Based on record review and interview, the facility failed to notify the physician when a resident's blood pressure was abnormal for one (#24) of five sampled residents reviewed for unnecessary medication. The administrator identified 81 residents resided in the facility. Findings: Resident #24 had a diagnosis of hypertension. A physician's order, dated 12/01/22, documented valsartan (an antihypertensive) 160 mg, give one tablet by mouth one time a day for hypertension. A physician's order, dated 05/10/23, documented amlodipine besylate (an antihypertensive) 5 mg, give one tablet by mouth one time a day for hypertension. A physician's order, dated 07/24/24, documented to obtain blood pressure and heart rate one time a day for monitoring if systolic blood pressure 170 or greater refer to as needed hydralazine (vasodilator) order. The January 2025 Medication Admin Audit Report documented amlodipine besylate was initialed as given on: a. 01/28/25 at 8:01 a.m., b. 01/30/25 at 7:52 a.m., and c. 01/31/25 at 8:10 a.m. The January 2025 Medication Admin Audit Report documented the valsartan was initialed as given on: a. 01/28/25 at 8:06 a.m., b. 01/30/25 at 7:52 a.m., and c. 01/31/25 at 8:10 a.m. A Blood Pressure Summary documented the following blood pressures: a. 93/49 mmHg on 01/28/25 at 8:06 a.m., b. 88/46 mmHg on 01/30/25 at 7:54 a.m., and c. 91/41 mmHg on 01/31/25 at 8:12 a.m. The February 2025 Medication Admin Audit Report documented the amlodipine besylate was initialed as given on: a. 02/02/25 at 6:36 a.m., and b. 02/03/25 at 7:33 a.m. The February 2025 Medication Admin Audit Report documented the valsartan was initialed as given on: a. 02/02/25 at 6:36 a.m., and b. 02/03/25 at 7:36 a.m. A Blood Pressure Summary documented the following blood pressures: a. 80/52 mmHg on 02/02/25 at 6:40 a.m., and b. 91/53 mmHg on 02/03/25 at 7:42 a.m. There was no documentation the provider was notified antihypertensives were administered with the abnormal blood pressures above. On 02/05/25 at 2:50 p.m., CMA #1 reviewed Resident #24's blood pressures above. They stated the blood pressures above were considered abnormal. They stated their process was to notify the charge nurse and document in the resident's electronic health record the nurse was notified of low blood pressures. On 02/05/25 at 2:54 p.m., CMA #1 stated they could not locate documentation the nurse was notified of the resident's abnormal blood pressures above. On 02/05/25 at 3:03 p.m., LPN #1 stated the CMAs would report to the nurse abnormal blood pressure readings and the nurse would notify the provider for further guidance. On 02/05/25 at 3:07 p.m., LPN #1 reviewed Resident #24's blood pressures and the medication administration record for January and February 2025. They stated the CMA should have reported the blood pressures to them. They stated they were not notified. On 02/05/25 at 3:10 p.m., LPN #1 stated there was no documentation the provider was notified of the blood pressures above. On 02/06/25 at 11:34 a.m., the DON reviewed Resident #24's blood pressures and the medication administration record for January and February 2025. They stated the resident's antihypertensive medications did not contain parameters for physician notification. They stated their process was to notify the charge nurse and the provider of abnormal blood pressure readings, and to recheck. On 02/06/25 at 11:45 a.m., the DON stated they could not locate documentation the resident's blood pressure was rechecked on the dates above.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed within the required timeframe for one (#170) of 18 sampled residents reviewed for care plans. The administrator identified 81 residents resided in the facility. Findings: Resident #170 admitted to the facility on [DATE]. Resident #170's admission Resident Assessment was dated 01/22/25. There was no comprehensive care plan located in Resident #170's clinical record. On 02/11/25 at 9:45 a.m., the case manager stated they were responsible for MDS resident assessments and care plans for the skilled residents. On 02/11/25 at 9:48 a.m., the case manager stated they put in basic care plans when residents initially admitted to the facility. They stated they would then complete the admission assessment. They stated the comprehensive care plan should be completed no more than 21 days after admission. On 02/11/25 at 9:50 a.m., the case manager stated Resident #170 admitted on [DATE]. They stated the care plan was not completed and had surpassed the 21 days. On 02/11/25 at 10:27 a.m., the DON stated the facility did not have a care plan policy.

Based on observation, record review and interview, the facility failed to: a. ensure expired medications were removed from circulation for three (#8, 46, and #56) of 10 sampled residents reviewed with controlled medications; and b. medications were administered as ordered for one (#24) of five sampled residents reviewed for unnecessary medications. The administrator identified 81 residents resided in the facility. Findings: The MEDICATION ADMINISTRATION-GENERAL GUIDELINES policy, dated 01/2022, read in part, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. 1. Resident #8 had diagnoses which included chronic obstructive pulmonary disease. A Physician Order, dated 05/18/24, documented hydrocodone-acetaminophen (an opioid) tablet 5-325 mg give one tablet by mouth every four hours as needed for pain. An Individual Resident's Narcotics Record, dated 05/18/24, documented the last dose of hydrocodone-acetaminophen 5-325 mg was administered to Resident #8 on January 25th. The remaining count was 62 tablets. On 02/10/25 at 9:59 a.m., CMA #2 stated the facility reordered medications on the computer, usually one to two times a week. On 02/10/25 at 10:06 a.m., CMA #2's medication cart was observed. Resident #8 had two medication cards for hydrocodone-acetaminophen 5/325, one with a count of 17 and the other with a count of 45. Both medications were observed to have an expiration date of 09/22/24. CMA #2 stated, Nobody caught it. They stated what they would do was write up a piece of paper and let the nurse know, and call hospice to get new cards. CMA #2 stated the medication was last administered on 01/25/25 at 9:00 a.m. 2. Resident #56 had diagnoses which included chronic obstructive pulmonary disease and paroxysmal atrial fibrillation. An Individual Resident's Narcotics Record, dated 05/22/24, documented the last dose of lorazepam concentrate 2 mg/ml amount 0.25 ml was administered to Resident #56 on 09/09/24. The remaining count was 8. A Physician Order, dated 09/10/24, documented lorazepam (an antianxiety) oral tablet 0.5 mg give one tablet by mouth two times a day for anxiety. The order summary report provided by the facility did not contain an order for the liquid lorazepam. An Individual Resident's Narcotics Record, dated 05/29/24, documented the last dose of lorazepam concentrate 2 mg/ml amount 0.25 ml was administered to Resident #56 on July 7th. The remaining count was 26. 3. Resident #46 had diagnoses which included chronic kidney disease and paroxysmal atrial fibrillation. The order summary report provided by the facility did not contain an order for the liquid lorazepam. An Individual Resident's Narcotics Record, dated 05/16/24, documented the last dose of lorazepam concentrate 2 mg/ml amount 0.25 ml was administered to Resident #46 on 10/09/24. The remaining count was 24. On 02/10/25 at 10:20 a.m., the following medications were observed in the locked box in the refrigerator in the medication storage room for halls 5, 6, 7, and 8: a. Resident #56's lorazepam concentrate 2 mg/ml amount in each syringe 0.25 ml count 8 with an expiration date of 08/13/24. LPN #1 stated the medication expired on 08/13/24; b. Resident #56's lorazepam concentrate 2 mg/ml amount in each syringe 0.25 ml count 26 with an expiration date of 08/27/24. LPN #1 stated, These are expired; and c. Resident #46's lorazepam concentrate 2 mg/ml amount in each syringe 0.25 ml count 24 with an expiration date of 11/15/24. LPN #1 stated the expiration date was 11/15/24. LPN #1 stated staff usually checked medications weekly for expiration dates through the cart audit. LPN #1 stated staff or the pharmacist would check them in the cubbies and in the carts. LPN #1 stated staff would pull expired and discontinued medications. On 02/10/25 at 12:50 p.m., the DON stated the medication aides were responsible for monitoring the expiration dates on medications. They stated staff would write the medication up with the destruction logs and they would get destroyed. 4. Resident #24 had diagnoses which included generalized anxiety, major depressive disorder, and insomnia. Physician orders, dated 11/21/23, documented buspirone HCl (an antianxiety) 10 mg, give one tablet by mouth one time a day for anxiety at 10:00 p.m. every night; and doxepin HCl (an antidepressant) to give 150 mg by mouth one time a day for insomnia at 10:00 p.m. every night. The December 2024 MAR documented blanks at 10:00 p.m. for buspirone and doxepin on the 5th, 6th, 13th, 20th, 21st, 25th, 26th, 28th, 29th, and 30th. The January 2025 MAR documented blanks at 10:00 p.m. for buspirone and doxepin on the 4th, 16th, 19th, 21st, 23rd, 25th, 27th, and 29th. On 02/05/25 at 2:48 p.m., CMA #1 reviewed Resident #24's December 2024 and January 2025 MAR. They stated the blanks meant the medications were not administered. On 02/06/25 at 11:33 a.m., the DON stated the process for administering medications was to punch, initial, give, and to notify the nurse if a resident refused medication. On 02/06/25 at 11:36 a.m., the DON reviewed Resident #24's December 2024 and January 2025 MAR. They stated the blanks on the MAR could mean the medication was not administered or the staff forgot to initial as given.

Based on record review and interview, the facility failed to ensure resident assessments were accurate for one (#94) of 20 sampled residents reviewed for resident assessments. The DON identified 96 residents resided in the facility. Findings: Resident #94 had diagnoses which included COPD and hypertension. A Discharge Summary, dated 10/18/23, documented Resident #94 was discharged home with their spouse. It documented Resident #94 was able to walk using a walker and put themselves in a car. Resident #94's discharge resident assessment, dated 10/18/23, documented Resident #94 had a planned discharge to a short-term general hospital (acute hospital). On 11/29/23 at 2:34 p.m., the CM stated Resident #94's discharge resident assessment documented the resident was discharged to an acute hospital. They stated Resident #94's discharge summary documented the resident was discharged home. The CM stated it could have been an error.

Based on observation, record review and interview, the facility failed to ensure food items were properly sealed, dated, and labeled during one of one kitchen observations. The DON identified 96 residents resided in the facility and received services from the kitchen. Findings: The facility's Dining Services Policies and Procedures - Food Storage policy, revised 04/30/09, read in part, .Food items will be stored, thawed, and prepared in accordance with approved sanitary practices .Fresh Fruits .Rotate so that oldest produce is used first .Fresh vegetables are to be checked and sorted for ripeness . On 11/27/23 at 1:24 p.m., the following items were observed in the walk in the freezer during the initial kitchen tour: a. an opened clear bag of mixed frozen vegetables in a carton not labeled or dated, b. frozen broccoli in a clear bag not properly sealed, and c. cheese pizza in a clear bag not properly sealed. On 11/27/23 at 1:36 p.m., a white bulk storage bin with a clear transparent lid containing a white powder had no label or date. On 11/27/23 at 1:42 p.m., the CDM stated the white powder in the storage was flour and the bin had no label or date. On 11/27/23 at 1:48 p.m., the following items were observed in the walk in refrigerator: a. three bottles of opened cranberry juice with no label or date, b. a carton of mighty shake with mold along the seal, c. orange liquid in a transparent pitcher dated 11/17/23, d. sweet and sour sauce half used with no label or date, e. a carton with nine cantaloupes with a gray and fuzzy substance on all of them, f. a carton with four yellow melons with multiple areas of a black substance on all of them, g. four bags of red grapes in a box dated 10/30/23 with a grey substance present, and not properly sealed, h. lettuce in a transparent bag with no label or date, and not properly sealed. The lettuce was wilted and had multiple dried leaves, and i. shredded cheese in a bag which was not properly sealed. On 11/27/23 at 2:03 p.m., the CDM stated the three bottles of cranberry juice were not labeled or dated. On 11/27/23 at 2:05 p.m., the CDM stated the carton of mighty shake had mold present. They stated the orange soda should be discarded. The CDM stated the sweet and sour sauce was not labeled or dated. On 11/27/23 at 2:10 p.m., the CDM stated there was mold on some of the cantaloupes, melons, and the red grapes. They stated the lettuce had started to go bad. They stated the lettuce and the shredded cheese were not properly secured. On 11/27/23 at 2:15 p.m., the CDM stated all opened food items must be labeled and dated. They stated the refrigerator was checked daily for perishable foods but they had been short staffed.

Based on record review and interview, the facility failed to report a communicable disease to the OSDH for four (#19, 47, 48, and #146) of four residents reviewed for COVID-19. The DON identified 96 residents resided in the facility. Four residents were positive for COVID-19 in the facility. Findings: 1. Resident #146 had diagnoses which included cerebral palsy and diabetes. A nursing note, dated 11/18/23, documented Resident #146 tested positive for COVID-19. 2. Resident #47 had diagnoses which included depression and transient ischemic attack. A nursing note, dated 11/23/23, documented Resident #47 tested positive for COVID-19. 3. Resident #19 had diagnoses which included acute kidney failure and COPD. A nursing note, dated 11/24/23, documented Resident #19 tested positive for COVID-19. 4. Resident #48 had diagnoses which included asthma and diabetes. A nursing note, dated 11/24/23, documented Resident #48 tested positive for COVID-19. On 11/30/23 at 9:53 a.m., state reportable incidents were reviewed and there was no documentation Resident #19, 47, 48, and #146's positive COVID-19 result had been reported to OSDH. On 11/30/23 at 10:10 a.m., the DON stated the administrator was responsible for reporting COVID-19 outbreak to the OSDH. On 11/30/23 at 10:28 a.m., the DON stated the administrator's process was to complete a state reportable after the COVID-19 outbreak was over.

Based on observation, record review, and interview, the facility failed to ensure the menu was followed for one of one meal service observed. The Resident Census and Conditions of Residents report, dated 08/21/23, documented 93 residents resided in the facility. The DON identified 93 residents received services from the kitchen. Findings: A Dietary Spreadsheet, dated 03/14/23, documented the lunch service was to contain Dsrt of Day. On 08/21/23 at 12:05 p.m., Resident #14 was observed in the dining room eating a salad. There was no observation a dessert had been provided. On 08/21/23 at 12:07 p.m., Resident #5 was observed in the dining room eating a salad. There was no observation a dessert had been provided. On 08/21/23 at 12:22 p.m., Resident #14 was asked how their lunch was. They stated it was good but they did not get any dessert. They stated it was normal not to be served any dessert. On 08/21/23 at 12:29 p.m., Resident #11 stated they weren't offered a dessert at the lunch meal. On 08/21/23 at 12:30 p.m., Resident #5 stated they didn't receive a dessert at the lunch meal. They stated they don't receive a dessert except Every once in a while. On 08/21/23 at 12:33 p.m., Resident #13 was asked if they received any dessert for lunch. They stated they did not get any dessert for lunch. On 08/21/23 at 12:40 p.m., Resident #17 was asked if they got any dessert for lunch. They stated they did not get any dessert for lunch. They stated they got desserts with meals sometimes, but not consistently. On 08/21/23 at 1:16 p.m., CNA #4 stated they checked the meal tickets to ensure the menu for the residents were followed. They stated there wasn't a dessert provided for lunch. On 08/21/23 at 1:31 p.m., the CDM was asked how staff ensured menus were followed. They stated they followed the menu in the kitchen. They were asked what the menu documented the dessert was for today's lunch meal. They stated, Dessert of the day. The CDM was asked if the Dessert of the day had been served to the residents. They stated, No. On 08/21/23 at 1:40 p.m., CNA #1 was asked if they were present in the dining room during today's lunch. They stated they were. CNA #1 was asked if there were any desserts served to the residents during lunch. They stated No.

Based on record review, observation, and interview, the facility failed to provide a clean homelike environment for one (hall 50 shower) of five shower rooms observed for homelike environment. The Resident Census and Conditions of Residents report, dated 11/27/22, documented 85 residents resided in the facility. The Administrator identified five shower rooms. Findings: Completed Work Orders list, dated 11/01/22 through 11/29/22, contained no documentation regarding the hall 500 shower room. On 11/28/22 at 7:37 a.m., the hall 500 shower room was observed to have brown/black substance covered in a cloudy coating along edge of floor/wall near the whirlpool tub. There were two hoses observed behind the whirlpool tub that are connected to the tub from the wall valve for water source. The hose on the left side was white in color with areas of a black substance covering parts of it. The hose on the right with the yellow handle at the valve was also white in color with the majority of it covered in a black substance. The hose with the yellow handle was observed dripping at the water connecting seal to the valve. On 11/28/22 at 2:30 p.m., the administrator was asked to provide the maintenance logs for January 2022 to current. She stated there were no maintenance logs available before the current month. On 11/29/22 at 8:30 a.m., CNA #1 was asked where the residents who resided on hall 500 received their baths/showers. They stated in the hall 500 shower room. On 11/29/22 at 8:40 a.m., Housekeeper #1 was asked how often the hall 500 shower room was cleaned. They stated twice daily. They were shown the hall 500 shower room and asked what the substance along the corner of the floor/wall was. They stated it was old buildup that doesn't go away. The Housekeeper was asked what was dripping off of the hose covered with black substance connecting the whirlpool tub to the water valve at the wall. They stated it was water because the water was left on, and needed repair. On 11/29/22 at 9:03 a.m., the DON was shown the shower room on hall 500 and was asked what they thought of it's condition. She stated this end of the building was in a re-model and it needed repair. The DON was asked if they would take a bath in that shower room. She stated, I would have to think twice about it. She was asked if residents showered in that shower room. She stated, Yes,

Based on record review, and interview, the facility failed to have an adequate system in place to ensure physician order to receive therapy services were followed for one (#60) of 24 sampled residents reviewed for physician orders. The Resident Census and Conditions report, dated 11/27/22, documented 85 residents resided in the facility. Findings: Resident #60 had diagnosis which included COPD, unilateral osteoarthritis right knee, fibromyalgia, scoliosis, bilateral artificial hips, chronic pain, and bed confinement status. Resident #60's quarterly assessment, dated 10/01/22, documented the resident's cognition was intact, and they required extensive to total assistance of one to two persons for mobility ADLs. It documented the resident had no ROM impairment. On 11/27/22 at 2:21 p.m., Resident #60 stated they want to be able to get therapy and walk. Resident #60's Physician Progress Note, dated 09/07/22, read in part, .Orders .po/Ot [sic] evaluation and treatment for generalized weakness and debility, pt requires strengthening, back exercises . Resident #60's Physician's Order, dated 09/08/22, documented an order for PT/OT evaluation and treatment. On 11/30/22 at 2:30 p.m., the therapy director was asked if they could locate the PT/OT therapy evaluation ordered for Resident #60. They stated they were unable to locate documentation the evaluation had been done. On 11/30/22 at 2:56 p.m., the corp. nurse consult #1 stated medical records was unable to locate PT/OT therapy evaluation.

Based on record review and interview, the facility failed to ensure allegations related to verbal and physical abuse was reported accurately and thoroughly investigated for two (#12 and #184) of three sampled residents reviewed for abuse. The Residents Census and Conditions, report, dated 11/27/22, documented 85 residents resided in the facility. Findings: The facility's Abuse, policy, revised 09/16/16, read in part, .A member of the administrative staff will then conduct a thorough investigation of the incident/allegation to obtain information about the incident . Resident #12 had diagnosis of diabetes mellitus type two, chronic kidney disease, and gout. Resident #12's quarterly assessment, documented the resident's cognition was intact, and they required extensive to total assistance with bed mobility, transfers, hygiene, and toileting. It documented the resident had impaired range of motion to bilateral lower extremities and was always incontinent of bowel and bladder. On 11/27/22 at 11:32 a.m., Resident #12 stated CNA #2 was terrible. Resident #12 stated the CNA screamed at the resident and the CNA refused to help anyone who couldn't help themselves. Resident #12 stated it made them cry for 30 minutes. Resident #12 stated the CNA stated they had worked at the facility for 22 years. Resident #12 stated this incident happened about a month ago around 3:30 a.m. Resident #12 stated they had reported it to everyone, including the staffing coordinator and nurses. An initial state report, dated 11/28/22, read in part, .staffing coordinator reported to the Administrator that [Resident #12] .had stated that [CNA #2] was rude to [them] during care last night . An untitled document, dated 11/28/22, read in part, .Interviewed [Staff coordinator] who states [staff coordinator] had told [administrator] a few weeks ago that [Resident #12] had stated that [the resident] had some issues with [CNA #2] .Interviewed [CNA #3] who when asked if [CNA #3] had reported the allegations any time before the 28th, [CNA #3] stated, yes, a few weeks ago, I don't remember the date, I told you that [Resident #12] had made an allegation against [CNA #2]. [CNA #3] stated that I always blow [CNA #3] off and don't listen to [CNA #3], then [CNA #3] walked away . The document was signed by the administrator. On 11/29/22 at 9:24 a.m., Resident #12 stated they peed a lot and needed to be changed every two hours. Resident #12 stated the morning CNA #2 came in and had asked if the resident was wet. Resident #12 stated they were. Resident #12 stated CNA #2 told the resident to roll over. Resident #12 stated CNA #2 yelled the entire time. Resident #12 stated CNA #2 turned the resident and was rough with them when cleaning them up. Resident #12 stated CNA #2 left the room and did not return. Resident #12 stated CNA #3 came in later that morning and Resident #12 reported the incident to CNA #3. Resident #12 stated it was very traumatic for them. Resident #12 recalled it happened on a week day at 3:30 a.m. Resident #12 stated they called their family member the day it happened. On 11/29/22 at 10:01 a.m., CNA #3 stated they were familiar with the hall Resident #12 resided on. CNA #3 stated the resident complained about CNA #2 Friday. CNA #3 stated Resident #12 had complained about CNA #2 three to four times. CNA #3 stated they reported it when it was abuse. CNA #3 stated Resident #12 was worried about retaliation and was terrified. CNA #3 stated Resident #184 complained about CNA #2 yesterday. CNA #3 stated the staffing coordinator was in the room when Resident #12 and #184 made complaints about CNA #2. On 11/29/22 at 10:22 a.m., Resident #184 stated the night before last, CNA #2 came in and asked if the resident was dirty. Resident #184 stated they had diarrhea and the CNA #2 was mad. Resident #184 stated CNA #2 pushed the resident over and left the covers off the resident. Resident #184 stated it was the same routine all night. Resident #184 stated they had been treated in-humane. Resident #184 stated they thought about filing charges and had asked CNA #2 what their name was and CNA #2 refused to give the resident their name. Resident #184 stated CNA #2 would tell the resident to turn over and if the resident didn't do it well enough, CNA would push the resident over. Resident #184 stated they haven't spoke with the administrator or the DON. On 11/29/22 at 10:36 a.m., the staff coordinator stated Resident #12 and #184 reported, yesterday, CNA #2 was rude and rough with them. The staff coordinator stated Resident #12 reported yesterday morning and Resident #184 reported yesterday around lunch time. The staff coordinator stated they had reported Resident #12's allegation to the administrator and CNA #3 reported Resident #184's allegation to the administrator. The staff coordinator stated they had reported to the administrator, in the last two weeks, Resident #12 complained of CNA #2 being rude and rough. The staff coordinator stated the administrator stated Okay, when they had reported it. On 11/29/22 at 11:02 a.m., Resident #12's family member was asked if the resident had reported any incidents to them. The family member stated the resident had called them a couple of weeks ago about CNA #2 being rude, rough, and had yelled at the resident. The family member stated the resident was crying when telling them about the incident. The family member stated they wanted to call the administrator but Resident #12 stated they had already told the staff and nurses. On 11/29/22 at 11:48 a.m., the DON was asked, with corp. nurse consult #1 present, if they were aware of any recent abuse allegations. The DON stated they were aware of Resident #12 and CNA #2 but wasn't aware of any details. On 11/29/22 at 11:55 a.m., the administrator stated the staff coordinator reported an allegation of abuse yesterday morning regarding Resident #12 and CNA #2. The administrator stated they denied having any knowledge regarding CNA #2 prior to this allegation. The administrator stated the DON and administrator went and spoke with Resident #12. The administrator stated Resident #12 stated an overnight shift aide was rude to them while providing care and denied anything physical. The administrator stated it had happened the night of the 27th on the 11:00 p.m. to 7:00 a.m. shift. The administrator stated they have started interviewing residents on the hall. Eight of the 23 resident safe surveys, conducted 11/28/22 and 11/29/22, documented the residents did not feel all staff treated them with respect all the time. Two of the 23 resident safe surveys, conducted 11/28/22 and 11/29/22, documented the residents did not feel comfortable and safe in the facility all the time. Three of the 23 resident safe surveys, conducted 11/28/22 and 11/29/22, documented the residents did not feel comfortable expressing concerns or complaints to some of the staff. An untitled document, dated 11/29/22, read in part, .Interviewed [Resident #184] who states [CNA #2] .exited the room to retrieve supplies and left [the resident] exposed the covers down and the door open when [CNA #2] exited. The resident states that [CNA #2] is not friendly . On 11/29/22 at 12:58 p.m., the corp. nurse consult #1 was asked if they were aware of any abuse allegations currently being investigated. They stated it was against an aide who was rough when changing a resident. The corp. nurse consult was made aware there were allegations of abuse that residents stated they have reported multiple times, and staff members reported notifying management and abuse has not been investigated. The initial state report reported by the administrator, did not identify CNA #2 had been rough with the residents and did not identify Resident #184. On 11/29/22 at 3:18 p.m., corp. nurse consult #1 provided an untitled document, dated 11/29/22, signed by DON with list of staff members interviewed with question regarding [CNA #2] and if there had been any complaints or care issues while CNA #2 was working. The untitled document did not document the staff currently working Resident #12 and #184's hall had been interviewed. The untitled document documented five of six staff who worked on the night shift the alleged abuse happened had not been interviewed. On 11/29/22 at 3:22 p.m., corp. nurse consult #1 accompanied a surveyor to speak with CNA #3. CNA #3 informed corp. nurse consult #1 Resident #12 had complained CNA #2 was rough, yanked the resident around and Resident #12 was terrified. CNA #3 informed corp. nurse consult #1 CNA #3 had notified management several times. CNA #3 stated, I have reported to [DON and Administrator] several times. [Administrator] is the abuse coordinator the person we report to. CNA #3 informed corp. nurse consult #1 Resident #12 had informed their family member. Corp. nurse consult #1 replied there had not mentioned that family had called the facility with a complaint. CNA #3 replied Resident #12's family member knows about the incident. Corp. nurse consult #1 asked CNA #3 if any other residents have complained about CNA #2. CNA #3 reported Resident #184 had also made complaints. CNA #3 stated the staff coordinator was aware of complaints and had reported them to the administrator. Corp. nurse consult #1 went to speak with Resident #12. Resident #12 stated they had talked about it so much, they didn't want to talk about it anymore. Corp. nurse consult #1 asked Resident #12 if the resident was afraid of CNA #2. Resident #12 stated, Yes [CNA #2] should not be taking care of any of the residents. Corp. nurse consult #1 stated, I don't do the hiring and firing. Corp. nurse consult #1 went to Resident #184. Corp. nurse consult #1 did not ask the resident about the Resident's concerns with CNA #2. Corp. nurse consult #1 asked the resident why the resident had called the police on 11/28/22. Resident #184 stated they were not getting help from the staff when the call light was on. Resident #184 stated the staff came to their doorway and told the resident not to call the police. On 11/30/22 at 11:11 a.m., Corp. nurse consult #1 was asked if anyone had spoken to Resident #184 regarding allegations of abuse with CNA #2. Corp. nurse consult #1 stated, the resident [Resident #184] who called the police, I will have to check. On 12/01/22 at 1:41 p.m., corp. nurse consult #1 was asked who was currently being investigated besides Resident #12. They stated they didn't know and they were trying to let the facility handle it. Corp. nurse consult #1 was asked if they received a complaint regarding staff members reporting complaints to administrator staff, and it comes up again, what were the facility doing about it. They stated they knew the incident before was handled as a grievance. The day CNA #3 and staff coordinator reported complaints to administrator and DON, the administrator and DON stated nothing had been reported. Corp. nurse consult #1 was asked what their role was in the facility. They stated they were a consultant and they don't do investigation for the facility. They stated they have not been in the facility, recently, prior to survey. Corp. nurse consult #1 was asked if they had concerns about the abuse coordinator/administrator being aware of abuse allegations and action had not been taken. They stated they had spoke with the administrator and the DON yesterday. They stated the administrator and DON stated they had issues, and it had been taken care of. Corp. nurse consult #1 stated the staff didn't go back to the administrator and ask what had been done with allegations. Corp nurse consult #1 was asked if they were concerned the abuse coordinator/administrator were investigation themselves. They stated noting was reported to them. Corp. nurse consult #1 stated they report to the regional manager and the regional manager has been made aware. Corp. nurse consult #1 was asked who would be interviewed related to allegations. They stated all staff and and cognitive residents. They stated they like to do a percentage of the hall. Corp nurse consult #1 was asked if the abuse happened on a specific shift, would staff on the specified shift be interviewed. They stated yes. Corp. nurse consult #1 was asked to provide all information regarding abuse investigation. On 12/01/22 at 2:03 p.m., the staff coordinator was asked if they had reported any abuse before 11/28/22. They stated they reported Resident #12's complaints to the administrator a couple of weeks ago. The staff coordinator stated they report to the administrator, while they were in there office, during a day shift, and the administrator stated Okay. On 12/01/22 at 2:19 p.m., the regional manager what their role was. They stated they over saw the operations of the whole building. The regional manager was asked what the abuse policy was. They stated every one is to direct report, report to the administrator, and they also have a corporation hotline. They stated if the CNA reported an incident, and it involved an employee, the employee would be suspended and residents and staff who worked with the alleged perpetrator would be interviewed. The regional manager was asked if staff were to follow up with abuse coordinator/administrator regarding abuse allegations that had not been investigated. They stated they would expect the staff to utilize the corporate hotline. The regional manager stated the staff coordinator stated it could have been different situations and the staff reacted to the state surveyors asking questions. The regional manager stated they don't show anything had been reported two weeks ago. The regional manager was asked if the alleged abuse happened on a night shift, would they interview the night shift staff. They stated, Yes, absolutely. We have a more extensive list we will get to you. The regional manager stated they had interviewed the administrator regarding the abuse allegations. The regional manager was asked if they had interviewed anyone else. They stated no. On 12/01/22 at 2:31 p.m., CNA #3 was interviewed with the regional manager. CNA #3 was asked if they had reported any allegations prior to this week to the administrator. They stated they had the week prior. CNA #3 was asked if the administrator was aware of issues prior to Monday of this week. They stated, Should be. CNA #3 stated they had spoke with a quality manager yesterday regarding abuse. On 12/01/22 at 2:34 p.m., the regional manager was asked if allegations of abuse had not been reported and investigated timely what would the facility do. They stated they would suspend the administrator/abuse coordinator. The regional manager was informed there had been a continued allegation of abuse from multiple residents and staff and it had been brought to the administrator/abuse coordinator. They stated, Understood. On 12/01/22 at 2:37 p.m., the negative responses from the safe surveys documentation from the residents were reviewed with the regional manager. They stated they have follow up. The regional manager stated the corp. nurse consult #1 inserviced the administrator on Day 1. On 12/01/22 at 2:42 p.m., the staff coordinator stated, in front of the regional manager, they had reported CNA #2 was rude to the resident to the administrator and the administrator stated they would take care of it. On 12/01/22 at 2:48 p.m., the regional manager was asked to provided all information related to the investigations. On 12/01/22 at 3:19 p.m., the DON stated the administrator had an AIT in their office and the AIT was asked if any abuse had been reported to the administrator and the AIT stated they never saw staff report to the administrator. On 12/01/22 at 3:24 p.m., the DON brought copies of inservices. The DON was asked who interviewed the staff coordinator. They stated the administrator asked the staff coordinator when had the staff coordinator first reports, where were they at, who was in the room when reporting, and the administrator asked the staff coordinator why the staff coordinator didn't ask the administrator if the facility was suspending the staff. On 12/01/22 at 4:00 p.m., the regional manager provided an initial state report with follow up information which read in part, .Follow up info 12/1/22 [staff coordinator] states [they] made [administrator] aware of an allegation of verbal abuse approximately [sic] 2 weeks ago .[staff coordinator] states [AIT] was in the office when report was made .Investigation Cont'd [sic] Part B .[Staff coordinator] states [they] reported the abuse to [administrator] as [CNA #2] being rude to [Resident #12]. [Staff coordinator] was asked if there was any report of physical harm in this instance and [staff coordinator] states not the first time [Staff coordinator] further states that [they] reported on Monday to [administrator] (which is the date of this intial [sic] report) that resident reported that resident reported that [CNA #2] was also rough with .[Resident #12]. Report Amended 12/1/22 to include Physical abuse as well .[Administrator] was suspended pending investigation of failure to investigate allegations of abuse on 12/1/22 [at 3:28 p.m.] .Report amended 12/1/22 to include [Resident #184] with same allegation of rude and rough against [CNA #2] .[CNA #3] reports that [they] reported to DON on Monday that [Resident #184] also had the same complaint for [CNA #2] related to being rude and rough .

Based on observation, interview, and record review, the facility failed to ensure medications were administrated as ordered for two (#26 and #134) of five sampled residents reviewed for medications. The Resident Census and Conditions of Residents report, dated 11/27/22, documented 85 residents resided in the facility. Findings: The facility's Preparation For Medication Administration policy, read in part, .The resident is always observed after administration to ensure that the dose was completely ingested . 1. Resident #26 had diagnosis which included chronic pain syndrome, hypertension, and chronic combined systolic and diastolic heart failure. A Resident Assessment, dated 10/03/22, documented the resident's cognition was intact. On 11/28/22 at 8:22 a.m., Resident #26 was observed laying in bed with a blanket covering them. A large white pill was observed on the resident's upper abdomen area. Five pills were observed on the floor. Resident #26 was observed to sit up on the side of the bed and the large white pill was still in the blanket. On 11/28/22 at 8:30 a.m., LPN #1 was asked how staff ensured residents take their medication. They stated the medication aide watched the resident take them. LPN #1 was asked to observed Resident #26. LPN #1 was observed to go into the resident's room and began to pick up medications off the floor. LPN #1 picked up seven pills off the floor. LPN #1 was alerted to the large white pill in the resident's bed. LPN #1 picked the large white pill off the resident's bed. Resident #26 stated, I knocked them over. LPN #1 stated the large white pill was potassium and one of the other pills was Lyrica. On 11/28/22 at 8:33 a.m., LPN #2 came up to LPN #1 and stated No, I watched both of them this morning. LPN #2 walked away after making the statement. LPN #1 was asked where the pills came from. LPN #1 stated, No telling. LPN #1 stated the medication could have been from the weekend. LPN #1 stated the staff might have walked off when the resident put the medications up to their mouth. On 11/28/22 at 8:56 a.m., ADON stated they spoke with Resident #26 and the resident stated they had spilled them. The ADON stated LPN #2 handed the medication to Resident #26 and the resident tipped them up to their mouth and spilled them. The ADON was notified LPN #2 stated they had watched Resident #26 take their medication. The ADON stated, Apparently not. The ADON was asked how staff ensured the residents took their medications. The ADON stated the staff stand there until the resident takes them. 2. Resident #134 had diagnosis which included allergies, shortness of breath, and hypertension. Resident #134's Hospital Discharge medications, dated 07/01/22, documented to administer Isosorbide Mononitrate CR 30 mg, take 40 mg once daily. Resident #134's physician's orders, dated 07/01/22, documented to administer Isosorbide Mononitrate ER 30 mg once daily, Budesonide-Formoterol Fumarate Aerosol twice a day, and Montelukast Sodium at bedtime. A Pharmacy Manifest, dated 07/01/22, documented Isosorbide Mono 20 mg tablet, Montelukast 10 mg tablet, and Budesonide-Formoterol Aerosol had been delivered for Resident #134. An Orders Administration Note, dated 07/01/22 at 9:16 p.m., documented Montelukast Sodium 10 mg was waiting for pharmacy. An orders Administration Note, dated 07/02/22 at 9:33 p.m., documented Budesonide-Formoterol was not available. An orders Administration note, dated 07/02/22 at 10:59 a.m., documented Budesonide-Formoterol was on order. An orders Administration Note, dated 07/03/22 at 9:18 a.m., documented Budesonide-Formoterol was on order. Resident #134's MAR, dated 07/02/22 and 07/03/22, documented the resident received Isosorbide Mononitrate ER 30 mg. On 11/29/22 at 11:43 a.m., LPN #2 was asked how staff ensured medications arrived and were given as ordered. LPN #2 stated they can order medications stat and received them within a couple of hours. On 11/29/22 at 11:45 a.m., CMA #1 was asked how staff ensured medication arrived and were given as ordered. CMA #1 stated medications were delivered between 9:00 p.m. and 10:00 p.m. at night. CMA #1 stated the staff would sign for the medications and received the medications for their assigned hall. CMA #1 stated new admissions medications were given as ordered the night the resident arrived. On 11/29/22 at 12:25 p.m., the DON stated they were not sure if the Montelukast had been administered. The DON stated if the Budesonide-Formoterol was here, then it should have been given. On 11/29/22 at 3:19 p.m., the DON was asked if the discharge order was for Isosorbide Mononitrate ER 40 mg, the physician's order that had been put into the computer was for Isosorbide Mononitrate ER 30 mg, and the pharmacy sent Isosorbide Mononitrate ER 20 mg, had the medication been administered as ordered. The DON stated they didn't know. The DON stated the Isosorbide Mononitrate ER mg should have been clarified.

Based on record review, observation, and interview, the facility failed to ensure the kitchen was maintained clean and in good repair, and food was stored in accordance with professional standards for food service safety. The DON identified 85 residents who received food from the kitchen. Findings: A Food Storage policy, revised 04/30/09, read in part, .Label and date all storage containers. Rotate stock. Use the first in, first out method . On 11/27/22 at 9:41 a.m., a tour of the kitchen was conducted. The following observations were made: a. filters on the back of four ovens, and on one oven motor had visible debris, b. undated and expired bread was observed on a rack in the kitchen, and c. the steam cart's splash guard was soiled and cracked. On 11/27/22 at 10:29 a.m., the DM was asked how long they kept bread after it had been opened. They stated for three days. They were asked when the bread had been received. They stated last week. The DM was asked how was the bread dated. They stated, the bread was not dated. They stated the bakery would replace the supply of bread weekly. They were shown the undated and expired bread. On 11/27/22 at 1:39 p.m., the corp. nurse consult #1 stated there was no specific policy for kitchen sanitation. On 11/27/22 at 2:08 p.m., the downstairs dining room steam table was observed to have a spider-like cracked splash guard with splatter-like substance visible on the guard. On 11/28/22 at 7:45 a.m., the downstairs steam table was observed with splash guard in same condition as the day before. On 11/28/22 at 1:20 p.m., the DM was asked how they ensured clean and sanitary kitchen equipment. They stated they came in every other Sunday and cleaned all the steel. They were asked if they cleaned the dust observed on the motor and the filters on the back of the ovens. The DM acknowledged the dust and stated that they believed the maintenance department handled the motor and filters. They stated if it was not the maintenance department then they did not know who cleaned them. The DM was asked how often was the steam tables including the splash guards cleaned. They stated two times a week. They were asked what parts were cleaned. They stated the inside of the steam table was cleaned and the exterior was wiped and shined. The DM stated the splash guards were glass and was cleaned with glass wipes twice a week. The DM was shown the steam table downstairs. The DM described the splash guard as broken and acknowledge it was not clean.