**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (129) who received psychotropic medications (any medication that affects brain activities associated with mental processes and behavior) had an attempted gradual dose reduction (systemic dose reduction over time to determine if the condition could be managed with a lower dose or discontinuation of the medication) (GDR) or a documented rationale to support that a GDR for those medications was clinically contraindicated (not appropriate based on the resident's condition, potential risks, or adverse effects) according to the provider's policy.Findings include:1. Observation on 8/18/25 at 2:31 p.m. of resident 129 from the hallway revealed:*The lights in her room were off.*She was lying in bed on her left side with her eyes closed.*She had a urinary catheter (flexible tubing placed in the bladder to drain urine) bag hanging on the side of her bed.2. Observation and interview on 8/18/25 at 4:18 p.m. with resident 129 in her room revealed she:*Was trying to read the newspaper but stated she could not because she did not have her glasses.*Stated the staff and the food were, pretty good.*Had no concerns.3. Interview on 8/19/25 at 8:11 a.m. with certified medication aide (CMA) M about resident 129 revealed:* Resident 129 received hospice services.*She slept a lot.*CMA M stated resident 129 often slept for a couple days at a time and then would have a normal sleep cycle for a couple of days.*That morning, she was awake and wanted to get out of bed for breakfast.4. Review of resident 129's electronic medical record (EMR) revealed:*She was admitted on [DATE].*Her 8/11/25 Minimum Data Set (MDS) indicated she was rarely understood or able to understand others and was severely cognitively impaired.*She was receiving hospice services.*She had diagnoses of Alzheimer's (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions), vascular dementia (a group of symptoms affecting memory, thinking, and social abilities), a history of strokes, and depression.*She had a history of falls.*She had a 7/8/22 physician's order for DULoxetine 60 MG [milligram] capsule [Cymbalta] 60 MG PO [by mouth] DAILY.-Duloxetine's indication for use was depression.*Resident 129's 8/21/25 care plan included:-A care area of psychotropic drug use.-The Mood State problem area indicated she had a diagnosis of depression with an intervention of, I would like to be reminded of daily activities, even though sometimes she prefers to sleep.-The Medication Side Effects problem area indicated resident 129 used, antidepressant medications daily for depression with an intervention of, Nurses to monitor for any adverse drug reactions and report any [reactions] noted to her hospice nurses so she can contact her provider. Medications are to be reviewed at least every 6 months and prn [as needed] per physician/pharmacy review to ensure lowest effective therapeutic dosage possible.*A 5/15/25 physician's visit note indicated, She has had some issues with depression. It is hard to assess her for that. She seems to be up and down a little bit with her mood. We will continue duloxetine as it helps her facial dysesthesias [an abnormal physical touch sensation without an outside cause].*There was no documentation that indicated a GDR was recommended from the consultant pharmacist or documentation from the physician to support that a GDR was clinically contraindicated within the past year.5. Interview on 8/21/25 at 10:28 a.m. with director of nursing (DON) B, consultant pharmacist X, and consultant pharmacy director Y revealed:*The consultant pharmacy's process for residents who were on a psychotropic medication was to address the resident's GDR of the psychotropic medication two times in the first year after the resident's admission or after starting a psychotropic medication and then yearly after that.*If the physician did not provide documentation of the reasoning for not having decreased a psychotropic medication, the consultant pharmacist would produce a document for the physician to complete which would include whether a GDR was to be attempted, and if it was not to be attempted, why it was not being attempted.*Consultant pharmacist X and consultant pharmacy director Y stated a GDR for resident 129's duloxetine was not addressed with her physician in the past year because in 2022 he had documented that a GDR on the duloxetine was contraindicated because it was helpful for resident 129's facial pain related to her stroke.*After the 2022 GDR documentation by the physician the consultant pharmacist no longer considered duloxetine as an antidepressant or psychotropic medication because it was being used to treat nerve pain.*DON B confirmed that the indication for use of the duloxetine in resident 129's physician's orders was depression, not nerve or facial pain.*Consultant pharmacy director Y stated he thought because resident 129's duloxetine was being used for facial nerve pain it no longer met the criteria for the required GDR of a psychotropic medication.Review of the provider's September 2023 Long Term Care Psychotropic Medication Use policy revealed:* 'All medications included in the psychotropic medication definition may affect brain activities associated with mental processes and behavior.Risks associated with psychotropic medications still exist regardless of the indication for their use (e.g., nausea, insomnia, itching), therefore the requirements pertaining to psychotropic medications in 483.45(e) apply to the four categories of drugs (anti-psychotic, anti-depressant, anti-anxiety, and hypnotic) listed in 483.45(c)(3) without exception.'* Residents who receive psychotropic medications will receive gradual dose reductions and behavioral interventions unless clinically contraindicated with the intention to decrease or discontinue the use of the psychotropic medication whenever safe and possible.* The objective of this policy is to monitor and ensure that the resident's drug regimen is managed to promote or maintain the resident's highest practicable mental, physical and psychosocial well-being. The goal is to monitor the resident's use of psychotropic drugs in an effort to assist with stabilizing or improving the resident's outcome, quality of life and functional capacity, while using psychotropic medications only when needed to treat a specific condition that is diagnosed and documented.* The purpose of tapering a medication is to find an optimal dose or to determine whether continued use of the medication is benefiting the resident. The time frame and duration of attempts to taper any medication must be consistent with accepted standards of practice and depend on factors including the coexisting medication regimen, the underlying causes of symptoms, individual risk factors, and pharmacological characteristics of the medications.* Within the first year in which a resident is admitted on a psychotropic medication or after the prescribing practitioner has initiated a psychotropic medication, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, a GDR must be attempted annually, unless clinically contraindicated.*A GDR may be considered clinically contraindicated for reasons that include, but are not limited to:-1. The resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility.-2. The physician has documented the clinical rationale for why any additional attempted dose reduction at that time would likely impair the resident's function or increase distressed behavior.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review the provider failed to ensure one of one residents (15) preadmission screening and resident review (PASRR) assessment level II (in-depth evaluation of a resident's needs, recommended services, and determination of what type of setting was appropriate for her care) was coded accurately on the Minimum Data Set (MDS) assessment (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs).Findings include:1. Review of resident 15's electronic medical record (EMR) revealed:* She was admitted to the facility on [DATE].*She had diagnoses of post-traumatic stress disorder (PTSD) and bipolar 2 disorder.*She took duloxetine (a medication to treat depression and pain) 30 mg daily and clonidine (a sedating medication) 0.1mg/24-hour patch.*Her care plan indicated she had a PASRR level II assessment completed and listed the recommendation for care.2. Interview with social worker designee (SWD) F on 8/21/25 at 11:42 a.m. revealed:*Resident 15 had a PASRR level II assessment completed on 11/20/23.*She completed the PASRR level II assessment for residents who resided on her assigned unit but did not document those in the MDS assessments.*Registered nurse (RN) coordinator EE would document those in the MDS assessments.3. Interview with RN coordinator EE on 8/21/25 at 1:10 p.m. revealed:*She documented resident 15's PASRR level IIs in the MDS assessments.*She verified the current comprehensive MDS assessment, signed on 8/13/25, was inaccurate.*She reported resident 15's quarterly MDS assessment, signed on 2/15/25, had been incorrectly marked as well.*She verified resident 15 had a documented diagnosis that would require a PASRR level II assessment.4. Interview with DON B on 8/21/25 at 3:38 p.m. revealed he expected the MDS data to be documented accurately.5. Review of the provider's 1/2025 LTC Resident-Assessment-Instrument (RAI)- System Standard Policy revealed:* .5. All persons who have completed any portion of the MDS Resident Assessment Form must sign the document attesting to its accuracy.6. An RN must sign the MDS Resident Assessment Form and thereby certify the assessment is complete.7. The Assessment Coordinator is responsible for electronically transmitting encoded, accurate, and complete MDS data to the CMS [Centers for Medicare and Medicaid Services] system.8. The Assessment Coordinator is responsible for the completion of correction and/or inactivation of assessment as follows the MDS Correction Policy.6. Review of the provider's 10/21/24 LTC PASRR-South Dakota-System Standard Policy revealed:* It is the policy to screen all potential admissions on an individualized basis. As part of the preadmission process, the facility participates in the Preadmission Screening and Resident Review (PASRR) screening process (pre-screening and Level I screen) for all new and readmissions per requirement to determine if the individual meets the criterion for mental disorder (SMI/SMD), intellectual disability (ID) or related condition. Based upon the Level I screen, the facility will not admit an individual with a mental disorder or allow for a nursing facility admission and the facility's ability to provide the specialized services determined in the Level II screen.*The objective of the PASRR policy is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting.

Based on observation, interview, and record review, the provider failed to ensure a medication error rate below 5%. Two of twenty-seven observed medications administered by certified medication aide (CMA) K and FF were completed with an error, which resulted in a 7.41% medication error rate. Findings include: 1. Observation and interview on 8/20/25 at 7:55 a.m. with certified medication aide (CMA) K while administering medications for resident 58 revealed:*He was to receive two tablets of carbidopa 25mg/levodopa 100mg (medication to manage motor symptoms such as shaking and stiffness) at 6:30 a.m., but it was administered at 7:55 a.m.*CMA K, who is working the day shift, reported that the night shift usually administered that medication.*That medication was ordered to be given three times per day.2. Observation and interview on 8/20/25 at 1:53 p.m. with CMA FF while administering medications for resident 20 revealed:*He was to receive 10 milliliters (mL) of Guaifenesin/DM SF 100-10 mg/5mL (milligrams per mL) (cough medication) three times per day.*She poured the medication into a medication cup to fill to approximately 8 mL (just above the 7.5mL mark on the med cup).*She verified the amount again and stated it was the correct dose.*She administered approximately 8 mL of the medication, the incorrect dose.4. On 8/21/25 at 3:48 p.m., DON B acknowledged the medication error rate.3. Review of provider's 1/2025 Medication Administration policy revealed:* .B. Medications may be administered by a registered nurse, licensed practical nurse, certified medication aide.-Medications with very specific time requirements will be considered specialty medications and will be given at the specific ordered time plus or minus 1 hour.*All medications are to be given following the 6 Rs: Right resident, right medication, right dose, right route, right time, and right documentation.*E. Medication Errors. The following situations are considered a medication error: Failure to administer, correct dosage., incorrect time.

Based on resident council meeting, resident council meeting minutes review, and interview, the provider failed to provide resource information and prompt resolution to residents' requests and concerns voiced in resident council meetings that were to the residents' satisfaction. Findings include:1. A resident council meeting on 8/21/25 at 11:15 a.m. was attended by twelve nursing home residents and revealed:*No residents in attendance were able to name the facility grievance official. *One resident stated she would talk to a nurse if she had a grievance.*Ten of the twelve residents expressed concern and fear of turning on call lights at night due to receiving negative responses from the certified nursing assistants (CNAs). *All residents expressed that it could take a long time for a staff member to respond to a call light and that at times: -The CNAs would turn the resident's call light off and tell the resident they would return, but did not. -Some CNAs will turn the call light off and leave without saying anything at all. -The CNAs would express anger with the residents through their tone of voice, snapping at them, complaining that they had turned their call light on again, and used aggressive actions with equipment and doors.-Several residents felt humiliated by needing to ask for help when the CNAs were upset when they responded to the residents' call lights.-A resident stated she had been incontinent because staff had taken so long to respond to her call light. -A resident stated that he suffered pain from needing to use the restroom when he had waited 15 minutes or longer to get assistance from a staff member.-A resident complained of having waited a long time for staff assistance in the morning. If the resident's call light was on at 7:30, the resident worried if he would get assistance and be able to make it to breakfast by 9:00 a.m.2. Review of the provider's resident council minutes from April 21, 2025, for the second floor neighborhoods revealed:*Four residents were in attendance.*Unresolved concerns from previous months included:-Catheter bins (small tub that holds a urine collection bag) were being left in the middle of residents' rooms.-Some residents wanted to know how often the sheets were washed/changed. Management responded that housekeeping staff were to change the bedding changes beds twice per month. Residents had determined the issue was unresolved.3. Review of the provider's resident council minutes from May 19, 2025, for the second floor neighborhoods revealed:*Five residents were in attendance.*New business included:-Residents reported extended wait times for their call lights to be answered.-Staff members would turn off the residents' lights, say they would be right back and did not come back, or leave without saying anything at all.*Items listed as unresolved from previous months included:-Residents wanted to know when their sheets were washed. This was noted as waiting on management response.-Residents would like their windows washed. This was noted as waiting on management response.-Catheter bins were left in the middle of residents' rooms. -Residents stated beds were not being made.*Management's response to resident council items in the minutes revealed:-The cath [catheter] bins have been a complaint x [for] 3 months. I have spoken to them . will address this issue again this month.-Will also mention the call light response times.4. Review of the provider's resident council minutes from June 16, 2025, for the second floor neighborhoods revealed:*Eight residents were in attendance. *Unresolved items from previous months again included:-Catheter bins were being left in the middle of resident rooms.-Residents' beds were not being made.-Call lights were turned off and staff told the residents they will be right back, never come back or they left without saying anything.5. Review of the provider's resident council minutes from July 21, 2025 revealed:*Four residents were in attendance.*No old, resolved, or unresolved items from previous meetings were noted in the minutes.6. Interview on 8/21/25 at 12:00 p.m. with Social Services Designee (SWD) F revealed:*She thought the residents knew to come to the social services staff if they needed something.*She had not discussed the grievance process or grievance official at resident council meetings.*She had not invited the area ombudsman (an advocate of residents' overall quality of care and rights) to a resident council meeting.*Grievances were filled out by social services staff and then given to assistant director of nursing (ADON) for resolution. *Resident council issues were given to the head of the department that the issue was related to for response.*She did not know how she could help initiate any resolution to they ongoing issues beyond the department leader response.

Based on observation, interview, and policy review, the provider failed to ensure resident personal and medical records remained secure and confidential in four of six observed resident neighborhoods (Bluegrass Way, Platinum Ridge, Boulder Creek, and Arrowhead Trail).Findings include: 1. Observation on 8/19/25 at 8:11 a.m. in the Boulder Creek hallway outside resident 129’s room revealed: *Resident 129’s door to her room was closed. *There was a computer on a rolling stand outside resident 129’s room. *The computer screen was open with residents' medical information visible on the screen. *The computer screen indicated certified medication aide (CMA) M was logged into the computer. *There were no staff within eyesight of that computer. *CMA M exited resident 129’s room and pushed the cart the computer was on down the hallway with the screen still open. 2. Observation on 8/20/25 at 11:08 a.m. in the Arrowhead Trail hallway outside resident 12’s room revealed: *There was a computer on a rolling stand in resident 12’s room facing the hallway with the computer screen open. *There were no staff within eyesight of that computer. *Residents’ medical information was visible on the computer screen. *Which staff member was logged into the computer at that time was not visible. 3. Observation on 8/20/25 at 8:11 a.m. in the Boulder Creek hallway outside of residents 59 and 13’s room revealed: *There was a computer on a rolling stand outside of resident 59 and 13’s room. *The computer screen was open with residents’ medical information visible on the screen. *Which staff member was logged into the computer at that time was not visible. *There were no staff present in the hallway. 4. Observation on 8/20/25 of the Platinum nurses' station revealed: *At 8:45 a.m. certified nursing assistant (CNA) N pushed a rolling computer stand behind the nurses' station with the screen up that showed the resident status board, which contained resident information, and then walked out of the nurse’s station. The screen had been visible from the hallway. *At 8:46 a.m., she came back to the computer and left it open at 8:48 a.m. when she again left the nurses' station. The screen had been visible from the hallway. 5. Observation on 08/20/25 9:32 AM in resident 76’s room revealed: *There was a computer on a rolling stand inside the residents' room by the medication cupboard. *The computer screen was open with the resident's medical information on it. *Which staff member was logged into the computer at that time was not visible. *There were no staff present inside or near the residents' room. 6. Observation on 8/20/25 at 11:30 a.m. of the nurses' station on the Rehab unit revealed: *There were 2 computer screens open to patient status boards, with visible resident information. *The screens were able to be visualized from the hallway. *Which staff member was logged into the computer at that time was not visible. *There were no staff present near the nurses' station. 7. Observation on 08/20/2025 2:09 p.m. in the Blue Grass Way hallway revealed: *There was a computer screen on a rolling stand near the staff bathroom. *The computer screen was open and displayed resident 4’s medications. *Which staff member was logged into the computer at that time was not visible. *There were no staff present in the hallway. 8. Interview on 8/20/25 at 11:55 a.m. with licensed practical nurse (LPN) Z revealed the computer screens should have been closed and locked to protect the residents’ private information when staff were not present. 9. Interview on 8/21/25 at 10:50 a.m. with registered nurse (RN) coordinator I revealed: *She expected the screens to be closed when staff were not present. *She indicated she would report to the health insurance portability and accountability act (HIPPA) compliance manager (a person who oversees protecting residents' private health information) if she was made aware that someone gained private resident information that they should not have. 10. Interview on 8/21/25 at 3:38 p.m. with director of nursing (DON) B revealed he expected the residents' private health information to be protected by the staff members. 11. Review of the providers' 1/2023 safeguarding PHI (public health information) policy revealed: *”The purpose of the policy was to provide guidelines to protect PHI and to limit disclosure, intentionally or unintentionally, to unauthorized persons. Also, to ensure the provider entities have appropriate …physical safeguards to protect PHI. *Office Equipment Safeguards for computer access: 1. Only staff members who need to use computers to accomplish work-related tasks shall have access to computer workstations or terminals. 2. All users of computer equipment must have unique login and passwords. 3. Access to computer-based PHI shall be limited to staff members who need the information for treatment…. 4. Facility staff members shall log off or lock their workstation when leaving the work area. 5. Computer monitors shall be positioned so that unauthorized persons cannot easily view information on the screen. …7. Employees will immediately report any violations of this policy to their supervisor, administrator, or the Privacy Office, or designee….”

Based on resident council meeting response, subsequent individual interviews, resident complaint/grievance reports, and policy review the provider failed to ensure residents were kept free from neglect as it related to ten of twelve residents who attended resident council on 8/21/25, in addition to 11 of 11 sampled residents (2, 44, 51, 61, 66, 73, 77, 79, 91, 108, and 126) who communicated complaints of long staff response times to call lights, which left the residents feeling humiliated, fearful, and in pain.Findings include: 1. A resident council meeting on 8/21/25 at 11:15 a.m. with twelve nursing home residents from long term care revealed: *Ten of twelve residents in attendance expressed concern and fear of turning on call lights at night due to receiving negative response from the certified nursing assistants CNAs. *All residents expressed that it could take a long time to get a response to a call light: -A long time was described by them as 30 minutes or longer. -They stated that the CNAs would turn off the call light and tell the resident they will return but do not. -Some CNAs would turn off the call light and leave, but did not say anything at all. -The CNAs would be angry with them for turning on the call light, and expressed that through their tone of voice, “snapping” at them, and by using aggressive actions with equipment and doors. -Several residents expressed that they felt humiliated by needing to ask for help when they knew the CNAs were busy. -A resident stated they had been incontinent due to the wait for call light response. -A resident expressed that he suffered pain from needing to use the restroom when he had to wait 15 minutes or longer to get assistance. -A resident stated that they had to wait a long time in the morning, and that if they put their call light on at 7:30, they still had to worry if they would get assistance and be able to get out for breakfast by 9. 2. Review of provider's resident council minutes from May 19, 2025 for the second floor neighborhoods revealed: *Five residents were in attendance. *New business included: -Residents reported extended wait times for someone to answer their call light. -Staff told the residents they would be right back and never come back, or they just left and didn’t say anything at all. *Items listed as unresolved from previous months: -Residents were waiting a long time for someone to answer their call light. -Staff told residents they would be right back and don’t return, or they would turn and leave and not say anything at all. *Leadership response to resident council items in the minutes revealed: -“Will mention the call light response times.” 3. Review of provider's resident council minutes from June 16, 2025 for the second floor neighborhoods revealed: *Unresolved items from previous months: -Call lights: Staff tell residents they would be right back and never come back or they just left and didn’t say anything. 4. Interview on 8/21/25 at 12:00 p.m. with Social Worker Designee (SWD) F revealed: *Resident council issues were sent to the head of the responsible department for response. *She did not know how she could help initiate any resolution to ongoing issues beyond the department leader response. 5. Interview on 8/21/25 at 11:10 a.m. with Director of Nursing (DON) B revealed he expected the staff to answer call lights ideally within 5 minutes, but he felt 10 minutes would be understandable due to staff duties. 6. Interview on 8/21/25 at 1:13 p.m. with DON B and Assistant Director of Nursing (ADON) C regarding resident concerns documented in the resident council meeting minutes and voiced during the 8/21/25 resident council revealed: *ADON C stated that the residents should never be afraid to turn on their call lights or ask for assistance in any way as that is what the staff are there for. *DON B stated that CNAs may have to tell a resident that they know they need assistance but the CNA may have to help with another task first, and then the CNA was expected to return to assist the resident. *In response to whether they have enough staff, both DON B and ADON C stated that there are busier times, especially in the morning, and they had been trying different activities such as delegating particular duties during the night staff/day staff overlap from 6:00 a.m. to 6:30 a.m. *DON B expressed that she would never want the residents to be afraid to use their call light or to feel bad about it, and residents should be treated with respect. 7. Interview on 8/21/25 at 1:20 p.m. with Administrator A revealed that he would expect call light answer times to average 10 minutes. He would not want residents to be hesitant or afraid to use their call lights. 8. Interview with resident 91 on 8/19/25 at 8:14 a.m. and on 8/21/25 at 2:02 p.m. revealed: *He felt some staff did not treat him with respect. *There were two CNAs he felt were rough with him. He was unsure of their names. *He identified CNA CC as always being in a hurry and rough with him at times. *He reported his complaints to a nurse, he was unsure of her name, and he was told she would look into it. *He felt that the staff took too long to answer his call light at times, and the call light wait times were typically longer in the morning. *It hurt him when staff were rough with him. He stated that made him feel sad and upset. *He filed a complaint on 4/17/25, resident 91 reported to SWD F during his care conference that he received rushed care from a CNA during his shower, that the CNA kept looking at her watch. -The specific staff member was not clearly identified in the report. -ADON C followed up with the CNA about not making the residents feel rushed during assisting with their care needs. *The call light audit from 8/14/25-8/21/25 for resident 91 revealed he had waited for staff to respond to his call light for over 10 minutes: -On 8/16/25 at 3:01 p.m. his call light was on for 11 minutes and 37 seconds -On 8/18/25 at 6:07 a.m. his call light was on for 11 minutes and 3 seconds -On 8/18/25 at 3:30 p.m. his call light was on for 13 minutes and 29 seconds -On 8/19/25 at 7:31 a.m. his call light was on for 13 minutes and 55 seconds -On 8/19/25 at 7:13 p.m. his call light was on for 12 minutes and 35 seconds. 9. Interviews with resident 126 on 8/19/25 9:19 a.m. and on 8/21/25 at 2:06 p.m. revealed: *He felt some staff did not treat him with respect. *He felt staff took too long to answer his call light at times. *Last week, he had to hold his bowels while waiting for staff assistance. When a CNA came to help him to the bathroom, he was not able to have a bowel movement. -A while later he turned his call light on again to use the bathroom and the CNA “screamed” at him and said she was not going to take him in there anymore since he did not go to the bathroom earlier. -He relied on staff to help him to the bathroom as he was physically unable to do that independently. -His eyes teared up when he described that incident. *When he had to wait for long periods for staff assistance to the bathroom, he was incontinent of his bladder at times. *He felt the staff did not keep him dry from urine. -He had a rash in his groin due to his incontinence. -He had an open sore on his buttocks, which had healed, and he stated he wanted to stay dry to keep it healed. -He felt the CNAs did not clean his skin after he was incontinent. *He reported he told both registered nurse (RN) I and social worker designee (SWD) F about the CNA yelling at him. He was unable to identify the CNA. *He felt that sometimes his complaints were ignored. *He had acquired bruising to his hands from bumping the doorway when certain CNAs brought him to the bathroom while using the stand aid lift (a mechanical lift used to assist from a seated to a standing position) *He had been “stewing” over and thinking about the incident where he was yelled at, often. *He liked to be positive and kind and wished he would be treated that way. *He would not turn his call light on sometimes when certain staff are working. *He filed complaints: -On 7/21/25 he reported to SWD F during a resident council meeting that he had bruises to his hands from hitting his hands on the frame of his bathroom when he was brought to the bathroom using a stand aid lift. Bruising was noted on his hands and arms. When ADON C asked the CNAs, they reported the stand aid lift was difficult to maneuver, and a maintenance report had been filed by ADON C, but the CNAs reported it had not been fixed. -Specific staff were not identified in the report. -ADON C made a note that she would provide staff education and follow up with maintenance. -On 8/18/25 he reported two concerns to SWD F. -The first concern was regarding that his hands had continued to be bumped on the frame to his bathroom when being transferred while using the stand aid lift. -Staff were not identified in the report -ADON C documented that she would educate staff regarding the use of the stand aid lift and she would follow up with maintenance. -The second concern was regarding that he had waited 15 minutes to use the bathroom and when he could not go a staff member yelled at him and told him she would never bring him to the bathroom again. He reported she was rude and he felt ashamed. -Staff were not identified in the report. -ADON C documented that she had educated the staff member about treating residents with dignity and respect. She talked to the resident about it and thought he was okay with the resolution. *The call light audit from 8/14/25-8/21/25 revealed he had waited for staff to respond to his call light for over 10 minutes: -On 8/14/25 at 6:12 p.m. his call light was on for 23 minutes and 54 seconds. -On 8/15/25 at 7:58 a.m. his call light was on for 18 minutes and 2 seconds. -On 8/16/25 at 6:39 a.m. his call light was on for 12 minutes and 19 seconds. -On 8/19/25 at 6:21 p.m. his call light was on for 12 minutes and 40 seconds. -On 8/20/25 at 8:59 a.m. his call light was on for 12 minutes and 8 seconds. -On 8/20/25 at 12:16 p.m. his call light was on for 2 minutes and 23 seconds. 10. Interview on 8/19/25 at 4:30 p.m. and on 8/21/25 at 2:24 p.m. with resident 61 revealed: *She had a CNA take care of her, who she felt was very rude to her. *She had to wait for long periods of time for the staff to answer her call light. *A staff member had told her that staff had 20 minutes after she put her call light on to help her. *When she had to wait for help to use the bathroom, she sometimes wet her pants. *If she had to wait a long time for assistance, she sometimes transferred herself to her recliner because her legs hurt when sitting in her wheelchair, and elevating them in her recliner helped to relieve the pain. She had transferred herself to the toilet so she would not wet her pants, even though she knew she was supposed to wait for help because she fell and broke her leg in the past. *She felt bad that she needed to turn her call light on for help when the facility was short-staffed. *She stated it hurt her feelings when the CNA was rude to her, because she thought if she was treated that way, other residents must have been treated that way. *She had filed a complaint : -On 4/17/25, the resident reported to SWD F during her care conference that she received care that was rough and rude from a CNA and the CNA pushed her up to the wall, told her to “stand up” and asked her why she couldn’t pull her own pants up. -Staff were not clearly identified in the report. -ADON C documented that she followed up with the staff member about the expectation of professionalism and coached her on communication with residents. -On 5/19/25 the resident reported to SWD F that she was left in her recliner for 12 hours and had been soaked in urine. She said the staff were not kind to her and did not want to take care of her. -Staff were not identified in the report. -ADON C documented that she talked with the resident, and the complaint was resolved. -The report did not include any other information about the investigation. *The call light audit from 8/14/25-8/21/25 revealed she had waited for staff to respond to her call light for over 10 minutes: -On 8/17/25 at 5:08 a.m. her call light was on for 11 minutes and 44 seconds. -On 8/17/25 at 6:58 a.m. her call light was on for 30 minutes and 45 seconds. -On 8/17/25 at 8:47 a.m. her call light was on for 20 minutes and 37 seconds. -On 8/18/25 at 6:28 a.m. her call light was on for 24 minutes and 1 second. -On 8/19/25 at 7:59 a.m. her call light was on for 19 minutes and 27 seconds. -On 8/19/25 at 8:54 a.m. her call light was on for 15 minutes and 27 seconds. -On 8/19/25 at 1:50 p.m. her call light was on for 21minutes and 46 seconds. 11. Review of the provider’s Complaints and Grievances received related to call light times and reports of staff being rude and/or rough from 3/7/2025 through 8/18/2025, excluding the above residents, revealed: *On 3/7/25, a staff member reported to SWD F that resident 108 and a CNA were arguing about the cares the resident wanted. Another CNA went and yelled at resident 108 to listen and be nice to the other CNA. The staff member also reported that another CNA said that when she saw that resident's call light go off, she purposely ignored it. -Staff were not clearly identified in the report. -DON B documented that the corrective action taken had included coaching and counseling of staff by ADON C. *On 3/7/25 resident 44 reported to SWD F and a nursing coordinator, who was not identified in the report, that some CNAs were talking badly about a CNA who was leaving the facility. A CNA asked resident 44 if she was going to cry about it in a rude tone. The report indicated that resident 44 was upset and started crying. -Staff were not clearly identified in the report. -DON B documented that the social worker (SW) had followed up with the resident and the complaint was resolved. *On 3/24/25 resident 2 reported to ADON AA that a CNA was rude to her about various things that included warming up her burger, adding cheese, and asking for fresh ice water. -CNA slammed the resident's door and told her “no” she would not get her fresh ice water. -Staff were not clearly identified in the report. -ADON AA and the RN coordinator, who was not identified on the report, talked with resident 2 about the event, and the resident was tearful during that conversation. -ADON AA documented that education was provided to the CNA involved. *On 4/4/25, an activity assistant reported to SWD F that a CNA told resident 51 “You shush, or I'll take you back to your room.” -Staff were not clearly identified in the report. -ADON C documented that she had followed up with the staff member and coached the staff member. *On 4/21/25, a complaint was made to social work supervisor BB from a staff member that resident 73 was unable to participate in activities without her hearing aids, and when she requested staff to bring them, they did not. When she brought the resident back to her room after the activity, the resident had been incontinent of bowel. She told the staff, and they walked away. She turned the residents' call light on and left the unit. When she returned to the unit after an undisclosed amount of time, she noticed the call light was still on. -Staff were not clearly identified in the report. -ADON C documented she had educated the staff about encouraging resident 73 to wear her hearing aids. *On 5/5/25, a complaint was made to SWD F from resident 77’s family about numerous skin tears she had received, long call light times, rough care from a CNA, even after the resident’s physician had given an order for staff to be slow and gentle, and the family requested another staff member to care for her mother. -Staff were not clearly identified in the report. -ADON C documented that she provided education to all staff on all shifts and called and talked with the family about their concerns. *On 5/13/25 a complaint was made by resident 79’s family member to administrator A and ADON C regarding concerns of staff being rough while providing resident care, rude staff, and delaying assistance to use the bathroom, which resulted in the resident being incontinent. Another incident in that report stated resident 79 had spilled water, and a staff member had told her she would need to wait for more water until staff refilled water pitchers at the scheduled pass time. -Staff were not clearly identified in the report. -ADON C documented that she talked with the resident and the possible staff member who was working with her, but that was unclear if she was the staff member involved. ADON C educated staff on all shifts regarding expectations of resident care and how each person will be treated with dignity and respect. *On 7/11/25 a complaint was received from a staff member to SWD F that a CNA was heard yelling at resident 66, while the staff member was sitting at the nurses’ station. The SWD F talked with the resident to find out what had happened. Resident 66 reported to SWD F that it was about dressing, and she did not pay attention to why because she did not appreciate being talked to in that way. The resident also reported that she asked the same CNA at lunch for help to use the bathroom and was told she could try it herself. The resident needed staff assistance with using the bathroom. -Staff were not clearly identified in the report. -ADON C documented that she interviewed all other staff who were working with that CNA that shift, and no one reported hearing any yelling, but the staff reported that the CNA had been rough with resident 66. ADON C followed up with the CNA and “stressed” the importance of helping residents and to be mindful of how she talked with residents, as it was sometimes perceived as harsh. 12. Interview with RN coordinator I on 8/21/25 at 1050 a.m. revealed: *When a resident had complaints about staff members, those complaints would go to SWD F, and an investigation would be completed. *She was aware of one resident with complaints of staff being rough when assisting the resident with transfers, and SWD F was looking into it. *She did not have a process for monitoring concerns of residents who resided on her assigned units. 13. Interview on 8/21/25 at 11:42 a.m. with SWD F revealed: *When she received a complaint, she would fill out a report, and then ADON C would complete the follow-up for the complaint. *Education was last provided to all staff on residents' rights and abuse, dignity, and respect around May 15, 2025. 14. Interview on 8/21/25 at 2:14 p.m. with ADON C revealed: *Facility incident reports, which included grievances, were filled out electronically by staff, and she reviewed them. *If the incident involved a staff member and a resident, she would talk to both involved. *If the resident had complained about a staff member being rude or rough, she would visit with the resident to get a picture of what happened, if the resident could recall the incident. *If the staff member could be identified, she would talk to them about the incident or complaint. *She had received complaints about a staff member being rude and rough to residents. She explained she told the staff member to be mindful of what they say and how they say it. She thought it was due to a cultural difference. *She stated if there was evidence of verbal abuse, then she would involve DON B and the human resources (HR) department. *She reported some corrective action scenarios in the past related to rude and rough staff. *She stated she tried to be clear with staff that they were expected to treat the residents with dignity and respect, regardless of what type of day they were having themselves. *Education was completed annually regarding resident rights, dignity, and abuse. The last education was completed in May 2025. *She reported she documented on the complaints and grievances report the outcomes of the investigations. *Regarding the 8/18/25 report about resident 126 having been yelled at by a staff member, ADON C identified certified medication aide (CMA) DD as being that staff member. -ADON C reported she told CMA DD she expected the staff to bring residents to the bathroom when they requested. She talked to CMA DD about her interaction with resident 126. ADON C stated she thought CMA DD’s accent could sound rude. ADON C educated her CMA DD about treating residents with dignity and respect. She talked to resident 126 about the incident and thought he had been okay with the resolution. *Regarding the 5/19/25 filed incident report of resident 61’s complaint, ADON C stated she investigated that complaint and was not able to substantiate that the resident had been left in her recliner for 12 hours. She verified she did not document that investigation in the report. *Regarding having 14 grievances in 6 months of residents being treated poorly, she stated that she looks for trends. *She stated she completed rounding (checking on residents’ status and assistance needs) on the units daily and asked residents if there was anything she should know about. She stated she did not document this. *The resident council minutes were given to department coordinators, and she expected them to come up with solutions to the complaints and to update SWD F. *She stated she thought RN coordinator I was watching her assigned unit for some of the reported issues. Review of the provider’s LTC abuse, neglect, mistreatment and misappropriation of resident property policy revised on 2/2025 revealed: *The term “abuse” included deprivation of goods and services and neglect. *The policy definition of abuse stated “the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish”. *Deprivation of goods and services definition was “the deprivation by staff of goods and services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing.” *Neglect was defined as “the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical pain harm, pain, mental anguish, or emotional distress.” *”Residents will be protected from abuse, neglect, and harm while they are residing at the facility.”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure: *Insulins with shortened expiration dates were dated properly for five of five random residents (27, 44, 60, 75, 76).*Medical supplies, such as glucose testing strips, sterile water, distilled water, and formula, were dated properly for seven of seven residents (4, 9, 27, 44, 63, 75, 119) in two of five observed units. *Medications were not accessible by unnecessary persons throughout the Rehab, Arrowhead Trail, Boulder Creek, Bluegrass Way, and Platinum Ridge units. *Proper medication administration for two of two residents (63 and 119) without a self-administration physician's order or safety assessment completed.Findings include:1. Observation and interview on [DATE] at 9:41 a.m., with RN G in resident 76's medication cupboard revealed he had a Novolog pen that was not dated with an expiration date and a Lantus pen that had been dated with an incorrect expiration date, as it was dated to expire on 9/18. It had approximately 100 units of the medication used from it, and it did not have a date on which it was opened on it.-RN G verified she did not open those insulin pens today ([DATE]), and they were incorrectly dated and undated.-According to the insulin expiration chart, if the Lantus pen had been opened today, it would have expired on [DATE].-RN G indicated she was unsure when they expired without the dates they were opened or the correct expiration dates written on them.-RN G put the insulin pens back into the resident's medication cupboard. *Observation on [DATE] at 9:46 a.m., with RN G in resident 44's medication cupboard revealed resident 44's Novolog pen did not have a legible expiration date written on it, which was verified by RN G.*Observation on [DATE] at 10:41 a.m. with licensed practical nurse (LPN) HH in resident 75's medication cupboard revealed resident 75 had a Novolog pen in her medication cupboard that did not have an opened date written on it.-LPN HH verified the Novolog pen was not dated when opened.-LPN HH stated she was unsure when the medication would have expired, without it having been dated when opened.*Interview on [DATE] at 10:55 a.m. with RN coordinator I revealed she expected the insulin pens to be dated with the expiration date once opened, and she was not aware of a reference sheet available to staff to know when the medications would expire after opening.*Observation on [DATE] at 11:39 a.m. with LPN Z in resident 60's medication cupboard revealed resident 60 had a Fiasp insulin pen that was not dated with the expiration date once opened.-LPN Z verified it was undated.*Observation on [DATE] at 11:40 a.m. with LPN Z of resident 27's medication cupboard revealed he had a Lantus pen that was not dated with the expiration date once opened.-LPN Z verified it was undated. *Interview on [DATE] at 3:38 p.m. with director of nursing (DON) B revealed he expected the staff would have followed the policy, and to have dated the insulin pens with the opened and/or expiration dates.-He verified that the Lantus that was missing approximately 100 units with the expiration date of 9/18, was incorrectly dated.*Review of the facility's 1/2025 medication administration policy revealed, All multi dose vials shall be initialed and dated when the first seal is broken.*Review of the [DATE] [NAME] long-term care pharmacy insulin expiration chart listed how many days each type of insulin was good for after opening.2. Observation on [DATE] at 3:45 p.m. of the Bluegrass Way nurse's station revealed:-A glucometer (device for testing blood sugar levels) box in the cupboard contained:-A bottle of control level 1 and a bottle of control level 3 (used to ensure the glucometer was properly functioning) that were open and not dated with an open date or expiration date.-Two bottles of glucose test strips that were not dated with an open date or expiration date.-There was a sign in the cupboard that stated how many days the controls and test strips were good for after being opened.3. Observation on [DATE] at 8:41 a.m., of resident 119's room revealed an undated jug of distilled water on his nightstand by his continuous positive airway pressure (CPAP) machine (a medical device used to deliver a constant steady air pressure to help a person breathe while they sleep).*Observation on [DATE] at 3:10 p.m., of resident 9's room revealed an undated jug of distilled water by her CPAP machine.*Observation on [DATE] at 4:29 p.m., of resident 4's room revealed an undated sterile water container on his nightstand, and a bag of formula and a bag of clear fluid were hanging on a pole on his wheelchair that were not dated. *Observation [DATE] 9:46 a.m., of resident 44's medication cabinet revealed there were undated glucose test strips stored in her medication cabinet.-RN G verified that observation and she stated she thought the test strips were good for one month after opening. *Observation on [DATE] at 10:25 a.m., of resident 63's medication cabinet revealed there were undated glucose test strips stored in his medication cabinet. *Observation on [DATE] at 10:41 a.m., of resident 75's medication cabinet with LPN HH revealed there were undated glucose test strips stored in her medication cabinet.*Interview with RN coordinator I on [DATE] at 10:55 a.m. revealed she expected glucose test strips, sterile water, distilled water, and formula to be dated once opened.* Observation on [DATE] at 11:39 a.m., of resident 27's medication cupboard with LPN Z revealed there were undated glucose test strips.*Observation on [DATE] at 11:40 a.m., of the Rehab unit's nurse's station revealed:- A bottle of glucose test strips that was opened and undated.- A bottle of control 1 that was open and undated. -LPN Z verified that glucose test strips and controls were to be dated once opened.*Interview with Infection Prevention and Control RNs II and JJ revealed that fluids were to be dated when opened.*Interview on [DATE] at 3:38 p.m. with DON B revealed he expected staff to follow the policy and to date fluids, glucose test strips, and controls after being opened. *Review of the facilities test strip bottle and daily quality control (QC) requirement reference sheet revealed:-Glucose test strips must immediately be labeled with an open date and a 180 day expiration date.-QC bottles are sent to your unit with a 90 day (3 month) expiration date already written on them.-DO NOT use any controls past the written expiration date.4. Observation on [DATE] at 8:11 a.m., in the hallway outside of residents 39 and 7's rooms, revealed there was a wheeled computer cart with a key attached to it, and no staff were present.*Observation on [DATE] at 9:32 a.m., inside of resident 76's room, revealed there was a wheeled computer cart with a key attached to it, and no staff were present.*Interview with RN coordinator I on [DATE] at 10:01 a.m. revealed:-The keys on the wheeled computer carts opened the medication cupboards in all of the residents' rooms.-She verified that anyone could have accessed the medication cupboards in the residents' rooms.-The keys had been attached to the wheeled computer carts because the medication aids had been taking the keys home. *Observation on [DATE] at 10:05 a.m. of three of three wheeled computer carts on the Platinum Ridge unit revealed they each had a key attached to them. *Observation on [DATE] at 10:06 a.m. of three of three wheeled computer carts on the Bluegrass Way unit revealed they each had a key attached to them. *Interview on [DATE] at 10:07 a.m. with CMA K revealed:- A few CNAs that were not medication aides would use the wheeled computer carts to document.- They had six wheeled computer carts on that floor, three for each unit, and all the medication computer carts had a key attached to them.-The wheeled computer carts were stored in an unlocked conference room on the units when not in use an anyone could have accessed them, even the residents. *Observation on [DATE] at 10:09 a.m. of the conference room in the Bluegrass Way unit revealed there was a wheeled computer cart that had a key attached to it.*Observation on [DATE] at 11:30 a.m., revealed both nurses' stations on the Rehab unit had wheeled computer carts with keys attached to them, and five of the five observed carts had a key attached to them. *Observation on [DATE] at 2:09 p.m. in the hallway by resident 4's door, revealed there was a wheeled computer cart with a key attached to it, and no staff were present. *Interview on [DATE] 3:38 p.m. with DON B revealed:-The keys attached to the wheeled computer carts unlocked the medication cupboards for all of the residents' rooms.-He verified an unauthorized person could have accessed all resident medications with those keys.*5. Observation on [DATE] at 8:41 a.m. of CMA GG while administering medications to resident 119 revealed:-Resident 119 was in the bathroom in his room.-CMA GG left his morning medications in a medication cup sitting on his bedside table, told him they were there, and left the room.-Interview with LPN HH on [DATE] at 10:46 a.m. indicated that no residents on the Bluegrass Way unit could self-administer medications. *Observation on [DATE] at 10:16 a.m. of LPN HH while administering medication through a nebulizer (a device that converts liquid medication into an inhalable mist) to resident 63 revealed LPN HH left the room while the resident was inhaling the medication.-Interview on [DATE] at 10:49 a.m. with CMA N indicated that no residents on the Platinum Ridge unit could self-administer medications and that only nurses were able to administer nebulized medications.*Interview with RN coordinator I on [DATE] at 10:55 a.m. revealed that no residents on the Platinum Ridge or Bluegrass Way units were able to self-administer medications.-For a resident to self-administer medications, the resident would need an to be assessed to ensure he or she was safe to do so.-They would need a doctor's order to self-administer medications.-She expected the nurse to stay in the room for the full time a medication was being administered through a nebulizer, and agreed that leaving the resident with the medication running through the nebulizer was considered self-administration of the medication. * Interview on [DATE] at 3:38 p.m. with DON B revealed:-No residents were allowed to self-administer medications at that time, and an assessment needed to be completed first to determine the resident's ability to safely self-administer medications.-It was considered self-administration for the resident to complete his nebulized medication without the nurse in the room.-He expected the staff to stay and monitor the residents while taking the medications. *Review of the provider' 1/2025 medication administration policy revealed:- Residents may self-administer prescribed medications under the supervision of a licensed nurse.-A physician's order is required.-The resident must be able to demonstrate administration of the medication and must be able to verbalize the drug name and strength and directions for use including the dose, route and time to be taken.-An evaluation and education will be documented every 90 days or upon any significant change regarding the resident's wish to self administer from bedside or self administer after setup will be documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the provider failed to follow standard food safety practices by not having ensured proper glove use and hand hygiene was performed during two of two observed resident meal services in two of three neighborhood dining rooms by three of three servers (O, S, and U), and five of five certified medication aides (P, Q, R, V, and W).Findings include: 1. Observation on 8/18/25 at 4:57 p.m. of the kitchenette in the Boulder Creek and Arrowhead Trail dining area revealed: *Server O removed the covers from the steam table. *She transferred the metal containers that were covered with foil from an insulated cart and placed them into the steam table. *Server O used a metal tong to puncture and open the foil on each of the containers of food. *She placed those tongs she used to open the foil covered containers into the container of bacon. *There was an uncovered tray of bread on the serving counter near the walkway between the kitchenette and the dining area. *Certified medication aide (CMA) P and CMA Q were not wearing hairnets and walk beside that uncovered tray of bread. 2. Observation on 8/18/25 beginning at 5:05 p.m. of the Boulder Creek and Arrowhead Trail dinner service revealed: *At 5:05 CMA R served drinks to a resident seated at a table, moved her hair from her shoulder, went behind the kitchenette, and prepared more drinks for residents without performing hand hygiene (handwashing). *At 5:34 CMA R pushed a resident in a wheelchair to her table and picked the resident’s purse up off the floor. CMA R then moved her hair off her shoulder, adjusted her uniform, went into the kitchenette, poured a cup of coffee, walked down the resident hallway with the cup of coffee, and did not perform hand hygiene between any of those tasks. 3. Observation on 8/19/25 beginning at 8:55 a.m. of the Boulder Creek and Arrowhead Trail breakfast service revealed: *At 8:55 server S used a gloved hand to cut a banana on a serving tray, removed her gloves, did not perform hand hygiene, picked up a frosted long [NAME] roll with her bare hand, placed the long [NAME] on a resident’s plate, used tongs to pick up another item for the resident’s plate, wrote on a piece of paper with a pen, applied a glove to her right hand, and picked up a food item from the freezer, removed the glove on her right hand, and then gathered items from the cupboard in the kitchenette. No hand hygiene was performed during those tasks. *There was a tray of frosted long [NAME] rolls sitting on the edge of the serving counter between the kitchenette and the dining room. *At 9:08 a.m. resident 38 self-propelled her wheelchair into the dining room, touched multiple long [NAME] with her bare hands, grabbed one of the long [NAME] and began to eat it. *Server T picked up the tray of long [NAME] rolls and placed them on top of the plastic cover over the prepared food, out of resident 38's reach. *After resident 38 had touched multiple frosted long [NAME], two more long [NAME] rolls from that same tray were served to residents during the breakfast food service. 4. Observation in the Bluegrass Way and the Platinum dining room on 8/18/25 at 5:21 p.m. revealed: *Server U, without performing hand hygiene, applied gloves, grabbed a package of bread, then removed slices of bread out of the package to make sandwiches with those same gloved hands. She removed those gloves, and no hand hygiene was performed. *She did the same process again of touching the bread package and then the bread slices with the same gloves. She made more sandwiches and used the same gloves to put the lettuce and bacon on the sandwiches. She removed those gloves, and no hand hygiene was performed. *CMA W touched areas around her mouth, her shirt, grabbed a clean tray, then took clean silverware from a bin, grabbed the resident's plated meal, and then served it to the resident without performing hand hygiene. 5. On 8/18/25 at 5:36 p.m. CMA V was observed touching her nose with her hand and then fed a resident with that same hand without performing hand hygiene. There was no hand hygiene completed by CMAs W and V between serving meal trays to the residents. 6. Interview with CMA W on 8/18/25 at 5:45 p.m. revealed she: *Should have washed her hands before and after serving resident trays. *Would clean her hands if they were dirty before serving the next resident. *Confirmed she should have washed her hands after touching her face and shirt. 7. Interview with server U on 8/18/25 at 5:55 p.m. revealed that she should have washed her hands before touching food, and she was not aware that touching the outer bread package and then the bread slice was considered non-sanitary. 8. Review of the provider's November 2024 Hand Hygiene policy revealed: *Hand hygiene (HH) continues to be the primary means of preventing the transmission of infection. -To cleanse hands to prevent the spread of infection. -To provide a clean and healthy environment for residents, staff, and visitors. *HH, either with soap and water or with alcohol based hand rub (ABHR): -Before a clean procedure . -After removing gloves. Review of the provider's January 2025 Food Handling and Hygiene policy revealed: *Purpose: To provide safe food for the residents. *Procedure: All Dietary personnel shall wear hairnets or bonnets which completely cover the hair while in the kitchen. -Gloves will be utilized when handling ready-to-eat (RTE) foods. -Do not cough, sneeze, or clear the mouth and/or nose near food or dishes . and wash hands immediately after . -Keep hands and fingers out of food . -Disposable gloves/utensils must be worn when direct contact with a food item is made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to ensure the staff had followed standard infection control practices to decrease the risk of infection to other residents, staff, and visitors for ten of ten sampled residents (4, 9, 20, 33, 49, 75, 76, 119,126, and 129) on enhanced barrier precautions by eight of eight observed staff members (certified medication aides (CMAs) M, FF, GG,NN licensed practical nurse (LPN)s HH, LL, MM, and registered nurse (RN) G) according to the provider's policy.Findings include: 1. Observation on 8/18/25 at 2:31 p.m. of resident 129’s room from the hallway revealed: *She had a magnet on her door frame at the entrance to her room which indicated she was on enhanced barrier precautions (EBP) (glove and gown use when providing contact care). *She had a urinary catheter (flexible tubing inserted into the bladder to drain urine) bag hanging on the side of her bed. *There was no personal protective equipment (PPE) (gown and gloves) visible from the hallway. 2. Observation on 8/19/25 at 8:11 a.m. of certified medication aide (CMA) M in resident 129’s room revealed: *CMA M was not wearing gloves or a gown. *CMA M performed a sit-to-stand (a mechanical lift used to assist from a seated to a standing position) assisted transfer of resident 129 from her bed to her wheelchair. *CMA M positioned resident 129 in her chair, brushed her hair, and adjusted resident 129’s clothing. *There were gowns available in a cupboard with the linen, in the resident 129’s room. 3. Review of resident 129’s electronic medical record revealed: *She was admitted on [DATE]. *She required the assistance of one staff member for all of her care needs, including transfers with a sit-to-stand mechanical lift. *Her care plan indicated she had a urinary catheter. 4. Observation and interview on 8/19/25 at 8:39 a.m. of CMA GG in resident 119’s room revealed: *A magnet on the door frame and a sign in the resident's room indicated the resident was on EBP. *It was observed that she showered the resident in his room and did not wear a gown. *She picked up dirty linens from his bathroom and did not wear a gown. *Resident 119 stated he had a wound on his foot. 5. Observation on 8/19/25 at 9:15 a.m. of housekeeper KK cleaning resident 126’s room revealed she was cleaning it without wearing a gown. *A magnet on the door frame and a sign in the resident's room indicated the resident was on EBP. 6. Observation on 8/19/25 at 9:51 a.m. of housekeeper KK cleaning resident 9’s room revealed she was cleaning it without wearing a gown. *A magnet on the door frame and a sign in the resident's room indicated the resident was on EBP. 7. Observation and interview on 8/19/25 at 3:13 p.m. with LPN LL in resident 9’s room and bathroom revealed: *Resident had a magnet on the door frame, and a sign in the resident's room indicated the resident was on EBP. *LPN LL reported and observed that resident 9 had a stage III or IV pressure ulcer on her coccyx (tailbone) that was covered with a foam dressing. *LPN LL assisted her to the bathroom using a sit-to-stand lift. *She wore a gown and gloves. *She removed her gloves, did not perform hand hygiene, and answered her portable work phone. *She did not perform hand hygiene and put on a new pair of gloves. *After wiping the resident's bottom, she removed her gloves and pulled the resident's incontinence product and pants up. Then she transferred the resident to her wheelchair and then removed her gown. *She then made the resident's bed without wearing gloves or a gown 8. Observation on 8/19/25 at 10:17 a.m. in resident 4’s room of LPN MM and CMA NN revealed: *A magnet on the door frame and a sign in the resident's room indicated the resident was on EBP. *LPN MM used the same pair of gloves to change the dressing on his feeding tube site and his dressing on his suprapubic urinary catheter (a flexible tubing surgically placed through the abdomen into the bladder to drain urine) site. *She touched a clean roll of tape without changing her gloves. *LPN MM removed those gloves, did not perform hand hygiene, and left the room. *She returned with the sit-to-stand lift and put on a gown and gloves without performing hand hygiene. *LPN MM and CMA NN transferred resident 4 to his wheelchair. *LPN MM then removed her gloves and, with her bare hands went to the resident's bedside, grabbed a graduated container, used for measuring sterile water to flush his feeding tube, brought it over to the clean pull-out table located in the resident's medication cupboard, set the container on a clean paper towel, and added sterile water to the container. *She put on a pair of gloves and administered a medication into his feeding tube. *She came back to the medication cupboard and, with those same gloved hands, grabbed a medication cup out of the clean bin in the medication cupboard. *When she finished administering his medications, she removed her gloves and did not perform hand hygiene. *She removed the resident's sterile oral suctioning supplies from his bedside drawer without performing hand hygiene. *She washed her hands, put on gloves, and set up the resident’s suctioning supplies. *She used a sterile suction catheter and completed a deep suctioning of the resident's mouth. She did not wear eye shields or a mask. The resident was coughing deeply during this procedure. *CMA NN put on gloves, went to the resident's bed, and touched his bedding. Then, with those same gloved hands, she obtained cleaning wipes and cleaned the lift. *A staff member brought CMA NN a package of white pads into the resident's room. With those same gloved hands, CMA NN removed one pad from the package and then placed the rest of the package in the clean cupboard with the resident’s feeding tube supplies. *Without gloves on, LPN MM grabbed the resident's graduated cylinder for his feeding tube flush and rinsed it out in the resident's bathroom sink. *She put on gloves without performing hand hygiene and then hooked up the resident's formula tubing to his feeding tube. *She removed her gloves and gown, touched the graduated cylinder with her bare hands, touched his call light, touched her left ear, touched her medication computer cart, and then left the room without performing hand hygiene. *LPN MM verified the resident was on EBP. She was not sure why he was on precautions. *She stated staff were to wear gowns and gloves when working with him. *She stated she should have changed her gloves between providing his care and the dressing changes. *She stated staff were to perform hand hygiene before administering his medications, before putting gloves on, before and after helping residents to the bathroom, and before performing a sterile procedure. -She stated deep suctioning of a resident’s mouth was considered a sterile procedure. 9. Observation and interview in resident 75’s room on 8/18/25 at 4:02 p.m. revealed: *She had a magnet on her door frame and a sign in her room that indicated she was on EBP. *She stated that the staff used to wear gowns, but now they usually did not. 10. Observation and interview on 8/20/25 at 9:18 a.m. with RN G and CMA M in resident 49’s room revealed: *They did not wear gowns or gloves to transfer the resident with the sit-to-stand aid. *After transferring the resident, RN G left the room with the sit-to-stand aid and did not perform hand hygiene. She put the sit-stand-aid in its designated location, walked to the nurses' station, obtained gloves, put them on without performing hand hygiene, and then cleaned the sit-to-stand aid with sanitary wipes. *CMA M stated the resident was on “somewhat EBP but not full-blown.” *She stated she was to wear a gown and gloves while assisting the resident with bathing and changing the resident’s linens. -After reading the EBP sign, she verified she was to wear a gown and gloves for transferring the resident. *She was not sure why the resident was on EBP. *RN G stated she was not sure if resident 49 was on EBP. *She stated when working with residents on EBP she needed to: perform hand hygiene, wear gloves, and gowns when providing resident hygiene care. *She stated she was not sure why the resident was on EBP as she did not have a multi-resistant drug organism (MDRO). 11. Observation and interview on 8/20/25 at 8:21 a.m. of CMA MM walking in the hallway revealed: *She had a resident gown in her bare hand, that was not in a bag, and carried it to the dirty linen room. *Interview with CMA MM revealed she was to have worn gloves and had the gown in a bag. *She verified that she had been in resident 33’s room, who had an EBP magnet on his door frame. *She was unsure why resident 33 was on EPB. 12. Observation on 8/20/25 at 9:41 a.m. in resident 76’s room revealed RN G administered the resident’s insulin, removed her gloves, did not perform hand hygiene, and then left the resident's room. 13. Observation on 8/20/25 at 1:58 p.m. of CMA FF in resident 20’s room revealed she did not perform hand hygiene before or after administering the resident's medications. 14. Observation on 8/20/25 at 2:21 p.m. of LPN HH in resident 4’s room revealed: *LPN HH put on gloves and exposed the resident's feeding tube from under his shirt. *With those same gloved hands, she grabbed her keys and opened the medication cupboard. Then she stated she was going to flush his catheter first. *Without changing her gloves, she exposed the urinary catheter port. *She touched the sterilized water container, which was stored in the clean medication cabinet, with those same gloved hands, poured the water into a clean plastic cup, and flushed the resident's urinary catheter. She did not wear a gown. * She removed her gloves, washed her hands in the residents' bathroom, turned the faucet off with her hand, and then grabbed a paper towel to dry her hands. * She then put on a gown and gloves, prepared and administered his medications. *She removed her gloves and put on new gloves, and without performing hand hygiene, flushed his feeding tube. *She then removed her gown and gloves, grabbed the garbage bag out of the garbage can, then locked the medication door without performing hand hygiene. *She buckled the resident's seat belt without wearing gloves. *Interview with LPN HH about urinary catheter flush revealed she thought it was a clean procedure, not sterile. *She stated the resident was on EBP due to the feeding tube and urinary catheter, so she should have worn a gown when flushing the catheter. 15. Observation on 8/20/25 at 3:06 p.m. of the medication room behind the Bluegrass Way nurses' station revealed there were five boxes of Peptamen nutritional formula for administration through a feeding tube stacked on the floor. 16. Observation on 8/20/25 at 4:05 p.m. of LPN HH flushing resident 75’s urinary catheter revealed she put the sterile flushing solution in a clean cup, and not in a sterile container. 17. Interview on 8/21/25 at 10:00 a.m. with facility services manager E revealed: *He expected dirty linen to be transported in a sealed bag, especially for residents who were on EBP. *He expected the housekeeper to wear gowns when cleaning a room for a resident on EBP. 18. Interview, record review, and policy review on 8/21/25 at 10:50 a.m. with RN coordinator I revealed: *She expected urinary catheter flushing to be a clean technique and staff to use a sterile syringe and solution, but the sterile solution did not need to be in a sterile container. *She stated resident 75 had a UTI on 6/27/25. -This was verified with residents' urine lab results. -Her culture indicated she had a Proteus and Staphylococcus aureus-MRSA (type of bacterium) infection. *She stated resident 4 had a UTI on 6/7/25 and 2/23/2025. -This was verified with residents' urine lab results. -His culture indicated he had a Proteus (type of bacterium) infection. *After review of the provider's bladder irrigation or urinary catheter flushing policy, she verified it was supposed to be a sterile technique, and they were to use a sterile container for the sterile solution. *She verified that not following sterile technique created a risk for an infection. *She expected the boxes of the nutritional formula not to be stored on the floor. 19. Interview with on 8/21/25 at 12:15 p.m. with Infection Prevention and Control RN II and Quality and Infection Prevention RN Supervisor JJ revealed: *They had current performance improvement projects regarding hand hygiene. *They expected staff to follow the five movements of hand hygiene (a reference for healthcare workers to follow for when to complete hand hygiene) and know when to use soap and water vs alcohol-based hand rub sanitizer (ABHR). *They stated they educated staff to let them know if soap or ABHR were not available. -Housekeeping had been making sure all of the alcohol dispensers were full and working. *They expected staff to wear gowns and gloves when completing high-contact activities with residents on EBP, such as: -transferring, dressing, bathing, linen changes, hygiene, device management, and administering medications through a feeding tube. *They completed hand hygiene and personal protective equipment (PPE) audits. *Staff were provided yearly education about different focuses on EBP during CNA and nurse meetings and one-on-one meetings. *Residents on EBP have a sign on the gown holders in their rooms and have an EBP magnet on their door. *Nurses were to follow sterile technique when flushing a urinary catheter and were to use a sterile solution and a sterile container. *They verified that putting a sterile solution into a clean cup to flush a resident's urinary catheter could risk a urinary tract infection. 20. Interview with the director of nursing (DON) B on 8/21/25 at 3:38 p.m. revealed: *He expected staff to wear gowns and gloves per the policy for residents who were on EBP. *He expected the staff to follow the hand hygiene policy. -He indicated they had started a performance improvement project regarding hand hygiene. 21. Review of the provider’s 3/2025 Cleaning an Occupied Resident Room policy revealed: *Housekeepers were to: “…4. Apply personal protective equipment (PPE) per standard and transmission based precautions and clean per recommendations in the [NAME] LTC-Transmission Based Precautions and Enhanced Barrier Precautions.” *Review of the provider’s 11/2024 Hand Hygiene policy revealed: *The purpose of hand hygiene (HH) was to: “ …prevent the transmission of infection.” -to cleanse hand to prevent the spread of infection. -to provide a clean and healthy environment for residents, staff, and visitors.” *HH should be done: ”either with soap and water or with alcohol based hand rub (ABHR): 1. immediately before touching a resident 2. before a clean procedure or handling an invasive medical device 3. after contact with potential for body fluid or contaminated surfaces 4. after touching a resident or the resident’s immediate environment 5. after removing gloves….” Review of the provider’s 11/13/2024 Transmission Based Precautions and Enhanced Barrier Precautions policy revealed: *The purpose was to: “provide infection prevention and control recommendations for long-term-care…” -“…2. Enhanced Barrier Precautions are used during high contact resident care activities for the following residents and should be implemented as facilities are able: a. Infection or colonization with an MDRO status b. Wound requiring a dressing, regardless of MDRO status c. indwelling medical device, regardless of MDRO status…. d. If a, b, or c apply, gown and gloves must be used during high contact resident care activities including (but not limited to) i. dressing ii. bathing or showering iii. transferring iv. providing hygiene v. changing linen vi. changing briefs or assisting with toileting vii. device care use…. viii. wound care…. B. Respiratory hygiene/Cough Etiquette will be followed as per [NAME] LTC Standard Precautions. -III. Isolation Room Procedure: Isolation supplies kept in a designated area can be kept on the units as long as they are properly stocked and cleaned. Place of the proper color-coded isolation sign for the type of precaution(s) on the resident's door or designated area. H. Equipment: 1. Any equipment brought into the resident’s room must be cleaned …prior to using on another resident…. K. Use of PPE: …2. In addition to what is posted on isolation signage, follow Standard Precautions by type of exposure anticipated with additional tasks: Work from ‘clean to dirty’ Limit opportunities for ‘touch contamination’-protect yourself, others, and the environment. If contamination occurs, remove PPE, complete hand hygiene and don [put on] clean PPE Do not touch your face or adjust PPE with contaminated gloves Do not touch environmental surfaces (including privacy curtains) except as necessary during resident care 3. Remove PPE appropriately and complete hand hygiene before leaving the room N. Resident Supplies: 1. Clean, disposable, wrapped supplies stored in an enclosed space a. Only clean, ungloved hands should enter supply drawers and cupboards b. Whenever you need to remove something from a drawer or cupboard, gloves are taken off, hand hygiene performed, and the item removed; hands are re-gloved and proceed with your task…. d. If gloved hands enter a supply drawer while in an isolation room, any disposables that are touched are considered contaminated and are to be used for that resident or discarded T. When a nurse phone is taken into an isolation room, clean the phone upon leaving the room U. When the key to the medication locked box is used in an isolation room, it is cleaned with facility approved disinfectant….” Review of the provider’s sign hanging in the resident’s room, indicating the resident required EBP revealed it indicated: *“EVERYONE MUST: Clean their hands, including before entering and when leaving the room.” *“PROVIDERS AND STAFF MUST ALSO: -Wear gloves and a gown for the following High-Contact Resident Care Activities. - Dressing - Bathing/Showering - Transferring - Changing Linens - Providing Hygiene - Device care or use: central line, urinary catheter, feeding tube, tracheostomy - Wound Care: any skin opening requiring a dressing….” Review of the provider’s 4/2025 Clean and Soiled Linens policy revealed: *The purpose was to “…B. Minimize the possibility of cross-contamination between patients and/or employees. *…Soiled Linen: -All soiled linen is considered contaminated and proper personal protective equipment (PPE) will be utilized when handling per standard precautions…. - Soiled linens and resident personal clothing will be bagged at the point of care prior to transport to the soiled utility room….” Review of the provider's 4/2025 Cather (Retention) Irrigation policy revealed: *…A. Equipment: 1. Sterile irrigating set…. 4. Sterile solution as ordered…. B. Method: … 3. Perform hand hygiene 4. Maintain sterile technique….”

Based on record review, interview, and policy review, the provider failed to ensure a thorough investigation was completed for one of one sampled resident (3) who fell in her bathroom and sustained a femoral (thigh bone) fracture. Findings include: 1. Review of resident 3's electronic medical record (EMR) revealed:*She had an unwitnessed fall on 2/9/25 at 6:05 a.m. while she was in the bathroom.*Her 2/9/25 Care Assessments indicated:-She self-transferred herself from her wheelchair onto the toilet while in the bathroom.-She had stated, I knew I needed to go.-She was standing, trying to pull own pants up at the time of the fall. resident acknowledges she knows she was supposed to use her call light for safety reasons. resident stating her right knee twisted and there is swelling and warmth to that knee.-Her previous fall risk score was a 2, which indicated she was at risk for falls.*Her 7/2/25 care plan indicated:-A safety intervention for a sensor pad (a device that alerts when pressure changes occur to indicate movement) under her at all times when she was in her chair or bed, as she forgets to use her call light.-She was to be transferred with the assistance of one staff member.*Her 2/9/25 hospital records revealed she had a right femoral fracture. Interview on 7/2/25 at 12:55 p.m. with certified nursing assistant (CNA) G revealed:*The CNAs referred to a cheat sheet that had specific information regarding the care needs of residents.*If a resident fell, he would call for a nurse or the nurse supervisor if the nurse was not available to let them know.-He would then write a statement of what he knew about the fall as part of the investigation regarding that fall. Interview on 7/2/25 at 1:15 p.m. with CNA E revealed:*The care needs of residents were reflected in their care plans.*If a resident fell, she would notify the nurse and then obtain the resident's vital signs (measurements of basic body functions, such as blood pressure, pulse, respirations, and temperature). Interview on 7/3/25 at 9:50 a.m. with assistant director of nursing (ADON) C regarding resident 3 revealed:*On 12/31/24, the use of a sensor pad alarm in her chair and bed was added to her care plan.*Sensor pad alarms were plugged into the resident's call light port in the room and alarmed for staff to know when they got up by themselves.*She confirmed resident 3 fell on 2/9/25 and fractured her femur. Interview on 7/3/25 at 9:59 a.m. with ADON B regarding resident 3's fall on 2/9/25 revealed:*Resident 3 had transferred from her wheelchair to the toilet in her bathroom by herself.*She activated her call light after she fell.*ADON B confirmed resident 3 had a sensor alarm that was used in her chair and her bed.-She stated the sensor alarm was not used in resident 3's wheelchair at that time.*She stated the sensor alarms were to be checked by staff routinely that they were working, and that was to be documented in the resident's EMR.-There was no place to document where a sensor alarm was located, such as on the chair or bed.*Resident 3 had been checked on 30 minutes before her fall on 2/9/25.*She stated the provider's investigation for resident 3's fall included:--The sensor alarm documentation was reviewed by her and indicated it had been working on 2/8/25 at 9:30 p.m., 2/9/25 at 2:25 a.m., and 30 minutes before resident 3's fall in the bathroom on 2/9/25 approximately 30 minutes before resident 3's fall.-She confirmed there was no documentation indicating where resident 3 was during those times indicated.-Resident 3's sensor alarm pad was checked after her fall and was working at that time.*She had considered the cause of the fall was resident 3 having attempted to transfer herself without staff assistance, and it had not been investigated further.*She confirmed the investigation of resident 3's 2/9/25 fall had not included:-When or how resident 3 had moved herself into her wheelchair to take herself to the bathroom, as the sensor pad had not activated.-Statements from staff members who were working at the time of that fall. Director of Nursing (DON) A was not available for an interview during the survey. Review of the provider's 10/2024 LTC (Long Term Care) Falls and Accidents-System Standard Policy revealed:*Policy Statement: To provide a systematic approach to fall and accident prevention and monitoring, including identifying and evaluating hazards and risk, individualizing approaches to reduce the risk of falls and accidents, and monitoring for effectiveness of interventions when necessary.*Definitions: Position change alarms: alerting devices intended to monitor a resident's movement. The devices emit an audible signal when the resident moves in a certain way. Types of position change alarms include chair and bed sensor pads, bedside alarmed mats, alarms clipped to a resident's clothing, seatbelt alarms, and infrared beam motion detectors. Position change alarms do not include alarms intended to monitor for unsafe wandering such as door or elevator alarms.*Resident falls: The fall must be investigated for cause, and reported in the facility quality management system for tracking and monitoring.- Review of individualized, resident-centered interventions, including adequate supervision and assistive devices, to reduce individual risks related to hazards in the environment must occur. The plan of care must be updated/modified accordingly.*All staff are expected to understand the policy and clarify with supervisory staff as needed. Review of the provider's 2/2025 LTC Abuse, Neglect, Mistreatment & Misappropriation of Resident Property policy revealed:*Position change alarms were defined as: are alerting devices intended to monitor a resident's movement. The devices emit an audible signal when the resident moves in certain ways.* The investigation is the process used to dry to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed.-The investigation will include statements from all individuals involved .-Environmental considerations: A complete and thorough documentation of the entire investigation.- Investigation of injuries of Unknown Origin or Suspicious injuries: must be immediately investigated to rule out abuse. Investigation must be thorough, include the resident, ., staff on all shifts that could potentially have contact with the resident and thoroughly documented. Injuries of unknown origin or suspicious injuries can include, but are not limited to:- The source of the injury was not observed by any person.- Factures, sprains, or dislocations unobserved or unexplained.

Based on observation, record review, interview, and policy review the provider failed to follow the pressure ulcer prevention interventions documented in the care plan for one of one sampled resident (3) who was at risk for developing pressure ulcers. Findings include: 1. Observation of resident 3 on 3/11/14 at 3:06 p.m., 3/12/24 at 1:31 p.m., and on 3/13/24 at 2:11 p.m. revealed: *She had been lying on her back in her bed. *Both heels were resting directly on the mattress without any devices used to prevent pressure from occurring. *Her heel-lift boots were sitting on the window ledge in her room. 2. Review of resident 3's electronic medical record revealed diagnosis of stroke due to thrombosis (blood clot) of the right middle cerebral artery causing left-side weakness and controlled diabetes mellitus type two with complications. Review of resident 3's current care plan revealed she had a problem of skin integrity with an intervention Heel lift boots on while in bed. 3. Interview on 3/13/24 at 2:12 p.m. with certified nursing assistant I regarding resident 3 revealed she: *Stated She only lays in bed for an hour and a half only lays down in the afternoon, so we do not put them on but, we probably should. *Confirmed her care plan indicated They should be on when in bed. *Was not aware of the resident having any history of skin issues on her heels and stated, Which is probably why she wears the heel-lifts. Interview on 3/14/24 at 9:04 a.m. with registered nurse D regarding resident 3's heel lift boots revealed she confirmed that Yes, her heel-lift boots should have been on whenever she was lying down per her care plan, whether it would have been twenty minutes or two hours. Interview on 3/14/24 at 12:03 p.m. with director of nursing B, regarding resident 3 revealed his expectation was that, Whenever the resident is in bed, she should be wearing the heel-lift boots. 4. Review of provider's 1/3/24 LTC [Long Term Care] Skin Assessment/Pressure Injury Prevention-System Standard Policy revealed: *Purpose: To provide guidelines and direction for health care professionals in . providing care and intervention to prevent residents from the prevention of skin issues. *Use elbow/heel protectors and multipodus boots if indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation on 3/11/24 at 3:30 p.m. with resident 21 revealed that she was seated in her wheelchair and self-propelling herself in the hallway. After greeting her, she made eye contact and smiled but did not answer any questions. Interview on 3/14/24 at 12:18 p.m. with agency certified nursing assistant(CNA)/medication aide(MA) M regarding resident 21 revealed: *Today was her first time working with the resident. *At the beginning of the shift, the other staff stated, I might have a little trouble with her. *The resident was a little combative and resistive to care, she requested help from another CNA to get the resident up and dressed for the day. *That morning, the resident refused her medications and had not eaten her breakfast because she was tired, but after a while, she reapproached the resident who then took her medications. *When asked where she would find resident 21's care plan, she stated, I'm not sure if it's in here [as she pointed to her laptop], but I know who to ask. Interview on 3/14/24 at 12:27 p.m. with CNA I, who had worked the past five years at the facility, regarding resident 21 revealed she: *Had dementia, was severely cognitively impaired, and usually did not talk. *Wandered in and out of resident rooms daily, taking items if they catch her eye. *Had physical altercations with other residents in their rooms, that required staff to separate and remove the resident from the room. *Was hard to redirect. *Could be disruptive at times. Review of resident 21's EMR revealed: *She had a special indicator of being Aggressive/Violent that included the following statement Clinical Staff have indicated this patient has a history of displaying aggressive/violent behavior towards themselves and/or others. Follow facility protocol for care of the patient with Aggressive/Violent behaviors. *A 9/3/23 at 10:14 p.m. nurse progress note revealed Several residents have complained on this night shift about [resident name] wandering into their rooms and either taking belongings or disturbing them. *A 9/14/23 at 7:01 p.m. social services progress note revealed [Resident name] wandered into another resident's room and broke the glass to the china [NAME]. Staff member observed [resident name] shaking china [NAME] and tried to use it to stand up. Staff member caught [NAME] before it fell. *A 11/29/23 at 6:46 p.m. nurse progress note revealed Behaviors Resident has increased wandering, going in other resident's rooms, touching personal belonging, etc. *A 2/14/24 at 7:31 p.m. nurse progress note revealed As per [resident 28], she saw [resident 21] in [resident 33]'s room and ask her to leave the room as the light was on. [Resident 28] went in front of the TV ., [resident 21] came after her. [Resident 21] started hitting [resident 28] in arm and squeezing her arm. [Resident 28] told her to stop hitting me and leave me alone. [Resident 28] started moving, [resident 21] grabbed her shirt . CNA saw this and took care of situation. *The 1/16/24 annual comprehensive Minimum Data Set (MDS) assessment revealed the following: -Her Brief Interview for Mental Status (BIMS) was scored at zero which indicated severe cognitive impairment. -Her physical behavior symptoms were directed toward others: --Occurred one to three days in the past seven days. --Significantly interfered with the resident's care. --Placed others at significant risk for physical injury. -Her wandering behavior: --Occurred daily and had worsened. --That placed the resident at significant risk of getting into a potentially dangerous situation. --Significantly intruded on the privacy or activities of others. *The 1/18/24 Care Area Assessment (CAA) for her behavioral symptoms stated it was .triggered due to resident having physical behavioral symptoms directed towards others. Resident also wonders [wanders] throughout the neighborhood, in others room and unsafe areas. Resident has Dx [diagnosis] of dementia which contributes to these behavioral symptoms. -She was at risk for more behavioral symptoms. Review of resident 21's thirty-page current care plan revealed that it did not address her goals, preferences, strengths, weaknesses, or needs that were related to her wandering behavior, resistance to care, and physical altercations with others. Interview on 3/14/24 at 12:41 p.m. with RN coordinator C revealed she: *Was the RN coordinator for two nursing units, where resident 21 resided. *Was not responsible for completing the resident MDS assessments or CAAs, as there were three RN coordinators who completed those. *Reviewed the CAAs and developed or updated the resident individual care plans. *Stated she was new to care planning as she had been in her position only a few months. *She stated she was aware of resident 21's wandering behavior, that she could be resistant to care, and the 2/14/24 physical altercation with another resident. Interview on 3/14/24 at 1:28 p.m. with director of nursing (DON) B revealed: *Resident 21's special indicator Aggressive/Violent had been entered upon her admission on [DATE] that alerted staff and those providing care of her behavior problems. *He was not aware of any facility protocol for care of the patient with Aggressive/Violent behaviors but stated there was a policy that addressed resident behaviors. *Stated that any resident exhibiting behaviors regularly should have an intervention on their care plan addressing that behavior. Interview on 3/14/24 at 2:47 p.m. with RN coordinator's F and E revealed: *They both were responsible for completing resident MDS assessments and the CAAs. *The RN coordinators on the nursing units were responsible for developing and updating the resident care plans. -RN coordinator C was responsible for updating resident 21's care plan. *After reviewing resident 21's 1/16/24 annual MDS, 1/18/24 CAA, and documentation in the EMR regarding her behaviors, RN coordinator F agreed that she would expect to see a behavior problem addressed on the resident's care plan: -She stated the following from resident 21's CNA documentation which identified: --On 2/14/24, physical aggression. --On 2/22/24, wandering behavior. --On 2/28/24, resistant to care with the note, resident 21 attempted to bite my arm. Review of the provider's 1/24/24 Special Indicators Crosswalk revealed: *The document had an overview to Provide education on purpose of and process for adding, editing, and removing Special Indicators for their EMR software. *Background: Special Indicators are available when registering and caring for patients in all care settings and will alert the [EMR brand name] user of special needs that will need to be considered while caring for them. *The document provided instructions on how to add, edit, and remove or delete an indicator. *The document listed twenty-nine special indicators including Aggressive/Violent. -The Aggressive/Violent special indicator was able to be entered and/or edited by All users of their EMR. --Patient has a history of displaying aggressive/violent behavior toward themselves and/or others. --Comment summarizing reason for indicators is required. Review of the provider's March 2021 Behavioral Health policy revealed: *Purpose: It is the policy of this facility that each resident must receive and the facility must provide the necessary behavioral health care and services .to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. *Policy Statement: .This facility will provide the necessary behavioral health care and services which include .Individualized non-pharmacological interventions will be care planned . *Definitions Behavior: Behavioral symptoms that may cause distress or are potentially harmful to the resident, or may be distressing or disruptive to facility residents, staff members or the environment. *Procedure . RAI Process: -The RAI process (MDS, CAA's and Care Planning) will be completed by the Interdisciplinary Team to determine person-centered care plan goals and approaches based upon the comprehensive assessment. -Based upon the assessment findings, the interdisciplinary team will complete a comprehensive Person-Centered Care Plan including individualized mood and behavior interventions and approaches . -Recognition and Management of Dementia: --The facility will assess and determine individualized behavioral care plan interventions for individuals with dementia in order to be able to provide specialized services and supports. -- .Care plan goals will be developed based upon the comprehensive assessment including input from the interdisciplinary team, resident, resident's representative and/or family and achievable [sic]. 3. Observation and interview on 3/11/24 at 5:22 p.m. of resident 66 in the dining room revealed: *She was seated in her wheelchair at the table, eating independently her pureed foods from a divided plate with a two-handled covered cup with thickened water. She responded to a greeting and replied, It's good, when asked about her supper meal. She did not answer any other questions. In person interview on 03/11/24 at 3:15 p.m. of resident 66's daughter-in-law revealed: *She visited the resident once a week, another daughter-in-law visited regularly, and the resident's daughter visited more often. *She stated the resident was on hospice care, but she had not met any of the hospice staff. Observation on 3/12/24 at 10:22 a.m. of resident 66 in the dining room at her table alone with a clothing protector on. In front of the resident was a glass of thickened juice with a plastic spoon inserted into the glass and a mug of thickened liquids with another plastic spoon inserted into the mug. An unidentified staff member stated her divided plate had been removed with the drinks remaining on the table. Both the glass and the mug was full of thickened fluids and it appeared that none of the fluids had been consumed. The unidentified staff member did not address the resident or encourage her to drink some of the fluids. Review of resident 66's EMR revealed: *A scanned agreement from the hospice provider, which was signed by the resident's daughter on 1/26/24, for hospice services to begin that day. -The agreement stated the qualifying hospice diagnosis was Senile degeneration of brain. *A 1/30/24 significant change comprehensive MDS assessment recorded: -Her BIMS was scored at four, which indicated severe cognitive impairment. -She was receiving hospice care. Review of resident 66's current care plan revealed it did not address what the hospice was responsible for and what the nursing home was responsible for. Interview on 3/14/24 at 2:35 p.m. with RN coordinator's F and E regarding resident 66 revealed: *The 1/30/24 significant change in status comprehensive MDS assessment was completed related to her hospice care which started on 1/26/24. *RN coordinator E located the hospice provider's scanned 1/26/24 Hospice Plan of Care in the EMR and stated that the hospice plan of care should have been integrated into her comprehensive care plan. *RN coordinator F stated the hospice agency provided a blue sheet that identified how often the RN, CNA, and social worker would visit the resident and that should have been included in the resident's care plan. *Both agreed that the hospice plan of care and frequency of visits should have been addressed in the resident's care plan. Review of the provider's June 2023 policy on LTC [Long Term Care] Baseline/Comprehensive Care Plans revealed: *Policy The interdisciplinary team will develop a . comprehensive care plan for each resident . to provide effective and person-centered care of the resident . *The care plan will be reviewed and revised by the interdisciplinary team after each assessment. Based on observation, interview, record review, and policy review, the provider failed to ensure resident care plans were revised to reflect the current needs of three of twenty-three sampled residents as follows: *One of one sampled resident (9) who had three fingers amputated on her dominant hand. *One of one sampled resident (21) who had behaviors of wandering, resistance to care, and physical altercations with other residents. *One of one sampled resident (66) who had received hospice services. Findings include: 1. Observation and interview on 3/11/24 at 5:41 p.m. with resident 9 revealed: *She had a wound dressing on her right hand where three fingers had been amputated. *She had emotional distress due to the loss of those fingers because she was dominantly right-handed. Review of resident 9's electronic medical record (EMR) revealed she had: *A hospital stay from 1/19/24 through 1/25/24 for cyanosis (blue discoloration) on three fingers of her right hand. *Been evaluated in the emergency department (ED) on 1/31/24 and was hospitalized . *Her right index, long, and ring fingers amputated. *Returned to the transitional care unit (TCU) on 2/3/2024. Review of resident 9's current care plan revealed it had not been revised to have: *Addressed her finger amputations in her activities of daily living (ADL) area or interventions relating to the amputations. *Identified and included her emotional needs or interventions related to the loss of those fingers. *Removed a pressure ulcer to her coccyx that had healed. Interview on 3/14/24 at 9:01 a.m. with registered nurse (RN) coordinator L regarding resident 9's care plan revealed: *She updated the care plans for the residents in the TCU. *She agreed resident 9's care plan had not been revised to include her finger amputations in the ADL area or her emotional needs relating to the loss of those fingers on her dominant hand. *She stated that resident 9's care plan should have been updated to reflect that information when she returned from the hospital. *She confirmed resident 9's pressure ulcer to her coccyx had healed and remained on her care plan. *She agreed the pressure injury should have been removed when it healed.

Based on observation, interview, and policy review, the provider failed to ensure proper infection prevention and control practices for the following: *One of one RN coordinator (I) exited resident 80's airborne isolation room and had not performed hand hygiene after removing his N95 mask and prior to putting on a surgical mask. *Glove use and hand hygiene for one of one registered nurse (RN) (J) and one of one licensed practical nurse (LPN) (H) while providing personal care for one of one sampled resident (48) who was on contact precautions for Klebsiella pneumoniae (a gram-negative bacteria) in her urine. *Handling a Foley catheter bag by one of one LPN (H) while transferring and providing cares for one of one sampled resident (48) who was on contact precautions for Klebsiella pneumoniae (a gram-negative bacteria) in her urine. Findings include: 1. Observation on 3/30/23 at 7:45 a.m. of RN coordinator I after exiting resident 80's airborne isolation room revealed: *He had performed hand hygiene and removed his N95 mask. *He had touched the front of the N95 mask while placing the mask into the garbage. *Without performing hand hygiene, he opened a drawer on the three-drawer container next to the room door, took out a surgical mask, and placed the surgical mask on his face. Interview on 3/30/23 with RN coordinator I directly after the above observation revealed he agreed he should have performed hand hygiene after removing his N95 mask and before placing a new surgical mask on his face. 2. Observation on 3/28/23 at 4:35 p.m. of RN J and LPN H providing personal care for resident 48 in her room revealed: *They both had been wearing a gown, gloves, and a face mask. *They both transferred resident 48 from the recliner into her bed with a total body mechanical lift. *Resident 48 had been incontinent of her bowels. *RN G: -Performed incontinence care for resident 48 and without removing his gloves or performing hand hygiene he applied barrier cream to the resident's clean buttocks. -Changed his gloves and had not performed hand hygiene. -Cleaned resident 48's abdominal fold and removed his gloves. -Without performing hand hygiene, he assisted LPN H position resident 48 in the bed. -Without performing hand hygiene he placed a new pair of gloves on his hands. -Adjusted the height of the bed, replaced the pillowcases on the pillows, and positioned resident 48 in bed to make her comfortable. *LPN H: -Held resident 48's Foley catheter bag above the level of resident 48's bladder while transferring her from the recliner to the bed with the total body mechanical lift. -Placed the Foley catheter bag on the floor next to the bed by her feet. -Assisted RN J with positioning the resident for personal care. -Performed peri care for resident 48. -Picked up the Foley catheter bag from off the floor and set it into a pink plastic basin on the floor. -Changed her gloves without performing hand hygiene. -Standing where the catheter bag had been on the floor, she assisted RN J position the resident in bed. -Put the resident's protective boots on her feet. -Without performing hand hygiene, changed her gloves, connected resident 48's tube feeding, and then turned on the feeding pump. Interview on 3/28/23 after the above observation with RN J and LPN H regarding glove use, the Foley catheter bag, and appropriate hand hygiene revealed: *They both agreed the Foley catheter bag should have been kept below the level of the bladder. *They both should have performed hand hygiene when they were moving from a dirty task to a clean task and changing gloves before and after use. *The pink plastic basin was used so the Foley catheter bag had not touched the floor. *The Foley catheter bag should have been placed in the pink plastic basin once the resident was transferred into the bed and not placed on the floor where staff were standing. 3. Interview on 3/28/23 at 5:17 p.m. and again on 3/30/23 at 3:00 p.m. and 4:31 p.m. with director of nursing (DON) B regarding the above observations revealed: *RN coordinator I should have performed hand hygiene after removing his N95 mask and prior to placing a new surgical mask on his face. *He expected all staff to perform hand hygiene when moving from a dirty task to a clean task and before and after glove use. *Agreed staff should have kept the Foley catheter bag below the level of the resident's bladder and the Foley catheter bag should not have been placed on the floor. 4. Review of the provider's July 2022 Hand Hygiene policy revealed staff should have performed hand hygiene after contact with body fluids, potentially contaminated surfaces, a resident, a resident's environment, and after removing gloves. Review of the provider's March 2023 Indwelling Catheter Care policy revealed: *Maintain unobstructed flow of urine -Catheter bag and tubing must be below the level of the bladder at all times including transport or ambulation -Catheter bag may not be place [placed] on the floor at any time

3. Observation and interview on 3/29/23 at 9:35 a.m. on the rehabilitation floor kitchenette with server G revealed she: *Used checklists to ensure she completed her kitchen tasks. *Had to get the temperature of each food item before serving the food. *Documented the temperatures of the food in the white three-ring binder for the rehab unit. *Agreed there was missing documentation for food temperatures in the binder. Review of the white, three-ring binder's temperature log sheet labeled March Rehab revealed: *Breakfast temperatures for food items were not recorded for 13 of the 29 meals to date in March. *Lunch temperatures for food items were not recorded for 13 of the 28 meals to date in March. Supper temperatures for food itmes were not recorded for 17 of the 28 meals to date in March. 4. Interview on 3/30/23 at 1:04 p.m. with support services manager E regarding the monitoring and documentation of food temperatures revealed she: *Agreed and confirmed the policy instructed staff to have taken and recorded food temperatures for each meal on each of the provider's four kitchenettes. *Stated her expectation was the nutrition service server assigned to each kitchenette would have taken and recorded the food temperatures prior to each resident meal service. Continued interview with support services manager E regarding the food temperature logs for March 2023 from three of the four kitchenettes revealed she could not provide documentation for the food temperatures for any of the hot food items that were not recorded. 5. Review three of the four white, three-ring binders in the provider's kitchenettes revealed: *The sheet on the front of the binder was titled Temperature and stated: -ALL foods MUST have the temperature taken and written down on the temperature log prior to serving. -This needs to be recorded on the sheet each shift. -The bottom of the sheet had the first and last name of the support services manager E and the date 12.28.21[.] Review of the provider's April 2021 policy on Food Temperatures revealed: *The purpose was to serve safe and palatable foods. *The policy was To keep food safe[.] *The procedure included Hot food temperature will be taken before placed in the steam table and recorded . Review of the October 2021 Support Services Manager job description revealed: *The summary included Responsible for the overall daily operations, to assure quality services to residents . *Supervisory responsibilities included .planning, assigning, and directing work; appraising performance; .resolving problems. *Essential functions included Provides for the analysis, collection and maintenance of records . Based on observation, interview, record review, and policy review, the provider failed to ensure their policies had been followed for monitoring and documenting food temperatures prior to meal services to ensure safe food temperatures in three of four kitchenettes. Findings include: 1. Observation and interview on 3/30/23 at 8:34 a.m. on the first floor's Arrow Head and Boulder Creek kitchenette with server F revealed: *When asked about her tasks, she stated there were checklists that guided her work. *She would document the meal's food temperatures in the binder located in the kitchenette. Review of the white, three-ring binders temperature log sheet labeled March '23 1st [floor] revealed: -Breakfast temperatures were recorded except for the six food items on 3/20/23. -Supper temperatures for food items were not recorded for 14 of 29 meals in March 2023. 2. Review on 3/30/23 at 11:09 a.m. on the second floor's Platinum Ridge and Bluegrass Way kitchenette revealed a white three-ring binder, similar to the binder on the first floor's kitchenette revealed: *A temperature log sheet labeled Platinum Ridge & Bluegrass Way with March 2nd [floor] contained documentation of: -Breakfast temperatures for the food items were not recorded for 6 of 30 meals in March 2023. -Lunch temperatures for the food items were not recorded for 8 of 29 meals in March 2023. -Supper temperatures for the food items were not recorded for 15 of 29 meals in March 2023.