Based on record review, and resident and staff interviews, the facility failed to address repeat concerns and to communicate the facility's efforts to address concerns voiced by residents during Resident Council meetings for 2 of 4 months reviewed (November 2024 and February 2025). The findings included: The Resident Council meeting minutes were reviewed for November 2024. Under the heading New Business, the minutes noted resident complaints of medication not being administered in a timely manner. The Resident Council meeting minutes were completed by the Activity Director. The Resident Council meeting minutes were reviewed for December 2024. Under the heading Old Business, there was no documented follow-up for the November 2024 complaint related to medication not being administered in a timely manner. The Resident Council Meeting minutes were reviewed for January 2025. Under the heading New Business, the minutes noted resident complaints of nursing assistants often rushing out of resident rooms during mealtimes without checking if they need help with opening condiment packages or containers. The minutes also noted a repeat complaint of medication not being administered at the correct time. The Resident Council meeting minutes were completed by the Activity Director. In the February 2025 meeting minutes, under the heading Old Business, there was no documented follow-up for the complaints reported in January 2025 meeting related nursing assistants rushing out of resident rooms and medication not being administered at the correct time. Under the heading New Business, was the repeat complaint regarding medication administration. The Resident Council meeting minutes were completed by the Activity Director A Resident Council meeting was conducted on 3/26/25 at 1:32 PM with the following residents; Resident #83. Resident #19, Resident #53, Resident #25, Resident #66 Resident #40, Resident #35, Resident #11, Resident #69. During the meeting residents voiced on-going concerns of medication not being administered in a timely manner and they felt staff continued to rush out of resident rooms during mealtime without offering help. Residents in the meeting stated they did not know when/if their grievances were resolved, or the outcome of complaints/grievances voiced during Resident Council meetings without asking the Social Worker. An interview conducted with the Activity Director on 3/26/25 at 5:56 PM revealed that when a grievance was brought up in the Resident Council, she would write it down on the Resident Council minutes meeting form. In the morning meeting with the interdisciplinary team, she would let the interdisciplinary team know what the resident's concerns were in the Resident Council meeting. The Activity Director reported that the Corporate Administrator reviewed the Resident Council meeting minutes every month. The Activity Director explained she was informed of a new protocol by the Corporate Administrator in early March 2025 to present the completed grievances at next month's Resident Council meeting. She explained Resident Council for March was held on 3/24/25 and she had not had time to complete the March grievances. An interview conducted with the Social Worker (SW) on 3/27/25 at 8:33 AM revealed that if a resident brought up grievance in the Resident Council meeting, the Activity Director would let her know what concerns she (Social Worker) needed to address. The Social Worker stated she would inform the Activity Director verbally how the grievances were resolved for Resident Council and the Activity Director would go over the grievances from the previous month and inform the residents' how the grievances were resolved at the next Resident Council meeting. The Social Worker stated that she did not attend the Resident Council meetings. An interview conducted with the Administrator and Director of Nursing (DON) on 3/27/25 at 12:30 PM stated the Activity Director was responsible for verbally providing the resolutions to grievances/complaints reported during Resident Council meetings at the next Resident Council meeting the following month.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, resident representative interviews and record reviews, the facility failed to convey (transfer) funds within 30 days to the resident's representative for 1 of 1 resident (Resident #194) reviewed for refund of deposit. Findings included: Resident #194 was admitted to the facility on [DATE] for respite care. The resident had an unplanned discharge to the hospital on [DATE]. Resident #194's medical record revealed there was no documentation of Resident #194's cognition. Review of a nursing note dated 12/27/24 written by Nurse # 2 revealed that all medication including narcotics and personal belongings were returned to Resident #194's resident representative and Resident #194 would be discharged from the hospital to home. On 3/25/25 at 03:45 PM an interview via telephone with Resident #194's representative occurred. The resident's representative explained her mother had been at the facility for respite care and she had submitted payment to the facility to cover the full duration of the planned stay for Resident #194. However, the resident's representative explained, the resident was discharged to the hospital, shortening the resident's stay at the facility, and then the resident was discharged from the hospital to home with the resident's representative. The resident's representative explained how she had expected a refund due to the resident's stay not being for the entire duration. She stated she called and talked to the Administrator the week of 3/17/25 about some other matters but the resident's representative had no recollection of the refund check being mentioned during the conversation with the Administrator. She stated she had still not received a refund from the facility. The Business Office Manager was interviewed on 03/26/25 11:02 AM. The Business Office Manager stated she had received payment for the intended full duration from Resident #194's resident representative and the funds were placed into a private pay account. The Business Office Manager stated she oversaw the refunds and had 30-60 days to refund the resident's money if a resident was discharged from the facility. The Business Office Manager stated she spoke with Resident #194's representative last week and she apologized to Resident #194's representative, because she had forgotten to take care of the refund after Resident #194 was discharged . The Business Office Manager stated the money for the refund was received from the corporate office late yesterday, 3/25/25. The Business Office Manager stated her plan was to call the resident's representative in the morning 3/26/25 to tell the resident's representative to come pick up her refund check. On 03/27/25 at 10:34 AM an interview occurred with the Administrator. She explained at the end of the month the facility sent a list of discharged residents sent to the corporate office. The list consisted of residents who were not expected to return and were due refunds. The Administrator stated upon receiving the check/funds from the corporate office, the Business Office Manager would then place a call to the resident or the resident's representative to pick up the refund. Pertaining to Resident # 194 the facility had documented the resident was coming back to the facility and the family chose to take the resident home from the hospital. When the facility realized the family was taking Resident #194 home, it was 15 days past the due date to provide the refund list to the corporate office.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff resident, and Medical Director interviews, the facility failed to secure a tube of medicated arthritis gel that was observed left at bedside for 1 of 1 resident (Resident #68) reviewed for medication storage. Finding included: Resident # 68 was admitted to the facility on [DATE] with a diagnosis of other specified rheumatoid arthritis. The annual [NAME] Data Set (MDS) dated [DATE] revealed Resident # 68 was moderately cognitively impaired. A physician order dated 3/11/25 for Resident #68 specified for diclofenac sodium topical gel, for arthritis pain reliever to be applied on bilateral hands, neck, right hip, and back twice a day for pain. Observation conducted during medication pass on 03/26/2025 at 11:23AM with Nurse #1 revealed a tube of topical medicated pain relief gel was kept in Resident #68's room in her bedside table in the top drawer. The arthritis pain reliver gel was visible when Resident #68 opened the top drawer. An interview with Nurse #1 on 3/26/25 at 11:23AM revealed that Resident #68 kept the topical medicated arthritis pain relief gel at her bedside. Resident # 68 would call the nurse when she was ready to have the gel applied. Nurse #1 stated the previous shift nurse gave her report that Resident # 68 kept the topical medicated arthritis pain relief gel in her bedside table in the top drawer. Nurse #1 was unaware residents could not keep medication at their bedside. An interview and observation with Resident #68 on 3/26/25 at 11:42AM revealed Resident #68's family brought the topical medicated arthritis pain relief gel from a drug store. The observation revealed the topical medicated arthritis pain relief gel remained in the top drawer of Resident #68's bedside table. Interview with Nurse #3 on 03/26/25 07:46PM revealed there was tube of topical medicated arthritis pain relief gel in the medication cart for Resident #68 that was delivered by the pharmacy. An interview with the Administrator and Director of Nursing (DON) on 3/27/25 at 8:00AM revealed the family of Resident #68 had brought the topical medicated arthritis pain relief gel to the facility without informing staff. The DON and Administrator stated Nurse # 1 was a new nurse that just started at the facility within the last week and was unaware medications could not be left at the bedside. The DON and the Administrator stated medications should not be left at the bedside and staff should have removed the topical medicated arthritis pain relief gel from Resident #68's room. A phone interview on 3/27/25 at 11:58AM with the Medical Director revealed he did not write an order for Resident #68 to have medication left at her bedside.

Based on observation and staff interviews, the facility failed to maintain food service equipment free from debris and/or dried spills, failed to remove chipped dishes for safety, failed to maintain properly functioning walk-in freezer door, failed to keep walk-in cooler floor free from standing water, failed to discard expired food from walk-in freezer, failed to ensure dishware was air dried prior to stacking for use and free from dried debris. The facility also failed to remove dented cans from usable stock for 2 of 2 kitchen observations. These practices had the potential to affect food served to residents. Findings included: a. An initial observation of kitchen equipment on 3/24/25 at 09:33am revealed the steam table had orange reddish colored debris on the steam table glass, 1 steam table divider, and 3 steam table lids. [NAME] crumbs were observed on the shelf above the stove. The initial observation further revealed 1 of 3 cake plates had white and tan debris, 1 of 3 cake plates had white debris and 1 of 3 cake plates had a chip approximately 1 inch with a sharp edge. The cake plates were stored on the tray line ready to be used. There were also 15 of 32 dome lid plate covers that were stacked wet and ready for use on the tray line. An interview with the Regional Dietary Manager on 3/24/25 at 09:35am revealed breakfast had just been served, and staff must have missed the dirty areas on the glass, 1 steam table divider and 3 steam table lids as well as the shelf above the stove. The Regional Dietary Manager stated it was her expectation that the steam table be completely cleaned after each meal and that the shelf above the stove was cleaned. The Regional Dietary Manager also said the cake plates should be clean prior to being placed on the tray line for use, broken cake plates should be thrown in the trash and the dome tray lids should be completely dry prior to stacking and placing them on the tray line. A follow up observation and interview with the Certified Dietary Manager in the kitchen on 3/26/25 at 11:33am revealed 1 divided plate with red/brown debris that was on the tray line ready for use during lunch. An interview with the Certified Dietary Manager further revealed the expectation was all dishes be clean prior to placing them on the tray line for use and she removed the dish from the tray line. b. A continued initial observation and interview on 3/24/25 at 09:40am revealed the door to the walk-in freezer door was ajar and did not close when pressed. There was ice build-up around the top of the threshold that covered the thermostat, and the temperature of the walk-in freezer was not visible/readable. There was a puddle of water on the floor at the entrance of the walk-in freezer. The Certified Dietary Manager revealed the freezer needed to be repaired so that it could close. The Certified Dietary Manager also stated the water on the floor in front of the walk-in freezer was condensation. An observation and interview the Certified Dietary Manager of the kitchen on 3/26/25 at 11:37 am further revealed the freezer door closed properly but ice remained around the threshold covering the thermostat and the temperature remained not visible/readable and the puddle of water was gone from in front of the walk- in freezer door but was now inside the walk-in cooler on the hinged side of the cooler door, in front of the produce. An interview with the Certified Dietary Manager revealed she did not know what caused the ice around the threshold or covering the thermostat but stated the water was from condensation. An interview with the Regional Dietary Manager on 3/24/25 at 09:43am revealed the walk-in freezer had previously been repaired and said she would provide paperwork and put in a new work order to repair the door by the following day. c. An observation and interview took place on 3/24/24 at 09:45 with the Regional Dietary Manager. A frozen sealed plastic bag labeled Angel Food Cake that had a discard date of 1/19/25 was found in the freezer. The Regional Dietary Manager revealed the Angel Food Cake should have been discarded already and must have been missed with the last check which she stated should have occurred on 3/21/25. d. An observation and interview with the Regional Dietary Manager and the Certified Dietary Manager took place on 3/24/25 at 09:50am of the dry food storage revealed one 7 pound can of original baked beans with 2-small, shallow linear dents at the top seal line and one 6.5 pound of canned sliced apples with one large, irregular, shallow dent along the seal line that was placed in the rack for use. An interview with both the Certified Dietary Manager and Regional Dietary Manager revealed the expectation was for dietary staff to remove dented cans from shelves and place dented cans on the bottom shelf for return. An interview with the Administrator and Director of Nursing on 3/27/25 at 1:15pm revealed the expectation was for kitchen staff to maintain clean food service equipment and follow all rules and regulations to maintain a safe and sanitary kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, family, and resident interviews, the facility failed to protect a resident's bank card from being accessed and used without resident permission for 1 (Resident #3) of 2 residents reviewed for misappropriation of resident property. Findings included: Resident #3 was admitted to the facility on [DATE] with multiple diagnoses some of which included chronic congestive heart failure and diabetes. Documentation on a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #3 was cognitively intact. Resident #3 was interviewed on 1/09/2025 at 8:45 AM and revealed the following information. A nurse aide (NA #2) had taken his bank card and used it at a local gas station in May 2024. The amount of money taken was approximately 30 to 35 dollars. The nurse aide was charged with theft, and the district attorney took the matter to court. The nurse aide no longer worked at the facility. Resident #3 indicated more information regarding the event could be obtained from his daughter, who was his power of attorney. The daughter of Resident #3 was interviewed on 1/09/2025 at 3:20 PM. The daughter explained the following events, detailing how she discovered Resident #3's missing bank card. The daughter stated she had her name on the bank account for Resident #3 and she handled his finances for him. The daughter of Resident #3 was alerted by the bank of two suspicious transactions on 5/29/2024, so she called Resident #3 to inquire if he used the bank card on those occasions. Resident #3 revealed to his daughter the bank card that he kept with his phone was missing. The daughter stated she immediately canceled the bank card and alerted the bank to the fraudulent charges, ordering Resident #3 a new bank card. The facility Administrator was interviewed on 1/09/2025 at 9:30 AM and provided the following information regarding the investigative steps and actions taken by the facility when it was brought to their attention Resident #3's bank card was missing. On 5/30/2024 at approximately noon, the Business Office Manager informed the Administrator that Resident #3 had told her his bank card was missing and had been used. Resident #3 had already left the facility for an appointment. The Administrator immediately contacted the daughter of Resident #3 and was informed the bank card of Resident #3 had been used two times at a local gas station on 5/29/2024 at 11:10 PM and 11:17 PM, the bank card was canceled, and another bank card was to be mailed to Resident #3. The family member revealed the last transaction made by Resident #3 with the missing bank card was on 5/28/2024. The local police department was called at approximately 12:30 PM on 5/30/2024 to file a report. A police officer arrived at the facility at 1:05 PM on 5/30/2024 to take a report but had to be informed Resident #3 was at an appointment and would be returning at 3:30 PM on that day. The responding police officer was provided photographs, of the fraudulent transactions made on Resident #3's bank card, which were provided to the facility by the daughter of Resident #3. On 5/31/2024 the facility interviewed all the cognitively intact residents residing in the same hallway as Resident #3, regarding any missing items, with no concerns voiced by the residents. On 5/31/2024 the Administrator spoke with a detective at the police department, who was working with the manager of the gas station where the fraudulent charges on the bank card of Resident #3 were made, to obtain video evidence to identify the suspect who used the bank card. Interviews with the facility staff were initiated on 5/31/2024 to inquire if anyone knew of the missing bank card of Resident #3, without any acknowledgment or awareness from any of the staff members. At approximately 11:30 AM on 5/31/2024, a facility housekeeper notified the Administrator the lost bank card was underneath the bed of Resident #3. The Administrator collected the bank card in a plastic bag to avoid getting fingerprints on it and notified the detective from the police department that the bank card of Resident #3 had been located. The Administrator notified the family member and Resident #3 that the bank card had been located. On 6/3/2024 the Administrator received a phone call from the detective revealing video evidence of the person using the bank card of Resident #3 was obtained from the local gas station. The Administrator received the image from the detective and identified the suspect using the debit card of Resident #3 as NA #2. On 6/3/2024 the detective came to the facility and was interviewed by the detective. NA #2 confessed to the crime and her employment was terminated with the facility. The Administrator provided the facility investigation file which included transaction details of a purchase made with Resident #3's debit card at a local gas station on 5/29/2024 at 11:10 PM and again at 11:17 PM in the amounts of $14.92 and another for $37.26. The investigation file provided by the Administrator also included the police report initiated on 5/30/2024 and completed on 6/4/2024. The police report included a supplemental narrative for the following events on 6/03/2024 at 3:00 PM. The detective interviewed NA #2 at the facility during which she was shown the photographs of herself at the local gas station on 5/29/2024 at 11:10 PM and 11:17 PM. NA #2 acknowledged that the person in the picture was her. The detective explained he was investigating the use of a stolen bank card that belonged to Resident #3. The detective told NA #2 that the photographs taken at the local gas station were of the person who used Resident #3's bank card to make purchases, explaining the bank notified Resident #3's family member of suspicious charges. At first, NA #2 denied she used Resident #3's bank card for the transactions for which she was pictured. The detective told her she was not being truthful because she was photographed at the local gas station, working in the facility the day the bank card went missing, and was assigned to the hallway where Resident #3 resided. NA #2 continued to deny she took the bank card from Resident #3 but told the detective she found the bank card in the hallway, used the bank card at the local gas station for food and then gas after the end of her nursing shift, and then returned the bank card to the hallway when she returned to work at the facility the next day. NA #2 denied she put the bank card under the bed of Resident #3 the next day despite being told of the improbability of that occurrence that someone else picked up the bank card from the hallway and put it under Resident #3's bed. NA #2 was informed by the detective that Resident #3 and a family member of Resident #3 were willing to press charges. The detective also told NA #2 he intended to seek a warrant for her arrest from the magistrate and contact her again after he had done so. The detective then went to inform the Administrator, Resident #3, and the daughter of Resident #3 of the results of the interview with NA #2. Current telephone contact information for NA #2 was not available at the time of the surveyor's investigation. The daughter of Resident #3 was interviewed on 1/9/2025 at 3:20 PM and provided the following additional information. The facility oversaw the entire investigation and made Resident #3 the priority. The bank reimbursed Resident #3 for the money charged to his bank card and acknowledged the charges made on 5/29/2024 at the local gas station were fraudulent. The District Attorney reached out to Resident #3 and with the assistance of his family member made a witness statement for the court. The case did go to court and NA #2 was given two years of probation because of her actions in fraudulently acquiring and using the bank card of Resident #3. The Administrator was interviewed again on 1/9/2025 at 1:02 PM and revealed the facility took immediate action when it was discovered Resident #3 had his bank card stolen. The proper reports to all entities required by policy and procedure, the investigation began, and interviews with 100 % of all cognitively intact residents were initiated on 5/31/2024. The QAPI (Quality Assurance and Performance Improvement) Committee met on 5/31/2024, and a Performance Improvement Plan (PIP) was implemented immediately. The facility provided the following corrective action plan with a completion date of 6/10/2024. Validation of the corrective action plan was completed on 1/10/2025. The facility's PIP for the problem area identified as Misappropriation of Property-Employee used resident's bank card for unapproved purchases initiated on 5/31/2024 was reviewed. On 5/31/2024 the bank card of Resident #3 was located. Law enforcement was notified by the administrator and law enforcement completed the investigation, substantiating the misappropriation of Resident #3's property. The facility Social Worker offered Resident #3 a lock box to contain valuables, including credit cards. On 6/10/2024 all residents/resident representatives were interviewed to determine if any other residents were affected. Residents were offered lock boxes for valuables. All cognitively impaired residents' family members/representatives were notified to retrieve valuables or obtain lock boxes from facility staff. The Administrator/designee educated staff on reporting misappropriation of property and offering lock boxes for resident valuables. This education was a part of the orientation process for newly hired staff. Beginning in July 2024 the Administrator/designee performed an audit of five residents monthly for 3 months ensuring that there had not been any misappropriation of resident property and lock boxes for valuables had been offered. The Administrator reported the results of these audits to the QAPI Committee monthly for three months for evaluation and further recommendations. Compliance date of 6/10/2024.

Based on observation and staff interview, the facility failed to maintain privacy and confidentiality for 1 of 3 resident's medical records reviewed for privacy during medication administration. (Resident #5) The findings included: An observation was conducted of Nurse #2 on 10/12/22 at 9:40 AM. Nurse #2 walked away from the 100 Hall medication cart to go to another resident's room. Nurse # 2 left the computer screen open with Resident #5's information displayed. Staff and visitors passed by the cart while the resident's information was visible. Nurse #2 returned to the cart at 9:42 AM. An observation was conducted of Nurse #2 on 10/12/22 at 9:46 AM. Nurse #2 pulled Resident #5's medication and turned to walk in the room. Nurse #2 left Resident #5's information visible on the computer screen when she left the medication cart. Staff and visitors passed by the cart while the resident's information was visible. An interview was conducted with Nurse #2 on 10/12/22 at 10:00 PM. Nurse #2 stated that should have placed the computer screen on the step away feature to prevent the resident's information from being on the screen while she was away. Nurse #2 stated that when she used this feature it required her to sign back in. An interview was conducted with the Director of Nursing and the Administrator on 10/12/22 at 11:53 AM. The Administrator stated that each computer had a tab in the right upper corner for the nurse to tap to prevent resident information from being viewed while the nurse was away from the cart. The Administrator stated that Nurse #2 should have used the privacy feature when walking away from the cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, staff and physician interviews, the facility failed to obtain a physician order for supplemental oxygen for 1 of 2 residents reviewed for oxygen (Resident #24). Findings included: Resident #24 admitted to the facility on [DATE] with diagnoses which included obstructive sleep apnea and respiratory failure. Record review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #24 was cognitively intact and was not coded for oxygen use. During observations on 10/12/22 at 3:34 pm and 10/13/22 at 9:10 am Resident #24 was observed with 2 liters (L) of oxygen via nasal canula (NC) in use. Record review of the active physician orders revealed no order for supplemental oxygen. During an interview on 10/13/22 at 9:10 am Resident #24 revealed he started using the oxygen a few days ago, but he was not sure why. Resident #24 stated he felt better with the oxygen in place. During an interview on 10/13/22 at 9:15 am Nurse #1 revealed Resident #24 had the oxygen in place for the two days she was assigned to his care. She stated Resident #24 had a history of respiratory distress and that may be the reason the oxygen was in use, but she was not certain. Nurse #1 stated she was not sure if it required a physician order. An attempt to interview Nurse #2, who was assigned to Resident #24 on 10/11/22 on the overnight shift, was unsuccessful. During an interview on 10/13/22 at 12:13 pm the Director of Nursing (DON) revealed a physician order was required for supplemental oxygen. She stated the nurse on the unit was required to enter a physician order for supplemental oxygen for Resident #24. The DON was not aware Resident #24 was on supplemental oxygen. During an interview on 10/13/22 at 12:40 the Medical Director revealed Resident #24's supplemental oxygen required an order and could be obtained from the on-call provider or himself when needed.