**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and observations, the facility failed to update a resident's care plan after the development of a pressure ulcer. This affected one (#91) of two residents reviewed for pressure ulcers. The facility census was 105. Findings include: Review of the medical record revealed Resident #91 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, chronic kidney disease, anxiety disorder, dysphagia hypertension, and tachycardia. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #91 had severe cognitive impairment. Resident #91 was assessed to require one-person extensive assistance with transfers, dressing, and bathing, supervision with eating, and two-person extensive assistance with toileting. Review of the care plan dated 06/04/22 revealed Resident #91 had impairment to skin integrity related to immobility, weakness, and open area on sacrum. Interventions included encourage good nutrition and hydration in order to promote healthier skin. Staff to keep her clean, dry, and comfortable with bathing, linen, and gown changes as needed. Wound nurse to follow her. Staff to keep skin clean and dry and use lotion on dry skin. Staff to ensure pressure relieving mattress and wheelchair cushion. Staff to complete treatments as ordered. Review of the care plan revealed Resident #91's skin integrity care plan had not been accurately updated after the development of her pressure sore on 06/14/22. An intervention for Resident #91 to be followed by the wound nurse was added on 07/26/22. No other interventions were added after a deterioration in pressure ulcer. Review of the physician order dated 06/05/22 revealed Resident #91 was ordered to apply Chasmosyn ointment to coccyx and monitor for redness every shift and as needed. Review of the physician order dated 06/07/22 revealed Resident #91 was ordered [NAME] supplement three times a day for supplement per family request. Review of the physician order dated 06/14/22 revealed Resident #91 was ordered to cleanse area on sacrum with normal saline, apply Silvadene and Aquaphor and cover with dry dressing every Tuesday and Thursday. Review of the progress note dated 06/14/22 at 1:47 P.M. revealed Resident #91 had an area noted on sacrum. Treatment was ordered and initiated. Call was placed to skin team for a follow-up, and a pressure relief cushion was placed to wheelchair and recliner. Review of the progress note dated 06/17/22 at 12:14 P.M. revealed Resident #91's coccyx was assessed, and an open area with slough was noted. Wound consult was obtained. Review of the wound progress note dated 06/20/22 revealed Resident #91 had a sacral wound that measured 1.7 centimeters (cm) length by 1.3 cm width and unable to determine in depth. Plan of care revealed to continue Aquaphor with Silvadene and gauze dressing every shift, and a pressure reduction mattress and cushion to bed and wheelchair. Review of the wound progress note dated 07/18/22 revealed Resident #91 had a sacral wound that measured 1.8 cm length by 1.2 cm width by 0.3 cm depth. Plan of care revealed to continue Aquaphor with Silvadene ad gauze dressing to sacrum every shift. Staff to continue to assist with activities of daily living and supplements. Review of the wound progress note dated 07/25/22 revealed Resident #91 had a sacral wound that measured 1.5 cm length by 0.8 cm width by 0.3 cm depth. Plan of care revealed to continue with Aquaphor with Silvadene and gauze dressing to sacrum every shift. Staff to encourage and assist Resident #91 to turn and reposition every two hours while in bed and to shift weight every hour while in chair. Review of the medical record revealed intervention to turn and reposition Resident #91 was not added to care plan or physician orders. Observation on 08/08/22 at 1:57 P.M. of wound Nurse Practitioner (NP) #300 and Licensed Practical Nurse (LPN) #146 completed a dressing change to Resident #91. The sacral wound measured 1.6 cm length by 0.6 cm width and 0.2 cm depth. The wound was cleaned with normal saline. Silvadene was applied to wound bed and covered with dry gauze. Interview on 08/08/22 at 2:03 P.M. with wound NP #300 revealed interventions including a pressure reduction mattress/cushion as well as turning and repositioning was part of the standard plan of care and should have been added accordingly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interviews, review of the facility shower schedules, and policy review, the facility failed to ensure residents received showers as scheduled. This affected two (#34 and #59) of three residents reviewed for activities of daily living (ADL) care. The facility census was 105. Findings include: 1. Review of the medical record revealed Resident #59 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), venous insufficiency, epilepsy, heart failure, and generalized anxiety disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 had intact cognition. Resident #59 was assessed to require one-person limited assistance with transfers, two-person extensive assistance with dressing, supervision with eating, and one-person extensive assistance with toileting and bathing. Review of the care plan dated 06/21/22 revealed Resident #59 had ADL functional rehabilitation potential related to history of L2 transverse fracture, seizures, weakness, and pain. Interventions included assess functional level and physical therapy and occupational therapy referrals as needed. Staff to assist with bathing and showering, able to wash upper torso but needs assistance cleaning groin area. Staff to encourage to use call light for assistance. Review of the physician order dated 04/24/22 revealed Resident #59 was ordered shower days on Wednesday and Saturday during the day. Review of the shower records for the last 30 days revealed Resident #59 was not given a shower on 07/23/22 and 07/30/22. Review of the facility's shower schedule revealed Resident #59 was scheduled on Wednesday and Saturday day shift for showers. Interview on 08/08/22 at 10:17 A.M. with State Tested Nurse's Aide (STNA) #244 confirmed Resident #59 did not receive a shower on 07/23/22 and 07/30/22. STNA #244 reported Resident #59 does not refuse a shower, and the only reason why he would not get one would be due to staffing levels. 2. Review of the medical record of Resident #34 revealed an admission date of 02/23/21. Diagnoses included parkinson's disease, anxiety disorder, major depressive disorder, essential hypertension, multi-system degeneration of the autonomic nervous system. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. The resident required extensive assistance of two staff for bed mobility, transfers, and toileting. The resident was dependent on two staff for bathing. Review of physician orders revealed an order dated 04/07/22 for the resident to receive showers three days per week, on Tuesday, Friday, and Sunday. Review of shower task charting revealed not applicable was checked on 07/31/22. Review of the facility shower schedule, last updated on 07/15/22, revealed Resident #34 was to receive showers on Sundays, Tuesdays, and Fridays on day shift. Interview on 08/01/22 at 12:52 P.M., Resident #34 stated he is supposed to receive showers on Tuesdays, Fridays, and Sundays and had not received a shower the day prior as scheduled. Resident #34 stated staff informed him they did not have enough people to provide his shower that day. Telephone interview on 08/09/22 at 12:45 P.M., STNA #165 verified she did not provide a shower to Resident #34 on 07/31/21 due to being short on staff. STNA #165 stated bathing Resident #34 requires two aides and there were four aides on the unit that day. STNA #165 stated Resident #34 is a very large individual and requires three showers per week to ensure appropriate care. Interview on 08/10/22 at 10:16 A.M., the Director of Nursing (DON) stated there was not a specific policy pertaining to showers, however the expectation is for residents to be showered per their schedule. Review of the facility policy titled, Bathing Choice, dated 03/19/12 revealed all residents will be offered a bath/shower as often as they would like. Resident choices will be posted in the resident's wardrobe readily available so they will know what choices they made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to follow physician orders as ordered. This affected one (#19) out of one resident reviewed for physician orders. The facility census was 105. Findings include: Review of the medical record revealed Resident #19 was admitted to the facility on [DATE]. Diagnoses included left femur fracture, acute kidney failure, type two diabetes mellitus, atrial fibrillation, and acute respiratory failure with hypoxia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had moderate cognitive impairment. Resident #19 was assessed to require two-person extensive assistance with transfers and toileting, and one-person extensive assistance with dressing, eating, and bathing. Review of the care plan dated 05/07/22 revealed Resident #19 was at risk for falls related to history of falls, hypertension, diabetes mellitus, anemia, and atrial fibrillation. Interventions included a beveled mat next to bed, a dual touch pad call light in place, staff to ensure end slouch cushion to recliner, staff to ensure urinal was always within reach, staff to move nightstand away from bed, staff to offer protective headgear as allows and as tolerated related to injury, and staff to have reminder sign in room to call for assistance. Review of the physician order dated 05/07/22 revealed Resident #19 was ordered orthostatic blood pressure and pulse lying, sitting, and standing every shift for six administrations. Review orthostatic blood pressures and notify physician of abnormal results. Review of the physician order dated 07/17/22 revealed Resident #19 was ordered orthostatic blood pressures for three days every day and night shift for hypotension after a fall on 07/17/22 for six administrations. Review of the physician order dated 07/26/22 revealed Resident #19 was ordered orthostatic blood pressures: lying, sitting, and standing every shift for six administrations. Review ortho blood pressures and notify physician of any abnormal results. Review of the progress note dated 07/17/22 at 7:13 P.M. revealed Resident #19 had a fall, and the intervention post-fall was to complete orthostatic blood pressures for three days. Review of the progress note dated 07/18/22 at 11:15 A.M. revealed plan of care was reviewed. Staff to check orthostatic blood pressures for three days. Review of the progress note dated 07/26/22 at 1:14 P.M. revealed plan of care reviewed. Orthostatic blood pressures were not completed and will restart orthostatic blood pressures for three days. Review of the treatment administration record (TAR) dated May 2022 revealed Resident #19's orthostatic blood pressures were not completed as ordered. Review of the TAR dated July 2022 revealed Resident #19's orthostatic blood pressures were not completed as ordered. Interview on 08/09/22 at 4:47 P.M. with Registered Nurse (RN) #265 revealed orthostatic blood pressures were not completed as ordered on 05/08/22 through 05/10/22, 07/17/22 through 07/19/22, and 07/26/22 through 07/28/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, interviews, and policy review, the facility failed to ensure fall interventions were in place. This affected one (#19) out of nine residents reviewed for falls. The facility census was 105. Findings include: Review of the medical record revealed Resident #19 was admitted to the facility on [DATE]. Diagnoses included left femur fracture, acute kidney failure, type two diabetes mellitus, atrial fibrillation, and acute respiratory failure with hypoxia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had moderate cognitive impairment. Resident #19 was assessed to require two-person extensive assistance with transfers and toileting, and one-person extensive assistance with dressing, eating, and bathing. Review of the care plan dated 05/07/22 revealed Resident #19 was at risk for falls related to history of falls, hypertension, diabetes mellitus, anemia, and atrial fibrillation. Interventions included a beveled mat next to bed. A dual touch pad call light in place. Staff to ensure end slouch cushion to recliner. Staff to ensure urinal was always within reach. Staff to move nightstand away from bed. Staff to offer protective headgear as allows and as tolerated related to injury. Staff to have reminder sign in room to call for assistance. Review of the progress note dated 05/15/22 at 11:03 A.M. revealed staff found Resident #19 on the floor on his buttocks next to his bed. Resident #19 reported he attempted to get up without help and raised recliner too high and slid onto buttocks. Resident #19 was assisted back to bed with three staff members. No injuries noted. Educated Resident #19 on not getting out of bed unassisted, to use call light, and reminder sign placed in room. Review of the progress note dated 05/17/22 at 1:49 P.M. revealed fall and care plan reviewed during fall team meeting. End-slouch added to recliner in room. Restorative nurse to reevaluate recliner chair in room. Review of the progress note dated 05/18/22 at 10:30 P.M. revealed Resident #19 was found on the floor face down. Resident #19 had a large red abrasion with swelling to right forehead. Resident #19 reported he fell asleep watching golf. Resident #19 was assisted to bed about 45 minutes before incident. Physician gave orders to send to emergency room for evaluation related to fall, being on a blood thinner, and other medical issues throughout the day. Review of the progress note dated 05/19/22 at 1:30 P.M. revealed fall and care plan reviewed with interdisciplinary team. New interventions were a touch pad call light in room, knee-height bed, beveled mat next to bed, neurological checks. Resident #19 aware and educated on interventions. Review of the progress note dated 05/19/22 at 4:33 P.M. revealed Resident #19 found kneeling on floor by the sofa. Resident #19 was trying to reach for urinal and lost his balance. Resident #19 landed on knees and couldn't get up. Resident #19 had skin tear to the right knee. Review of the progress note dated 05/20/22 revealed new interventions for fall on 05/19/22 revealed staff should keep urinal and call light within reach at all times and place reminders signs in room to remind to call for help. Review of the progress note dated 05/23/22 at 2:24 P.M. revealed Resident #19 was found on his knees in front of bed. Intervention revealed to remind staff to place beveled mat on floor next to bed. Review of the fall investigation report dated 05/23/22 revealed Resident #19 did not have a beveled mat next to bed during the time of his fall. Observation on 08/04/22 at 10:24 A.M. revealed Resident #19 was lying in bed with eyes closed. No beveled fall mat in place next to bed. Observation on 08/08/22 at 10:33 A.M. revealed Resident #19 was lying in bed watching television without a beveled fall mat in place next to bed. Interview on 08/04/22 at 10:36 A.M. with Resident #19 revealed fall mat was not next to bed with previous falls and did not currently have a mat in his room. Interview on 08/04/22 at 11:03 A.M. with Registered Nurse (RN) #59 confirmed Resident #19 did not have a beveled mat next to his bed. Interview on 08/09/22 at 5:13 P.M. with RN #265 revealed the fall on 05/23/22 confirmed Resident #19 did not have a fall mat in place at the time of his fall. Review of the facility policy titled, Accident and Incident - Investigating and Reporting, dated 07/27/22 revealed the policy was to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Staff were to implement appropriate interventions taken to prevent future falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy review, the facility failed to accurately document in the resident record regarding fall investigations. This affected two (#19 and #56) out of nine residents reviewed for falls. The facility census was 105. Findings include: 1. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE]. Diagnoses included left femur fracture, acute kidney failure, type two diabetes mellitus, atrial fibrillation, and acute respiratory failure with hypoxia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had moderate cognitive impairment. Resident #19 was assessed to require two-person extensive assistance with transfers and toileting, and one-person extensive assistance with dressing, eating, and bathing. Review of the care plan dated 05/07/22 revealed Resident #19 was at risk for falls related to history of falls, hypertension, diabetes mellitus, anemia, and atrial fibrillation. Interventions included a beveled mat next to bed, a dual touch pad call light in place, staff to ensure end slouch cushion to recliner, staff to ensure urinal was always within reach, staff to move nightstand away from bed, staff to offer protective headgear as allows and as tolerated related to injury, and staff to have reminder sign in room to call for assistance. Review of the progress note dated 05/15/22 at 11:03 A.M. revealed staff found Resident #19 on the floor on his buttocks next to his bed. Resident #19 reported he attempted to get up without help and raised recliner too high and slid onto buttocks. Resident #19 was assisted back to bed with three staff members. No injuries noted. Educated Resident #19 on not getting out of bed unassisted, to use call light, and reminder sign placed in room. Review of the progress note dated 05/17/22 at 1:49 P.M. revealed fall and care plan reviewed during fall team meeting with end-slouch added to recliner in room and restorative nurse to reevaluate recliner chair in room. Review of the progress note dated 05/18/22 at 10:30 P.M. revealed Resident #19 was found on the floor face down. Resident #19 had a large red abrasion with swelling to right forehead. Resident #19 reported he fell asleep watching golf. Resident #19 was assisted to bed about 45 minutes before incident. Physician gave orders to send to emergency room for evaluation related to fall, being on a blood thinner, and other medical issues throughout the day. Review of the progress note dated 05/19/22 at 1:30 P.M. revealed fall and care plan reviewed with interdisciplinary team. New interventions were a touch pad call light in room, knee-height bed, beveled mat next to bed, neurological checks. Resident #19 aware and educated on interventions. Review of the progress note dated 05/19/22 at 4:33 P.M. revealed Resident #19 found kneeling on floor by the sofa. Resident #19 was trying to reach for urinal and lost his balance. Resident #19 landed on knees and couldn't get up. Resident #19 had skin tear to the right knee. Review of the progress note dated 05/20/22 revealed new interventions for fall on 05/19/22 revealed staff should keep urinal and call light within reach at all times and place reminders signs in room to remind to call for help. Review of the incident charting dated 05/15/22 revealed Resident #19 was observed on the floor with no apparent injuries on 05/15/22. Review of the incident charting dated 05/19/22 revealed Resident #19 was observed on the floor with an apparent injury including the head on 05/15/22. Review of the incident charting dated 05/22/22 revealed Resident #19 was observed on the floor with an apparent injuring including the head on 05/22/22. Interview on 08/09/22 at 5:13 P.M. with Registered Nurse (RN) #265 revealed Resident #19 had a fall on 05/15/22 with no apparent injuries. On 05/18/22, Resident #19 had a fall with a head abrasion noted. On 05/19/22, Resident #19 had a fall where he obtained a skin tear to the right knee. On 05/23/22, Resident #19 had a fall where he obtained a skin tear to right great toe. RN #265 revealed documentation on incident charting was not accurate with injuries or dates of falls. 2. Review of the medical record revealed Resident #56 was admitted to the facility on [DATE]. Diagnoses included parkinson's disease, chronic kidney disease stage three, major depressive disorder, heart failure, and acute myocardial infarction. Review of the quarterly MDS assessment dated [DATE] revealed Resident #56 had moderate cognitive impairment. Resident #56 was assessed to require two-person extensive assistance with transfers, dressing, and toileting, independent with eating, and one-person total dependence with bathing. Review of the care plan dated 06/15/22 revealed Resident #56 was at risk for falls related to weakness, refused to wear head gear, refused physical therapy evaluation. Interventions included offered protective sleeves as allows. Staff to prompt toileting program initiated. Staff to place reminder sign in room to call for assistance with transfers. Staff to ensure standard house fall precautions per policy. Staff to use standard wheelchair with anti-tipping devices for transfers involving sit-stand lift. Review of the progress note dated 02/27/22 at 7:16 P.M. revealed Resident #56 had an unwitnessed fall in his room at approximately 4:00 P.M. Resident #56 said he hit his head and had an extensive skin tear to posterior right hand. Resident #56 was sent to the emergency room for evaluation. Review of the progress note dated 04/29/22 at 12:56 P.M. revealed Resident #56 was being assisted to the stand-up lift with two staff members when Resident #56 lifted foot to place onto lift and the transfer chair titled back. Resident #56 fell and hit his head. Resident #56 had a quarter size bump on back of his head. Review of the incident charting dated 02/28/22 revealed Resident #56 had a fall on 02/27/22 with a skin tear to right hand/wrist and a small arachnoid hemorrhage on computed tomography (CT) scan. Review of the incident charting dated 04/29/22 revealed Resident #56 had fall on 04/29/22 involving his head. Review of the incident charting dated 04/30/33 revealed Resident #56 had a fall on 04/29/22 involving his head with injuries including a skin tear to right hand/wrist and a small subarachnoid hemorrhage on CT scan. Incident charting for 05/01/22 and 05/02/22 show the same injuries, which were inaccurate. Interview on 08/09/22 at 5:13 P.M. with RN #265 revealed Resident #56 had a fall on 02/27/22 a fall, which included a skin tear to right hand/wrist and a small subarachnoid hemorrhage on CT scan. On 04/29/22, Resident #56 had a fall during a transfer with a quarter size bump on back of head. RN #265 revealed documentation on incident charting was not accurate with injuries or dates of falls. Review of the facility policy titled, Accident and Incident - Investigating and Reporting, dated 07/27/22 revealed the policy was to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. When a resident fall occurs, the date and time of the incident or when the resident was noted on the floor, assessment data including vital signs and injuries should be documented in the medical chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record of Resident #09 revealed an admission date of 05/19/16. Diagnoses included cerebral infarction, anxiety disorder, morbid obesity, hyperlipidemia, dementia with behavioral disturbance, major depressive disorder, psychotic disorder, essential hypertension, and gastro-esophageal reflux disease. Review of the quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required extensive assistance of one staff for eating, extensive assistance of two staff for bed mobility, and was dependent on two staff for transfers and toileting. The resident was assessed as having impaired range of motion to all four extremities. Review of a progress notes dated 07/07/22 revealed Resident #09 was found with a small, round, dime sized brown/purple bruise on the right side of her jaw/chin during the morning med pass. Resident #09 was unaware it was there or of how she obtained it. The family, Nurse Practitioner, and Nurse Manager were notified. Review of the facility's SRIs revealed the incident was not reported to the state agency. Interview on 08/04/22 at 3:04 P.M., Executive Director (ED) #110 verified there was not an SRI completed, regarding Resident #09's bruise. Interview on 08/04/22 at 3:43 P.M., LPN #146 stated she followed up on the incident, however she did not make a note about said follow-up. LPN #146 stated she talked with the staff who cared for Resident #09, however she did not have them write statements, nor did she talk to like residents, or check for additional skin issues on the unit. LPN #146 stated an SRI was not completed because there was no suspicion of abuse. Review of the facility policy titled, Injuries of Unknown Source-Bruises, Skin Tears, dated 08/20/09, revealed, regardless of how minor an injury (bruise, skin tear, injury of unknown source) may be, it must be reported and investigated as soon as it is discovered. 4. Review of the medical record of Resident #18 revealed an admission date of 06/03/20. Diagnoses included dementia without behavioral disturbance, heart failure, major depressive disorder, chronic kidney disease, type 2 diabetes mellitus, hemiplegia affecting right dominant side, hyperlipidemia, Alzheimer's disease with late onset, essential hypertension, gastro-esophageal reflux disease without esophagitis, personal history of transient ischemic attack and cerebral infarction without residual deficits. Review of the comprehensive MDS assessment dated [DATE] revealed the resident had moderately impaired cognition. The resident was independent with bed mobility, transfers, eating, and toileting. Interview on 08/02/22 at 9:35 A.M., Resident #18 stated, approximately two weeks prior, another resident looked at him, told him they did not like him and hit him. Review of a progress note dated 07/25/22 revealed Resident #18 was witnessed being slapped repeatedly by another resident. Resident #18 told the other resident to stop touching him and the other resident was mocking him while slapping him. No injury was noted. 5. Review of the medical record of Resident #92 revealed an admission date of 03/20/20. The resident transferred to the hospital on [DATE]. Diagnoses included Alzheimer's disease, dementia with behavioral disturbance, blindness, major depressive disorder, generalized anxiety disorder. Review of the quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident exhibited fluctuating inattention and 4-6 days of physical behavioral symptoms directed towards others and wandering during the assessment period. The resident required extensive assistance for bed mobility, transfers, locomotion on and off the unit, dressing, and toileting. The resident required supervision for eating. Review of a progress note dated 07/25/22 revealed Resident #92 was witnessed slapping another resident (Resident #18). Resident #18 stated several times for Resident #92 to stop touching him and Resident #92 was mocking what he was saying and continuously smacking him. Review of the facility's SRIs revealed the incident was not reported to the state agency. Interview on 08/04/22 at 10:11 A.M., ED #110 verified there was not an SRI completed for the incident on 07/25/22 because it was described as a light tapping. ED #110 verified the other resident was Resident #92, who was sent to the hospital a few days later. ED #110 further stated the incident was not investigated because it was witnessed. 6. Review of the medical record of Resident #65 revealed an admission date of 08/30/12. Diagnoses included postpolio syndrome, gastro-esophageal reflux disease, anxiety disorder, mild cognitive impairment, vascular dementia without behavioral disturbance, unspecified intellectual disabilities, and major depressive disorder. Review of the quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognitive status. The resident required extensive assistance of one staff for bed mobility, and was totally dependent on two staff for transfers and toileting. The resident required supervision for eating. Review of a progress note dated 07/24/22 revealed Resident #65 was touched inappropriately by another resident. Resident #65 voiced concerns to the staff. Review of the Daily Behavior Assessment for Resident #92 dated 06/24/22 revealed Resident #92 was wandering and touching residents inappropriately. Resident #65 stated Honey, she keeps rubbing my breast. I keep telling her to stop touching me, but she won't stop. Resident #92 was removed from the area and extensive one-on-one supervision was provided by the activity staff. Review of the facility's SRIs revealed neither of the incidents involving Resident #65 and #92 were reported to the state agency. Interview on 08/08/22 at 3:33 P.M., LPN #160 stated Resident #65 told her a few weeks ago that Resident #92 touched her breast and in the groin area and she was really upset about it. Interview on 08/08/22 at 4:36 P.M., STNA #17 stated she recently heard Resident #65 yell out that a resident had touched her breast. STNA #17 stated she did not physically see it occur, however Resident #92 was right next to her when it happened. STNA #17 further stated she heard Resident #92 had touched Resident #65 inappropriately a few times. Interview on 08/09/22 at 8:51 A.M., STNA #70 stated she had not seen Resident #92 touch Resident #65, however noticed Resident #65 telling everyone that Resident #92 had touched her breasts and private area for a few days following the incident. Interview on 08/09/22 at 4:24 P.M., the Director of Nursing (DON) verified there were no SRIs completed for either of the incidents between Resident #92 and #65. The DON stated an SRI was not completed because Resident #92 has dementia and was not touching the other resident with the intention of harm and the other resident did not seem to be in any distress. Review of the facility policy titled, Resident Abuse, dated 03/12/18, revealed abuse is defined as the willful infliction of injury, intimidation or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguis. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual abuse is non-consensual sexual contact of any type with a resident. The investigation shall consist of interviews with any witnesses, interviews with staff members on all shifts having contact with the resident during the period of the alleged incident, interviews with the resident's family members and visitors, and interviews with other residents. The incident will be reported to the state agency within 24-hours of the reported abuse and completed within five working days. Based on record review, staff interview and policy review, the facility failed to ensure injuries of unknown origin were reported to the state agency for Resident #09, failed to ensure resident-to-resident altercations were reported to the state agency for Residents #18, #92, #26 and #146, and failed to ensure allegations of sexual abuse were reported to the state agency for Residents #18 and #65. This affected six Residents (#09, #18, #26, #65, #92, and #146) out of 32 reviewed for abuse. The facility census was 105. Findings included: 1. Review of the clinical record revealed Resident #26 was admitted to the facility on [DATE]. His diagnoses included dementia with behavioral disturbance, encephalopathy, malignant neoplasm of the colon, complete traumatic metacarpophalangeal amputation of the right ring finger, malignant neoplasm of connective and soft tissue, anxiety disorder, repeated falls, incisional hernia, hypertension, fall, weakness, protein-calorie malnutrition, abnormal levels of serum enzymes, disorientation, altered mental status, acquired absence of parts of the digestive tract, encounter for screening for malignant neoplasm of the bladder, presence of orthopedic joint implant, difficulty in walking, gastro-esophageal reflux disease, major depressive disorder, benign prostatic hyperplasia, and insomnia. Review of the annual Minimum Data Set (MDS) assessment completed on 05/17/22 revealed he had severe cognitive impairment. He needed extensive assist of two staff for bed mobility, transfer, dressing, and toilet use. He did not walk. He needed extensive assist of one staff for locomotion and personal hygiene. He needed supervision and setup for eating. He was totally dependent on one staff for bathing. Review of the clinical record revealed behavior note dated 07/31/22 which indicated the resident was smacked in the face three times by another resident on 07/31/22 at 5:55 P.M. The resident had no injuries noted. 2. Record review of Resident #146's chart revealed she was admitted to the facility on [DATE]. Her diagnoses included dementia with behavioral disturbance, major depressive disorder, Alzheimer's disease with early onset, hypothyroidism, hyperlipidemia, and hypertension. Review of the admission MDS completed on 07/19/22 indicated she had severe cognitive impairment. She needed supervision of one staff for bed mobility, transfer, walking, and locomotion. She required limited assist of one staff for dressing and personal hygiene. She required extensive assist of one staff for eating. She needed supervision and setup help for toileting and was totally dependent on one staff for bathing. She exhibited physical and verbal behavioral symptoms directed towards others one to three days during the lookback period. She exhibited rejection of care one to three days during the lookback period and wandered four to six days during that timeframe. Review of care plan revealed she had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's disease, dementia with behavioral disturbance, behaviors including resisting care (medications, meals, and activities of daily living care), hitting, swinging at staff during care, yelling at staff/others, and wandering. Review of the clinical record revealed a behavior note dated 07/31/22. It indicated the aide came at at 5:55 P.M. reporting Resident #146 was smacking another resident in the face three times. It stated the intervention was redirection and separated. It indicated the resident was a threat to herself and others and that she would be monitored. Further review revealed a health status note dated 08/01/22 which indicated regarding the incident on 07/31/22 at 5:55 P.M. where Resident #146 hit a male resident (Resident #26) in the face three times, staff intervened and Resident #146 was redirected back to her room. Due to the nature of this event, the interdisciplinary team (IDT) agreed to have the resident (Resident #146) evaluated at psychiatric hospital as the incident was unprovoked and aggressive behaviors continued towards the State Tested Nursing Assistant (STNA) through out the night. It revealed she had been acclimating to a new unit over two weeks and continued with aggression. There was a Social Service note dated 08/01/22 which indicated they were made aware of Resident #146's increased agitation, behaviors hitting at staff and other residents. A resident to resident altercation was reported/noted occurring on 07/31/22. It indicated Resident #146 was with advancing dementia and was unaware to why, reasoning or recall of reported aggressive behaviors. She was approved to be sent for her current inpatient psychiatric needs. Self-reported incidents (SRIs) were reviewed on 08/09/22. There were no SRIs completed regarding this incident. An interview was conducted with the Administrator on 08/04/22 at 3:00 P.M. She indicated there was no SRI done due to it being witnessed by staff, there was no harm to either one, and both residents resided on the dementia unit. She indicated the families were notified, and the aggressor was sent out. An interview was conducted with Licensed Practical Nurse (LPN) #146 and Registered Nurse (RN) #60 on 08/04/22 at 3:46 P.M. They indicated Resident #146 was acclimating to the unit and was known to tap residents. She ended up chasing the STNA around and went out for a psychiatric evaluation in the morning. They indicated the STNA on the unit was a witness, but no statement was collected. They revealed they did not know the STNA's name. They indicated Resident #26 was taken in to his room and went to bed for the night. They revealed no other residents were assessed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record of Resident #09 revealed an admission date of 05/19/16. Diagnoses included cerebral infarction, anxiety disorder, morbid obesity, hyperlipidemia, dementia with behavioral disturbance, major depressive disorder, psychotic disorder, essential hypertension, and gastro-esophageal reflux disease. Review of the quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required extensive assistance of one staff for eating, extensive assistance of two staff for bed mobility, and was dependent on two staff for transfers and toileting. The resident was assessed as having impaired range of motion to all four extremities. Review of a progress notes dated 07/07/22 revealed Resident #09 was found with a small, round, dime sized brown/purple bruise on the right side of her jaw/chin during the morning med pass. Resident #09 was unaware it was there or of how she obtained it. The family, Nurse Practitioner, and Nurse Manager were notified. Review of the facility's SRIs revealed the incident was not reported to the state agency. Interview on 08/04/22 at 3:04 P.M., Executive Director (ED) #110 verified there was not an SRI completed, regarding Resident #09's bruise. Interview on 08/04/22 at 3:43 P.M., Licensed Practical Nurse (LPN) #146 stated she followed up on the incident, however she did not make a note about said follow-up. LPN #146 stated she talked with the staff who cared for Resident #09, however she did not have them write statements, nor did she talk to like residents, or check for additional skin issues on the unit. LPN #146 stated an SRI was not completed because there was no suspicion of abuse. Review of the facility policy titled, Injuries of Unknown Source-Bruises, Skin Tears, dated 08/20/09, revealed, regardless of how minor an injury (bruise, skin tear, injury of unknown source) may be, it must be reported and investigated as soon as it is discovered. 4. Review of the medical record of Resident #18 revealed an admission date of 06/03/20. Diagnoses included dementia without behavioral disturbance, heart failure, major depressive disorder, chronic kidney disease, type 2 diabetes mellitus, hemiplegia affecting right dominant side, hyperlipidemia, Alzheimer's disease with late onset, essential hypertension, gastro-esophageal reflux disease without esophagitis, personal history of transient ischemic attack and cerebral infarction without residual deficits. Review of the comprehensive MDS assessment dated [DATE] revealed the resident had moderately impaired cognition. The resident was independent with bed mobility, transfers, eating, and toileting. Interview on 08/02/22 at 9:35 A.M., Resident #18 stated, approximately two weeks prior, another resident looked at him, told him they did not like him and hit him. Review of a progress note dated 07/25/22 revealed Resident #18 was witnessed being slapped repeatedly by another resident. Resident #18 told the other resident to stop touching him and the other resident was mocking him while slapping him. No injury was noted. 5. Review of the medical record of Resident #92 revealed an admission date of 03/20/20. The resident transferred to the hospital on [DATE]. Diagnoses included Alzheimer's disease, dementia with behavioral disturbance, blindness, major depressive disorder, generalized anxiety disorder. Review of the quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident exhibited fluctuating inattention and 4-6 days of physical behavioral symptoms directed towards others and wandering during the assessment period. The resident required extensive assistance for bed mobility, transfers, locomotion on and off the unit, dressing, and toileting. The resident required supervision for eating. Review of a progress note dated 07/25/22 revealed Resident #92 was witnessed slapping another resident (Resident #18). Resident #18 stated several times for Resident #92 to stop touching him and Resident #92 was mocking what he was saying and continuously smacking him. Review of the facility's SRIs revealed the incident was not reported to the state agency. Interview on 08/04/22 at 10:11 A.M., ED #110 verified there was not an SRI completed for the incident on 07/25/22 because it was described as a light tapping. ED #110 verified the other resident was Resident #92, who was sent to the hospital a few days later. ED #110 further stated the incident was not investigated because it was witnessed. 6. Review of the medical record of Resident #65 revealed an admission date of 08/30/12. Diagnoses included postpolio syndrome, gastro-esophageal reflux disease, anxiety disorder, mild cognitive impairment, vascular dementia without behavioral disturbance, unspecified intellectual disabilities, and major depressive disorder. Review of the quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognitive status. The resident required extensive assistance of one staff for bed mobility, and was totally dependent on two staff for transfers and toileting. The resident required supervision for eating. Review of a progress note dated 07/24/22 revealed Resident #65 was touched inappropriately by another resident. Resident #65 voiced concerns to the staff. Review of the Daily Behavior Assessment for Resident #92 dated 06/24/22 revealed Resident #92 was wandering and touching residents inappropriately. Resident #65 stated Honey, she keeps rubbing my breast. I keep telling her to stop touching me, but she won't stop. Resident #92 was removed from the area and extensive one-on-one supervision was provided by the activity staff. Review of the facility's SRIs revealed neither of the incidents involving Resident #65 and #92 were reported to the state agency. Interview on 08/08/22 at 3:33 P.M., LPN #160 stated Resident #65 told her a few weeks ago that Resident #92 touched her breast and in the groin area and she was really upset about it. Interview on 08/08/22 at 4:36 P.M., STNA #17 stated she recently heard Resident #65 yell out that a resident had touched her breast. STNA #17 stated she did not physically see it occur, however Resident #92 was right next to her when it happened. STNA #17 further stated she heard Resident #92 had touched Resident #65 inappropriately a few times. Interview on 08/09/22 at 8:51 A.M., STNA #70 stated she had not seen Resident #92 touch Resident #65, however noticed Resident #65 telling everyone that Resident #92 had touched her breasts and private area for a few days following the incident. Interview on 08/09/22 at 4:24 P.M., the Director of Nursing (DON) verified investigations were nor completed for either of the incidents between Resident #92 and #65. The DON stated an investigation was not completed because Resident #92 has dementia and was not touching the other resident with the intention of harm and the other resident did not seem to be in any distress. Review of the facility policy titled, Resident Abuse, dated 03/12/18, revealed abuse is defined as the willful infliction of injury, intimidation or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguis. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual abuse is non-consensual sexual contact of any type with a resident. The investigation shall consist of interviews with any witnesses, interviews with staff members on all shifts having contact with the resident during the period of the alleged incident, interviews with the resident's family members and visitors, and interviews with other residents. The incident will be reported to the state agency within 24-hours of the reported abuse and completed within five working days. Based on record review, staff interview and policy review, the facility failed to ensure injuries of unknown origin were investigated for Resident #09, failed to ensure resident-to-resident altercations were investigated for Residents #18, #92, #26, and #146, and failed to ensure allegations of sexual abuse were investigated for Resident #18 and #65. This affected six Residents (#09, #18, #26, #65, #92, and #146) out of 32 reviewed for abuse. The facility census was 105. Findings included: 1. Review of the clinical record revealed Resident #26 was admitted to the facility on [DATE]. His diagnoses included dementia with behavioral disturbance, encephalopathy, malignant neoplasm of the colon, complete traumatic metacarpophalangeal amputation of the right ring finger, malignant neoplasm of connective and soft tissue, anxiety disorder, repeated falls, incisional hernia, hypertension, fall, weakness, protein-calorie malnutrition, abnormal levels of serum enzymes, disorientation, altered mental status, acquired absence of parts of the digestive tract, encounter for screening for malignant neoplasm of the bladder, presence of orthopedic joint implant, difficulty in walking, gastro-esophageal reflux disease, major depressive disorder, benign prostatic hyperplasia, and insomnia. He had an annual Minimum Data Set (MDS) assessment completed on 05/17/22. He had severe cognitive impairment. He needed extensive assist of two staff for bed mobility, transfer, dressing, and toilet use. He did not walk. He needed extensive assist of one staff for locomotion and personal hygiene. He needed supervision and setup for eating. He was totally dependent on one staff for bathing. Review of the clinical record revealed behavior note dated 07/31/22 which indicated the resident was smacked in the face three times by another resident on 07/31/22 at 5:55 P.M. The resident had no injuries noted. 2. Record review of Resident #146's chart revealed she was admitted to the facility on [DATE]. Her diagnoses included dementia with behavioral disturbance, major depressive disorder, Alzheimer's disease with early onset, hypothyroidism, hyperlipidemia, and hypertension. She had an admission MDS completed on 07/19/22 indicating she had severe cognitive impairment. She needed supervision of one staff for bed mobility, transfer, walking, and locomotion. She required limited assist of one staff for dressing and personal hygiene. She required extensive assist of one staff for eating. She needed supervision and setup help for toileting and was totally dependent on one staff for bathing. She exhibited physical and verbal behavioral symptoms directed towards others one to three days during the lookback period. She exhibited rejection of care one to three days during the lookback period and wandered four to six days during that timeframe. She had a care plan addressing her impaired cognitive function/dementia or impaired thought processes related to Alzheimer's disease, dementia with behavioral disturbance, behaviors including resisting care (medications, meals, and activities of daily living care), hitting, swinging at staff during care, yelling at staff/others, and wandering. Review of the clinical record revealed a behavior note dated 07/31/22. It indicated the aide came at at 5:55 P.M. reporting Resident #146 was smacking another resident in the face three times. It stated the intervention was redirection and separated. It indicated the resident was a threat to herself and others and that she would be monitored. Further review revealed a health status note dated 08/01/22 which indicated regarding the incident on 07/31 at 5:55 P.M. where Resident #146 hit a male resident (Resident #26) in the face three times, staff intervened and Resident #146 was redirected back to her room. Due to the nature of this event, the interdisciplinary team (IDT) agreed to have Resident #146 evaluated at psychiatric hospital as the incident was unprovoked and aggressive behaviors continued towards the State Tested Nursing Assistant (STNA) through out the night. It revealed she had been acclimating to a new unit over two weeks and continued with aggression. There was a Social Service note dated 08/01/22 which indicated they were made aware of Resident #146's increased agitation, behaviors hitting at staff and other residents. A resident to resident altercation was reported/noted occurring on 07/31/22. It indicated Resident #146 was with advancing dementia and was unaware to why, reasoning or recall of reported aggressive behaviors. She was approved to be sent for her current inpatient psychiatric needs. Self-reported incidents (SRIs) were reviewed on 08/09/22. There were no SRIs completed regarding this incident. An interview was conducted with the Administrator on 08/04/22 at 3:00 P.M. She indicated there was no SRI or investigation done due to it being witnessed by staff, there was no harm to either one, and both residents resided on the dementia unit. She indicated the families were notified, and the aggressor was sent out. An interview was conducted with Licensed Practical Nurse (LPN) #146 and Registered Nurse (RN) #60 on 08/04/22 at 3:46 P.M. They indicated Resident #146 was acclimating to the unit and was known to tap residents. She ended up chasing the STNA around and went out for a psychiatric evaluation in the morning. They indicated the STNA on the unit was a witness, but no statement was collected. They revealed they did not know the STNA's name. They indicated Resident #26 was taken in to his room and went to bed for the night. They revealed no other residents were assessed.

Based on observation, staff interview, policy review, review of personal files, and review of the Centers for Disease Control (CDC) guidance, the facility failed to ensure staff wore personal protective equipment (PPE) in a manner to prevent the potential spread of Covid-19. The facility identified six residents who had tested positive for COVID-19 in the past two weeks and four residents who were in isolation precautions for positive COVID-19 on the day of entrance. The facility failed to ensure newly hired employees had their first and second step tuberculosis skin test (PPD) as required. This affected two State Tested Nursing Assistants (STNAs) #95 and #170 out of five newly hired staff reviewed. The facility also failed to ensure that individuals were safely removing their personal protective equipment (PPE) before leaving resident rooms where isolation precautions were in place to prevent the spread of infectious diseases. This affected three residents (#55, #200, and #247) of 32 residents reviewed for infectious diseases and had the potential to affect all residents residing in the facility. The facility census was 105. Findings include: 1. Observation on 08/01/22 at 11:41 A.M. revealed Food Service Specialist (FSS) #92 in the Hillside unit's dining area taking resident's lunch orders and delivering trays to residents. FSS #92 was observed wearing an N-95 mask with the upper strap secured around the head and the lower strap dangling in front of the mask. Random observations between 11:41 A.M. and 12:41 P.M. revealed FSS #92 continued serving residents wearing the N-95 mask incorrectly. Interview on 08/01/22 at 12:48 P.M. FSS #92 verified she was not wearing the lower strap of the N-95 mask. FSS #92 stated she was wearing it in that manner because she was hot. 2. Observation on 08/08/22 at 3:15 P.M. revealed State Tested Nursing Assistant (STNA) #500 on the Hillside unit entering an unidentified resident's room and answer a call light. STNA #500 was observed wearing an N-95 mask with the upper strap secured around the head and the lower strap dangling in front of the mask. Observation and interview on 08/08/22 at 4:47 P.M., STNA #500 was seated at the table in the activity room and continued to have the lower strap of the N-95 mask dangling unsecured in front of the mask. STNA #500 verified she was not wearing the lower strap of the N-95 mask and stated her hair gets in the way of the lower strap. STNA #500 further stated she forgot to secure the lower strap when she came back from her last break. 3. Observation on 08/10/22 at 11:57 A.M. revealed Nursing Student (NS) #500 on the Hillside unit wearing glasses but no eye protection. Interview at the same time, NS #500 verified she was not wearing eye protection. NS #500 stated she had been working on the unit, assisting residents, since 7:00 A.M. and nobody had told her she needed to wear eye protection. 4. Observation on 08/10/22 at 11:57 A.M. revealed Licensed Practical Nurse (LPN) #501 on the Hillside unit not wearing any eye protection. Interview at the same time, LPN #501 verified she was not wearing eye protection. LPN #501 stated she was wearing her glasses up until a few minutes prior, however was not told she needed to wear eye protection upon starting her shift. 5. Observation on 08/10/22 at 11:58 A.M. revealed NS #503 on the Hillside unit not wearing any eye protection. Interview at the same time, NS #503 stated she had been working on the unit, assisting residents, since 7:00 A.M. and had not been told she needed to wear eye protection. 6. Observation on 08/10/21 at 11:59 A.M. revealed NS #504 on the Hillside unit not wearing any eye protection. NS #504 was observed entering Resident #76's room to answer the call light. Observation on 08/10/22 revealed NS #504 and NS #503 exit Resident #76's room. Neither were wearing eye protection. NS #504 affirmed she was not wearing eye protection. NS #504 stated she had been on the Hillside unit, assisting residents, since 7:00 A.M., and she had not been told she needed to wear eye protection. NS #504 further stated there was not any eye protection where the masks were located at the front entrance, where she checked in earlier that morning. Review of the facility policy titled, Coronavirus Infection Control Plan, dated 11/30/21, revealed staff and visitors will wear eye protection while in the facility based on county positivity and transmission rates. Review of the Centers for Disease Control (CDC) COVID-19 County Check (https://www.cdc.gov/coronavirus/2019-ncov/your-health/covid-by-county.html) revealed the facility was located in a county where the transmission level was high. Review of the CDC article, How to Use Your N-95 Respirator (chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/COVID-19_NIOSH_Freemasks_PRINT_F.pdf), dated 01/28/22, revealed the respirator straps should be placed over the crown of the head (top) and at the back of the neck below the ears (bottom strap). The N-95 must form a seal around the face to work properly. Gaps occur if the N-95 is not put on correctly. 7. Review of medical records for Resident #55 revealed an admission date of 03/03/22 with diagnoses including heart failure, pulmonary hypertension, chronic kidney disease, and tested positive for Covid-19 on 07/24/22. Review of physician order dated 07/25/22, Resident #55 was placed in quarantine due to positive Covid status. 8. Review of medical record for Resident #200 revealed an admission date of 07/09/22 with diagnosis of nontraumatic intracerebral hemorrhage and tested positive for Covid-19 on 07/28/22. Review of physician order dated 07/28/22, Resident #200 was placed in quarantine due to positive Covid status. Observation and interview on 08/02/22 at 12:50 P.M. revealed clean PPE containers and trash cans containing contaminated PPE. Infection Control Preventionist #38 verified the donning and doffing area for Residents #55 and #200 were in a public area and not inside the individual rooms or in a secured care area. 9. Review of the medical record of Resident #247 revealed an admission date of 07/29/22. Diagnoses included covid-19. Review of the Admit/Readmit note dated 07/29/22 revealed the resident was alert to person, place, and situation. The resident was noted to be forgetful and had difficulty with short-term memory at the time of admission. Review of an order dated 07/29/22, ending on 08/04/22 revealed the resident was to be in quarantine due to testing for positive for covid. Observation on 08/01/22 at approximately 3:30 P.M., revealed a trash can containing used gowns outside of Resident #247's door. The door to Resident #247's room contained a sign stating, See nurse before entering and there was a plastic drawer bin containing PPE and instructions for donning and doffing on top of the plastic bin. Interview at the same time, LPN #144 verified the trash can had used PPE should be contained inside the room, where PPE should be doffed prior to exiting the room. Review of policy Coronavirus Infection Control Plan, dated 11/30/21, revealed Removing and discarding the gown in a dedicated container for waste or linen before leaving the resident room or care area. 10. Record review of STNA #95 personnel file revealed the employee was hired on 06/22/22. STNA #95's 1st step tuberculosis skin test (PPD) was given on 06/23/22 that was not read. STNA #95's personnel file did not contain information regarding a second step PPD being completed. Record review of STNA #170 personnel file revealed the employee was hired on 07/13/22. STNA #170's 1st step PPD was given on 07/11/22 and read on 07/13/22. STNA #170's personnel file did not contain information regarding a second step PPD being completed. Email correspondence with the Administrator on 08/04/22 at 4:06 P.M. verified STNA #95's did not have her first step PPD read and STNA #95 and STNA #170 did not have second step PPDs. Review of the facility's tuberculosis testing and exposure management policy revised on 09/30/18 revealed newly hired employees will receive an initial TB test as part of the employee physical examination. This PPD will be read by the nursing supervisor. Newly hired employees may not begin work until the first step is read. Review of the facility's new employee orientation policy revised June 2014 revealed employees must complete the first step of the two step Mantoux TB test.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the hospital record, review of facility policy, and staff interview, the facility failed to implement their abuse policy to report and investigate an injury of unknown origin for one resident (#63) of five reveiwed for accidents. The facility census was 102. Findings include: Medical record review revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including difficulty walking, repeated falls, and vascular dementia without behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had severely impaired cognition and required extensive assistance for activities of daily living. Review of the facility's Fall Investigation report dated 06/26/19, revealed Resident #63 fell from her wheel chair and was wearing hipsters at the time of the fall. The report revealed the resident sustained a skin tear to the left elbow and there were no other injuries. Review of Resident #63's progress note dated 07/08/19 at 12:42 P.M., revealed a late entry for 07/05/19 which documented the resident had no pain or discomfort. Review of Resident #63's progress note dated 07/06/19 at 8:50 P.M., revealed a State Tested Nursing Assistant (STNA) had assisted the resident to bed and noticed the resident was having a lot of pain, was yelling out, and was grabbing at her left inner thigh and hip. The nurse was notified. The nurse's assessment revealed the resident's left foot to be rotated outward, the resident had extreme pain with range of motion, was grabbing at the left inner thigh, yelling out, and became tearful. The note further revealed the resident had a fall on 06/26/19 with no injuries noted. There was an old green bruise to left knee noted and thought to be from the fall on 06/26/19. The physician was notified and ordered x-rays of the left hip. The resident's family was notified and revealed they took the resident out of the facility on 07/04/19, transferring the resident in and out of the car, and the resident did not appear to be in pain. Review of the radiology report dated 07/06/19 at 11:14 P.M., revealed Resident #63 had an acute (sudden) transcervical versus basicervical left hip fracture. Review of the progress note dated 07/07/19 at 1:35 A.M., revealed the facility contacted Resident #63's physician with the hip x-ray results and the resident was sent to the hospital emergency room for evaluation. Review of the hospital history and physical dated 07/07/19 revealed Resident #63 presented to the acute care hospital with the chief complaint of hip pain. The note documented the resident had an x-ray of the left hip which revealed an acute left subcapital femoral neck fracture. Interview on 07/16/19 at 5:13 P.M., with the Director of Nursing (DON) and Nurse Supervisor (NS) #285 revealed Resident #63 had been out of the facility with family on 07/04/19, transferring in and out of a car multiple times. The DON reported the family was adamant the resident was not in any pain during the outing. The DON and NS #285 revealed the staff noted hip pain on 07/06/19, an x-ray revealed a hip fracture, and an order was received to send the resident to the hospital for treatment. The DON and NS #285 denied the resident had any bruising to the hips prior to sending the resident to the hospital. Interview on 07/17/19 at 9:56 A.M., with the DON revealed Resident #63's hip fracture was not related to the fall on 06/26/19, and the facility thought something may have happened when the resident went out with the family 07/04/19. She was unsure if the facility investigated the injury of unknown origin. Interview on 07/17/19 at 10:47 A.M., with NS #285 revealed Resident #63 had a fall on 06/26/19 and had no signs of injury at the time. NS #285 confirmed the resident went out of the facility with the family on 07/04/19 and the family denied there was any injury or incident while transferring the resident in and out of the car. NS #285 revealed the facility then attributed the resident's hip fracture to the fall sustained on 06/26/19 (10 days prior). NS #285 verified the facility had no evidence a thorough written investigation was completed when the injury was discovered, including interviews/written statements with the STNA who assisted the resident to bed and reported the resident's sudden severe pain on 07/06/19 or other staff. Interview on 07/17/19 at 11:15 A.M., with the DON verified the facility did not have evidence of a written investigation of Resident #63's hip fracture. There were no injuries from staff who provided care up to the time of the noted injury. The DON verified the facility did not submit a Self-Reported Incident (SRI) to the state survey agency for the injury of unknown source. During an additional interview on 07/17/19 at 1:50 P.M., at the request of the DON, the DON revealed the facility had always thought Resident #63's hip fracture was related to her fall on 06/26/19, which was 10 days prior. NS #285 presented an unsigned, undated summary/timeline of the events surrounding the resident's fracture and stated she had just written it today (07/17/19). The summary noted the resident's daughter stated she would have noticed if the resident was having pain on 07/04/19, and there was no pain noted on 07/05/19. NS #285 also presented an undated written statement signed by the STNA who assisted the resident to bed when the resident initially complained of hip pain on 07/06/19. NS #285 verified the STNA had just written the statement today (07/17/19). Review of the facility policy titled, Resident Abuse revised 03/09/09, revealed an injury should be classified as an injury of unknown source when the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury or the location of the injury. The policy further revealed when a serious injury of an unknown source is reported, the DON or appointed designee and a member of social services would investigate the incident, the incident would be reported to the Ohio Department of Health within 24 hours and the investigation completed within five days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the hospital record, review of facility policy, and staff interview, the facility failed to report an injury of unknown origin to the state agency for one resident (#63) of five reveiwed for accidents. The facility census was 102. Findings include: Medical record review revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including difficulty walking, repeated falls, and vascular dementia without behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had severely impaired cognition and required extensive assistance for activities of daily living. Review of the facility's Fall Investigation report dated 06/26/19, revealed Resident #63 fell from her wheel chair and was wearing hipsters at the time of the fall. The report revealed the resident sustained a skin tear to the left elbow and there were no other injuries. Review of Resident #63's progress note dated 07/08/19 at 12:42 P.M., revealed a late entry for 07/05/19 which documented the resident had no pain or discomfort. Review of Resident #63's progress note dated 07/06/19 at 8:50 P.M., revealed a State Tested Nursing Assistant (STNA) had assisted the resident to bed and noticed the resident was having a lot of pain, was yelling out, and was grabbing at her left inner thigh and hip. The nurse was notified. The nurse's assessment revealed the resident's left foot to be rotated outward, the resident had extreme pain with range of motion, was grabbing at the left inner thigh, yelling out, and became tearful. The note further revealed the resident had a fall on 06/26/19 with no injuries noted. There was an old green bruise to left knee noted and thought to be from the fall on 06/26/19. The physician was notified and ordered x-rays of the left hip. The resident's family was notified and revealed they took the resident out of the facility on 07/04/19, transferring the resident in and out of the car, and the resident did not appear to be in pain. Review of the radiology report dated 07/06/19 at 11:14 P.M., revealed Resident #63 had an acute (sudden) transcervical versus basicervical left hip fracture. Review of the progress note dated 07/07/19 at 1:35 A.M., revealed the facility contacted Resident #63's physician with the hip x-ray results and the resident was sent to the hospital emergency room for evaluation. Review of the hospital history and physical dated 07/07/19 revealed Resident #63 presented to the acute care hospital with the chief complaint of hip pain. The note documented the resident had an x-ray of the left hip which revealed an acute left subcapital femoral neck fracture. Interview on 07/16/19 at 5:13 P.M., with the Director of Nursing (DON) and Nurse Supervisor (NS) #285 revealed Resident #63 had been out of the facility with family on 07/04/19, transferring in and out of a car multiple times. The DON reported the family was adamant the resident was not in any pain during the outing. The DON and NS #285 revealed the staff noted hip pain on 07/06/19, an x-ray revealed a hip fracture, and an order was received to send the resident to the hospital for treatment. The DON and NS #285 denied the resident had any bruising to the hips prior to sending the resident to the hospital. Interview on 07/17/19 at 9:56 A.M., with the DON revealed Resident #63's hip fracture was not related to the fall on 06/26/19, and the facility thought something may have happened when the resident went out with the family 07/04/19. She was unsure if the facility investigated the injury of unknown origin. Interview on 07/17/19 at 10:47 A.M., with NS #285 revealed Resident #63 had a fall on 06/26/19 and had no signs of injury at the time. NS #285 confirmed the resident went out of the facility with the family on 07/04/19 and the family denied there was any injury or incident while transferring the resident in and out of the car. NS #285 revealed the facility then attributed the resident's hip fracture to the fall sustained on 06/26/19 (10 days prior). NS #285 verified the facility had no evidence a thorough written investigation was completed when the injury was discovered, including interviews/written statements with the STNA who assisted the resident to bed and reported the resident's sudden severe pain on 07/06/19 or other staff. Interview on 07/17/19 at 11:15 A.M., with the DON verified the facility did not have evidence of a written investigation of Resident #63's hip fracture. There were no injuries from staff who provided care up to the time of the noted injury. The DON verified the facility did not submit a Self-Reported Incident (SRI) to the state survey agency for the injury of unknown source. During an additional interview on 07/17/19 at 1:50 P.M., at the request of the DON, the DON revealed the facility had always thought Resident #63's hip fracture was related to her fall on 06/26/19, which was 10 days prior. NS #285 presented an unsigned, undated summary/timeline of the events surrounding the resident's fracture and stated she had just written it today (07/17/19). The summary noted the resident's daughter stated she would have noticed if the resident was having pain on 07/04/19, and there was no pain noted on 07/05/19. NS #285 also presented an undated written statement signed by the STNA who assisted the resident to bed when the resident initially complained of hip pain on 07/06/19. NS #285 verified the STNA had just written the statement today (07/17/19). Review of the facility policy titled, Resident Abuse revised 03/09/09, revealed an injury should be classified as an injury of unknown source when the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury or the location of the injury. The policy further revealed when a serious injury of an unknown source is reported, the DON or appointed designee and a member of social services would investigate the incident, the incident would be reported to the Ohio Department of Health within 24 hours and the investigation completed within five days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the hospital record, review of facility policy, and staff interview, the facility failed to thoroughly investigate an injury of unknown origin for one resident (#63) of five reveiwed for accidents. The facility census was 102. Findings include: Medical record review revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including difficulty walking, repeated falls, and vascular dementia without behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had severely impaired cognition and required extensive assistance for activities of daily living. Review of the facility's Fall Investigation report dated 06/26/19, revealed Resident #63 fell from her wheel chair and was wearing hipsters at the time of the fall. The report revealed the resident sustained a skin tear to the left elbow and there were no other injuries. Review of Resident #63's progress note dated 07/08/19 at 12:42 P.M., revealed a late entry for 07/05/19 which documented the resident had no pain or discomfort. Review of Resident #63's progress note dated 07/06/19 at 8:50 P.M., revealed a State Tested Nursing Assistant (STNA) had assisted the resident to bed and noticed the resident was having a lot of pain, was yelling out, and was grabbing at her left inner thigh and hip. The nurse was notified. The nurse's assessment revealed the resident's left foot to be rotated outward, the resident had extreme pain with range of motion, was grabbing at the left inner thigh, yelling out, and became tearful. The note further revealed the resident had a fall on 06/26/19 with no injuries noted. There was an old green bruise to left knee noted and thought to be from the fall on 06/26/19. The physician was notified and ordered x-rays of the left hip. The resident's family was notified and revealed they took the resident out of the facility on 07/04/19, transferring the resident in and out of the car, and the resident did not appear to be in pain. Review of the radiology report dated 07/06/19 at 11:14 P.M., revealed Resident #63 had an acute (sudden) transcervical versus basicervical left hip fracture. Review of the progress note dated 07/07/19 at 1:35 A.M., revealed the facility contacted Resident #63's physician with the hip x-ray results and the resident was sent to the hospital emergency room for evaluation. Review of the hospital history and physical dated 07/07/19 revealed Resident #63 presented to the acute care hospital with the chief complaint of hip pain. The note documented the resident had an x-ray of the left hip which revealed an acute left subcapital femoral neck fracture. Interview on 07/16/19 at 5:13 P.M., with the Director of Nursing (DON) and Nurse Supervisor (NS) #285 revealed Resident #63 had been out of the facility with family on 07/04/19, transferring in and out of a car multiple times. The DON reported the family was adamant the resident was not in any pain during the outing. The DON and NS #285 revealed the staff noted hip pain on 07/06/19, an x-ray revealed a hip fracture, and an order was received to send the resident to the hospital for treatment. The DON and NS #285 denied the resident had any bruising to the hips prior to sending the resident to the hospital. Interview on 07/17/19 at 9:56 A.M., with the DON revealed Resident #63's hip fracture was not related to the fall on 06/26/19, and the facility thought something may have happened when the resident went out with the family 07/04/19. She was unsure if the facility investigated the injury of unknown origin. Interview on 07/17/19 at 10:47 A.M., with NS #285 revealed Resident #63 had a fall on 06/26/19 and had no signs of injury at the time. NS #285 confirmed the resident went out of the facility with the family on 07/04/19 and the family denied there was any injury or incident while transferring the resident in and out of the car. NS #285 revealed the facility then attributed the resident's hip fracture to the fall sustained on 06/26/19 (10 days prior). NS #285 verified the facility had no evidence a thorough written investigation was completed when the injury was discovered, including interviews/written statements with the STNA who assisted the resident to bed and reported the resident's sudden severe pain on 07/06/19 or other staff. Interview on 07/17/19 at 11:15 A.M., with the DON verified the facility did not have evidence of a written investigation of Resident #63's hip fracture. There were no injuries from staff who provided care up to the time of the noted injury. The DON verified the facility did not submit a Self-Reported Incident (SRI) to the state survey agency for the injury of unknown source. During an additional interview on 07/17/19 at 1:50 P.M., at the request of the DON, the DON revealed the facility had always thought Resident #63's hip fracture was related to her fall on 06/26/19, which was 10 days prior. NS #285 presented an unsigned, undated summary/timeline of the events surrounding the resident's fracture and stated she had just written it today (07/17/19). The summary noted the resident's daughter stated she would have noticed if the resident was having pain on 07/04/19, and there was no pain noted on 07/05/19. NS #285 also presented an undated written statement signed by the STNA who assisted the resident to bed when the resident initially complained of hip pain on 07/06/19. NS #285 verified the STNA had just written the statement today (07/17/19). Review of the facility policy titled, Resident Abuse revised 03/09/09, revealed an injury should be classified as an injury of unknown source when the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury or the location of the injury. The policy further revealed when a serious injury of an unknown source is reported, the DON or appointed designee and a member of social services would investigate the incident, the incident would be reported to the Ohio Department of Health within 24 hours and the investigation completed within five days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to properly store and label medications in three of eight medication cabinets observed. This affected three residents (#23, #63 and #96). The facility census was 102. Findings include: 1. Review of Resident #23's physician orders dated [DATE] revealed an order for Humalog Kwikpen 100 units per milliliter (ml) and instruction to administer six units with meals for type two diabetes. Observation on [DATE] at 10:21 A.M., of the medication storage cabinet in Resident #23's room revealed a Humalog Kwikpen 100 units per milliliter (insulin pen) did not have a date opened on the product. Interview with Licensed Practical Nurse (LPN) #53 on [DATE] at 10:23 A.M., confirmed the insulin pen in Resident #23's medication storage cabinet was opened and did not have an open date to ensure that the product was not expired prior to administration. Review of Humalog insulin pen product insert revealed to not use the product past the expiration date printed on the label or for more than 28 days after you first start using the pen. Review of the facility's policy titled Medication Storage Guidelines dated [DATE] revealed storage recommendations to date when multiple dose vials for injections when opened and discard unused portions after 28 days. 2. Review of Resident #96's physician orders dated [DATE] revealed an order for Polyethyl Glycol-Propyl (Refresh) 0.4-0.3% eye drops to be administered one drop in each eye every eight hours as needed for dry eyes. Observation on [DATE] at 10:00 A.M., of the medication storage cabinet in Resident #96's room revealed a vial of Polyethyl Glycol-Propyl (Refresh) 0.4-0.3% eye drops with an open date of [DATE]. Interview with LPN #53 on [DATE] at 10:02 A.M. confirmed that the Refresh eye drops in Resident #96's medication storage cabinet were dated [DATE]. Review of Refresh eye drops product insert revealed drops can be stored for 28 days after opening to ensure the safety of the drops and beyond 28 days there was a strong risk of the eye drops being contaminated by bacteria which could damage the eyes. Review of the facility's policy titled Medication Storage Guidelines dated [DATE] revealed to properly handle and dispose of any expired or unused products in accordance with facility policy or local, state, and federal regulations. 3. Observation on [DATE] at 10:09 A.M., of the medication storage cabinet in Resident #63's room revealed a pill vial containing the medication Loratadine (an allergy relief medication) with a disregard product by date of [DATE]. Interview with LPN #52 on [DATE] at 10:10 A.M., confirmed the pill vial of Loratadine for Resident #52 was dated [DATE] and was expired. LPN #52 further stated that the nurses go through the resident's medication storage cabinets when they can, however sometimes they were not sure what medications other shifts utilize. LPN #52 took the vial of Loratadine medication and placed it in a cup to be destroyed. Review of the facility's policy titled Medication Storage Guidelines dated [DATE] revealed to properly handle and dispose of any expired or unused products in accordance with facility policy or local, state, and federal regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide notification of resident transfer/discharge to the ombudsman. This affected three Resident's (#17, #82, and #87) of the four residents reviewed for hospitalizations during the annual survey. The facility census was 106. Findings include: 1. Review of the medical record revealed Resident #87 was admitted to the facility on [DATE] with diagnoses including weakness, vascular dementia without behavioral disturbance, cerebral infarction, major depressive disorder, and irritable bowel syndrome. Review of the Minimum Data Set (MDS) completed 05/30/18 revealed Resident #87 was severely cognitively impaired, required extensive assistance with bed mobility, dressing, toileting, and personal hygiene, supervision with eating, and total dependence with transfers, locomotion, and bathing. Further review of the medical record revealed Resident #87 was transferred to the hospital on [DATE] (re-admitted to the facility on [DATE]) with bilateral femur fractures. The medical record was silent for verification of notification to the Ombudsman. 2. Review of the medical record revealed Resident #82 was admitted on [DATE] with diagnosis including pneumonia, influenza, dementia, diabetes, obstructive sleep apnea, hypertension, acute embolism, depression, trigeminal neuralgia, muscle weakness, Alzheimer's, angina pectoris, amnesia, anxiety, congestive heart failure, hyperlipidemia, vitamin D, personality and behavioral disorder, and osteoarthritis. Review of the Quarterly MDS dated [DATE] revealed Resident #82 had severe cognitive deficits, required limited assist with personal hygiene, extensive assistance for bed mobility, transfers, dressing, toileting, and is frequently incontinent bladder, and always continent of bowel. Further review of the medical record revealed Resident #82 was admitted to the hospital on [DATE] for chest pain, on 03/29/18 for a psych evaluation, and 04/19/18 for an evaluation for behaviors and chest pain. Resident's #82 medical record was silent for verification of notification to the Ombudsman. 3. Review of the medical record revealed Resident #17 was admitted on [DATE] with diagnoses including hypertension, diabetes mellitus with diabetic neuropathy, hyperlipidemia, and vascular dementia without behavioral disturbance. The comprehensive MDS assessment dated [DATE] documented the resident had adequate hearing and vision with corrective lenses, clear speech, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 (cognitively intact), and required limited to extensive assistance with activities of daily living (ADLs). Further medical record review revealed the resident was hospitalized from [DATE] to 04/14/18. The medical record contained no evidence the Ombudsman was notified in writing of the resident's transfer to a hospital. Interview conducted on 06/14/18 at approximately 9:40 A.M. with facility Social Worker #254 stated the facility was unable to provide documentation of verification the Ombudsman was notified of Resident's #17, #82 and #87 being transferred and/or discharged . Phone interview conducted on 06/14/18 at 10:12 A.M. the facility Ombudsman stated she did have a conversation with Social Worker #254 regarding notification of transfer/discharge, however she had not received any notifications from the facility of residents that were transferred or discharged .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and staff interview, the facility failed to provide written bed notices to residents when hospitalized . This affected one Resident (#17) of four residents reviewed for hospitalizations. The facility census was 106. Findings include: Resident #17 was admitted on [DATE] with diagnoses including hypertension, diabetes mellitus with diabetic neuropathy, hyperlipidemia, and vascular dementia without behavioral disturbance. Further medical record review revealed the resident was hospitalized from [DATE] to 04/14/18. The medical record contained no evidence that a written bed hold notice was provided to the resident or representative within 24 hours of the transfer. The Minimum Data Set (MDS) dated [DATE] documented the resident had adequate hearing and vision with corrective lenses, clear speech, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, and required limited to extensive assistance with activities of daily living (ADLs). Interview on 06/14/18 at 10:53 A.M. with the Director of Nursing (DON) verified the medical record contained no documentation written bed hold information was provided to the resident or representative at the time of the hospitalization on 04/11/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to ensure residents were provided the opportunity to participate in the review and revision of their care plans. This affected two (#46 and #57) of three residents reviewed for care planning. The facility census was 106. Findings include: 1. Resident #46 was admitted [DATE] with diagnoses including cerebrovascular disease, vascular dementia, major depressive disorder, and dysphagia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had minimal difficulty hearing, usually made self understood, usually understood others, had a Brief Interview for Mental Status (BIMS) score of nine out of 15 (indicative of moderate cognitive impairment), and required extensive assistance for activities of daily living (ADL). Review of Social Service Multidisciplinary Care Conference forms documented care conferences were held for Resident #46 on 03/16/18 and on 01/11/18. The medical record contained no evidence that the resident was invited to, attended, refused to attend or that it was not practicable for the resident to attend the meeting. Interview on 06/11/18 at 10:54 A.M., Resident # 46 reported having received no invitations from the facility to attend a care conference to discuss or review the care plan. Interview on 06/12/18 at 3:32 P.M. with the director of nursing (DON) revealed the facility's social services department invited residents and their families to attend care conferences to review care plans. Interview on 06/12/18 with Resident Services Coordinator (RSC) #254 of the Social Services department verified care conferences were held for Resident #46 on 01/11/18 and again on 03/16/18. RSC #254 reported the resident refused to attend the care conferences. RSC #254 verified the Social Services Multidisciplinary Care Conference forms Dated 01/11/18 and 03/16/18 contained no documentation that the resident was invited to, attended or refused the care conferences, or that it was not practicable for the resident to attend. 2. Resident #57 was admitted [DATE] with diagnoses including vascular dementia without behavioral disturbance, anxiety disorder, and major depressive disorder. The annual MDS assessment dated [DATE] documented the resident had minimal difficulty hearing, adequate vision, clear speech, usually made self understood and usually understood others. The assessment further documented the resident had a BIMS score of 11 out of 15, and required extensive assistance for ADL's. Review of a Social Service Multidisciplinary Care Conference forms dated 02/15/18 documented a care conference was held by the interdisciplinary team for Resident #57. The medical record contained no evidence that the resident was invited to, attended, refused, or that it was not practicable for the resident to attend the meeting. Interview on 06/12/18 at 10:54 A.M., Resident # 57 denied being invited by the facility to attend a meeting to discuss or review the care plan. Interview on 06/12/18 at 3:32 P.M. with the DON revealed the facility's social services department invited residents and their families to attend care conferences to review care plans. Interview on 06/12/18 with RSC #254 at 5:07 P.M. of the Social Services department verified a care conference was held for Resident #57 on 02/15/18. RSC #254 verified the Social Services Multidisciplinary Care Conference form dated 02/15/18 contained no documentation that the resident was invited to, attended or refused the care conference, or that it was not practicable for the resident to attend.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure interventions were implemented for a resident with a significant weight loss. This affected one (#29) of three residents reviewed for nutrition. The facility census was 106. Findings include: Medical record review revealed Resident #29 was admitted to the facility on [DATE] with diagnosis including dementia. Review of the annual minimum data set (MDS) assessment dated [DATE] revealed severely impaired cognitive skills for daily decision making, Resident #29 was totally dependent upon staff for transfers, bed mobility, toileting, personal hygiene, and supervision was required with eating. Review of the care plan updated June 2018 revealed Resident #29 was at nutritional risk with potential for dehydration due to diagnosis of dementia, congestive heart failure, gastroesophageal reflux disease, behaviors, and edema with routine diuretic. Resident #29 had a history of a significant weight loss of 10.82% for one month in February 2018. Interventions included to serve a regular diet as ordered, monitor intake and record every meal, monitor weight monthly and as needed, report significant changes to medical doctor, assist and cue at all meals, offer selective menu and appropriate substitutions for dislikes. Review of weights revealed Resident #29 weighed 194 pounds on 01/17/18 and 173 pounds in February 2018 for a 10.82% weight loss in one month. Review of nutrition progress note dated 02/16/18 at 1:37 P.M. revealed February weight was reviewed with a current body weight of 173 pounds on 02/14/18. Resident #29 weighed 194 pounds one month ago, 201.2 pounds three months ago, and 200.8 pounds six months ago. Resident #29 triggered for a significant weight loss of 10.82% at one month, 14.02% at three months and 13.84% at six months. Body mass index (BMI) of 29.7 remained above normal limits. Intake of a regular diet was increasingly variable from zero to 100% with an average of 50%. Resident #29 required extensive verbal cueing due to being resistant to assistance. History of edema with trace to bilateral lower extremities and resident received a routine diuretic. Overall decline noted with increased confusion, lethargy, and intermittent delusions with progressing dementia. Will request reweigh and monitor need for supplementation. Further medical record review revealed there wasn't any medical doctor notification, reweigh, or follow up until 03/12/18 when monthly weight of 179 pounds was obtained and a nutritional weight review note dated 03/16/18. Observation on 06/12/18 at 6:02 P.M. revealed Resident #29 was fed dinner in bed by State Tested Nursing Assistant (STNA) #116 and ate approximately 25% of the meal. Resident #29 refused the main pasta dish, spit it out, but did consume nutritional supplement. STNA #116 reported Resident #29 required a lot of cueing, loved fruit which was provided when she refused meals, and always consumed the nutritional supplement drink. Interview on 06/14/18 at 11:02 A.M. with dietetic technician (DT) #256 reported weights were obtained monthly and if more than a five to six pound weight difference, a reweigh was requested. Resident #29 weighed 194 pounds in January 2018 and 173 pounds on 02/14/18 for a significant loss of 10.82% in one month. Resident #29 had variable intakes, required extensive verbal cueing, was resistive to assistance, had edema to lower extremities, received a routine diuretic, and had progressive dementia with an overall decline, however the residents BMI remained 29.7 which was above normal limits. Interventions included to obtain a reweigh and monitor the need for nutritional supplements. DT #256 verified there wasn't any record of a reweigh being obtained and Resident #29 was not monitored again until the next month at which time weight revealed a six pound gain. DT #256 reported the medical doctor was not informed or consulted about the significant one month weight loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to ensure the medical doctor was informed or addressed a residents significant weight loss. This affected one (#29) of three residents reviewed for nutrition. The facility census was 106. Findings include: Medical record review revealed Resident #29 was admitted to the facility on [DATE] with diagnosis including dementia. Review of the annual minimum data set (MDS) assessment dated [DATE] revealed severely impaired cognitive skills for daily decision making, Resident #29 was totally dependent upon staff for transfers, bed mobility, toileting, personal hygiene, and supervision was required with eating. Review of the care plan updated June 2018 revealed Resident #29 was at nutritional risk with potential for dehydration due to diagnosis of dementia, congestive heart failure, gastroesophageal reflux disease, behaviors, and edema with routine diuretic. Resident #29 had a history of a significant weight loss of 10.82% for one month in February 2018. Interventions included to serve a regular diet as ordered, monitor intake and record every meal, monitor weight monthly and as needed, report significant changes to medical doctor, assist and cue at all meals, offer selective menu and appropriate substitutions for dislikes. Review of weights revealed Resident #29 weighed 194 pounds on 01/17/18 and 173 pounds in February 2018 for a 10.82% weight loss in one month. Review of the nutrition progress note dated 02/16/18 at 1:37 P.M. revealed February weight was reviewed with a current body weight of 173 pounds on 02/14/18. Resident #29 weighed 194 pounds one month ago, 201.2 pounds three months ago, and 200.8 pounds six months ago. Resident #29 triggered for a significant weight loss of 10.82% at one month, 14.02% at three months and 13.84% at six months. Body mass index (BMI) of 29.7 remained above normal limits. Intake of a regular diet was increasingly variable from zero to 100% with an average of 50%. Resident #29 required extensive verbal cueing due to being resistant to assistance. History of edema with trace to bilateral lower extremities and resident received a routine diuretic. Overall decline noted with increased confusion, lethargy, and intermittent delusions with progressing dementia. Will request reweigh and monitor need for supplementation. Further medical record review revealed there wasn't any medical doctor notification, reweigh, or follow up until 03/12/18 when monthly weight of 179 pounds was obtained and a nutritional weight review note dated 03/16/18. Observation on 06/12/18 at 6:02 P.M. revealed Resident #29 was fed dinner in bed by State Tested Nursing Assistant (STNA) #116 and ate approximately 25% of the meal. Resident #29 refused the main pasta dish, spit it out, but did consume the nutritional supplement. STNA #116 reported Resident #29 required a lot of cueing, loved fruit which was provided when she refused meals, and always consumed the nutritional supplement drink. Interview on 06/14/18 at 11:02 A.M. with dietetic technician (DT) #256 reported weights were obtained monthly and if more than a five to six pound weight difference, a reweigh was requested. Resident #29 weighed 194 pounds in January 2018 and 173 pounds on 02/14/18 for a significant loss of 10.82% in one month. Resident #29 had variable intakes, required extensive verbal cueing, was resistive to assistance, had edema to lower extremities, received a routine diuretic, and had progressive dementia with an overall decline, however the residents BMI remained 29.7 which was above normal limits. Interventions included to obtain a reweigh and monitor the need for nutritional supplements. DT #256 verified there wasn't any record of a reweigh being obtained and Resident #29 was not monitored again until the next month at which time weight revealed a six pound gain. DT #256 reported the medical doctor was not informed or consulted about the significant one month weight loss. Further medical record review of medical doctor assessment dated [DATE] for Resident #29 revealed the section for weight was blank and assessment did not include any documentation related to weight loss.

Based on observation, interviews, review of Diet Spreadsheet and review of list of residents prescribe diets the facility failed to provide adequate portions of food to meet the nutritional needs of the residents. This affected seven Residents (#7, #20, #31, #36, #53, #59, #72) on the Garden Side Hall whom were prescribed a regular diet, 26 Residents (#1, #9, #13, #16, #18, #19, #23, #25, #26, #27, #33, #38, #39 #44, #46, #50, #57, #60, #63, #74, #78, #79, #81, #83, #87, #89) on the Gardens Hall whom were prescribed regular and mechanical soft diets, eight Residents (#6, #10, #15, #55, #64, #66, #67, #75) on the Hillside Hall who were on pureed and mechanical soft diets, and one Resident (#45) on the Orchard Hall prescribed a pureed diet. The facility census was 106. Findings include: 1. Observation on 06/13/18 at 11:13 A.M. of the Orchards Hall pantry serving area revealed Food Service Specialist (FSS) #241 was unable to identify which pan on the steam table contained the pureed tomato rice soup and which contained the pureed beef stew. FSS #241 asked Nutrition Supervisor (NS) #124, whom was present at the pantry, if the food should be sampled to determine what it was but it was then decided, without tasting, which pan contained the soup and which one contained the stew although they appeared identical in color and texture. FSS #241 then served Resident #45 four ounces of the soup in the pan which was identified as pureed tomato rice soup. Review of Diet Spreadsheet for 06/13/18 revealed with FSS #241 and NS #124 revealed pureed diet was to receive six ounces of tomato rice soup. Interview with NS #124 at the time of the observation confirmed Resident #45 was served the incorrect amount of soup and was served four ounces instead of six ounces of soup. 2. Observation on 06/13/18 at 11:53 A.M. of the Hillside Hall pantry serving area revealed two mechanical soft summer beef stew, one with a three ounce serving scoop, the other with a six ounce serving scoop, and pureed summer beef stew with a four ounce serving scoop. Interview at the time of the observation with [NAME] #197 first identified the mechanical soft summer beef stew with the six ounce serving scoop as the mechanical meat and identified the one with the three ounce serving scoop as pureed. [NAME] #197 then consulted with Food Service Supervisor #192 whom confirmed the pans with the six and three ounce serving scoops were both mechanical meats and should have the same six ounce serving scoop. They then decided the pan with the four ounce scoop was pureed meat, initially they were unsure if it was meat or soup but then decided it was meat as the soup was located in another area. Food Service Supervisor #192 confirmed residents on pureed diets were being served four ounces of summer beef stew. Review of the Diet Spreadsheet for 06/13/18 revealed mechanical soft diets and pureed diets were to receive six ounces of summer beef stew. 3. Observation on 06/13/18 at 4:45 P.M. of the Gardens Hall pantry serving area revealed residents on a regular diet were being served three ounces of green beans by FSS #199. Interview with FSS #199 at the time of the observation verified the residents received three ounces of green beans. Review of Diet Spreadsheet for 06/13/18 revealed regular diets were to receive four ounces of green beans. 4. Observation on 06/13/18 at 4:53 P.M. of the Garden Side Hall revealed residents were served three ounces of potatoes by State Tested Nursing Assistant (STNA) #163. Interview at the time of the observation with STNA #163 confirmed residents on a regular diet received three ounces of potatoes. Review of Diet Spreadsheet for 06/13/18 revealed regular diets were to receive 4 ounces of Au Gratin Potatoes at dinner. Interview on 06/14/18 at 11:42 A.M. with NS #194 acknowledged the wrong serving size scoops were utilized for lunch and dinner on 06/13/18. NS #194 reported the Diet Spreadsheets were based upon residents likes, dislikes, and then reviewed by the dietician to ensure adequate nutritional needs were met. The facility provided a list of all Residents with prescribed diets which included seven Residents (#7, #20, #31, #36, #53, #59, #72) on the Garden Side Hall whom were prescribed a regular diet, 26 Residents (#1, #9, #13, #16, #18, #19, #23, #25, #26, #27, #33, #38, #39 #44, #46, #50, #57, #60, #63, #74, #78, #79, #81, #83, #87, #89) on the Gardens Hall whom were prescribed regular and mechanical soft diets, eight Residents (#6, #10, #15, #55, #64, #66, #67, #75) on the Hillside Hall on pureed and mechanical soft diets, and one Resident (#45) on the Orchard Hall prescribed a pureed diet.