**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy, and staff interview, the facility failed to ensure the resident's right to request, refuse, and/or discontinue treatment for 1 of 1 closed record resident (Resident #4) reviewed for advanced directives. Failure to honor the resident/resident representative's wishes for code status resulted in unwanted treatment for Resident #4. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: This surveyor determined a deficient practice existed on [DATE]. The facility implemented corrective action and completed on [DATE]. Review of the facility policy titled Initiation of CPR/AED [cardiopulmonary resuscitation/automated external defibrillator] and BLS [basic life support] Associate Training Expectations occurred on [DATE]. This policy, dated 2018, stated, . CPR/AED will be initiated on a resident who is found unresponsive, except when: 1) a Provider medical order states a code status of DNR [do not resuscitate] . Review of Resident #4's medical record occurred on all days of survey. A Physician Order for Life Sustaining Treatment form, dated [DATE], stated, . DNR/DO NOT ATTEMPT RESUSCITATION . Review of Resident #4's nursing notes, dated [DATE], identified the following: * 7:39 a.m., At 0300hrs [3:00 a.m.], neighbor [Resident #4] was found irresponsive [sic] . was turning blue in color so I performed CPR . I checked . blood sugar and it was 66 mg/dL [milligrams per deciliter] and I called 911. [Resident #4] was sent out to [hospital] for further evaluation. * 10:13 a.m., 0920 [9:20 a.m.] - neighbor came back from [hospital] assisted by CNA [certified nurse aide] per wheelchair. Neighbor is alert, awake and conversant, confused at times. Neighbor still has dry cough, clear lung sounds, bilateral, audible grunting upon inspiration, SPO2 [oxygen saturation]: 91% [percent] at room air . [Resident #4] received only Glucagon [medication used to treat low blood sugar] nasal spray as per nurse, no IV [intravenous] fluids were given. Chest x-ray was done, no significant changes as per nurse. Labs done. During an interview on [DATE] at 1:25 p.m., an administrative staff (#1) confirmed the nurse (#2) performed CPR on Resident #4 even though the resident had a DNR order, and expected staff to follow resident code status orders. Based on the following information, non-compliance at F578 is considered past non-compliance. The facility implemented corrective actions as follows: * Educated staff nurse (#2) on the facility policy Initiation of CPR/AED and BLS Associate Training Expectations on [DATE]. * Implemented a new process to easily identify residents with a Full Code code status at the resident bedside and educated all staff on the new process on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy, and staff interview the facility failed to report incidents of resident-to-resident abuse to the State Survey Agency (SSA) for 2 of 3 sampled residents (Resident #24 and #51) and 1 supplemental resident (Resident #31). Failure to report resident-to-resident abuse allegations and the results of the facility's investigation to the SSA placed all residents at risk for possible abuse. Findings include: Review of the facility policy titled, Abuse Prevention Plan occurred on 07/24/24. This undated policy stated, . All events will be investigated whether they cause injury or harm or no injury or harm. Events may include, but are not limited to, . resident to resident altercations [a resident to resident altercation is an incident involving a resident who willfully inflicts injury upon another resident. 'Willful' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm], . If the event that caused suspicion involves abuse or results in serious bodily injury, the individual is to report the suspicion to the state immediately, but not later than 2 hours after forming the suspicion. If the event does not involve abuse and does not result in bodily injury, the individual is required to report to the state no later than 24 hours after forming the suspicion. - Review of Resident #24's medical record occurred on all days of survey. Diagnoses included psychotic disorder, schizoaffective disorder, major depressive disorder, and Alzheimer's disease. A progress note dated 06/13/24 at 10:16 a.m., stated, at 8pm last night, neighbor [Resident #24] was at [another resident] room, she started kicking him and punch him like 3-4 times while he was checking the O2 [oxygen] tubing that was tangled at [Resident #24's] wheelchair. [The other resident] then held her hand and told her to go, by the time CNA [certified nurse aide] seen her in his room and moved her back to her apartment. no injury noted, nor [sic] neighbor reported any pain, although she has known dementia [sic] and cannot recall what happened last night. neighbor to neighbor incident documentation done, POA [Power of Attorney] was notified. -Review of Resident #31's medical record occurred on 07/23/24. Diagnoses included bipolar disorder, current episode manic severe with psychotic features, primary insomnia, and other drug induced secondary parkinsonism. A progress note dated 06/08/24 at 3:02 p.m., stated, At 1:30pm, one neighbor reported to CNA that somebody slapped him, this morning the same CNA overheard a conversation of [Resident #31] that she slapped him telling at story to [another resident] about it. When [Resident #31] confronted about it, then she admitted that this [sic] happened this morning around 6-6:30 am. She verbalized that [Resident #51] was all over her face following her from nook to chapel and she was annoyed and suddenly slapped him, cannot remember if once or 2 times. She verbalized she just got up and didn't sleep well, then upon realizing what happened, she then started avoiding him. - Review of Resident #51's medical record occurred on all days of survey. The MDS, dated [DATE], showed Resident #51 unable to complete the BIMS interview. The care plan stated Problem. Behavior: I may show fluctuations in behavior r/t [related to] Korsakoff's syndrome [brain changes due to prolonged alcohol consumption] . Resident #51's progress notes showed the following: * 06/22/24 at 3:36 p.m. Neighbor was reported by the homemaker in Sunflower area that he hit [another resident], while the [Resident #51] is walking down the hallway at 2:25pm he hit him in [sic] the top of the head and cussed him. * 07/15/24 at 8:00 p.m. [Recorded as Late Entry on 07/16/2024 12:34 AM] [Resident #51] had gotten upset about something said to him by a male neighbor. He was moved away from that neighbor. A female neighbor was mad and put her fists up towards [Resident #51's] face. This triggered [Resident #51] to slap her across the left side of her face. Neighbors were again moved away from each other. CNA was able to redirect [Resident #51] to another area. The facility lacked evidence the above incidents were reported to the administrator and the SSA. During an interview on 07/23/24 at 11:45 a.m., an administrative staff member (#1) confirmed the resident-to- resident incidents had not been reported to the SSA.

Based on observation, record review, review of manufacturer's instructions for use, and staff interview the facility failed to ensure staff followed standards of practice for 3 of 4 residents (Resident #6, #23, and #40) observed during administration of rapid acting insulin. Failure to administer rapid acting insulin within the time specified by the manufacturer may result in a hypoglycemic (low blood sugar) reaction. Findings include: Prescribing information for Humalog insulin (a raid acting insulin), found at https://www.humalog.com, occurred on 07/24/24 and stated, Administer HUMALOG . within 15 minutes before a meal or immediately after a meal. Important safety information for NovoLog (a rapid acting insulin), found at novolog.com, occurred on 07/24/24 and stated, Novolog starts acting fast. Eat a meal within 5 to 10 minutes after taking it. - Review of Resident #6's medical record occurred on all days of survey. Current physician's order included, Novolog insulin; 20 units with meals three times a day. Observations on 07/22/24 showed the following: * 3:38 p.m., a nurse (#2) prepared and administered 20 units of Novolog insulin to Resident #6. *4:50 p.m., Resident #6 received the evening meal. (One hour and 12 minutes after receiving a rapid acting insulin) - Review of Resident #23's medical record occurred on all days of survey. Current physician's order included, Humalog insulin; give 8 units three times a day and sliding scale insulin based on the resident's blood glucose level. Observations on 07/22/24 showed the following: * 4:04 p.m., a nurse (#2) prepared and administered 20 units of Humalog insulin to Resident #23. *4:33 p.m., Resident #23 received the evening meal. (29 minutes after receiving a rapid acting insulin) - Review of Resident #40's medical record occurred on 07/24/24. Current physician's order included, Novolog insulin; 2 units and sliding scale insulin based on the resident's blood glucose level. Observations on 07/23/24 showed the following: * 8:43 a.m., a nurse (#3) prepared and administered 2 units of Novolog insulin to Resident #40. * 9:11 a.m., Resident #40 received the morning meal. (28 minutes after receiving a rapid acting insulin) The facility failed to follow prescribing instructions for fast-acting insulin related to timing and meals for Resident #6, #23, and #40. During an interview on 07/24/24 at 10:40 a.m., an administrative nurse (#5) confirmed she expected staff to follow the manufacture's guidelines for administering rapid acting insulin

Based on observation, review of professional reference, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 2 of 4 residents (Resident #20 and Resident #40) observed during medication administration. Four medication errors occurred during staff administration of 32 medications, resulting in a 12.5 percent error rate. Failure to properly prepare medications may result in residents receiving an ineffective dose and experiencing adverse reactions. Findings include: Review of the prescribing information for NovoLog insulin, found at www.novo-pi.com/novolog.pdf, occurred on 07/24/24, and stated, Instructions for use . C. Pull off the big outer needle cap . E. Turn the dose selector to select 2 units. F. Hold your NovoLog FlexPen with the needle pointing up. G. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to zero. - Observation of medication administration on 07/23/24 at 8:43 a.m. showed a nurse (#3) prepared a Lantus (long-acting) insulin pen and a Novolog (rapid-acting) insulin pen for Resident #40. The nurse attached a needle and with the cap on, dialed each pen to two units to prime the insulin pen. The nurse (#3) failed to remove the cap prior to priming the insulin pen. - Observation of medication administration on 07/23/24 at 9:00 a.m. showed a nurse (#4) prepared a Lantus (long-acting) insulin pen and a Novolog (rapid-acting) insulin pen for Resident #20. The nurse attached a needle, removed the cap, dialed each pen to two units, and held each pen pointed down to prime the insulin pen. The nurse (#4) failed to prime the insulin pen with the needle pointing upward. During an interview on 07/24/24 at 10:40 a.m., an administrative nurse (#5) stated she expects staff to prime the insulin pens with the cap off and with the needle pointing upwards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy, and staff interviews the facility failed to ensure residents remained free from resident-to-resident abuse for 2 of 3 sampled residents (Residents #24 and #51) and 4 supplemental residents (Resident #3, #11, #31, and #36) who received or displayed physical and/or verbal abuse. Failure to identify physical altercations between residents as physical abuse placed residents at risk for possible emotional distress and/or physical injury. This citation is considered past non-compliance based on review of the corrective action the facility implemented following the incidents. Findings include: This surveyor determined a deficient practice existed on 06/08/24. The facility implemented corrective actions and staff education on 07/16/24. Review of the facility policy titled Abuse Prevention Plan occurred on 07/24/24. This policy, dated 2017, stated, Prevention Plan: . Population of neighbors [residents] who reside in facility vary in their ability to ambulate. Neighbors may have diagnoses of dementia or other cognitive impairment. These same neighbors may exhibit behaviors which place them or others at risk. Neighbors who are not able to verbalize needs may be at increased risk for abuse/neglect. 'Abuse': The willful infliction of injury, . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. In includes verbal abuse . physical abuse, and mental abuse . (1) hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult; (2) use of repeated or malicious oral, written, or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening: . - Review of Resident #24's medical record occurred on all days of survey. The record identified diagnoses of psychotic disorder, schizoaffective disorder, major depressive disorder, and Alzheimer's disease. The current care plan stated, I am susceptible to abuse related to cognitive impairment due to Alzheimer's, dementia, and psychosis and physical impairment due to obesity and gout. I have a hx [history] of verbal and physical aggression. Report and investigate suspected abuse cases in accordance with facility policies and procedures . If I become violent or physically aggressive the facility shall implement interventions to minimize risk to self, others within the facility, or visitors and community members as appropriate . Review of Resident #24's progress notes identified the following: * 06/13/24 at 10:16 a.m., at 8pm last night, [Resident #24] was at [Resident #3's room], [Resident #24] started kicking him and punch [sic] him like 3-4 times while he was checking the O2 [oxygen] tubing that was tangled at [Resident #24's] wheelchair. [Resident #3] then held her hand and told her to go, by the time CNA [certified nursing assistant] seen her in his room and moved her back to her apartment. no injury noted, nor neighbor reported any pain, although she has known dementia case [sic] and cannot recall what happened last night. neighbor to neighbor incident documentation done . * 06/17/24 at 10:30 a.m., IDT [interdisciplinary team] met to review neighbor to neighbor incident that was documented on 6/13/24. [Resident #3] was trying to help [Resident #24] out by untangling his oxygen tubing from her w/c [wheelchair]. [Resident #24] mistook the other neighbor's actions and was physically aggressive with him. His response was appropriate and did not cause any harm to [Resident #24]. Will educate neighbor to call for staff assistance to remove other neighbors from his room to avoid future conflict. Review of the facility's investigation documents identified the facility notified the POAs for each resident involved and completed 15-minute safety checks for 24 hours for each resident. -Review of Resident #31's medical record occurred on July 23, 2024. Diagnoses included bipolar disorder, current episode manic severe with psychotic features, primary insomnia, and other drug induced secondary parkinsonism. The current care plan stated, I am susceptible to abuse related to my mental health disorders. Report and investigate suspected abuse cases in accordance with facility policies and procedures; I will not commit abuse to other vulnerable adults. If I become violent or physically aggressive the facility shall implement interventions to minimize risk to self, others within the facility, or visitors and community members as appropriate. Review of Resident #31's progress notes identified the following: * 06/08/24 at 3:02 p.m., At 1:30pm, one neighbor reported to CNA that somebody slapped him, this morning the same CNA overheard a conversation of [Resident #31] that she slapped him telling at [sic] story to [another resident] about it. When [Resident #31] confronted about it, then she admitted that this was [sic] happened this morning around 6-6:30 am. She verbalized that [Resident #51] was all over her face following her from nook to chapel and she was annoyed and suddenly slapped him, cannot remember if once or 2 times. She verbalized she just got up and didn't sleep well, then upon realizing what happened, she then started avoiding him. * 06/10/24 at 11:06 a.m.,IDT [interdisciplinary team] to review neighbor to neighbor incident that occurred on 6/8/24 at approximately 6:30am. [Resident #31] did verbalize that she slapped another neighbor as he was following her around and she became irritated. This is not in [Resident #31's] baseline behavior and due to her current manic state she is having difficulty controlling her impulses. [Resident #31] was seen on rounds on 6/7/24 for her mania and was prescribed Lyrica [medication to treat nerve pain] as she complained to the provider of pain at that time. [Resident #31's] sister/POA [name] has advised IDT that the only way to get [Resident #31] out of this mania state is for her to sleep. All facility policies and procedures were followed including both neighbors being on 15 minute checks and all proper notifications were made. [Resident #31] has not exhibited any further instances of aggression towards staff or other neighbors since the incident. - Review of Resident #51's medical record occurred on all day of survey. The care plan stated Problem. Behavior: I may show fluctuations in behavior r/t [related to] Korsakoff's syndrome [brain changes due to prolonged alcohol consumption]. I explore my environment frequently. I enjoy moving things around within my environment. At times you may hear me talking to myself. I have been verbally and physically aggressive with staff. I become agitated when unable to locate my 'stuff' or my room. I have been involved in neighbor to neighbor incidents. I have made sexual comments to staff. Approach . If I am following other neighbors around and they don't like it, redirect me to another area. You may trial aromatherapy with me during times of restlessness, agitation, or tearfulness. Resident #51's nursing progress notes identified the following: * 06/08/24 at 2:47 p.m., at 1:30 pm, neighbor reported to CNA that some lady slapped him. Early that morning the CNA overheard a conversation of [Resident #31] that she slapped 'him' telling a story to [another resident] about it. when [Resident #31] were interviewed, she admitted that this happened this morning around 6-6:30 am. She verbalized that room [Resident #51] was all over her face following her from nook to chapel and she was annoyed and suddenly slapped him, cannot remember if once or 2 times. she verbalized she just got up and didn't [sic] sleep well, then upon realizing what happened, she then started avoiding him. this incident was unwitnessed. [Resident #51] was then interviewed and assessed for any injury and said the same thing that some lady slapped him, although he denies pain. no redness on face. * 06/10/24 at 11:11 a.m., IDT met to review neighbor to neighbor incident that occurred on 6/8/2024 at approximately 6:30am. Another neighbor did verbalize that she slapped [Resident #51] as he was following her around and she became irritated. Due to [Resident #51's] cognitive impairment he does follow other people around at times if not redirected. Staff will be educated that if he is following a neighbor around and they do not want him to, staff should redirect [Resident #51] to a different area. All facility policies and procedures were followed including both neighbors being on 15 minute checks and all proper notifications were made. The other neighbor has not exhibited any further instances of aggression towards staff or other neighbors since the incident. [Resident #51] has not exhibited any ill effects from the incident and his mood has been intact since. Will continue with current plan of care. * 06/22/24 at 3:36 p.m. Neighbor [Resident #51] was reported by the homemaker in Sunflower area that he hit neighbor [Resident #36], while the neighbor [Resident #36] is walking down the hallway at 2:25pm he hit him in [sic] the top of the head and cussed him. Neighbor came back to the homemaker and apologized. Aroma therapy given and monitored. After 15min, neighbor was seen in good mood and greeting other neighbors. [Resident #51 power of attorney (POA)] informed thru phone. * 06/24/24 at 9:45 a.m. IDT met to review neighbor-to-neighbor incident that occurred on 6/22/24 and behavior documented on 6/23/24. The neighbor to neighbor incident was not witnessed but was reported by the other neighbor involved. Although that neighbor also has cognitive impairment, it is within his cognitive ability to reliably report the incident. Staff reactions were appropriate to neighbor to neighbor incident. All notifications were made per facility policy. Nursing appropriately conducted necessary assessments. 15-minute checks were implemented and completed per facility policy as well. [Resident #51] has been showing increased anxiety and aggression in the afternoons. Staff reaction and interaction can exacerbate these symptoms at times. Many of these times it is difficult to determine a trigger. Food, fluids, and aromatherapy have been trialed with some effectiveness. It is also known that he does not sleep for long amounts of time and does not nap during the day. IDT recommends that [Resident #51] be seen by [Psychiatrist's name] on psych rounds on 6/25/24 as previously scheduled. Staff training and education also recommended on how to approach [Resident #51] when he is showing s/s [signs/symptoms] of anxiety and how to de-escalate the situation when he is seeming aggressive. * 07/15/24 at 8:00 p.m. [Recorded as Late Entry on 07/16/2024 12:34 AM] [Resident #51] had gotten upset about something said to him by a male neighbor. He was moved away from that neighbor. A female neighbor [Resident #11] was mad and put her fists up towards [Resident #51's] face. This triggered [Resident #51] to slap her across the left side of her face. Neighbors were again moved away from each other. CNA was able to redirect [Resident #51] to another area. [Resident #51's POA] was notified of the event. Told her that we would be doing 15-minute checks on him for the next 24 hours. She is worried that we are changing his meds to fast. Explained that we work with [Psychiatrist's name] and he does the actual med changes. She seem [sic] alright with this. * 07/16/24 at 5:55 p.m. IDT met to review neighbor-to-neighbor that occurred on 7/15/24. [Resident #51] had gotten upset about something said to him by a male neighbor. He was moved away from that neighbor. CNA was able to redirect [Resident #51] to another area. [Resident #51's POA] was notified of the event. Told her that we would be doing 15-minute checks on him for the next 24 hours. She is worried that we are changing his meds to fast. Explained that we work with [Psychiatrist's name] and he does the actual med changes. She seem alright with this. All community policies were followed and all notifications made per policy as well. [Resident #51] does not recall the situation and has not displayed any adverse effects from the incident. [Resident #51] has had multiple med changes since admission. Group staff education completed as well as 1:1 [one to one] staff education specific to redirecting and interacting with [Resident #51] throughout the day and during times of agitation. IDT has been unable to determine triggers and/or patterns as to the behaviors. Care conference will be held with [POA] to discuss appropriateness of placement. During an interview, on 07/23/24 at 11:45 a.m. an administrative staff member (#1) identified she provided education to the staff on interventions/tools for Resident #51 to prevent resident and/or staff harm. The facility failed to identify the above incidents as physical abuse. Based on the following information, non-compliance at F600 is considered past non-compliance. The facility implemented corrective actions. * The IDT met after each incident to problem solve and implement changes * Policies were reviewed to make sure they were followed * Providers and resident representatives were notified * Group staff education was completed as well as 1 to 1 staff education specific to redirecting and interacting with residents' with behaviors

Based on observation, record review, review of facility policy, staff and resident interview, the facility failed to ensure the interdisciplinary team assessed the appropriateness to self-administer medications (SAM) for 1 of 1 supplemental resident (Resident #2) with medications observed in the room. Failure to determine whether SAM is a safe practice has the potential to limit a resident's right to SAM or result in a medication error and/or harm to a resident. Findings include: Review of the facility policy titled Self-Administration of Medication occurred on 09/07/23. This policy, dated 2020, stated, . 1. The nursing associates will assess each resident's mental and physical abilities. Assessment is documented in the EHR [Electronic Health Record]. 3. If it is determined a resident cannot safely administer medications, the nursing associates will administer the medication. Observations during medication administration on 09/05/23 at 4:11 p.m., showed a bottle of Refresh Plus (Sterile eye drops) located in Resident #2's room. When asked, Resident #2 stated, I'm allowed to use them and do them by myself whenever I need them. Review of Resident #2's medical record occurred on 09/05/23. The record showed a SAM assessment on 06/29/21 documented in the EHR indicated Resident #2 cannot safely self-administer medications. During an interview on 09/07/23 at 8:14 a.m., an administrative staff member (#1) confirmed Resident #2 is not appropriate for SAM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of professional reference, and staff interview, the facility failed to ensure staff followed standards of practice for 1 of 3 sampled residents (Resident #13) with an indwelling catheter. Failure to follow physician's orders for residents with indwelling catheters may result in delayed treatment, pain and/or worsening of resident's condition. Findings include: [NAME], [NAME], and Frandsen's Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th ed., Pearson Education, Inc., page 63, states, . Carrying Out a Physician's Orders . If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out. Review of Resident #13's medical record occurred on all days of survey. Diagnoses included neuromuscular dysfunction of bladder and urinary retention. A physician order signed on 02/23/22, stated, Next appointment 1 [one] year. The medical record lacked evidence of a follow up physician visit. During an interview on 09/07/23 at 10:03 a.m., an administrative staff member (#1) confirmed the facility failed to make the follow-up appointment as ordered.

Based on observation, record review, and staff interview, the facility failed to provide appropriate and sufficient supervision and/or assistive devices for 1 of 4 sampled residents (Resident #13) observed during a pivot transfer. Failure to provide adequate assistance and use the assistive devices properly during transfers placed the residents at risk for accidents, falls, or injuries. Findings include: The facility failed to provide a copy of their policy addressing transfers. Review of Resident #13's medical record occurred on all days of survey and included diagnoses of multiple sclerosis and incomplete paraplegia. The current care plan stated, . I do need assistance with mobility due to weakness, unsteadiness, and diagnosis of multiple sclerosis and paraplegia. A1 [assist of one] to stand pivot transfer with FWW [front wheeled walker] and gait belt . During an observation on 09/06/23 at 8:29 a.m., a certified nurse aide (CNA) (#5) stood at the end of Resident 13's bed while the resident slid himself to the edge of the bed, stood, swung his hips towards the wheelchair, and landed roughly and misaligned into the wheelchair. The CNA (#5) failed to assist the resident with the transfer by using the walker and applying a gait belt. During an interview on 09/07/23 at 10:01 a.m., an administrative nurse (#1) confirmed Resident #13 transferred incorrectly and stated she expected staff to follow the resident's care plan.

Based on facility policy, record review, and staff interview, the facility failed to ensure a physician's response to changes in resident's weight for 3 of 3 sampled residents (Resident #23, #44, and #45) with significant weight loss. Failure to ensure the physician responded in a timely manner may result in a delay of treatment and further weight loss for residents. Findings include: Review of the facility policy titled Weight Monitoring and Documentation occurred on 09/07/23. This policy, dated August 2019, stated, . 7. Resident's weights are tracked monthly through an established monitoring system to ensure that significant changes are identified and addressed . 10. The physician . will be notified on any significant weight change. - Review of Resident #23's medical record occurred on all days of survey. Diagnoses included diabetes mellitus, diverticulosis, Parkinson's, and dementia. The current care plan stated, . I'm at risk for weight changes/nutritional deficiency due to dx Dementia, Diabetes and Diverticulosis. Assist me with meals. Review of dietary progress notes identified the following: 08/22/23 at 4:41 p.m., Nutrition: Weight-119.8# [pounds] (8/22). Weight has been decreasing over the past several months with a weight loss of 11# noted from 3 months ago. Review of the physician progress notes from February 2023 through August 2023 lacked evidence the physician acknowledged or addressd Resident #23's significant weight loss. - Review of Resident #44's medical record occurred on all days of survey. Diagnoses included diabetes mellitus and hypothyroidism. The current care plan stated, . I'm at risk for weight changes/nutritional deficiency due to dx's[diagnoses] of type II [two] diabetes mellitus, hypertension and hypothyroidism. I may be forgetful and confused at times . A dietary progress note dated, 03/17/23 at 11:35 a.m., stated, .Weights: 179.8# (3/16), 187.2# (2/19), 203#(12/14), 220.6# (9/14). Neighbor continues to lose weight with significant weight loss of 40.8# (18%) noted in the past 6 months. Review of physician progress notes from October 2022 through September 6, 2023 lacked evidence the physician acknowledged or addressed Resident #44's significant weight loss. - Review of Resident #45's medical record occurred on all days of survey. Diagnoses included dementia and macular degeneration. The current care plan stated, . I'm at risk for weight changes/nutritional deficiency due to Dementia. A dietary progress note, dated 05/30/23 at 3:50 p.m., stated, . Weights: 82# (5/29), 86.1# (4/30), 84.8# (3/5), 92.2# (12/1). Significant weight loss of 10.2# (11%) noted in the past 6 months. Review of physician progress notes from January through July 2023 lacked evidence the physician acknowledged or addressed Resident #45's significant weight loss. During an interview on 09/07/23 at 9:25 a.m., an administrative nurse (#1) confirmed the physician progress notes lacked evidence the physician acknowledged or addressed the significant weight loss for Resident #23, #44, and #45.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 5 of 13 sampled residents (Resident #11, #14, #21, #26, and #27) and one supplemental resident (Resident #33). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION K: SWALLOWING/NUTRITIONAL STATUS The Long-Term Care Facility RAI User's Manual, revised October 2019, page K-3 through K-9, stated, . Coding Instructions . K0310: Weight Gain . Code 0, no or unknown: if the resident has not experienced weight gain of 5% or more in the past 30 days or 10% or more in the last 180 days or if information about prior weight is not available. Code 2, yes, not on physician-prescribed weight-gain regimen: if the resident has experienced a weight gain of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight gain was not planned and prescribed by a physician. - Review of Resident #14's medical record occurred on all days of survey. Diagnoses include congestive heart failure and chronic kidney disease. A dietary progress note dated, 06/28/23 at 9:11 a.m., stated, . Weight continues to increase with weight gain of 8.4# [pounds] (5.7%) in the past month and 20.8# (15.4%) in the past 6 months. The quarterly MDS, dated [DATE], identified section K0310, coded 0, no weight gain. During an interview 09/07/23 at 9:15 a.m., the dietary manager (#8) confirmed staff incorrectly coded section K of the MDS for Resident #14. SECTION I: ACTIVE DIAGNOSES IN THE LAST 7 DAYS The Long-Term Care Facility RAI User's Manual, revised October 2019, page I-7, stated, . Identify diagnoses: The disease conditions in this section require a physician-documented diagnosis . in the last 60 days. Medical record sources for physician diagnoses include progress notes, the most recent history and physical, transfer documents, discharge summaries, diagnosis/problem list, and other resources as available. Diagnostic information, including past history obtained from family members and close friends, must also be documented in the medical record by the physician to ensure validity and follow-up . Review of Resident #27's medical record occurred on all days of survey. The resident's current diagnosis list identified schizoaffective disorder as of 08/18/22. The quarterly MDS assessments, dated 11/04/22, 02/04/23, and 05/04/23, identified schizoaffective disorder as an active diagnosis. Resident #27's medical record failed to show a clinical rationale for the diagnosis of schizoaffective disorder. During an interview on 09/07/23 at 11:39 a.m., an administrative nurse (#1) confirmed the facility staff incorrectly coded Resident #27's MDSs for a diagnosis of schizoaffective disorder. SECTION N: MEDICATIONS The Long-Term Care Facility RAI User's Manual, revised October 2019, pages N-6 and N-7, stated, . Coding Instructions . N0410E, Anticoagulant (e.g., warfarin, heparin, or low- molecular weight heparin): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). - Review of Resident #11's medical record occurred on all days of survey. Diagnoses included cerebral vascular accident (stroke) due to thrombosis (blood clot). A physician's order, dated 11/26/19, stated, Eliquis (apixaban) [anticoagulant] tablet; 5 mg [milligrams]; amt [amount]: 1 tab [tablet]; oral Twice A Day . The quarterly Minimum Data Set (MDS), dated [DATE], identified Resident #11 received an anticoagulant on 0 of 7 days. Staff failed to code the MDS accurately for anticoagulants. - Review of Resident #21's medical record occurred on all days of survey. A physician's order, dated 03/09/23, stated, Eliquis (apixaban) tablet; 5 mg; amt: 1 tab; oral Twice A Day. The quarterly MDS, dated [DATE], identified Resident #21 received an anticoagulant on 0 of 7 days. Staff failed to code the MDS accurately for anticoagulants. - Review of Resident #26's medical record occurred on all days of survey. A physician's order, dated 11/14/2022, stated, Xarelto (rivaroxaban) [anticoagulant] tablet; 20 mg; amt: 1 tab; oral Once A Morning . The annual MDS, dated [DATE], identified Resident #26 received an anticoagulant on 0 of 7 days. Staff failed to code the MDS accurately for anticoagulants. - Review of Resident #33's medical record on all days of survey. Diagnoses included embolism and thrombosis (blood clot). A physician's order, dated 12/26/22, stated, Eliquis (apixaban) tablet; 5 mg; amt: 1 tablet; oral Twice A Day . The quarterly MDSs, dated 03/26/23 and 06/23/23, identified Resident #33 received an anticoagulant on 0 of 7 days. Staff failed to code the MDS accurately for anticoagulants. During an interview on 09/07/23 at 9:20 a.m., an administrative nurse (#7) confirmed staff incorrectly coded section N of the MDS for Resident #11, #21, #26, and #33.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 2 of 7 sampled residents (Resident #14 and Resident #27) and 5 supplemental residents (#1, #12, #18, #39, and # 47) observed during personal cares or transfers. Failure to practice infection control standards related to hand hygiene and cleaning of mechanical lifts has the potential to spread infection throughout the facility. Findings include: HAND HYGIENE: Review of the facility policy titled Hand Hygiene occurred on 09/06/23. This policy, effective June 2017, stated, . all associates will be trained and competent in following proper hand hygiene practices. Times to Perform Hand Hygiene are, but not limited to .Before and after direct resident contact . Before and after assisting a resident with personal cares . Before and after assisting a resident with toileting . After contact with a resident's mucous membranes and body fluids or excretions . After removing gloves or aprons . - Observation on 09/05/23 at 3:53 p.m. showed two certified nurse aides (CNAs) (#2 and #3) completed perineal cares for Resident #18. The CNA (#2) cleansed the resident's perineal area, discarded the wet incontinent product, removed his gloves, donned a new pair of gloves, and placed a clean incontinent product on the resident. The CNA (#2) without performing hand hygiene, placed the resident's shoes on, transferred the resident with a mechanical lift, removed the lift sling and strap, emptied the garbage, combed the resident's hair and turned on the television. The CNA failed to perform hand hygiene between glove changes and before completing other tasks. - Observation on 09/05/23 at 4:08 p.m. showed two CNAs (#2 and #11) completed perineal cares for Resident #27. A CNA (#11) cleansed the resident's perineal area with a wipe and rolled the resident onto their right side. The CNA (#11) then removed her gloves and donned a new pair of gloves without performing hand hygiene. While Resident #27 was on their side, the other CNA (#2) placed a clean incontinent product under the resident, cleansed the resident's bottom with a wipe, removed his gloves and donned a new pair of gloves without performing hand hygiene. Both CNAs transferred the resident with a mechanical lift, adjusted her clothing, and removed the lift sling and strap. CNA #2 sanitized the lift, combed the resident's hair, gave the resident a drink of water, and opened the blinds before washing his hands. CNA #11 exited the room with the lift and the garbage without performing hand hygiene prior to exit. Both CNAs (#2 and #11) failed to perform hand hygiene between glove changes and before completing other tasks. - Observation on 09/06/23 at 9:07 a.m. showed a CNA (#6) donned gloves, performed perineal cares for Resident #14, removed the soiled brief, removed her gloves, adjusted her uniform top, and without performing hand hygiene, donned new gloves, applied skin barrier cream and applied a clean brief. The CNA removed her soiled gloves, tied the garbage bag, adjusted her uniform top, and without performing hand hygiene donned new gloves, washed Resident #14's underarms, dressed the resident's lower half, and assisted the resident to the wheelchair. The CNA (#6) removed her gloves, exited the room, obtained a portable oxygen concentrator, and returned to the room. The CNA failed to perform hand hygiene when he/she exited/entered the room. The CNA (#6) switched Resident #14's oxygen tubing from the room concentrator to the portable unit and touched the nasal cannulas as she applied the tubing to the resident. The CNA (#6) donned gloves, stripped the linen from the bed, put linen in a plastic bag, removed her gloves, failed to perform hand hygiene and exited the room. DISINFECTING LIFTS Review of the facility policy titled Resident Care Equipment occurred on 09/07/23. This policy, dated July 2017, stated, . Associates will disinfect reusable equipment between resident uses using EPA approved disinfectant. Observation on 09/05/23 showed staff completed resident transfers with mechanical lifts and failed to disinfect the lifts after or between each resident use as follows: * At 12:49 p.m., Resident #1 full body transfer lift. * At 1:15 p.m. and 4:11 p.m., Resident #12 sit-to-stand transfer lift. * At 2:31 p.m., Resident #47 sit-to-stand transfer lift. * At 3:03 p.m., Resident #39 sit-to-stand transfer lift. During an interview on 09/07/23 at 10:25 a.m., two administrative staff members (#1 and #10) stated, Our expectation of our staff regarding hand hygiene is to follow the Hand Hygiene policy. They further stated, Our expectation of our staff regarding disinfecting mechanical lifts is to follow the policy. Staff are to clean the lifts between and after each resident use.

Based on information provided by the complainant, policy review, and staff interview, the facility failed to report an abuse allegation to the State Survey Agency within two hours and the results of the investigation within five working days for 1 of 1 sampled resident (Resident #1) who alleged they were sexually assaulted. Failure to report an abuse allegation and the results of the facility's investigation to the State Survey Agency placed all residents at risk for possible abuse. Findings include: The complainant reported Resident #1 hollered he tried to rape me in the dining room in front of other residents, staff members, and visitors on 03/19/23. When questioned, Resident #1 gave a vague description of one of the staff members as the alleged perpetrator. The complainant alleged the facility failed to report and investigate the allegation. Review of the facility policy titled Abuse Prevention Plan occurred on 04/03/23. This policy, dated 2017, stated, . Possible Incidents Which Need Investigation . Any person with the knowledge or suspicion of suspected abuse . must report immediately, without fear of reprisal and/or retaliation. If the event that caused the suspicion involves abuse . the individual is required to report the suspicion to the state immediately, but not later than 2 hours after forming the suspicion. Within five working days . the Director of Nursing, Director of Social Services, or their designee will electronically submit the facility's investigative report to the appropriate state agency. 'Sexual abuse': non-consensual sexual contact of any type with a resident . When asked questions pertaining to the facility's reporting process, staff interviews on 03/30/23 identified the following: * At 2:18 p.m., a social services staff member (#2) indicated, A concern is reported to the charge nurse who passes it on to me. We do not have a form for a concern [abuse allegation]. Sometimes we use a behavior sheet. The form goes to the charge nurse who signs it, showing they received it. The forms are filed in one of two boxes, in my office or on the unit. * At 2:25 p.m., a CNA (certified nursing assistant) (#3) stated, We fill out a behavior form and let the charge nurse know. It [the form] goes in the social worker's box. I gave the sheet [regarding Resident #1's allegation] to [the nurse]. It was during change of shift. * At 4:05 p.m., the social services staff member (#2) stated, They called me on the 19th [of March - the day Resident #1 made the allegation] about this. The charge nurse had assessed her. There was nothing [no visible injuries], no bruises. If the nurse said she saw something [an injury], then I would have reported it. Review of State Agency records lacked evidence the facility reported Resident #1's sexual assault allegation. Facility staff failed to report Resident #1's assault allegation within two hours and failed to report the results of their investigation within five working days of the incident. Refer to F610.

Based on information provided by the complainant, record review, policy review, and staff interview, the facility failed to thoroughly investigate an abuse allegation for 1 of 1 sampled resident (Resident #1) who alleged they were sexually assaulted. Failure to thoroughly investigate all abuse allegations, ensure residents are protected, and implement safety measures during the investigation placed all residents at risk for possible abuse. Findings include: The complainant reported Resident #1 hollered he tried to rape me in the dining room in front of other residents, staff members, and visitors on 03/19/23. When questioned, Resident #1 gave a vague description of one of the staff members as the alleged perpetrator. The complainant alleged the facility failed to report and investigate the allegation. Review of the facility policy titled Abuse Prevention Plan occurred on 04/03/23. This policy, dated 2017, stated, . All . allegations of abuse . will be thoroughly investigated by the Director of Social Services, Director of Nursing, or their appropriate designees. All events will be investigated whether they cause injury or harm or no injury or harm. Measures will be taken to identify the source of the alleged abuse and prevent future incidents. Identify and interview all who might have knowledge of the incident including the alleged victim, perpetrator . or others who may have had related contact with the alleged perpetrator, related to the incident in question. The focus of the investigation is to determine the extent, cause and future prevention with thorough documentation of the investigative process completed . safety measures may include . Responding immediately to protect the resident or alleged victim from further abuse . Examining the alleged victim for any sign of injury, including a physical examination . Providing increased staff supervision of resident, as needed . Providing alternate caregiver(s) to the resident, as appropriate. 'Sexual abuse': non-consensual sexual contact of any type with a resident . Review of Resident #1's medical record occurred on 03/30/23. Diagnoses included anxiety, dementia, depression, and psychotic disorder with hallucinations. A social services assessment, dated 02/20/23, identified, . [Resident #1] . scored 3 on the BIMS [Brief Interview for Mental Status] indicating . severe impairment. When asked questions pertaining to the facility's abuse investigation process, staff interviews on 03/30/23 identified the following: * At 2:18 p.m., a social services staff member (#2) indicated, A concern is reported to the charge nurse who passes it on to me. She enters a progress note. The forms [behavior tracking sheets] are filed in one of two boxes, in my office or on the unit. ITD [the interdisciplinary team] then reviews the incident and will update the care plan if needed. * At 2:25 p.m., a CNA (certified nursing assistant) (#3) stated, I put in a behavior form [regarding Resident #1 on 03/19/23]. She [Resident #1] told me, 'A . guy came in and took my clothes off, took his clothes off, and was about to do something bad to me, when the door suddenly opened, and he ran out.' Another . CNA walked into the room with another resident. I [CNA #3] asked her [Resident #1] if that was him [alleged perpetrator] and she said, 'No, it was the meaner looking one.' This was not typical behavior for her. I gave the sheet to [the nurse]. It was during change of shift. On 03/30/23 at 3:50 p.m., the social services staff member (#2) located and provided copies of the behavior tracking forms submitted by three CNAs (#3, #6, and #7) on 03/19/23 addressing Resident #1's assault allegation. The forms identified the following: * CNA (#6) stated, [CNA #7] brought [Resident #1] into [sic] dining room to her table. She [Resident #1] said to me as I approached in a loud voice 'he tried to rape me .' I asked 'rip' you [sic] she screamed, banged her fist on the table [sic] yelled 'no, rape me.' I said who him pointing to [CNA#7] she said 'no the other [male]' then repeated pointing at [CNA #7] 'not him the other [male] he's not here.' * CNA (#7) stated, . I asked her [Resident #1] can I put your feet back from [sic] the padel [sic]. After that she started [sic] agitate [sic]. Getting her close to dinner table, [CNA #6] stopped by and asked her if everything [sic] okay. [Resident #1] said he rap [sic] me. [CNA #6] ask [sic] again is [CNA #7] and she said no. * CNA (#3) stated, I was approached by Culinary staff that [Resident #1] was upset and to please come talk to her. I approached the neighbor [Resident #1] slowly and kneeled down beside her. I asked her if she was okay and she said I guess I have to be. I then asked what happened she said a . man ripped her clothes off and took his clothes off and was trying to do bad things to her, the door opened and he [ran out] . On 03/30/23 at 4:05 p.m., when asked questions pertaining to the steps taken after the allegation was reported to the nurse, the social services staff member (#2) stated, They [the nurse] called me on the 19th [03/19/23] about this. The charge nurse had assessed [Resident #1]. There was nothing [no visible injuries], no bruises. [Resident #1] is always making claims. She tells wild stories. Ever since her [femur] surgery, she has been declining and hallucinating. She is not a valid witness. If the nurse said she saw something [an injury], then I would have reported it. When I talked to her on the 20th, [Resident #1] wasn't saying this [assault allegation]. When asked if it was typical for Resident #1 to make assault accusations, an administrative staff member (#5) and the social services staff member (#2) responded, No. On the afternoon of 03/30/23, the social services staff member (#2) indicated she interviewed Resident #1 on 03/20/23 and provided a copy of her handwritten notes. She documented that the resident used nonsensical speech, talked about cats and dogs, appeared unafraid, and did not mention men. The medical record lacked evidence the nurse examined Resident #1 for any sign of injury as per facility policy. On 03/31/23 at 11:00 a.m., the administrative staff member (#5) confirmed the nurse failed to document the results of Resident #1's physical examination. Per facility policy, the facility failed to: * thoroughly investigate an allegation of sexual assault, whether there was evidence of an injury or not, * examine the alleged victim for any sign of injury and document the results of the exam in the resident's medical record, * identify and interview everyone who had knowledge of the incident, * take measures to identify the source of the alleged abuse, * provide increased supervision for the alleged victim and/or provide alternate caregivers as deemed appropriate, and * ensure thorough documentation of their investigation process. Refer to F609.