Provide environment that is conducive to the patients ability to get adequate sleep and maintain preferred sleep/wake schedule, created 8/23/23, Allow time for expression of feelings, provide empathy, encourage, and reassurance, created 8/23/23. Further review of Resident #3's care plan revealed no other behavior care plans. Interview on 8/8/24 at approximately 1:10 p.m. with Staff F (Director of Nursing) revealed that Resident #1 and Resident #3 both had a room change in response to allegations and medication review requested in response to the above incidents.

Based on observation, interview and record review it was determined that the facility failed to ensure that residents who are trauma survivors were free from re-traumatization for 1 of 1 residents reviewed for trauma (Resident Identifier #4). Findings include: Review on 8/7/24 of a facility reported incident revealed Resident #4 yelled out for help. Staff observed Resident #3 exiting Resident #4's room. Resident #4 was found lying on the floor with a hematoma to the top right side of his/her head, a skin tear to the right elbow and complaints of rib pain. Interview on 8/7/24 at approximately 12:40 p.m. with Staff G (Social Services) revealed that Resident #4 had told Staff G that he/she had a past history of trauma. Staff G further revealed that Resident #4's daughter had revealed to Staff G that Resident #4 had a past history of trauma. Interview on 8/7/24 at approximately 1:15 p.m. with Resident #4 revealed that he/she remembered Resident #3 coming to his/her room and hitting him/her. Resident #4 stated that he/she had a traumatic past and was upset with Resident #3 trying to get into the room. Resident #4 further revealed that the lanyard that was worn around his/her neck with a whistle at the end is in case Resident #3 comes close to him/her. Review on 8/7/24 of Resident #4's medical record revealed a nurses note written by Staff C (Registered Nurse) that documented that Resident #3 entered Resident #4's room without consent and that Resident #4 told Resident #3 to get the hell out. Further review of the nurses note revealed that Resident #3 then hit Resident #4 and knocked him/her to the ground. Further review of Resident #4 medical record revealed no evidence of care plan interventions for history of trauma.

Based on interview and record review it was determined that the facility failed to ensure an accurately documented medical record for 1 of 4 allegations of abuse (Resident Identifier is #1). Interview on 8/16/24 at approximately 8:30 a.m. with Staff K (Licensed Nursing Assistant) revealed that Staff K had witnessed an interaction between Resident #1 and Resident # 5 on 8/13/24 around dinner time. Interview further revealed that Resident #1 was seen touching Resident #5 on [pronoun omitted] inner thigh almost to [pronoun omitted] [genital area]. Staff K stated that he/she immediately separated the residents and reported the incident to Staff M (Licensed Practical Nurse). Interview on 8/16/24 at approximately 9:00 a.m. with Staff M revealed that he/she was the nurse on duty when the above incident occurred. Staff M also revealed that he/she wrote a nurse's note, on 8/13/24, giving an accurate account of the above incident. Staff M further revealed that their nurse's note detailing the incident had been struck out, not by Staff M. Staff M was told by Staff F (Director of Nursing) that it was put in the wrong part of the medical record and it needed to be moved to another section. Review on 8/16/24 of Resident # 1's medical record confirmed that a nurse's note written by Staff M on 8/13/24 at 11:02 p.m. had been struck out. Further review of the medical recorded revealed no evidence of the incident that occurred on 8/13/24. Interview on 8/16/24 at approximately 10:20 a.m. with Staff F confirmed the above finding and revealed the incident had been struck out of the medical record and a note about the incident had been added to the Risk Management System, which is not part of the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and interviews, it was determined that the facility failed to provide appropriate care and services to aide in the prevention of an avoidable pressure ulcer for 1 of 1 residents reviewed for pressure ulcers in a final survey sample of 19 residents (Resident Identifier is #48). Findings include: Review on 5/15/24 of the facility policy Pressure Injury Prevention and Management, dated 07/2021 and Reviewed and Revised 10/2022 and 10/2023 revealed: .4. Interventions for Prevention and to Promote Healing .a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries .c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present .i. Redistribute pressure (such as repositioning, protecting and/ or offloading heels, etc.) Review on 5/13/24 of the Nursing assessment dated [DATE] revealed: Section K. Skin Integrity: 4.) Skin observation a. skin intact. Further review of the Nursing Assessment revealed that in Section L. Braden Scale (For Predicting Pressure Sore Risk), the score was a 17, indicating that Resident #48 was considered at risk for developing a pressure ulcer. Review on 5/15/24 of Resident #48's care plan dated 5/5/24 revealed: care plan focus: Resident at risk for skin breakdown related to weakness with decline in functional mobility and bowel incontinence, and care plan goal: The resident will not show signs of skin breakdown by next review. Further review revealed interventions to observe skin for sign and symptoms of skin breakdown, weekly skin check, observe skin condition daily with Activities of Daily Living (ADL) care, and obtain a Physical Therapy and Occupational Therapy evaluation to improve functional mobility. Review also revealed no interventions for offloading and repositioning. Review on 5/15/24 of the Physician note dated 5/6/24 revealed: Skin: New left heel concern. Left heel DTI [Deep Tissue Injury] noted that is intact and non-tender Float heels. Further review of physician note dated 5/14/24 revealed: Acute concerns: Follow up left heel DTI, noted right heel DTI. Review on 5/15/44 of Resident #48's Point of Care Task Record revealed the task for offloading started on 5/6/24. Interview on 5/15/24 at approximatley 12:25 p.m. with Staff C (Licensed Nursing Assistant) revealed that he/she believed that Resident #48's heels had been floated for the last 5 days. Interview on 5/15/24 at approximately 12:20 p.m. with Staff B (Licensed Practical Nurse) assigned to care for Resident #48 confirmed that he/she did not know the date that Resident #48 was supposed to have heels floated. Staff B stated Maybe as of yesterday 5/14/24. Interview on 5/15/24 with Staff D (Director of Nursing) confirmed above findings. Staff D stated Resident #48's DTI on left and right heels were facility acquired.

Based on observation and interview, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards as is possible regarding storage of chemical cleaning solutions on 2 of 3 units observed (Birch Unit & Spruce Unit). Findings include: Observations on 5/13/24 at 1:15 p.m; 5/14/24 at 8:30 a.m and 9:30 a.m; and 5/15/24 at 7:40 a.m. of the Birch Unit Tub Room revealed that the door was open with a bottle of Rapid Multi Disinfectant Spray chemical cleaning solution hanging on the wall within reach of wandering residents. Interview on 5/15/24 at 7:40 a.m. with Staff F (Licensed Practical Nurse) confirmed the above finding. Observation on 5/15/24 at 7:30 a.m. of the Spruce Unit Tub Room revealed that the door was open with a container of Super Sani-Cloth Germicidal wipes on top of a portable cart within reach of wandering residents. Interview on 5/15/24 at 7:30 a.m. with Staff I (Licensed Nursing Assistant) confirmed the above finding. Interview on 5/15/24 with Staff D (Director of Nursing) further confirmed the findings and revealed there were 13 wandering residents in the facility. Review on 5/15/24 of the facility's policy titled, Hand Washing, Chemical Use, and PPE [Personal Protective Equipment], revealed: .Any area used for storing chemicals should be locked at all times, including carts and closets . Review on 5/15/24 of the facility's policy titled, Accidents and Supervision, last revised 10/2023, revealed: .The resident environment will remain free of accident hazards as is possible . Review on 5/15/24 of Rapid Multi Surface Disinfectant Cleaner Safety Data Sheet, revealed: .Section 11. Toxicological Information - Potential Health Effects: Eyes: Causes eye irritation .Eye Contact: Redness, Irritation. Review on 5/15/24 of Super Sani-Cloth Germicidal Wipes Data Sheet, last revised 2/18/2019, revealed: .11. Toxicological Information - Inhalation of high concentrations of vapors may cause upper respiratory tract irritation, headache and dizziness. May be harmful if inhaled .Eye Contact - This product is expected to cause moderate irritation to eyes based on test data .May cause redness, itching, and pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure medications were stored under proper temperature controls in 1 of 1 medication room observed and failed to ensure that open injectable medications were labeled in accordance with the manufacturer's instructions in 1 of 2 medication carts observed. Findings include: Birch Unit Medication Room: Review on 5/13/24 at approximately 9:30 a.m. of the Birch Unit Temperature Log for Medication/Vaccine Refrigerators, revealed missing temperatures on the following dates: 3/23/24, 3/24/24, 4/16/24, 4/17/24, 4/18/24, 4/19/24, 4/20/24, 4/21/24, 4/24/24, 4/25/24, 4/29/24, 4/30/24, 5/1/24, 5/2/24, 5/3/24, 5/4/24, and 5/5/24. Observation on 5/13/24 at approximately 9:30 a.m. with Staff F (Licensed Practical Nurse) of the Birch Unit Medication Room revealed the refrigerator temperature was 50 degrees Fahrenheit (F), and contained 3 boxes of Sanofi High-Dose Influenza Vaccinations, 9 unopened Insulin Flex Touch Pens (2 Novolog, 4 Basaglar, and 3 Tresiba) and 1 open vial of Purified Protein Derivative (PPD). Interview on 5/13/24 at approximately 9:30 a.m. at the time of the observation with Staff F confirmed the above finding. Review on 5/15/24 of the facility's policy titled, Medication Storage in the Facility, with an effective date of 5/2018, revealed: .Medications requiring refrigeration are kept in a refrigerator at temperatures between 2 degrees C [Celsius] (36 degrees F) and 8 degrees C (46 degrees F) with a thermometer to allow temperature monitoring .The Facility should maintain a temperature log in the storage area to record temperatures at least once a day .The Facility should check the refrigerator or freezer in which vaccines are stored, at least two times a day, per CDC Guidelines. Review on 5/15/24 of Sanofi Influenza manufacture instructions (https://www.sanofiflu.com/fluzone-quadrivalent-influenza-vaccine/), dated 2024, revealed: Store all Fluzone Quadrivalent presentations refrigerated at 2° [degrees] to 8°C (35° to 46°F). Review on 5/15/24 of Novolog manufacture instructions (https://www.mynovoinsulin.com/insulin-products/novolog/taking-novolog.html), revealed: Store unused NovoLog® pens and vials in refrigerator at 36°F to 46°F until expiration. Review on 5/15/24 of PPD solution manufacture instructions (https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fglobaltb.njms.[NAME].edu%2Fdownloads%2Fproducts%2FMantoux_Appendices%2Ftbmantouxapp03.doc&wdOrigin=BROWSELINK) revealed: Purified protein derivative (PPD) solution must be kept refrigerated at 36-46° F. Pine Unit Medication Cart: Observation on 5/13/24 at approximately 10:00 a.m. with Staff H (Licensed Practical Nurse) of the Pine Unit (Nancy's Way) Medication Cart revealed an open Lispro Insulin Pen and Lantus Insulin Pen without an open or open expiration date. Further observation revealed 1 open vial of Lispro Insulin that had an open date of 3/22/24 and an expiration date of 4/22/24 (beyond 28 days). Interview on 5/13/24 at approximately 10:00 a.m. with Staff H confirmed the above finding. Review on 5/15/24 of the Lantus Insulin Pen manufacturer's instructions revealed: After 28 days, throw your opened Lantus pen away - even if it still has insulin in it. Review on 5/15/24 of Humalog/Insulin Lispro Injection manufacturer specifications revealed: .Storage and Handling .In-use HUMALOG vials, cartridges, pens, and HUMALOG KwikPen .must be used within 28 days or be discarded, even if they still contain HUMALOG . Review on 5/15/24 of the facility's policy titled, Medication Storage in the Facility, with an effective date of 5/2018, revealed: .The nurse shall place a 'date opened' sticker on the medication and enter the date opened and the new date of expiration .The expiration date of the vial or container will be [30] days unless the manufacturer recommends another date .

Based on observation, interview, and policy review, it was determined that the facility failed to ensure that dietary staff washed their hands before handling clean and sanitized utensils during dishwashing procedures. Findings include: Standard: Review on 5/14/24 of the FDA 2017 Food Code, retrieved from: (https://www.fda.gov/media/110822/download), revealed .2-3 PERSONAL CLEANLINESS .2-301.11 Clean Condition. FOOD EMPLOYEES shall keep their hands and exposed portions of their arms clean .2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: .(E) After handling soiled EQUIPMENT or UTENSILS; . Observation on 5/14/24 at approximately 8:45 a.m. in the kitchen dishwashing area revealed that Staff K (Dietary Aide) was stacking plate warmers, bowls and plates onto racks, then rinsing the food debris off the plates and bowls with ungloved hands prior to sanitizing them through the high temperature dish machine. Staff K then wiped their hands with a paper towel and did not perform hand hygiene before removing clean and sanitized plate warmers, bowls and plates from the dish machine, and handling meal trays for storage and handling utensils to air dry. Interview on 5/14/24 at approximately 8:45 a.m. with Staff K confirmed the above observation. Review on 5/14/24 of the facility's policy titled, Cleaning Dishes/Dish Machine, with no date, revealed: .The person loading dirty dishes will not handle the clean dishes unless they changed into clean apron and wash hands thoroughly before moving from dirty to clean dishes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident # 212 Observation on 5/13/24 at approximately 1:49 p.m. of Resident #212's room revealed a contact precautions sign on the door and PPE outside of the door in the hallway. Interview on 5/14/24 at approximately 12:04 p.m. with Staff B (Licensed Practical Nurse (LPN), who was identified as Resident #212's nurse, revealed that he/she did not know why Resident #212 was on contact precautions. Interview on 5/14/24 at approximately 12:08 p.m. with Staff G (LPN) revealed that he/she did not know why Resident #212 was on contact precautions. Interview on 5/14/24 at approximately 12:15 p.m. with Staff D (Director of Nursing) revealed that Resident #212 had a diagnosis of viral herpes on admission and confirmed Resident #212 should be on contact precautions. Interview on 5/14/24 at approximately 1:00 p.m. with Staff M (Advanced Practice Nurse Practioner) confirmed that Resident #212 was treated at the hospital for viral herpes, and that Staff M assessed Resident #212 on 5/14/24 and confirmed that Resident #212 had viral herpes. Staff M further confirmed that he/she follows the facility's infection preventionists recommendations for precautions, and placed Resident #212 on contact precautions. Observation on 5/14/24 at approximately 10:40 a.m. at the [NAME] Way Unit revealed that Staff B was carrying a medicine cup with medications and fluids and entered Resident #212's room without donning PPE. Further observation revealed that Resident #212's room had a contact precaution sign outside the door. Staff B was administering medications to Resident #212. Interview on 5/14/24 at approximately 10:40 a.m. with Staff B confirmed the above findings. Staff B stated that he/she would don PPE only when performing Resident #212's wound treatment and/or caring for Resident #212's catheter. Staff B did not know the reason for Resident #212 being on contact precautions. Staff B also stated that when residents are on contact precautions he/she would don gown, gloves and goggles before entering a resident room. Review on 5/14/24 of the facility policy titled Isolation Precautions, revised on 4/2024, revealed: Policy Explanation and Compliance Guidelines: 2. Facility staff will apply Transmission Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission .8. Information regarding the particular type of precaution to be utilized will be communicated through verbal reports, written in-house communication forms, and signage .9. For questions related to what precautions to take for a particular resident, refer to the resident's nurse. Review on 5/16/24 of Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs) on the CDC website, found at https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html updated 7/12/22, revealed: .Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing [11-15]. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs [3,5,6]. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization . Based on record review, observation, interview, and policy review, it was determined that the facility failed to follow Center For Disease Control (CDC) guidance for wearing Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) and Transmission Based Precautions (TBP) for 2 of 7 residents reviewed for infection control (Resident Identifiers are #25 and #212). Findings Include: Resident #25 Review on 5/14/24 of Resident #25's medical record revealed they received medication Intravenously (IV) and had a wound. Observation on 5/14/24 at approximately 8:30 a.m. of Resident #25 revealed an EBP sign on the door and PPE available outside of the resident's room. Further observation of Staff J (Registered Nurse) revealed while administering IV medications, they did not don a gown. Interview on 5/14/24 at approximately 8:30 a.m. with Staff J confirmed the above finding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, it was determined that the facility failed to fully assess a resident's complaint of left leg pain after falling for 1 of 2 residents reviewed for falls (Resident identifier is #51) and failed to obtain physician's orders for wound care for 1 of 1 resident reviewed for skin conditions (Resident Identifier is #44) in a final sample of 21 residents. Findings include: Resident #51 Journal of Nursing; AJN, November 2007 Vol. 107, No. 11. Retrieved from https://www.nursingcenter.com/pdfjournal?AID=751198&an=00000446-200711000-00030&Journal_ID=54030&Issue_ID=751137 on 10/30/20: When a Fall Occurs Step one: assessment. When a patient falls, don't assume that no injury has occurred - this can be a devastating mistake. Before moving the patient .Observe the leg rotation, and look for hip pain, shortening of the extremity, and pelvic or spinal pain. From Merck Manual Consumer Version, Hip Fractures by [NAME], MD, University of San Francisco - Fresno last modified [DATE]. Retrieved from https://www.merckmanuals.com/home/injuries-and-poisoning/fractures/hip-fractures?query=hip%20fracture on 10/30/20: Hip fractures usually occur in older people and often result from minor falls, particularly in people with osteoporosis .Hip fractures are usually very painful and usually cause pain in the groin .However, if the broken pieces have been jammed together and the fracture is small, people can sometimes walk and may have only mild pain, and the leg appears normal .Sometimes when the hip is broken, pain seems to come from the knee instead of the hip. It feels that way because the knee and the hip share part of the same nerve pathways. Such pain is called referred pain. Review on 3/16/23 of Resident #51's medical diagnosis list revealed diagnosis of age related osteoporosis with current pathological fracture of right femur, and dementia. Review on 3/16/23 of Resident #51's resident progress notes dated 3/8/23 at 3:52 a.m. and signed by Staff A (Licensed Practical Nurse) revealed Resident noted to be on bathroom floor on his/her left side verbalizing pain and discomfort .Poor ROM [Range of Motion] to left knee and hip .[pronoun omitted] voiced knee, leg, hip and arm all on left side are painful . Review on 3/16 of Resident #51's resident progress notes dated 3/8/23 at 8:52 a.m. and signed by Staff M (Licensed Practical Nurse) revealed Resident #44 was admitted to hospital, status post fall with hip fracture. Interview on 3/21/23 with Staff A, who was present at time of fall, confirmed that Resident #51 was complaining of pain on his/her left side and was lifted into bed with a hoyer lift. Interview on 3/21/23 with Staff N (Registered Nurse), who was present at time of fall, confirmed that Resident #51 was complaining of pain on his/her left side and was lifted into bed with a hoyer lift. Resident #44 Review on 3/15/23 of Resident #44's resident progress notes dated 2/17/23 at 11:26 a.m. signed by Staff J (Licensed Practical Nurse) revealed that Resident #44 was observed to have a skin tear. Resident stated It's been there a few days. Staff J then documented . UM [Unit Manager] notified of wound. Clean dry dressing applied. Interview on 3/16/23 with Staff G (Registered Nurse / Unit Manager) stated that a protective dressing was placed on Resident #44's left lower leg for about 4 days. Staff G confirmed that there was no physician's order obtained for the dressing. Interview on 3/16/23 with Staff B (Director of Nursing) confirmed that when a resident has a skin injury/tear it is Staff B's expectation that the physician is notified and an order obtained for wound care.

Based on interview and record review it was determined the facility failed to ensure that pain management was provided to a resident who requested pain medication based on physician's orders for 1 of 2 residents reviewed for pain management in a final sample size of 21 residents (Resident Identifier #49). Findings include: Interview on 3/15/23 at 11:48 a.m. with Resident #49 revealed that he/she had not received his/her Tylenol with Codeine for a few days when they had asked for it earlier in the week. Resident #49 stated that the facility had run out of his/her medication. Resident #49 stated he/she used Tylenol with Codeine on an as needed basis. Review on 3/17/23 of Resident #49's Tylenol with Codeine Narcotic Sheet revealed that on 3/11/23 at 8:00 p.m. the narcotic count for the medication was at 0. Further review revealed on 3/15/23 at 7:45 a.m. 60 tablets were added to the narcotic count. Observation and interview on 3/17/23 at 3:30 p.m. with Staff O (Licensed Practical Nurse (LPN)) of the facility's emergency medication kit revealed that it did not contain Tylenol with Codeine. Staff O confirmed that Tylenol with Codeine was not available to Resident #49 from 3/11/23 to 3/15/23. Review on 3/17/23 of Resident #49's March 2023 Medication Administration Record (MAR) revealed the following physician's order: Acetaminophen with Codeine 300-30 milligrams [mg] give 2 tablets by mouth every 6 hours as needed for pain management. Further review revealed that Resident #49 had received this medication on 3/3/23, 3/4/23, 3/5/23, 3/9/23 and 3/16/23. Continued review of Resident #49's March 2023 MAR revealed that between 3/11/23 and 3/15/23 Tylenol 650 mg were administered on the following dates for pain; 3/13/23 at 5:20 p.m. for a pain level of 7 and at 11:38 p.m. for a pain level of 4; 3/14/23 at 5:42 p.m. for a pain level of 7. Tylenol with Codeine was not available during the above medication administrations. Interview on 3/17/23 at 9:16 a.m. with Staff M (LPN) confirmed that Resident #49 had run out of the Tylenol with Codeine during the above timeframe. Review on 3/17/23 of Resident #49's Tylenol with Codeine tablet blister pack revealed that 60 tablets were dispensed by the pharmacy on 3/14/23. Additionally, the pharmacy received the refill order on 3/13/23. Interview on 3/17/23 at 11:08 a.m. with Resident #49 revealed that he/she had been told by the nursing staff that the Tylenol with Codeine was not available during the above timeframes and was offered Tylenol instead. Resident #49 stated the Tylenol was not as effective as the Tylenol with Codeine. Resident #49 stated he/she did not use the Tylenol with Codeine a lot, but it was more effective for his/her pain. Interview on 3/17/23 at 11:32 p.m. with Staff B (Director of Nursing) confirmed that Resident #49's medication prescription was sent to the pharmacy on 3/13/23 and that Resident #49 was without the medication during the above timeframe. Review on 3/20/23 of the facility's policy titled Pain Management revised on 10/22 revealed, .The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered plan of care, and the residents' goals and preferences . Pain Management and Treatment: 1. Based on the evaluation, the facility in collaboration with the attending physician/prescriber . and the resident . will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain . 7. Pharmacological interventions will follow a systematic approach for selecting medications and doses to treat pain .

Based on interview and record review, it was determined that the facility failed to ensure that as needed (PRN) orders for psychotropic medications were limited to 14 days, except if the attending physician believed that it was appropriate for the PRN order to be extended beyond 14 days he/she would document their rational and indicate the duration for the PRN order, for 2 of 5 residents reviewed for psychotropic medication side effects in a final sample of 21 residents (Resident Identifiers are #27 and #47). Findings include: Resident #47 Review on 3/17/23 of Resident #47's active physician's order revealed an order for Olanzapine [antipsychotic] 5 milligram [mg], give 1 tablet every 6 hours as needed for agitation with a start date of 9/29/22, no duration or end date. Interview on 3/17/23 at approximately 2:40 p.m. with Staff L (Licensed Practical Nurse) confirmed the above findings. Review on 3/20/23 of Resident #47's provider notes and psychiatry consult notes revealed no documentation of duration or end date of the PRN Olanzapine 5 mg order and no documentation of rationale for extending the PRN Olanzapine order for more than 14 days. Interview on 3/20/23 at approximately 10:00 a.m. with Staff G (Unit Manager) confirmed there was no duration or end date for Resident #47's Olanzapine 5 mg PRN order and no documentation of rationale for extending the PRN Olanzapine order for more than 14 days. Staff G stated that PRN orders for psychotropic medications should have a duration of 14 days unless the provider documents a rational to indicate the PRN order beyond 14 days. Review on 3/20/23 of the facility's policy titled Use of Psychotropic Medication, dated 7/21, revised 10/22 revealed, .9. PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. [example] 14 days). a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order.Resident #27 Review on 3/17/23 of Resident #27's medical diagnosis list revealed that Resident #27 has diagnosis of bipolar depression, major depressive disorder, drug induced subacute dyskinesia, and post-traumatic stress disorder. Review on 3/17/23 of Resident #27's Medication Administration Record revealed an order for Clonazepam tablet 0.5 mg, give 0.25 mg by mouth every 24 hours as needed for anxiety with a start date of 11/19/22. Further review of Resident #27's medical record revealed that there has been no stop date for the medication since it was ordered on 11/19/22. Interview on 3/20/23 with Staff G (Unit Manager) who confirmed that Resident #27's as needed order for Clonazepam had not been limited to 14 days since it was started on 11/19/22.

Based on observation, interview, and policy review it was determined that the facility failed to label, date, and store food in accordance to professional standards, maintain a sanitary environment, and ensure that the ice machine was properly cleaned for food service safety in 2 out of 2 kitchenettes (Birch and Country/Spruce) observed. Findings include: Birch Kitchenette: Observation on 3/15/23 at 10:20 a.m. revealed that the floor was sticky, had crumbs, and built up dirt in the corners by the base of the cabinets. Observation on 3/15/23 at 10:21 a.m. revealed a counter top ice machine with what appeared to be white water stains down the front and dripping water from a white plastic straw into a collection tray filled with murky, stagnant water to the top of the collection tray. Observation further revealed a pink stained substance collecting around the base of the white straw on the ice dispenser. Observation on 3/15/23 at 10:22 a.m. revealed a purple sticky substance on the bottom shelf of a kitchen cabinet containing condiments. Observation on 3/15/23 at 10:25 a.m. of the refrigerator revealed a brown liquid stains on the shelves, food crumbs in the produce drawers, dried food, and red and brown liquid stains on the door shelves. Interview on 3/15/23 at 10:30 a.m. with Staff G (Unit Manager) confirmed the above condition of the floors, kitchen cabinet, ice machine and refrigerator. Staff G states that it is the responsibility of the kitchen staff to clean the contents within the refrigerator and housekeeping staff to clean the kitchenette surfaces. Review on 3/15/23 of the facility's refrigerator temperature logs for the Birch refrigerator from 3/1/23 to 3/15/23 revealed refrigerator temperatures were not recorded for 3/1, 3/3, 3/4, 3/5, and 3/9. Country/Spruce Kitchenette: Observation on 3/15/23 at 10:45 a.m. of the refrigerator revealed the following: A sticky substance with dried crumbs on the shelves; Two (2) individual containers of egg salad with a use by date of 3/11/23; Three (3) individual containers of syrup with no use by date; One (1) plate of chocolate cake, exposed with no use by date; Two (2) blue plastic coffee cups with a dark liquid with no lids. Interview on 3/15/23 at approximately 11:10 p.m. with Staff M (Licensed Practical Nurse) confirmed the above findings. Review on 3/15/23 of the facility's refrigerator temperature logs for Country/Spruce refrigerator from 3/1/23 to 3/15/23 revealed refrigerator temperatures were not recorded for 3/1, 3/3, 3/4, 3/5, 3/9. Observation on 3/16/23 at 1:50 p.m. of the counter top ice machine revealed a green and brown substance built up around the sides of the internal ice shoot. Interview on 3/16/23 at 1:55 p.m. with a service man from [company name omitted] confirmed the green and brown substance inside the internal ice shoot of the ice machine. Review on 3/16/23 of the facility's policy titled, Food: Safe Handling for Foods from Visitors, revised July 2019, revealed Procedures . 5. Refrigerator/freezers for storage of food brought in by visitors . Have temperatures monitored daily for refrigeration . Daily monitoring for refrigerate storage duration and discard any foods . Review on 3/16/23 of the facility's policy titled, Sanitation Inspection, revealed Policy Interpretation and Compliance: 1. All food services areas shall be kept clean, sanitary, free from litter . 2. The dietician, dietary manager and others that are designated by the administrator will conduct inspections . 3. Sanitation inspections will be conducted in the following manner: a: Daily . b. Weekly . 4. Inspections will be conducted but not limited to the following areas: i. Kitchenettes . Review of 3/16/23 of the manufacturer's instructions for the facility's Manitowoc Counter Top Nugget Ice Machine and Dispenser, Section 4: Maintenance revealed .Preventative Maintenance Cleaning Procedure: Perform this procedure as required for your water conditions. Recommended monthly

Based on interview and record review, it was determined the facility failed to notify resident representatives and families of those residing in the facility by 5:00 p.m. the next calendar day following the occurrence of a single confirmed COVID-19 infection for 4 out of 9 days reviewed from 2/7/23 to 2/25/23 when there were newly identified positive COVID-19 antigen tests. Findings include: Review on 3/16/23 of the facility's COVID-19 line list revealed that the facility had positive COVID-19 antigen test results on the following dates: 2/7/23 (1 resident); 2/8/23 (1 staff); 2/9/23 (1 resident); 2/11/23 (1 resident, 2 staff); 2/12/23 (2 residents); 2/15/23 (2 residents); 2/18/23 (1 resident, 2 staff); 2/20/23 (10 residents, 1 staff); 2/23/23 (1 staff). Interview on 3/16/23 at approximately 11:00 a.m. with Staff B (Director of Nursing) revealed that Staff C (Administrator) was the staff responsible for notifying residents, representatives, and families of confirmed or suspected COVID-19 cases in the facility. Staff B stated that email was the primary mechanism used to inform residents, their representatives, and families. Those that did not have email were called directly. Interview on 1/16/23 at approximately 11:00 a.m. with Staff B confirmed that the facility received positive COVID-19 antigen test results on 2/7/23, 2/8/23, 2/9/23, 2/11/23, 2/12/23, 2/15/23, 2/18/23, 2/20/23, and 2/23/23. Review on 1/16/23 of the facility notifications sent from 2/7/23 to 2/27/23 revealed that the facility was unable to provide notifications for the COVID-19 positive antigen test results on 2/8/23, 2/11/23, 2/18/23 and 2/23/23. Interview on 1/16/23 at approximately 1:30 p.m. with Staff B revealed that the facility did not send notifications of COVID-19 positive cases to resident representatives, and families on weekend days (Saturday and Sundays).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure that the residents' call system was functioning as designed or to provide residents with an alternate method to call for staff assistance for 1 resident in a facility census of 59 residents (Resident Identifier is #25). Findings include: Interview on [DATE] at 11:00 a.m. with Resident #25 revealed that the call system in the resident's bathroom was not working since [DATE]. Resident #25 stated he/she told staff but it hasn't been fixed yet. Observation on [DATE] at 11:10 a.m. revealed Resident #25's call system was not sounding at the nurse's station nor was the light blinking above the resident's door to alert staff. Interview on [DATE] with Staff G (Unit Manager) revealed that Staff G was not aware Resident #25's bathroom call system was not working. Interview on [DATE] at 9:31 a.m. with Resident #25 revealed that the call system was still not working. Interview on [DATE] at 9:32 a.m. with Staff H (Licensed Practical Nurse) revealed he/she was not aware that Resident #25s call system was not working. Interview on [DATE] at 9:30 a.m. with Staff I (Maintenance Manager) revealed that he/she was not aware of Resident #25's call system not working in the bathroom. Interview on [DATE] at 9:41 a.m. with Staff B (Director of Nursing) confirmed the call system in Resident #25's bathroom was not working. Staff B stated he/she gave Resident #25 a hand bell as an alternate method to alert staff while in the bathroom. Review of facility policy titled Call Lights: Accessibility and Timely Response , reviewed/revised date 10/22, revealed .8. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied. (Examples include: replace call light, provide a bell or whistle, increase frequency of rounding, ect.) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #24 Review on 3/17/23 of Resident #24's current physician's orders revealed that Resident #24 has an order for the following medications: Seroquel 25 mg give 1 tablet by mouth in the afternoon related to restlessness and agitation with a start date of 1/31/23. Seroquel 25 mg give 2 tablets by mouth one time a day for combative behaviors, intrusive behaviors related to restlessness and agitation with a start date of 2/1/23. Trazadone HCL [Hydrochloric Acid] give 125 mg by mouth at bedtime related to sleep disorder, unspecified with a start date of 1/31/23. Trazadone HCL 25 mg by mouth every night shift for behaviors and wandering. Give at midnight every night with a start date of 5/10/22. Review on 3/17/23 of Resident #24's comprehensive care plan revealed that there was no intervention in place for psychotropic medication use, and no intervention in place to monitor for behavior or side effects from psychotropic medications. Review on 3/20/23 of Resident #24's MDS annual assessment, CAA triggers summary, Section V, dated 2/15/23 revealed that an antipsychotic medication was administered to resident in the last 7 days, coded in section N0410A and that an antidepressant medication was administered to the resident in the last 7 days, coded in section N0410C. Further review of the CAA summary revealed that psychotropic drug use would be addressed in Resident #24's care plan. Interview on 3/20/23 at approximately 12:15 p.m. with Staff O (Registered Nurse) confirmed that there was no were no interventions in place for Resident #27's psychotropic medication use, and no interventions place to monitor for behaviors or side effects from psychotropic medications. Review on 3/20/23 of the facility's policy, titled Use of Psychotropic Medication, dated 7/21, revised 10/22 revealed Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the residents response to the medication(s) Policy Explanation and Compliance Guidelines: .12. The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as: .d. In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care . 13. The resident's response to the medication(s), including progress towards goals and the presence/absence of adverse consequences, shall be documented in the resident's medical record. Review on 3/20/23 of the facility's policy, titled Comprehensive Care plans dated 7/21, revised 10/22 revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the resident's comprehensive assessment. Resident #31 Observation on 3/15/23 at approximately 1:15 p.m. of Resident #31 revealed a urinary catheter drainage bag. Review on 3/17/23 of Resident #31's medical diagnosis list revealed that Resident #31 has a diagnosis of Huntington's disease and Hydronephrosis. Review on 3/17/23 of Resident #31's comprehensive care plan revealed that there were no interventions place for indwelling catheter use, and no interventions in place to monitor risks associated with the use of a catheter. Review on 3/20/23 of Resident #31's MDS quarterly assessment dated [DATE] revealed Section H0100. Appliances, A. Indwelling catheter was coded Yes. Interview on 3/20/23 at approximately 12:20 p.m. with Staff O (Registered Nurse) confirmed that there was no interventions in place for Resident 31's indwelling catheter use, and no interventions in place to monitor risks associated with the use of a catheter. Resident #47 Review on 3/17/23 of Resident #47's current physician's orders revealed that Resident #47 has an order for the following medications: Olanzapine 5 mg give 1 tablet by mouth two times a day for delusional behavior, exit seeking, agitation related to agitation, and restlessness with a start date of 11/23/22. Olanzapine 5 mg give 1 tablet by mouth every 8 hours as needed for agitation with a start date of 9/29/22. Seroquel 25 mg give 1 tablet by mouth one time a day for agitation with delusional behavior related to restlessness and agitation with start date of 11/16/22. Seroquel 25 mg give 1 tablet by mouth in the afternoon for agitation, delusional behaviors related to restlessness, and agitation with a start date of 11/15/22. Seroquel 50 mg give 1 tablet by mouth at bedtime for agitation with start date of 9/29/22. Review on 3/17/23 of Resident #47's comprehensive care plan revealed that there was no interventions in place for psychotropic medication use, and no interventions in place to monitor for behavior or side effects from psychotropic medications. Review on 3/20/23 of Resident #47's MDS annual assessment, CAA triggers summary, Section V dated 9/29/22 revealed that an antipsychotic medication was administered to resident in the last 7 days, coded in section N0410A. Further review of the CAA Summary revealed that psychotropic drug use would be addressed in Resident #47's care plan. Interview on 3/20/23 at approximately 12:20 p.m. with Staff O (Registered Nurse) confirmed that there was no interventions in place for Resident #47's psychotropic medication use, and no interventions in place to monitor for behaviors or side effects from psychotropic medications. Review on 3/20/23 of the facility's policy, titled Use of Psychotropic Medication, dated 7/2021, revised 10/2022 revealed Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the residents response to the medication(s) Policy Explanation and Compliance Guidelines: .12. The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as: .d. In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care 13. The resident's response to the medication(s), including progress towards goals and the presence/absence of adverse consequences, shall be documented in the resident's medical record. Based on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive care plan for 5 of 21 residents reviewed for care plans (Resident Identifiers are #24, #27, #31, #47 and #49). Findings include: Resident #49 Interview on 3/15/23 at 11:48 a.m. with Resident #49 revealed that Resident #49 does have pain and takes pain medication as needed. Review on 3/17/23 of Resident #49 March Medication Administration Record revealed that Resident #49 received Acetaminophen 650 milligrams (mg) for pain on 3/2/23, 3/13/23, 3/14/23 and 3/17/23. Further review revealed that Acetaminophen with Codeine 300-30mg was administered on 3/3/23, 3/4/23, 3/5/23, 3/9/23 and 3/16/23. The resident's pain levels were documented between a 3 and 8 (out of 10 pain scale). Review on 3/20/23 of Resident #49's admission Minimum Data Set (MDS) with an assessment reference date of 3/5/23 revealed that the resident admitted to the facility on [DATE]. Further review under Section J revealed that Resident #49 had occasional pain, received as needed pain medication and the pain limited his/her day to day activities. Further review of Resident #49's MDS Section V revealed that pain was addressed in Resident #49's care plan. This was signed in Section V0200C by Staff K (MDS Coordinator) on 3/6/23. Review on 3/20/23 of Resident #49's comprehensive care plan revealed that there were no interventions that addressed pain. Interview on 3/20/23 at 11:47 a.m. with Staff K confirmed that pain should have been addressed in Resident #49's care plan and was not. Review on 3/21/23 of Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual dated October 2019 page V-9 retrieved from https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_October_2019.pdf revealed, .V0200C2, Date - The date on which a staff member completes the Care Planning Decision column (V0200A, Column B), which is done after the care plan is completed. The care plan must be completed within 7 days of the completion of the comprehensive assessment (MDS and CAAs [Care Area Assessments]), as indicated by the date in V0200B2 . Resident #27 Review on 3/17/23 of Resident #27's medical diagnosis list revealed that Resident #27 has diagnosis of bipolar depression, major depressive disorder, drug induced subacute dyskinesia, and post-traumatic stress disorder. Review on 3/17/23 of Resident #27's current physician's orders revealed that Resident #27 has orders for the following medications: Olanzapine tablet 10 mg give 1 tablet by mouth at bedtime related to bipolar disorder, give with 2.5 mg tablet for total dose of 12.5 mg with a start date of 10/19/21. Ritalin LA [long acting] capsule extended release 24 hour 10 mg, give 2 capsules by mouth in the morning for depression, bipolar disorder with a start date of 8/2/22. Citalopram hydrobromide tablet 40 mg, give 40 mg by mouth one time a day for depression with a start date of 5/10/22. Clonazepam tablet 0.5 mg, give one tablet by mouth with meals for anxiety, give 1/2 tablet for TD [tardive dyskinesia] of 0.25 mg 3 times a day with a start date of 11/15/22. Bupropion tablet extended release 24 hour 150 mg, give 1 tablet by mouth one time a day for depression with a start date of 8/5/21. Review on 3/17/23 of Resident #27's comprehensive care plan revealed that there was no interventions in place for psychotropic medication use, and no interventions in place to monitor for behaviors or side effects from psychotropic medications. Interview on 3/20/23 with Staff G (Registered Nurse / Unit Manager) who confirmed that there was no interventions in place for Resident #27's psychotropic medication use, and no interventions in place to monitor for behaviors or side effects from psychotropic medications. Further interview with Staff G revealed that the staff do not document for behavioral side effects of psychotropic medications, and that Abnormal Involuntary Movement Scale (AIMS) assessments are completed quarterly.

Based on observation, interview, and policy review, it was determined that the facility failed to follow professional standards for labeling and storage of food items brought to residents by visitors to the facility for 2 of 2 kitchenettes reviewed. Findings include: Birch Kitchenette: Observation on 3/15/23 at 10:25 a.m. of the refrigerator revealed the following: One (1) container of strawberries with no resident name or received date; One (1) container of chocolate dip with a best by date of 10/3/22 with no resident name or received date; One (1) bottle of prune juice with no resident name or received date; Interview on 3/15/23 at 10:30 a.m. with Staff G (Unit Manager) confirmed the above. Country/Spruce Kitchenette: Observation on 3/15/23 at 10:45 a.m. of the refrigerator revealed the following: One (1) jar of maraschino cherries with no resident name or received by date; One (1) bottle of fat free balsamic vinaigrette with no resident name; One (1) bottle of Thousand Island dressing with no resident name; One (1) plastic bag filled with raisin bread with a use by date of 2/10/23, an Oikos yogurt and k-cup coffee pod with no resident name and no received by date; One (1) plastic bag with one (1) container with an unknown substance, one (1) container with an unknown substance, two (2) oranges, one (1) soft nectarine with brown spots, with no resident name and no received by date; One (1) container with a brown meat substance with no resident name and no received by date; One (1) styrofoam cup partly filled with a brown liquid with no resident name and no received by date; One (1) container of cream cheese with no resident name. Observation on 3/15/23 at approximately 11:00 a.m. of the freezer revealed the following: One (1) breakfast wrap with no resident name and no received by date; One (1) frozen cheesy bowl with a use by date of 10/22 with no resident name and no received by date. Observation on 3/15/23 at approximately 11:05 a.m. of the kitchen cabinets revealed the following: One (1) can of diced beets with no resident name and expired date of 12/20; One (1) can of apple sauce with an expired date of 9/25/2015; Two (2) styrofoam cups with liquid. Interview on 3/15/23 at approximately 11:10 p.m. with Staff M (Licensed Practical Nurse) confirmed the above findings. Staff M stated that the expectation is for the Licensed Nursing Assistants to label food brought from the outside with the residents name and the received date. Review on 3/16/23 of the facility's policy titled, Food: Safe Handling for Foods from Visitors, revised July 2019, revealed Procedures . 4. When food items are intended for later consumption . Label foods with the resident name and the current date . 5. Refrigerator/freezers for storage of food brought in by visitors . Have temperatures monitored daily for refrigeration . Daily monitoring for refrigerate storage duration and discard any foods .