**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff and resident interviews, the facility failed to protect a resident's right to be free from verbal and physical abuse when Family Member #1 pulled Resident #50 by her hair back into her room, which resulted in no physical harm to Resident #50. In addition, Family Member #1 raised her hand and stated to Resident #50 I will slap you out of the chair, this resulted in restricted visitation for the Family Member of Resident #50. This affected 1 of 3 residents reviewed for abuse (Resident #50). Findings included:Resident #50 was admitted to the facility on [DATE] with the diagnoses of chronic obstructive pulmonary disease (a lung disease that makes it hard to breathe), and Parkinson's disease (a movement disorder that affects the nervous system and worsens over time).The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 was cognitively intact and had no behaviors or rejection of care.Review of the initial allegation report submitted to the State Agency (SA), on 9/10/2025 by the facility for abuse, indicated that Family Member #1 visited Resident #50. Resident #50 and Family Member #1 became verbally aggressive towards each other. Family Member #1 pulled Resident #50, who was sitting in a wheelchair, back into her room by grabbing Resident #50 by the hair. Resident #50 reported to the facility she and Family Member #1 had fought all their lives. The facility investigation report stated Resident #50 had no physical or mental harm. In addition, the facility reported the incident to local law enforcement.A review of Resident #50 skin assessment dated [DATE] revealed no new areas of concern.An interview was conducted with Nursing Assistant (NA) #1 on 09/11/25 at 3:25 PM. NA #1 stated on 9/10/25 Resident #50 was sitting in her wheelchair in her doorway, and Family Member #1 was in the room. NA #1 approached and asked Resident #50 if she wanted to take a shower. Resident #50 declined the shower. Family Member #1 said Resident #50 took a shower once a month, followed by profanity directed at Resident #50. NA #1 stated Resident #50 argued and used profanity toward her Family Member #1 then Family Member #1 grabbed and pulled Resident #50 by the hair, moving her in her wheelchair from the doorway back into her room. NA #1 did not state the distance Resident #50 was pulled. Resident #50 and Family Member #1 were separated by about 5 feet by NA #1. NA #1 stated Resident #50 and Family Member #1 had bickered in the facility in the past, but this was the first time she had witnessed it escalate into a physical altercation. NA #1 called NA #2 for assistance. NA #1 went to report the incident to the Director of Nursing (DON). An interview was conducted with NA #2 on 9/11/25 at 3:16PM. NA #2 stated when she arrived at the room, Resident #50 and Family Member #1 were about five feet apart and still engaged in an argument. NA #2 remained with Resident #50 and Family Member #1 while NA #1 went to report the incident to the DON. NA #2 revealed that Family Member #1 raised her hand and stated to Resident #50 I will slap you out of the chair. Resident #50 told Family Member #1 to leave, which Family Member #1 responded that she would never step foot in the building again and exited the facility. An interview and observation were conducted with Resident #50 on 9/11/25 at 4:09PM which revealed Resident #50 had grey, wavy hair with the top half of her hair pulled back into a ponytail. Resident #50's ponytail was approximately 3 to 5 inches in length. Resident #50 recalled Family Member #1 had yelled at her throughout their relationship. Family Member #1 was angry that the closet was not organized and had dirty clothes. Resident #50 listened from the doorway of her room while Family Member #1 yelled and everyone on the hall heard. NA #1 was talking to her and that was when Family Member #1 pulled her by her ponytail, moving her in her wheelchair from the doorway back into her room. Resident #50 denied any injury. Resident #50 stated it did not hurt having her ponytail pulled but rather made her angry towards Family Member #1. Resident #50 told Family Member #1 to leave, which she did. Resident #50 stated Family Member #1 left within 15 minutes of her arrival at the facility. Resident #50 stated she spoke with a Law Enforcement Officer and declined to press charges.On 9/11/25 at 5:04PM an attempt to interview Family Member #1 via telephone call was unsuccessful. There was no option for a voice mail. On 9/11/25 at 3:56PM an interview conducted with Assistant Director of Nursing (ADON) revealed after the incident a skin assessment was conducted of Resident #50's scalp. She stated Resident #50 denied injuries or pain. An interview on 09/11/2025 at 3:53PM with the Social Worker (SW) revealed Resident #50 informed the SW that Resident #50 declined to see the physician or mental health services for the incident and requested that Family Member #1 not return for the time being. She did not want Family Member #1 banned from the facility. During an interview with the DON on 9/11/25 at 3:37PM, the DON revealed NA #1 reported the incident to her and went out on the hall and confirmed that Family Member #1 had left the facility. She interviewed Resident #50 who stated Family Member #1 had pulled her hair and that she was not injured. The DON revealed that Family Member #1 was allowed to return with supervised visits, but stated Family Member #1 had not answered her phone or responded to text messages since the incident. She indicated that law enforcement did not file a report. An attempt to telephone law enforcement on 9/11/25 at 5:16PM was unsuccessful.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident and staff interviews, the facility failed to implement a pressure-relieving chair cushion for 1 of 4 resident reviewed for pressure ulcers (Resident #30). This resulted in Resident #30 experiencing discomfort while up in her wheelchair and prevented her from remaining in her wheelchair for social activities. The findings included:Resident #30 was admitted on [DATE] with diagnoses including pressure ulcers, diabetes, heart failure, and debility.Review of the physician orders dated 7/9/2025 indicated a gel cushion to wheelchair for pressure reduction and to check placement daily. The Minimum Data Set (MDS) comprehensive assessment dated [DATE], revealed Resident #30 was cognitively intact. The initial assessment indicated one Stage II pressure ulcer, one Stage III pressure ulcer, and one unstageable, deep tissue injury. Resident #30 was at risk for developing pressure ulcers and a pressure reducing device was provided in the chair. Record review of the initial care plan dated 7/28/2025 with a revision on 9/10/2025, revealed a current stage III pressure ulcer to the left buttock and the intervention to aid in healing was to provide a gel cushion to wheelchair for pressure reduction. Review of the Kardex (a resident care guide for the Nursing Assistants) indicated to provide a gel cushion to chair. Resident #30's Treatment Administration Record (TAR) for 9/2025 indicated gel cushion to wheelchair had been checked daily by the Wound Care Nurse on September 8th, 9th 10th. An interview and observation were conducted on 9/08/2025 at 11:28 AM with Resident #30 while she was sitting in a wheelchair in her room. She indicated there was a sore on her bottom and it hurt when sitting up for a while. She stated that her bottom was hurting because she had been up for an hour. Resident #30 stated she tried turning on her side in bed when uncomfortable but asked for pain medication when it gets bad. She further stated the cushion behind her legs on the wheelchair was comfortable. When asked if she had a pad or cushion for her wheelchair seat, she stated she thought she did but wasn't sure. No wheelchair cushion was observed in the chair or in the room. An interview and observation were conducted on 09/09/2025 at 9:24 AM with Resident #30 while she was lying in bed. Resident #30 stated she liked to get up for activities several days a week. She explained she can't walk and had been using a wheelchair for a long time. Resident #30 indicated it was painful to sit up too long in chair. No cushion was observed in the wheelchair or anywhere in the room. An observation on 09/09/2025 at 10:49 AM revealed Resident #30 sitting up in wheelchair in activities room attending church service. No cushion was observed in the wheelchair. A follow up observation and interview was done on 09/09/2025 at 11:47 AM. Resident #30 was observed back in bed. She stated she had wanted to stay up longer but her bottom hurt too much and replied that her pain level was 5 out of 10 (5 is moderate pain on a scale of 1 being minimal pain to 10 being great pain). No cushion was observed in the wheelchair. An observation of the activity calendar on the wall in the hall revealed bingo was scheduled as the activity at 2:00PM on 09/09/2025. During an interview on 09/09/2025 at 4:28 PM Resident #30 stated she didn't stay up after bingo this afternoon because her bottom was hurting from sitting in the wheelchair. Resident #30 stated she doesn't remember if she had a wheelchair cushion and didn't think to ask for one. No cushion was observed in the wheelchair. An observation and interview were conducted on 09/10/2025 at 10:09 AM with the Wound Care Nurse (WCN) during which she looked at Resident #30's wheelchair and stated the cushion was not in the chair. She indicated she had signed off on the TAR that the cushion was in the chair on September 8th, 9th and 10th. She explained that the person who signed off on the TAR that the cushion was in the chair was validating it was present, and she must not have checked to confirm if the cushion was present. She further stated that she didn't specifically remember seeing the cushion recently in the chair. She explained that when checking the chair, if the cushion wasn't there, she would replace it. An interview with Nurse Aide (NA) #4 on 09/10/2025 at 10:20 AM revealed she remembered Resident #30 having a cushion in the wheelchair but didn't recall when she had last seen it. She further explained that cushions were normally left in the chair. The cushions were replaced when a soiled cushion was sent to laundry. The Kardex provided information that there was a cushion in Resident #30's wheelchair. During an interview on 09/10/2025 at 11:17 with NA #11, she stated she did remember seeing a wide black cushion in Resident #30's wheelchair recently but wasn't sure the exact day. She revealed Resident #30's Kardex had the wheelchair cushion listed. If the cushion wasn't in the chair she would check with the nurse and retrieve one from the supply room. During an interview with on 09/11/2025 at 11:19 AM, the Director of Nursing (DON) stated that it was standard practice that everyone with a wheelchair got a cushion and that this was part of the admission. Three types of cushions were available from the supply room, and it was nursing judgement as to which type was used. The DON remarked that staff have been in-serviced to document on the TAR after it was validated that treatment interventions were present. She also explained that when an NA recognized a cushion was missing, they should let the nurse know and replace it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to develop a baseline care plan that addressed a resident's weight-bearing status and the use of a sling to the right upper extremity for 1 of 1 resident (Resident #47) reviewed for baseline care plan. The findings included: Resident #47 was admitted to the facility on [DATE] with a diagnosis of a right distal clavicle (collarbone) fracture (break). A review of a baseline care plan dated 7/30/2024 revealed Resident #47 had a fracture and staff were to follow rehabilitation orders and/or recommendations. A review of a physician's order dated 7/30/2024 revealed Resident #47 was to always wear sling on his right upper extremity and was non-weightbearing to his right upper extremity. An interview was conducted on 8/6/2024 at 10:05 am with the Care Plan Nurse. The Care Plan Nurse stated a baseline care plan was completed when a resident was admitted to the facility. The Care Plan Nurse stated it was the responsibility of the hall nurse who admitted the resident to complete the baseline care plan. The Care Plan Nurse stated Resident #47 was ordered to always wear a sling to his right upper extremity and was non-weightbearing to his right upper extremity. The Care Plan Nurse verified the sling and weight-bearing status were not on his baseline care plan and should have been. The Care Plan Nurse stated she was not sure why the sling and weight-bearing status were not included because she was not the person who completed the baseline care plan. An interview was conducted on 8/6/2024 at 11:11 am with Nurse #2. Nurse #2 stated she admitted residents to the facility and completed the admission for Resident #47. Nurse #2 stated Resident #47 was wearing a sling to his right upper extremity when he was admitted to the facility. Nurse #2 stated she knew that he was non-weightbearing to his right upper extremity. Nurse #2 verified the baseline care plan did not include the application of a sling to the right upper extremity and the non-weightbearing status of the right upper extremity. Nurse #2 stated the sling and weight-bearing status should have been included in the baseline care plan but she must have forgotten to write that information in. An interview was conducted on 8/7/2024 at 8:24 am with the Director of Nursing (DON). The DON stated the baseline care plan was completed by the hall nurse when a resident was admitted to the facility. The DON stated the baseline care plan should include information/instructions specific to the resident and their needs. The DON stated she was unaware the sling and weight-bearing status had not been documented on the baseline care plan and it should have been. An interview was conducted on 8/7/2024 at 8:31 am with the Administrator. The Administrator was not aware the sling and weight-bearing status for Resident #47 had not been documented on the baseline care plan and stated it should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews the facility failed to provide fingernail care for a dependent resident for 1 of 4 residents reviewed for activities of daily living (ADL) (Resident #35). The findings included: Resident #35 was admitted to the facility on [DATE] with diagnosis' which included hemiplegia (inability to move one side of the body). A review of a care plan dated 5/13/2024 revealed Resident #35 had impaired mobility related to left-sided hemiplegia with interventions which included for staff to encourage Resident #35 to participate in activities of daily living (ADL) care as able and to assist him as needed. A review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #35 was cognitively intact and was not coded for rejection of care. Resident #35 was coded for impairment on one side of his upper extremities and required moderate assistance with personal hygiene. A review of the Electronic Health Record shower documentation dated 8/3/2024 revealed Resident #35 received a shower from Nurse Aide (NA) #1. An observation was conducted on 8/4/2024 at 9:55 am. Resident #35 was observed to have half-inch long fingernails over the tip of the finger with a brown substance noted under all ten fingernails on both hands. An observation was conducted on 8/5/2024 at 8:18 am. Resident #35 was observed to have half-inch long fingernails over the tip of the finger with a brown substance noted under all ten fingernails on both hands. An interview was conducted on 8/5/2024 at 3:11 pm with Resident #35. Resident #35 stated his fingernails had gotten long and he had asked staff to cut his fingernails but was unable to recall when he asked or who he had asked. Resident #35 stated his fingernails look awful and had been snagging his bedding. An interview was conducted on 8/5/2024 at 3:15 pm with NA #2. NA #2 stated she was assigned Resident #35 and worked second shift (3:00 pm to 11:00 pm). NA #2 stated she was not sure who was responsible for cleaning and cutting fingernails and stated any NA could clean underneath fingernails. NA #2 observed Resident #35's fingernails and agreed that they were long, dirty, and need to be cleaned and cut. NA #2 stated she had not noticed his fingernails and had not offered to cut or clean his fingernails. An interview was conducted on 8/6/2024 at 9:54 am with NA #4. NA #4 stated she worked first shift (7:00 am to 3:00 pm) and was on the shower team. NA #4 stated the shower team was primarily responsible for cleaning and cutting nails. NA #4 stated Resident #35 was scheduled to receive showers on Tuesdays, Thursdays, and Saturdays. NA #4 stated she had given Resident #35 a shower last week and he had refused to have his nails cut, but she reported she cleaned his nails when she gave him a shower. An interview was conducted on 8/6/2024 at 9:01 am with the Charge Nurse. The Charge Nurse stated the shower team was responsible for providing nail care. The Charge Nurse stated that Resident #35 would occasionally refuse to have his fingernails cut. The Charge Nurse was not aware that Resident #35's fingernails were long and dirty. An interview was conducted on 8/6/2024 at 1:48 pm with NA #1. NA #1 stated she worked on second shift (3:00 pm to 11:00 pm) and was assigned Resident #35. NA #1 stated she had not given Resident #35 a shower or performed nail care that day and stated she had documented she had given Resident #35 a shower to get the task to go away. NA #1 stated the shower team was responsible for completing nail care and stated she had not noticed Resident #35's fingernails and reported he had not asked her to cut and clean his fingernails. A follow-up interview was conducted on 8/6/2024 at 10:01 am with the Charge Nurse. The Charge Nurse stated she went and performed fingernail care for Resident #35 and that he had agreed to have his fingernails cut, cleaned, and filed. An interview was conducted on 8/7/2024 at 8:17 am with the Director of Nursing (DON). The DON stated nail care was performed by the shower team on the resident's shower days. The DON stated NAs and Nurses on the hall could perform nail care, but nail care was primarily completed by the shower team. The DON stated she was not aware Resident #35 had long, dirty nails. An interview was conducted on 8/7/2024 at 8:28 am with the Administrator. The Administrator stated he was not aware Resident #35 had long, dirty fingernails but knew that he did not like to have his fingernails cut.

Based on observations, record review and interviews the facility failed to secure an indwelling urinary catheter tubing to prevent tension or trauma for 1 of 3 residents reviewed for urinary catheter (Resident #86). The finding included: Resident #86 was admitted to on 08/02/24 to the facility with diagnoses that included urinary retention. The baseline care plan dated 08/02/24 revealed Resident #86 was alert and oriented to person and to check catheter strap every shift. The admission Minimum Data Set assessment was not yet completed as of 08/07/24. A review of Resident #86's physician orders dated 08/02/24 revealed an order for a urinary catheter to straight drainage due to the diagnosis of urinary retention. There was also an order to check placement of a catheter strap every shift. On 08/04/24 at 9:49 AM an observation was made of Resident #86 lying in bed with an indwelling urinary catheter attached to the left side of the bed frame. When asked the Resident uncovered her left thigh to show there was no stabilizing device present on the catheter tubing to prevent tension or trauma. A review of Resident #86's Treatment Administration Record (TAR) for 08/2024 revealed the catheter strap placement check was initialed off as completed at 2:30 PM on 08/04/24 by Nurse #1. On 08/05/24 at 2:54 PM an observation was made of Resident #86 being toileted by Nurse #4 and Nurse Aide (NA) #5. It was noted that the Resident did not have a stabilizing device in place on the catheter tubing to prevent tension or trauma. An interview was conducted with Nurse #4 and NA #5 on 08/05/24 at 2:54 PM. The staff explained that they both got Resident #86 up out of bed and dressed earlier that morning and did not notice that the Resident did not have a stabilizing device in place for the catheter tubing. Nurse #4 stated it was protocol that they used stabilizing devices on all residents with urinary catheters. During an interview with Nurse #1 on 08/06/24 at 1:58 PM the Nurse confirmed that she initialed the TAR on 08/04/24 to indicate that Resident #86 had a stabilizing device in place. The Nurse explained that when she checked the Resident she was up in her wheelchair and could not positively determine the device was in place but thought it was, so she initialed the TAR to indicate she checked it. Nurse #1 stated she should not have initialed the TAR unless she was sure the device was in place. During an interview with the Director of Nursing (DON) on 08/07/24 at 8:59 AM the DON explained that it was policy that residents who have an indwelling urinary catheter have a stabilizing device in place to prevent tension and trauma.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews the facility failed to post cautionary safety signs that indicated the use of oxygen for 5 of 7 residents reviewed for oxygen use (Resident #47, #30, #48, #19, and #70). The findings included: a. Resident #47 was admitted to the facility on [DATE] with a diagnosis of respiratory failure. A physician's order dated 7/30/2024 revealed Resident #47 was ordered to wear 2 liters per minute of oxygen continuously. An observation was conducted on 8/4/2024 at 9:56 am. Resident #47 was observed with his eyes closed in bed and oxygen being administered at a rate of 2 liters per minute via nasal cannula. There was no oxygen signage outside of Resident #47's room or on the doorframe. An interview was conducted on 8/5/2024 at 3:34 pm with Medication Aide (MA) #1. MA #1 stated when a resident was ordered oxygen, there was an order on the Medication Administration Record (MAR). MA #1 stated the nurses let the Nurse Assistants (NAs) know if a resident was ordered oxygen. MA #1 stated the facility staff used to have an indication outside of the room that oxygen was in use but stopped due to the signage being a violation of the resident's privacy. An observation was conducted on 8/5/2024 at 5:00 pm. Resident #47 was observed with his eyes closed in bed and oxygen being administered at a rate of 2 liters per minute via nasal cannula. There was no oxygen signage outside of Resident #47's room or on the doorframe. An observation was conducted on 8/6/2024 at 8:09 am. Resident #47 was observed awake in bed and oxygen was being administered at a rate of 2 liters per minute via nasal cannula. There was no oxygen signage outside of Resident #47's room or on the doorframe. An interview was conducted on 8/6/2024 at 9:04 am with the Charge Nurse. The Charge Nurse stated if a resident was supposed to wear oxygen there was an order in the chart from the physician. The Charge Nurse stated she was unsure if the facility still used oxygen signage outside of resident rooms to indicate that oxygen was in use. An interview was conducted on 8/7/2024 at 8:22 am with the Director of Nursing (DON). The DON stated if a resident was on oxygen, oxygen usage was displayed on the resident's vital signs in the Electronic Health Record (EHR). The DON stated the facility did not use oxygen signage outside of resident rooms because they had been told that was a violation of the resident's privacy. An interview was conducted on 8/7/2024 at 8:33 am with the Administrator. The Administrator stated that in the past, the facility would place a magnet outside of the resident's room if oxygen was in use but had stopped because they were told that was a privacy/dignity issue. d. Resident #30 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), and chronic respiratory failure. Review of Resident #30's most recent quarterly Minimum Data Set assessment dated [DATE] revealed she was cognitively intact. She was coded with having shortness of breath or trouble breathing while lying flat and was coded as utilizing oxygen therapy while admitted to the facility. A review of Resident #30's care plan revealed a care plan area for [Resident #30] has the diagnoses of COPD a d respiratory failure and requires oxygen therapy. Interventions included to administer her oxygen as ordered and ensure that Resident #30's oxygen supply was available as needed. Review of Resident #30's physician orders revealed the following orders: - Check oxygen saturation every shift and record results - may increase oxygen as needed to maintain oxygen saturation at greater than 92%. - Continuous oxygen at 2 liters per minute via a nasal cannula. An observation of Resident #30 completed on 08/04/24 at 10:22 AM revealed resident to be in her wheelchair in her room. Resident was observed with her nasal cannula on her face and was receiving oxygen from her room concentrator at 2 liters per minute. An observation of Resident #30's room and doorway revealed no documented signage indicating the use of oxygen in the room. An additional observation of Resident #30's room and doorway completed on 08/05/24 at 2:55 PM continued to revealed no documented signage that indicated oxygen was in use in the room. An interview with Nurse Aide #6 on 08/05/24 at 3:15 PM revealed she was aware the Resident #30 wore oxygen. She further reported she was unsure if the facility utilized oxygen in use signs and verified that there was not one in Resident #30's room or on her doorway. An interview was conducted on 8/7/2024 at 8:22 am with the Director of Nursing (DON). The DON stated if a resident was on oxygen, oxygen usage was displayed on the resident's vital signs in the Electronic Health Record (EHR). The DON stated the facility did not use oxygen signage outside of resident rooms because they had been told that was a violation of the resident's privacy. An interview was conducted on 8/7/2024 at 8:33 am with the Administrator. The Administrator stated that in the past, the facility would place a magnet outside of the resident's room if oxygen was in use but had stopped because they were told that was a privacy/dignity issue. e. Resident #48 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia. Review of Resident #48's most recent quarterly Minimum Data Set assessment dated [DATE] revealed resident to be moderately impaired. Resident #48 was coded as having shortness of breath with exertion and shortness of breath when lying flat. Resident #48 was coded as receiving oxygen therapy while admitted to the facility. Review of Resident #48's care plan last updated 07/19/24 revealed a care plan for: [Resident #48] has chronic respiratory failure and requires oxygen therapy. Interventions included to administer oxygen as ordered, ensure the [Resident #48's] oxygen supply is available at all times, and oxygen at 2 liters per minute via nasal cannula continuously - check oxygen saturations every shift and record results. Review of Resident #48's physician orders revealed the following order: - Oxygen at 2 liters per minute via nasal cannula continuously - check oxygen saturation every shift and record results, may titrate as needed to maintain oxygen saturation greater than 92%. An observation of Resident #48 completed on 08/04/24 at 12:34 PM revealed resident to be in her room. Resident #48 was observed with her nasal cannula on her face and was receiving oxygen from her room concentrator at 2 liters per minute. An observation of Resident #48's room and doorway revealed no documented signage indicating the use of oxygen in the room. An additional observation of Resident #48's room and doorway completed on 08/05/24 at 2:59 PM continued to revealed no documented signage that indicated oxygen was in use in the room. An interview with Nurse Aide #6 on 08/05/24 at 3:21 PM revealed she was aware the Resident #48 wore oxygen. She further reported she was unsure if the facility utilized oxygen in use signs and verified that there was not one in Resident #48's room or on her doorway. An interview was conducted on 8/7/2024 at 8:22 am with the Director of Nursing (DON). The DON stated if a resident was on oxygen, oxygen usage was displayed on the resident's vital signs in the Electronic Health Record (EHR). The DON stated the facility did not use oxygen signage outside of resident rooms because they had been told that was a violation of the resident's privacy. An interview was conducted on 8/7/2024 at 8:33 am with the Administrator. The Administrator stated that in the past, the facility would place a magnet outside of the resident's room if oxygen was in use but had stopped because they were told that was a privacy/dignity issue. c. Resident #19 was admitted to the facility on [DATE] and had diagnoses that included respiratory failure and hypercapnia (abnormal carbon dioxide levels in the blood). Review of Resident #19's Minimum Data Set, dated [DATE] revealed his cognition was severely impaired and he wore oxygen. A review of Resident #19's physician orders dated 03/22/24 revealed an order for continuous oxygen at 2 liters per minute via nasal cannula. An observation made on 08/04/24 at 10:19 AM revealed Resident #19 was wearing oxygen via nasal cannula, and it was being delivered by an oxygen concentrator. There was no oxygen cautionary sign posted near the Resident's room to indicate that oxygen was in use. Subsequent observations made on 08/05/24 at 11:06 AM and 2:49 PM and on 08/06/24 at 8:30 AM and 9:07 AM revealed Resident #19 wore continuous oxygen via nasal cannula and there were no oxygen cautionary signs posted near the Resident's room. On 08/06/24 at 10:40AM during an interview with the Charge Nurse, she stated that they did not post oxygen signs on the residents' doors anymore because it was a dignity issue. During an interview with the Director of Nursing (DON) on 08/07/24 at 8:22 AM she explained the facility did not utilize the cautionary oxygen signs throughout the facility because the facility was smoke free which included vapes (electronic cigarettes) and were not allowed in the facility. The DON indicated the oxygen cautionary signs were a violation of the residents' privacy. An interview was conducted on 8/7/2024 at 8:33 AM with the Administrator. The Administrator stated the facility was smoke free. The Administrator stated that in the past, the facility would place a magnet outside of the resident's room if oxygen was in use but had stopped because they were told that was a privacy/dignity issue. b. Resident #70 was readmitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease and shortness of breath. Review of physician order dated 09/06/23 read: oxygen at 3 liters via nasal cannula continuously. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #70 was cognitively intact and required the use of oxygen. An observation of Resident #70 was made on 08/04/24 at 1:04 PM. Resident #70 was resting in bed and was noted to have oxygen in use at 3 liters per minute via nasal cannula. There was no cautionary signs noted on the door frame or in Resident #70's environment where the oxygen was being delivered. An observation of Resident #70 was made on 08/05/24 at 10:33 AM. Resident #70 was resting in bed and was noted to have oxygen in use at 3 liters per minute via nasal cannula. There was no cautionary signs noted on the door frame or in Resident #70's environment where the oxygen was being delivered. An interview was conducted on 8/6/2024 at 9:04 am with the Charge Nurse. The Charge Nurse stated if a resident was supposed to wear oxygen there was an order in the chart from the physician. The Charge Nurse stated she was unsure if the facility still used oxygen signage outside of resident rooms to indicate that oxygen was in use. An observation of Resident #70 was made on 08/06/24 at 11:24 AM. Resident #70 was resting in bed and was noted to have oxygen in use at 3 liters per minute via nasal cannula. There was no cautionary signs noted on the door frame or in Resident #70's environment where the oxygen was being delivered. Nurse Aide (NA) #6 was interviewed on 08/06/24 at 2:22 PM. She stated that Resident #70 wore his oxygen all the time when in his room and if he was out of his room, they obtained him a portable oxygen tank to use. NA #6 stated she was not sure if the facility used oxygen signs or no smoking signs, but she did not think there was any signs on Resident #70 door or in his room that indicated no smoking or that oxygen was in use. Nurse #5 was interviewed on 08/06/24 at 4:24 PM. Nurse #5 stated that she was not sure about any cautionary signs within the facility, but she thought the front door of the facility stated, no smoking. She stated she would have to find out if the facility used cautionary signs on the doors or in resident rooms where oxygen was being used. An interview was conducted on 8/7/2024 at 8:22 am with the Director of Nursing (DON). The DON stated if a resident was on oxygen, oxygen usage was displayed on the resident's vital signs in the Electronic Health Record (EHR). The DON stated the facility did not use oxygen signage outside of resident rooms because they had been told that was a violation of the resident's privacy. An interview was conducted on 8/7/2024 at 8:33 am with the Administrator. The Administrator stated that in the past, the facility would place a magnet outside of the resident's room if oxygen was in use but had stopped because they were told that was a privacy/dignity issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident, staff, Psychiatric Nurse Practitioner, and Medical Director interviews the facility failed to protect a resident's right to be free from abuse when Resident #1 hit Resident #2 with a tissue box causing a very small cut to his left eyebrow with a bruise because Resident #2 was banging a tissue box on his bedside table. This affected 1 of 2 residents (Resident #1) reviewed for resident-to-resident abuse. The findings included: Resident #1 was readmitted to the facility on [DATE] with diagnoses that included: restlessness, agitation, anxiety, and cognitive communication deficit. A review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #1 was moderately cognitively impaired and had no signs of delirium and no behaviors, rejection of care, or wandering were noted. Review of 24-hour initial report dated 11/10/23 read in part, at 4:05 PM Resident #1 threw a tissue box at Resident #2 causing a laceration and discoloration to lateral left eye. Local law enforcement was notified as well as the state survey agency. The report was signed by the Director of Nursing (DON). At the time of the incident on 11/10/23 Resident #1 had no care plan in place for his restlessness or agitation. Resident #2 was admitted to the facility on [DATE] with diagnoses that included: hemiparesis following a stroke, major depressive disorder, anxiety, and cognitive communication deficit. Review of Resident #2's quarterly MDS dated [DATE] revealed that Resident #2 was cognitively intact and no behaviors, rejection of care, or wandering were noted during the assessment reference period. An observation and interview were conducted with Resident #2 on 12/05/23 at 9:51 AM. Resident #2 was resting in a low bed with a fall mat to the right side of his bed. He was alert and verbal. His bedside table was next to his bed and contained a box of tissues. Resident #2 stated that he recalled the incident with Resident #1 that occurred on 11/10/23. He stated that he was banging his tissue box on the bedside table to get the staff's attention that he needed a diaper change. Resident #2 stated he could not get to his call bell, so he was using the tissue box to alert the staff of his needs and Resident #1 came over and hit me with the tissue box on my left eye. There was very light-yellow fading bruise still evident to Resident #2's left eyebrow area. Resident #2 stated that he had no pain at the time of the incident and still had no pain to the area and explained that he and Resident #1 had lived together for a while and never had issues before. He stated that Resident #1 had never hit him before and indicated that he was not scared of Resident #1, and he felt safe in the facility. He further explained that after the incident the facility moved Resident #1 to a different room, and he had not seen him since that day. An observation and interview were conducted with Resident #1 on 12/05/23 at 10:00 AM. Resident #1 was resting on his bed and was dressed in pajama pants and white t-shirt. Resident #1 recalled the event that occurred on 11/10/23. He stated that Resident #2 was banging on his table, and I hit him with the tissue box in the head because he was getting on my nerves. Resident #1 stated that he had lived with Resident #2 for some time, and they never had any issues but, on that day, he just got on my nerves, he added that he had never hit anyone before the incident and had not hit anyone since the incident occurred. Resident #1 stated that they had not been arguing or anything that day but when Resident #2 began banging his table, he just got on my nerves. Resident #1 stated that he was moved to this current room on the same day of the incident and did not have a roommate at the time. The Social Worker was interviewed on 12/05/23 at 10:07 AM who stated that she recalled the event that occurred on 11/10/23 between Resident #1 and Resident #2. She stated that she was walking to her office when Nurse #1 called and stated that Resident #1 and Resident #2 were not getting along and were arguing. The Social Worker stated she told Nurse #1 she would be down there in just minute. The Social Worker stated maybe a minute or two later she went to the nurse's station where she saw Nurse Aide (NA) #1 talking to Nurse #1 and the Social Worker approached them and asked them what was going on as they proceeded to walk down the hallway towards Resident #1 and Resident #2's room. She stated that NA #1 stated that they were both calm at this point and were each in their own bed when she had gone to the nurse's station to tell Nurse #1 that Resident #1 and Resident #2 were not getting along. The Social Worker stated that when they reached the room, she asked Resident #1 what was going on and he replied that Resident #2 was getting on his nerves because he was banging a tissue box on his table. The privacy curtain was pulled so the Social Worker stated she pushed the curtain back to speak to Resident #2 and when she pulled the curtain back, she noted that Resident #2 had blood on his left eyebrow area. Resident #2 stated that Resident #1 had hit him. She added that she had NA #1 stay in the room while she went to get the DON. The Social Worker stated that she told the DON what had happened, and they proceeded back to the resident's room and on the way, they asked the Staff Development Coordinator to join them and they all 3 went to Resident #1 and Resident #2's room. When the 3 of them entered the room the Staff Development Coordinator went directly to Resident #2 and began administering first aid while she and the DON spoke with Resident #1. The Social Worker explained that the 2 residents had lived together for a while and never had any issues and Resident #1 was generally calm and pleasant and it was a total shock to the staff that he would hit someone. She further explained that they immediately moved Resident #1 to an empty room on the hall, but they quickly decided that because he was ambulatory, they did not want them on the same hall, so they chose to move Resident #2 to a different hall and put Resident #1 back in the original room. While the Staff Development Coordinator was administering first aid to Resident #2, she was able to calm him down and they asked him if he felt safe in the facility and if he was scared of Resident #1. She stated that Resident #2 denied being scared and stated he felt safe in the facility. She added that she continued to check on Resident #1 and Resident #2 often to ensure no further issues arose with either of them. The Staff Development Coordinator was interviewed on 12/05/23 at 10:24 AM who stated that she was asked by the DON on 11/10/23 to accompany her and the Social Worker to Resident #1 and Resident #2's room and was made aware of what had occurred. The Staff Development Coordinator stated that when she entered the room, she immediately went to Resident #2 and began administering first aid and attempting to calm Resident #2 down. She stated that he was flustered initially and used profanity but as they talked about it Resident #2 calmed down and indicated he was not having any pain and felt safe in the facility. She added that she cleaned the area to Resident #2 left eyebrow area with normal saline and applied triple antibiotic ointment and covered it with dry dressing and the direct care staff initiated neurologic checks on Resident #2 and began every 15-minute checks on Resident #1. The Staff Development Coordinator indicated that following the incident she and the other administrative nurses did a lot of staff education on abuse and reporting and that all staff were required to have the education prior to the start of their next scheduled shift. NA #2 was interviewed on 12/05/23 at 11:36 AM who stated that on 11/10/23 she was working the unit where Resident #1 and #2 resided. She stated that she was providing incontinent care in another room on the unit when she stepped out of that room to get something off the linen cart, and she heard Resident #2 yell you motherf and saw Resident #1 walking back to his side of the room and sat down on his bed. She explained that NA #1 was coming down the hall and was asked her to go in and check on Resident #1 and #2 while she finished providing care in the room, she was in. NA #1 was interviewed on 12/05/23 at 3:18 PM who stated that she recalled the event that occurred on 11/10/23 between Resident #1 and #2. She stated that she heard Resident #2 banging his tissue box on his table which was his normal behavior even with his call bell directly in his reach he would bang on his table to get the staff's attention. NA #1 was headed to their room when NA #2 stepped out of another room to get something off the linen cart and asked me to go and check on Resident #1 and #2. She stated she entered their room, and both residents were in their beds and appeared calm. She stated that she asked Resident #2 what was wrong, and he said that Resident #1 had threatened to hit him, and NA #1 stated she asked Resident #1 if he had said that and he stated, yes because he kept beating the table. NA #1 told Resident #1 that she was going to have to report that to the nurse and she left the room to go tell Nurse #1 about what had been said. She further stated that the Social Worker came to the desk, and they all began down the hallway back Resident #1 and #2's room. NA #1 stated that when they reached the room she did not go back in because she knew the Social Worker would talk to the residents in private. She stated a few minutes later the Social Worker came out and stated that Resident #1 had hit Resident #2 and he was bleeding, and the DON was immediately notified. NA #1 stated that Resident #1 and #2 had lived together for awhile and never had any issues like this before and it was very unlike Resident #1 to act out like that. NA #1 confirmed that she had received the packet of abuse training that the facility gave after the incident and was aware of the different types of abuse, who to report to, and the signs of potential abuse. Nurse #1 was interviewed on 12/05/23 at 3:27 PM who confirmed that she was working on 11/10/23 when the incident between Resident #1 and #2 occurred. Apparently Resident #1 had told Resident #2 that if he did not quite banging on his table, he was going to hit him. The NAs on the unit came to the desk to report what had been said. Nurse #1 stated she picked up the phone and called the Social Worker and we walked back down the hallway. When she entered the room Resident #1 was sitting on his bed and Resident #2 was laying in his bed and he had a very small almost like a paper cut to his left eyebrow area and Resident #2 stated that Resident #1 had hit him with the tissue box. Nurse #1 stated that they immediately removed Resident #1 from the room and first aid was given to Resident #2 and got him calmed down. She further explained that this type of behavior was very uncharacteristic of Resident #1 and stated that the 2 residents had never had issues like this before. Resident #1 was placed on every 15-minute checks and neurologic checks were initiated on Resident #2. Nurse #1 confirmed that she had received the education on abuse following the event and was able to recite the types of abuse and who to report to and to always protect the resident first then alert your supervisor. The Psychiatric Nurse Practitioner (NP) was interviewed via phone on 12/05/23 at 3:53 who stated that she was asked to evaluate Resident #1 on her visit on 11/28/23 and was told of the incident that had occurred on 11/10/23. The NP stated that she had previously evaluated Resident #1 in the past and this type of behavior was very unusual for him. She stated that the 2 residents had roomed together for a while with no issues that she was aware of. The NP stated that when she saw Resident #1 on 11/28/23 he recalled the event on 11/10/23 and stated that Resident #2 was getting on his nerves and was keeping him awake at night banging on his table. During the conversation the NP stated that Resident #1 also mentioned another resident across the hallway that hollered all night and he reported he had told her to shut up which again was very unusual for Resident #1. The NP stated that Resident #1 denied any depression or anxiety but since he had a change in behavior, she started him some Zoloft (antidepressant) to see if that would help keep him calm and pleasant. The Medical Director (MD) was interviewed via phone on 12/05/23 at 4:30 PM who stated that the facility had made him aware of the incident that occurred on 11/10/23 between Resident #1 and #2. The MD stated that he was shocked when they told him because it was very uncharacteristic of Resident #1, he was generally quite with a flat affect and never got excited about anything. The MD stated that he evaluated Resident #1 on 11/13/23 and the exam revealed no acute findings, he added that during that visit Resident #1 spoke to him more than he ever had in the past. The MD also stated that he did not feel like Resident #1 posed a safety risk to himself or other residents. The DON was interviewed on 12/05/23 at 4:30 PM who stated on 11/10/23 she was in her office when the Social Worker came and notified her that Resident #1 had hit Resident #2 and he was bleeding. The DON stated on her way down the hallway she asked the Staff Development Coordinator to come with them and assist as needed. When she entered the room, the DON stated she and the Social Worker began questioning Resident #1 on what had happened while the Staff Development Coordinator administered first aid to Resident #2. The DON stated that Resident #1 just stated that Resident #2 was banging on his table, and it was getting on his nerves and that was why had hit him with the tissue box. She stated that he was started on every 15 minute checks and moved to an empty room on the hall but ended up returning to the original room and Resident #2 was moved to different unit and neither resident had a roommate at this time. The DON stated that neurologic checks were initiated on Resident #2 and families were notified as was the MD. She stated that they placed both residents on the book to be evaluated by the MD and the Psychiatric NP on their next visits and began performing skin sweep on all residents and interviewing alert and oriented resident to ensure that no other abuse had occurred. She further stated all staff, and all residents were educated on the abuse policy and procedures and who to report to along with the different types of abuse including resident to resident abuse prior to their next scheduled shift and the education was included in the new hire packet. The DON stated that all residents were to receive a full skin assessment weekly times 4 weeks and random residents were interviewed about abuse weekly by the Social Worker and Activities staff. The Administrator was interviewed on 12/05/23 at 5:11 PM who stated that he was notified of the incident that occurred on 11/10/23 between Resident #1 and #2 and his first reaction was shock because this was so very uncharacteristic of Resident #1. He stated that the residents were separated, and Resident #1 placed on 15-minute checks, first aid was given to Resident #2, skin sweeps were done, all alert and oriented residents and staff were interviewed to identify if any other abuse had occurred. All staff were educated on abuse prior to the start of their next shift and all families were notified along with all regulatory agencies as well. The Administrator stated that the plan of correction was on the agenda to be discussed in their next quality assurance meeting which was scheduled for 01/18/24. The facility provided the following plan of correction: DATE: 11-10-23 Occurrence: On 11-10-23, Resident #2 was beating his tissue box against his bedside table as part of his normal behavior. Resident #1 got up, grabbed the tissue box and hit resident #2 forcefully across the face. # 1 - Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; On 11-10-23 the Staff Development Nurse immediately assessed Resident # 2 for the cut to his left lateral eye and initiated cleaning and dressing to the area per facilities standing orders, at this time nuero checks were also initiated. Resident # 2 was immediately moved to 300 hall and Resident # 1 resides in same room on 100 hall alone. Both residents now reside in a single occupancy room on 11-10-23. Resident #1 was placed on Q15 minute checks on 11-10-23; 15 minute checks were continued until further evaluation from Medical Director. Law enforcement was immediately notified and a report was completed and filed by the responding officer. [NAME] County Department of Social Services were immediately notified and a report being filed. The facility Medical Director was immediately notified. Resident #1 and Resident #2 families were immediately notified. Resident #1 was immediately placed on facility psych and MD rounds and labs were also drawn per MD telephone order. Resident # 1 was assessed on 11-13-23 by the Medical Director for any potential underlying issues as well as any potential need for continued monitoring. Resident # 2 was assessed by the Medical Director for further evaluation of left eye laceration as well as resident's overall well-being with no areas of concerned noted. Both residents were placed on psychiatric rounds to assess for any underlying psychiatric issues on 11-10-23. These two Interdisciplinary Team Members (Medical Director and Psychiatric Physician) along with Social Work and both resident representatives will discuss findings before the consideration of potential roommates. Education was immediately provided by the Director of Nursing with all 100 hall staff members. Education included, monitoring any type of aggression, 15 minute checks, and immediate reporting on 11-10-23. # - 2 Address how the facility will identify other residents having the potential to be affected by the same deficient practice; On 11-14-23, the Staff Development Nurse, Infection Preventionist, Nurse Scheduler, Wound Nurse, Registered Nurse Supervisor, and 300 Hall Nurse immediately completed skin assessments on all residents to determine if there were any injuries or suspicion of injury that could have been caused by resident to resident altercation . There were no new areas of concern noted. On 11-14-23, interviews were completed by Social Worker, Activity Director, Medical Records Supervisor, and Minimum Data Set (MDS) Coordinator with all alert and oriented residents to determine if there any other resident to resident altercations have occurred that facility staff were not aware of. The interview questions included: Is everyone treating you well? Has anyone hurt you? Has anyone ever said anything that hurt you or made you feel uncomfortable? Do you feel safe? Has your roommate or any other resident hurt you? Has your roommate or any other resident said anything that upset you? Are there any residents who live here that make you feel uncomfortable? Do you know who to talk to if anyone makes you feel uncomfortable? There were no new areas of concern noted. On 11-14-23, the Director of Nursing interviewed direct care staff to determine if there were any other potential resident to resident altercations. The question was: Do you have any concerns about any residents that may not always get along? There were no new areas of concern noted by any interviewed staff members. # -3 Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; On 11-10-23, members of the Interdisciplinary Team met to discuss mechanisms, policies, training of staff relative to resident to resident abuse and determined the following would continue and/or be implemented. The Administrator notified each of the staff listed below of their responsibilities (as listed). On 11-14-23, the Staff Development Nurse and/or her designee immediately began educating all staff including full-time, part time, and agency staff on the Abuse Policies and Procedures with an emphasis on (Resident to Resident Abuse). Highlights of this education included: what were potential signs of resident to resident abuse, how to intervene if you witness resident to resident abuse, who to report any instances of resident to resident abuse to, to never leave a resident to resident altercation/abuse situation (to remain with the victimized resident/residents until the situation is completely resolved or the threat of harm is over), and the importance of reporting resident to resident abuse immediately. During this education, the Staff Development Nurse and/or her designee performed Question and Answer (Q&A) with staff to ensure understanding of all education provided. On 11-14-23, the Staff Development Nurse and/or her designee educated facility staff to observe residents for aggressive/inappropriate behavior towards other residents, family members, visitors, and/or staff members and to immediately report all occurrences to the Nurse Supervisor, Director of Nursing, or Administrator. On 11-14-23, all staff were given the Abuse Policy and Procedure and the facilities Abuse Reminders Sheet. Which includes: definitions associated with abuse, ways to prevent abuse, monitoring of residents for aggressive/inappropriate behavior, occurrences of such incidents being reported immediately, and remaining with the victimized resident/residents until the situation is completely resolved or the threat of harm is over. This is not an all-inclusive list of the Abuse Reminder Sheet. On 11-14-23, the Activity Director, Activity Assistants, and/or their designee immediately completed education with facility residents on the following: Who to report any type of abuse instances/situations to. How to report any type of abuse instances/situations. Education on how there will be no type of retaliation for reporting abuse. Education on how the facility will keep you protected during the entirety of the investigation. All staff were required to sign educational rosters to validate they received the education. As outlined above (Abuse Policy and Procedure and the Abuse Reminders Sheet). The Staff Development Nurse and/or her designee monitored and tracked which staff received education by running an employee roster and checking each staff member off when they received the education. All staff received the education on or before the beginning of their next shift. Newly hired employees and agency staff will be educated on the Abuse Policy and Procedure during orientation. # - 4 Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; and Include dates when corrective action will be completed. The Director of Nursing and/or her designee will conduct weekly skin assessments x 4 weeks to determine if there are any injuries/areas suspicious of resident to resident altercations. An audit tool titled Weekly Skin Assessments was created to record the weekly results. Audits will be completed by 12-8-23. The Social Worker and/or her designee will conduct resident interviews with all alert and oriented residents weekly x 4 weeks to determine if there has been any resident to resident altercations or other forms of abuse that have not been reported to facility staff. An audit tool titled Resident Interviews was created to record all weekly results. Weekly interviews will be completed by 12-8-23. The Staff Development Nurse and/or her designee will continue to do abuse education with all staff upon hire, annually, and at all mandatory general staff meetings on Abuse Policy and Procedures. Resident to Resident Abuse will be highlighted during continuous education. The Director of Nursing and Social Worker will share results of the above audits in the Quality Assurance Performance Committee meetings where the information will be reviewed and discussed. The Quality Assurance Committee will assess and modify the action plan as needed to ensure continued compliance. Compliance Date: 11-14-23 The plan of correction was validated onsite on 12/05/23. The validation included review of the initial assessment of Resident #2. The immediate separation of both residents, the 15-minute checks that were initiated for Resident #1 and the neurologic checks initiated for Resident #2. All skin checks were reviewed for completeness and all resident interviews were reviewed with no additional findings noted. The 24 hour and 5 working day report were sent to the State Survey agency and all regulatory agencies along with family and MD were notified of the incident. Staff interviews revealed that they had received recent education on abuse and were able to verbalize the procedure. Monitoring tools were reviewed and continued. Signature sheets were reviewed to confirm all staff were educated. The compliance date of 11/14/23 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to develop and implement their abuse policy in the area of reporting for 2 of 2 residents reviewed for abuse (Resident # 1 and Resident #2) The findings included: A review of the facility's policy titled, Abuse Prevention Program: Policies and Procedures dated revised 10/24/22 indicated all alleged violations involving abuse, neglect, and misappropriation of patient property were to be reported immediately to the Administrator and the Director of Nursing (DON). The policy also indicated that any time there was an allegation of staff to resident abuse Adult Protective Services (APS) was to be contacted. Additionally, the policy stated the administrator or his/her designee will report allegations to the Health Care Personnel Registry within the specified timeframes: (a) immediately, but no later than 2 hours if the alleged violation involves abuse or results in serious bodily injury or (b) not later than 24 hours if the alleged violation involved neglect, exploitation, mistreatment, or misappropriation of resident property, and does not result in serious bodily injury, and (c) the administrator or his/her designee, will provide the Health Care Personnel Registry Section of the division of Facility Services, with a written report of the findings on their investigation within 5 days of the alleged occurrence of the incident. 1. Resident #1 was re-admitted to the facility on [DATE] with diagnoses that included anxiety disorder, depressive disorder, and respiratory failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively moderately impaired and could usually make herself understood and was able to understand others. A review of the facility's 24-Hour Initial Report dated 07/13/23 indicated there was an allegation of staff to resident abuse made by Resident #1. The report indicated the incident between Resident #1 and Nurse Aide (NA) #2 on 07/13/23 was not reported to the local law enforcement or APS. The report indicated Resident #1 alleged NA #2 hit her on her left forearm. An interview on 08/04/23 at 9:41 AM with NA #1, who cared for Resident #1 the morning of the alleged abuse revealed at approximately 3:30 AM, when she entered Resident #1's room with NA #2 to change her brief and Resident #1 asked her for the name of the person (NA #2) who was in her room [ROOM NUMBER] minutes prior. NA #1 stated she told Resident #1 she did not know but would find out. NA #1 stated Resident #1 reported the person who was in her room [ROOM NUMBER] minutes earlier hit her on her left forearm. She stated Resident #1 stated when she asked NA #2 why she had hit her, NA #2 replied because you touched me, don't touch me. NA #1 stated NA#2 did not say anything while they were in the room when Resident #1 verbalized her allegation or when she reported the allegation to Nurse #1 and Nurse #2. She stated Nurse #1 and Nurse #2 went to speak to Resident #1 and when they returned to the nurses' station, they escorted NA #2 to the chapel and called the Administrator and the Director of Nursing (DON) to report the allegation. She stated they all knew it was NA #2 because she had told her when she was at lunch that she had been in Resident #1's room, and she was the only other NA working on the 300 hall. She stated the Administrator and DON came into the facility quickly, interviewed Resident #1 and NA #2, and NA #2 never came back to work. NA #1 stated she looked at Resident #1's left arm and saw no signs of injury. NA #1 stated Resident #1 had some periods of confusion but was very clear, alert, and oriented when she reported that she had been hit. In a written statement by the facility Administrator dated 07/14/23, he documented that the Director of Nursing (DON), the Social Worker (SW), and himself all interviewed Resident #1 and that Resident #1 gave the same details in all the interviews. In the Administrator's written statement, he reported that during Resident #1's interviews, she stated she had been hit on her left forearm by an African American person (NA #2). She stated NA # 2 hit her intentionally because when Resident #1 asked NA #2 why she had hit her, and NA #2 told her it was because Resident #1 had touched her, and she didn't want Resident #1 to touch her. A phone interview on 08/04/23 at 4:38 PM with the Administrator revealed he submitted the 24-Hour Initial Report and the 5-Working Day Report for Resident #1 to the State Survey Agency within the required timeframes; however, he was not aware that he was required to notify the local law officials. He stated he knew he had to notify APS regarding Resident #1's allegation, but he had not yet contacted them at the time the State Survey Agency called him on 07/25/23. A follow up phone interview was conducted with the Administrator on 08/07/23 at 3:41 PM who stated that when the incident with Resident #1 occurred he was unaware of the requirement for notification to local law enforcement and to APS. He stated on 07/25/23 he received a call from the State Survey agency inquiring if he had contacted local law enforcement and APS and during that phone call he learned of the requirement. He also confirmed that his policy was not up to date with the most current reporting requirements and time frame and that it would need to be amended and updated. 2. Resident #2 was re-admitted to the facility on [DATE] with diagnoses that included diabetes, respiratory failure, anxiety disorder and depressive disorder, anxiety disorder, depression disorder, paralysis pf vocal cords and larynx and obstructive sleep apnea. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively intact and could make herself understood as was able to understand others. A review of the facility's 24-Hour Initial Report dated 07/25/23 indicated there was an allegation of staff to resident abuse made by Resident #2. The report indicated the incident between Resident #2 and Nurse #3 on 07/25/23 and was not reported to the local law enforcement or APS. The report indicated Resident #2 alleged Nurse #3 took her nebulizer treatment from her before it was finished. Per a written statement by the Director of Nursing (DON) on 07/25/23, she documented that on the morning of 07/25/23 a family member of Resident #2 informed her when she told Nurse #3 that she needed go to the bathroom, Nurse #3 told Resident #2 that she didn't need to go to the bathroom. Additionally, the family member stated that Nurse #3 unhooked something and said to Resident #2 I've had enough, I'm done with you. The written statement further revealed that the DON interviewed Resident #2, and Resident #2 reported that on 07/25/23 around 4:30 AM, Nurse #3 took her nebulizer treatment away from her before it was completed, and she felt like she couldn't get any air. Resident #2 then said that Nurse #3 told her I've had enough, I'm done with you. In an interview on 08/03/23 at 11:15 AM with Resident #2, she stated a nurse (Nurse #3) came into her room a few days ago and took away her nebulizer treatment before it was finished. She stated she told Nurse #3 the treatment was not done and needed it for her breathing and Nurse #3 told her she had enough, and she was done with her. She stated she was not having problems breathing at that time. A phone interview on 08/04/23 at 4:38 PM with the Administrator revealed the Administrator submitted the 24-Hour Initial Report and the 5-Working Day Report for Resident #2, to the State Survey Agency within the required timeframes; however, he was not aware that he was required to notify the local law officials. A follow up phone interview was conducted with Administrator on 08/07/23 at 3:41 PM who stated that when the incidents with Resident #2 occurred he was unaware of the requirement for notification to local law enforcement and to APS. He stated on 07/25/23 he received a call from the State Survey agency inquiring if he had contacted local law enforcement and APS and during that phone call he learned of the requirement. The Administrator stated he had not yet contacted local law enforcement and APS regarding Resident #2, but he planned to. He also confirmed that his policy was not up to date with the most current reporting requirements and time frame and that it would need to be amended and updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and Resident and staff interviews the facility failed to treat a Resident in a dignified manner when a staff member made comments about the Resident's weight for 1 of 1 residents reviewed for dignity (Resident #68). This caused Resident #68 feelings of hurt and anger. The findings included: Resident #68 was admitted to the facility on [DATE] with diagnoses including muscle weakness and dependence on wheelchair (WC). Review of the quarterly Minimum Data Set (MDS) assessment for Resident #68 dated 10/05/2021 revealed her cognition was intact. She required the total assistance of two persons for transfers, the extensive assistance of two persons for toileting. She was frequently incontinent of bladder. Resident #68 used a WC for mobility. Review of the current care plan for Resident #68 initiated 03/18/2020 and last updated 10/14/2021 revealed a focus area of impaired mobility. The goal was to promote maintenance of current activities of daily living. An intervention was for Resident #68 to use her WC for out of bed mobility. An additional focus area of requires assistance for toileting to improve continence revealed a goal of promote improvement of continence. An intervention was to offer the use of a bed pan as tolerated per Resident #68's preference. Review of a facility reported incident dated 10/22/2021 revealed Resident #68 reported Nurse Aide (NA) #6 told her, Your (sic) getting too fat. In an interview on 11/09/2021 at 1:50 PM Resident #68 stated she experienced an incident in the facility that made her feel hurt and angry because she had struggled with her weight her whole life. She stated she could not recall the exact date or the name of the NA. She went on to say it had been time for her to go to an activity. She stated she used her call bell for assistance to use the bed pan. She further indicated she was in her WC and needed to get in bed to use the bedpan. Resident #68 stated when the NA was moving her WC, the NA commented that she must be gaining weight and getting fatter because her WC was difficult to move. Resident #68 went on to say this NA then told her if she got in bed to use the bedpan she would have to stay in bed because she was too heavy to be moving back and forth. Resident #68 stated the same NA called her fat seven times before but this was the first time she reported it to the facility. She went on to say although she felt hurt and angry at the time, the feelings did not last. She further indicated the NA had not provided her care again since she reported the incident. She stated she felt the incident was resolved. Review of a nurse practitioner progress note for Resident #68 dated 10/25/2021 revealed she was seen in the facility for a follow-up visit. It further revealed Resident #68 denied having any issues. Resident #68's mood and behavior were stable. Review of a psychologist progress note dated 10/29/2021 revealed Resident #68 was provided supportive psychotherapy. It further revealed Resident #68 discussed an issue that developed where she was putting up with verbal comments where her weight was part of the conversation. She denied that she had been having crying episodes. On 11/09/2021 at 3:56 PM a telephone interview with Nurse #13 indicated he was familiar with Resident #68 and assigned to her care on 10/22/2021 from 7AM-7 PM. He stated Resident #68 was alert and oriented and a reliable historian. He further indicated Resident #68 usually went to activities. He stated on 10/22/2021 at about 4:00 PM he noticed Resident #68 was still in bed although there was an activity. Nurse #13 further indicated when he spoke with Resident #68 about why she was not up to go to the activity she told him she had needed to get in bed to use the bedpan. He stated Resident #68 went on to describe the NA who assisted her as having dark hair, wearing glasses, and speaking with an accent. He stated he recognized this as being NA #6. Nurse #13 went on to say Resident #68 had tears in her eyes when she told him NA #6 told her she was getting fat when she had trouble moving her WC and was too heavy to be moving back and forth so if she got in bed to use the bedpan she would have to stay in bed. He went on to say he immediately reported this to Nurse #7 who was the charge nurse. Nurse #13 stated he offered to get Resident #68 up for the activity that evening as there was still time but Resident #68 refused. On 11/09/2021 at 3:31 PM a telephone interview with NA #6 indicated on 10/22/2021 Resident #68 rang her call bell for assistance. NA #6 stated when she responded, Resident #68 asked to be assisted to bed to use the bedpan. NA #6 went on to say she commented to Resident #68 that she must be getting heavier because her WC was getting harder to move. NA #6 denied calling Resident #68 fat. She stated she did not tell Resident #68 that she would not get her back up after using the bedpan. She further indicated she asked Resident #68 if she would get back up after using the bedpan and Resident #68 said she would not. NA #6 went on to say she had been immediately reprimanded after the incident and her employment with the facility had been terminated. On 11/09/2021 at 2:11 PM in an interview the Director of Nursing (DON) indicated she received a message on 10/22/2021 from Nurse #7 regarding the incident between NA #6 and Resident #68. She stated she immediately went to the facility to investigate. She went on to say this investigation included interviewing staff who were working at the time of the incident, interviewing other alert and oriented residents who received care from NA #6 and conducting skin assessments for cognitively impaired residents who received care from NA #6. The DON stated NA #6 was suspended pending this investigation. She stated some in servicing was done with staff on treating residents with dignity and respect after the incident. The DON stated Resident #68 reported the same account of the event she reported to other staff. She stated Resident #68 was alert and oriented, a reliable historian, and she had no reason to doubt Resident #68's report of the event. She further indicated NA #6's comments about Resident #68 getting heavier, being too fat, and having to stay in bed because she was too heavy to be moving back and forth were unacceptable. The DON went on to say NA #6's employment with the facility had been terminated. On 11/09/2021 at 2:47 PM an interview with Resident #68's Social Worker (SW) indicated she visited with Resident #68 at least every other week for in depth conversations. She stated she felt she had a good rapport with Resident #68. She went on to say Resident #68 was alert and oriented and a reliable historian. The SW further indicated Resident #68 did not have any history of making allegations against staff and had never shared with her any concerns related to staff making comments about her weight before. She stated when she spoke with Resident #68 on 10/25/2021, Resident #68 told her an NA was trying to move her in her WC and the NA told her she must be getting fatter and gaining weight because her WC was hard to move. The SW went on to say Resident #68 shared with her these comments were hurtful to her because she had always struggled with her weight. On 11/09/2021 at 4:15 PM an interview with the Administrator indicated NA #6's comments about Resident #68's weight were unacceptable. He stated he expected all staff to always treat residents with dignity and respect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and Resident interviews the facility failed to protect a Resident's right to be free from physical abuse for 1 of 1 Resident reviewed for abuse (Resident #36). The finding included: Resident #36 was admitted to the facility on [DATE] with diagnoses that included heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was cognitively intact and had no physical behaviors. The MDS also indicated the Resident required extensive assistance with bed mobility and was incontinent of bladder. During an interview with Resident #36 on [DATE] at 12:07 PM the Resident reported that a while back there was a girl that hit me on my hip and talked ugly to me. Resident #36 refused to elaborate on the incident and stated she did not want to discuss the matter anymore because the facility had fired the girl and she was satisfied that the girl could not harm anyone else. The initial 24 hour report submitted to the Health Care Personnel Registry (HCPR) by the facility on [DATE] indicated the allegation type was resident abuse between Resident #36 and Nurse Aide (NA) #3 which occurred on [DATE] at an unknown time. The report indicated that Resident #36 reported that after NA #3 gave her incontinent care the NA talked hateful to her and hit her on her left side. No physical harm (occurred) but the Resident stated she was afraid of the nurse aide. The 5 day investigative report submitted to the HCPR by the facility on [DATE] indicated that Resident #36 informed two nurse aides NA #4 and #5 on Sunday [DATE] that NA #3 hit her on her left side the previous night. The report noted the incident did not result in physical injury or mental anguish lasting more that 5 days. Resident #36's allegation of abuse was substantiated by the facility and NA #3 was terminated. During an interview with Nurse Aide #4 on [DATE] at 5:40 PM the NA explained that while she was assisting NA #5 with Resident #36 around 10:00 PM on [DATE] the Resident asked them who would be coming in to care for her that night and the NAs informed the Resident that they thought it would be NA #3. The NA continued to explain that the Resident told them that the previous night ([DATE]) NA #3 hit her twice on her hip and it was not just a love tap. An interview was conducted with NA #5 on [DATE] at 5:47 PM. The NA explained that on the night of [DATE] she was assisting Resident #36 of her nighttime routine when the Resident asked her who would be taking care of her that night (third shift). The NA stated when she told the Resident that it was probably NA #3 the Resident stated that she did not want NA #3 in her room because the night before ([DATE]) NA #3 hit her twice on her left hip and it hurt but it did not make her cry. An interview with the Director of Nursing (DON) was conducted on [DATE] at 5:11 PM. The DON explained that on [DATE] at 4:30 PM two nurse aides NA #4 and #5 reported that the night before on [DATE] when they were preparing Resident #36 for bed the Resident told them that NA #3 had hit her twice on her left side during the night of [DATE]. The DON explained that NA #3 knew what the allegation was about before the DON informed the NA of the allegation and the NA admitted she gave Resident #36 a love pat and stated if anyone stresses me out, it is her. The DON continued to explain that she interviewed Resident #36 who explained that while NA #3 was checking her that night the NA began to fuss at her because she felt that the Resident could do more for herself and while the Resident was turned on her right side the NA hit her twice on her left hip. The Resident also reported that NA #3 would hold her head so that she would have to look at the NA which was a little rough. The DON stated she assessed Resident #36's left side and hip and there were no marks on her. A review of an undated written statement by NA #3 revealed, on the night of [DATE] during the second round the NA answered Resident #36's call light who requested the bed pan. The NA explained that she had to pull the Resident's pants down which was a struggle and roll her over to get on the bed pan and the Resident accused her of being too rough. The NA continued to explain that when Resident #36 finished she got her situated in the bed and gave her three love pats on her left hip. An interview was conducted with the Administrator on [DATE] on 9:37 AM who explained that he was notified of the allegation of employee to Resident abuse of Resident #36 by NA #3 by the DON on [DATE] at 4:30 PM. He continued to explain that he directed the DON to notify NA #3 of the allegation of abuse made against her and that she would be suspended pending the outcome of the investigation. The Administrator stated that after the abuse investigation was completed the allegation of abuse of Resident #36 was substantiated which resulted in the termination of NA #3.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and Resident interviews, the facility failed to implement their abuse policy in the area of immediately reporting an employee-to-Resident abuse allegation to the facility administration and to the Division of Health Service Regulation (DHSR) within the required timeframe. The facility also failed to include in their abuse policy to notify the DHSR within a two-hour timeframe of being notified of abuse for 1 of 2 residents (Resident #36) reviewed for abuse. The findings included: The facility's policy titled Abuse Prevention Program updated [DATE], read in part, ABUSE INVESTIGATIONS, REPORTING AND CORRECTIVE ACTIONS, reports of abuse, neglect and misappropriation of resident property shall be reported immediately to the DON and Administrator and then promptly and thoroughly investigated by the facility administration. The facility's policy did not include reporting abuse within a two-hour timeframe to the state agency. Resident #36 was admitted to the facility on [DATE] with diagnoses that included heart failure. The recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was cognitively intact. The MDS also revealed the Resident required extensive assistance with bed mobility and was incontinent of bladder. On [DATE] at 12:07 PM an interview was conducted with Resident #36 who reported a while back there was a girl that hit me on my hip and talked ugly to me. The Resident stated she did not want to discuss the incident anymore because the facility fired the girl and she could not harm anyone else. The initial 24-hour investigative report submitted by the facility to the Health Care Personnel Registry (HCPR) on [DATE] at 9:30 AM revealed the allegation type of resident abuse between Resident #36 and Nurse Aide #3 occurred on [DATE] at time unknown. The report indicated Resident #36 reported NA #3 talked hateful to her and after receiving her incontinence care, the NA hit the Resident on her left side. No physical harm (occurred). Resident stated she was afraid of the NA. An interview was conducted with Nurse Aide (NA) #4 on [DATE] at 5:40 PM. The NA explained that while she was providing care for Resident #36 on [DATE] around 10:00 PM the Resident asked who was coming in (third shift) to care for her that night and the NA told her it was probably NA #3. The Resident reported that last night NA #3 hit her twice on her hip and it was not a love tap. The NA stated she immediately reported the conversation to the Assistant Director of Nursing (ADON) who was in the building at the time and the ADON wrote it on a piece of paper and told her that she would take care of it. During an interview with Nurse Aide (NA) #5 on [DATE] at 5:47 PM she explained that on the night of [DATE] Resident #36 asked who would be taking care of her that night (third shift) and when the NA told her it was going to be NA #3 the Resident stated she did not want NA #3 in her room because the night before the NA hit her twice on her left hip and it hurt but it did not make her cry. NA #5 stated she reported it to the ADON who was in the building at the time the allegation was reported to her. An interview conducted with the Assistant Director of Nursing (ADON) on [DATE] at 9:01 AM revealed, the ADON explained that on the night of [DATE] she was on her way out the door of the facility when NA #4 and NA #5 stopped her and reported that Resident #36 told them that NA #3 hit her the night before. The ADON continued to explain that she knew allegations of abuse had to be immediately reported to the Administrator but she was exhausted and told the nurse aides to write their statements and leave them for the Director of Nursing (DON) to get in the morning because she knew when the DON received the statements, the facility would still be in the 24-hour timeframe of reporting an abuse allegation. The ADON added, she knew NA #3 was not scheduled to work on third shift that night of [DATE]. A review of the facility's staffing schedule for [DATE] confirmed that NA #3 was not scheduled to work the night of [DATE]. An interview with the Director of Nursing (DON) was conducted on [DATE] at 5:11 PM. The DON explained that on [DATE] at 4:30 PM two Nurse Aides (NA) #4 and NA #5 reported to her that the night before on [DATE] Resident #36 told them that NA #3 hit her twice on her left side during the night of [DATE]. The NAs reported the allegation to the ADON who was in the building at the time of the allegation and the ADON told them to let me know about it the next morning ([DATE]). The DON continued to explain that she immediately reported the allegation to the Administrator who advised the DON to notify NA #3 and inform her that she needed to come to the facility and provide her statement and she would be placed on administrative leave pending the outcome of an investigation. The DON stated NA #3 admitted she gave Resident #36 a love pat and stated, if anyone stresses me out, it is her. The DON reported she interviewed Resident #36 who explained that while the NA was checking her that night the NA began to fuss at her because she felt that the Resident could do more for herself and while she was turned on to her right side the NA hit her twice on her left hip. The Resident also reported that NA #3 would hold her head so that she would have to look at the NA which was a little rough. The DON stated she assessed Resident #36's left side and hip and there were no marks on her. The DON explained that the NA met with the Administrator and herself on the morning of [DATE] and was notified that she was terminated. The DON stated NA #3 was not scheduled to work on the night of [DATE] for third shift. A review of an undated written statement by NA #3 revealed, on the night of [DATE] during the second round the NA answered Resident #36's call light who requested the bed pan. The NA explained that she had to pull the Resident's pants down which was a struggle and roll her over to get on the bed pan and the Resident accused her of being too rough. The NA continued to explain that when Resident #36 finished she got her situated in the bed and gave her three love pats on her left hip. During an interview with the Administrator on [DATE] at 9:37 AM he explained that he was notified of the allegation of abuse of Resident #36 by NA #3 on [DATE] at 4:30 PM by the Director of Nursing (DON). The Administrator stated he immediately made sure that NA #3 was not scheduled to work that night and directed the DON to notify the NA that there was an allegation of abuse made against her and that she would be suspended pending the outcome of the investigation. The Administrator explained that the allegation of abuse was investigated and substantiated which resulted in the termination of NA #3. The Administrator also explained that the Assistant Director Nursing was reprimanded for not immediately notifying the Administration of an allegation of abuse at the time the allegation was reported to her. A follow up interview with the Administrator was conducted on [DATE] at 2:30 PM. The Administrator explained that his understanding was that the state required two notifications of abuse 1) the initial 24-hour report and 2) the 5-day summary investigation. Notified the Administrator of the 2-hour notification time frame to the state for abuse and he stated that he was sure the policy did not include a 2-hour timeframe of reporting abuse and stated he would develop a policy for it. The Administrator added, whatever the state regulation was is what they should be doing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and facility staff interviews, the facility failed to ensure a Resident's catheter remained off the floor for 1 of 2 residents reviewed for catheters (Resident #21). The Finding Included: Resident #21 was admitted to the facility on [DATE] with diagnoses that included neuromuscular dysfunction of bladder. A review of Resident #21's most recent quarterly Minimum Data Set assessment dated [DATE] revealed Resident #21 to be cognitively impaired for daily decision making. Resident #21 was coded as having an indwelling catheter. An observation of Resident #21 on 10/18/21 at 12:37 PM revealed her catheter bag was not attached to her bed frame and was resting flat on the floor. An observation made of Resident #21 on 10/19/21 at 10:14 AM revealed her catheter bag to be attached to her bed frame but the bottom of the bag was resting on the floor causing a crease to develop one-forth from the bottom of the bag. An observation made of Resident #21 on 10/20/21 at 9:30 AM revealed Resident #21's catheter was again attached to the bed frame, but the bottom of the bag was observed resting on the floor. There was a white hand towel on the ground providing a barrier between the catheter bag and the floor of the room. An interview with Nurse #5 on 10/20/21 at 9:34 AM revealed she did not know why Resident #21's catheter bag was left in contact with the floor. She guessed it was due to the hall Nurse Aide (NA) not ensuring the catheter bag was off the floor but wasn't sure. Nurse #5 reported it looked like the hall NA tried to hang the catheter bag back on the bed frame after emptying it and hung in on a strap which sagged, allowing the catheter bag to come into contact with the floor. She reported it was the responsibility of the hall NAs to ensure catheter bags were elevated off the floor. During an interview with the Director of Nursing on 10/20/21 at 3:40 PM, she reported it was the hall Nurse's responsibility to ensure that catheter bags remained off the floor. She stated a Resident's catheter bag should not be touching the floor and although it was ultimately the responsibility of the hall Nurse assigned to the Resident to ensure it was off the floor, she expected all staff to monitor catheter bags and elevate them if they saw them in contact with the floor.

Based on observation and staff interviews, the facility failed to discard expired food, label frozen food items stored in 1 of 1 walk in freezer, discard expired food in 1 of 1 walk in refrigerator and failed to remove opened and expired food and unlabeled food in 1 of 1 nourishment room. Findings include: An initial tour of the kitchen on 10/18/21 at 10:05 AM with the [NAME] revealed 6 boxes of white icing mix with an expiration date of 09/19/21, 2 cans of peaches with light syrup with an expiration date of 07/21/21, frosted flakes, opened and in a covered tub with a date of 05/07 and rice krispies, opened and in a covered tub with a date of 05/30. The tour of the walk in refrigerator revealed a bag of shredded lettuce, opened and in a zip lock bag, not dated and a used by date of 10/09/21 and a bag of shredded lettuce not opened with a used by date of 10/09/21. The tour of the walk in freezer revealed a bag of sausage patties in the original package, not sealed and opened with no date when opened and a bag of popcorn chicken in a zip lock bag with no date when opened. A tour of the nourishment room refrigerator on 10/19/21 at 1:15 PM revealed an open chocolate pie dated 09/26/21 and an opened pumpkin pie with a used by date of 10/10/21 and the freezer revealed a white Styrofoam cup with contents frozen inside with no name or date and a white sealed bag with no name or date. During an interview with the [NAME] on 10/18/21 at 10:04 AM revealed the dry storage room is checked at least once a week and if new staff were brought on, they were educated on safety of the dry storage, walk in refrigerator, and walk in freezer. The [NAME] further revealed the cereal in the tubs should have been thrown out as they only keep cereal in the tubs for 2 weeks and they were now using individual boxes of cereal. The [NAME] further revealed the lettuce should not have been in there and the sausage patties and popcorn chicken should have been dated. The [NAME] stated we need more education on putting dates on food going into the refrigerator and freezer. An interview with the Dietary Supervisor on 10/19/21 at 2:15 PM indicated the peaches, cereal, lettuce, sausage patties and popcorn chicken should have been discarded and stated the [NAME] had already done it. The Dietary Supervisor further indicated the pies in the nourishment room refrigerator had been discarded as well as the Styrofoam cup and the white sealed bag in the nourishment room freezer. She stated she would be doing more education with the dietary staff regarding the dry storage room, walk in refrigerator and freezer and the nourishment room. The Dietary Supervisor stated they should be checking storage areas more often and follow-up to make sure food items are labeled and discarded after the expiration date. During an interview on 10/21/21 at 11:45 AM the Administrator revealed he was aware of the issues found in the kitchen and nourishment room. He further revealed he expected food to be labeled and discarded after the expiration date and felt the residents and families needed more education on labeling food they placed in the nourishment room refrigerator. He stated the policy was on the refrigerator door but probably wasn't being looked at.