**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the Resident Assessment Instrument (RAI) Manual 3.0 review, medical record review, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 resident (Resident #7) of 13 residents reviewed. The findings include: Review of the RAI Manual 3.0 dated 10/1/2023, revealed .the assessment [MDS] accurately reflects the resident's status . Medical record review revealed Resident #7 was admitted to the facility on [DATE] and discharged on 7/27/2024 with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction, Muscle Weakness, Atherosclerotic Heart Disease, Chronic Obstructive Pulmonary Disease, Epilepsy, Diabetes Mellitus, Fracture of Lower End of Right Tibia, Fracture of Shaft of Right Tibia. Review of the Nurse's Notes for Resident #7 dated 6/18/2024 at 7:21 PM, revealed .Reason resident was hospitalized or received service at a hospital .CVA [Cardiovascular Accident] [Stroke], Right Hemiparesis, Seizure, Fall from standing .fall precautions . Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 scored 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. The section for history of falls indicated the resident had not had a fall anytime in the last month. Review of the comprehensive care plan dated 6/25/2024, revealed resident at risk for falls related to history of falls, Cardiovascular Accident. During an interview on 9/26/2024 at 12:45 PM, Registered Nurse (RN) A/MDS Coordinator confirmed .[Resident #7] had a fall at home prior to being admitted to the hospital on [DATE], and the fall which had occurred in the last 30 days was not coded on the resident's admission MDS assessment dated [DATE] and further stated .it should have been I [MDS Coordinator RN A] failed to do so .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure a privacy cover was maintained for a urinary catheter drainage bag for 1 resident (Resident #34) of 5 residents reviewed for urinary catheters, and failed to provide assistance to maintain desired physical appearance for 1 resident (Resident #34) of 46 residents reviewed for dignity. The findings include: Review of the facility's policy titled, Resident Dignity - Rehab/Skilled, revised 10/26/2022, showed .The location will promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity .Grooming residents as they wish to be groomed .Refraining from practices demeaning to residents such as keeping urinary catheter bags uncovered . Resident #34 admitted to the facility on [DATE], with diagnoses including Dementia, Heart Failure, Retention of Urine, Neuromuscular Dysfunction of Bladder, Urogenital Implants, and Atrial Fibrillation. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] showed Resident #34 had at Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairement, and the resident had an indwelling urinary catheter. Review of Resident #34's physician order dated 1/15/2023 showed .Catheter [a device placed in the bladder to drain urine] 6 fr [french/size] catheter with 10cc [cubic centimeter] balloon to dependent drainage . Review of Resident #34's comprehensive care plan dated 3/16/2023 showed .The resident has indwelling .catheter R/T [related to] urinary retention .Catheter care .Qshift [every shift] . During an observation on 5/2/2023 at 9:25 AM, Resident #34 was laying on the bed in her room with an uncovered urinary catheter bag containing visible urine, attached to the resident's bed and visible from the hallway at the entrance to Resident #34's room. During an observation and interview in Resident #34's room on 5/2/2023 at 9:45 AM, Resident #34 was observed to have facial hair on her chin. Resident #34 was asked if she would like the staff to pluck the chin hairs for her and Resident #34 responded, .I would like that if they would . During an observation on 5/2/2023 at 2:40 PM, Resident #34 was observed in a wheelchair in a group activity with an uncovered urinary catheter bag attached to her wheelchair. The urinary catheter bag was visible from the front and sides of the wheelchair. During an observation and interview in Resident #34's room on 5/2/2023 at 4:04 PM, Certified Nurse Assistant (CNA) #2 confirmed Resident #34's urinary catheter bag was uncovered and visible. CNA #2 stated Resident #34 .does not have a bag [privacy bag] on her catheter . CNA #2 further confirmed Resident #34 had facial hair that was present and stated Resident #34 .has a little bit of stubble . During an observation and interview in Resident #34's room on 5/2/2023 at 4:08 PM, Registered Nurse (RN) #1 confirmed Resident #34's catheter bag was not covered. RN #1 stated the urinary catheter bag was not covered with a privacy bag and confirmed Resident #34 had facial hair on her chin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure medical information was not visible for 1 resident (Resident #27) of 46 residents reviewed for dignity. The findings include: Review of the facility's policy titled, Resident Dignity - Rehab/Skilled, revised 10/26/2022, showed .The location will promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity .Maintaining an environment in which there are no signs posted in residents' rooms .able to be seen by other residents and/or visitors that include confidential clinical or personal information . Resident #27 was admitted to the facility on [DATE], with diagnoses including Unspecified Dementia, Alzheimer's Disease, Delusional Disorders, and Chronic Kidney Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #27 had a Brief Interview of Mental Status (BIMS) assessment score of 12, which indicated Resident #27 had moderate cognitive impairment. Review of Resident #27's physician order dated 12/16/2022, showed .BP [Blood pressure] only in right arm only .every shift . Continued review showed no orders for signage to be posted in the resident's room. Review of a comprehensive care plan initiated on 12/16/2022, showed the care plan had not addressed the posting of a sign in Resident #27's room. During an observation on 5/1/2023 at 10:05 AM and on 5/2/2023, at 9:28 AM in Resident #27's room, a sign was observed above Resident #27's bed that showed .No blood pressure cuffs or sticks on resident's left arm please . The sign was visible to other residents, staff, and visitors who entered the room. During a telephone interview on 5/2/2023 at 10:19 AM, Resident #27's daughter stated family members had not placed the sign on Resident #27's wall. During an observation and interview on 5/3/2023 at 9:43 AM, in Resident #27's room, the Nursing Manager confirmed the sign was posted and contained personal information and was visilble to anyone who entered the room. The Nursing Manager further stated .I didn't even know that she [Resident #27] had it in her room . Resident #27 stated, .I don't know why they [facility staff] put that [the sign] there .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interviews, the facility failed to ensure an allegation of employee to resident abuse was reported immediately to the facility administration and to the State Agency (SA) within two hours, in accordance with Federal Law, for 1 resident (#147) of 25 residents reviewed for abuse. The findings include: Review of facility policy titled, Abuse And Neglect-Rehab/Skilled, Therapy & Rehab, revised 12/23/2020 showed .Alleged or suspected violations involving .abuse .will be reported immediately to the administrator .other officials in accordance with state law .In the absence of the administrator from the location, the following individuals have the administrative authority of the administrator for purposes of immediate reporting of alleged violations: the director of nursing services or the supervisor of social services . Resident #147 was admitted to the facility on [DATE] with diagnoses including Left Hip Fracture, Chronic Kidney Disease, Dementia, and Cerebral Infarction. Review of the admission Minimum Data Set (MDS) dated [DATE] showed Resident #147 scored 15 on the Brief Interview for Mental Status, indicating the resident was cognitively intact. Review of a Care Plan note dated 4/18/2023, showed .up with extensive assist X [times] 2 with a stand aid .alert and oriented .Resident is able to verbalize his needs . Review of an Incident note dated 5/1/2023, showed Resident #147 reported yesterday (4/30/2023) around 10:00 AM, Certified Nursing Assistant (CNA) #3 came into his room and told him to .Get up . Resident #147 informed CNA #3 .I can't . The resident stated CNA #3 stated .Well figure it out .jerked his legs to the side and it hurt . During an interview on 5/2/2023 at 1:57 PM, Resident #147 stated he was able to recall the events that occurred on Sunday 4/30/2023. He stated he was lying in the bed on his back and CNA #3 came in told him he needed to get out of bed. He was unable to give the CNA's name, but stated she worked yesterday with CNA #4. He informed her that he couldn't get out of bed without assistance. CNA #3 told him he would have to do it on his own. He stated CNA #3 then grabbed his knees and twisted his legs and feet off the bed. Resident #147 stated he did not call out for help and did not tell CNA #3 to stop. He then stated CNA #4 came into the room and he reported what happened to him. Resident #147 stated no one came to speak with him about the events that happened on Sunday (4/30/2023), until he reported to the ladies (Social Services Coordinator and Nurse Manager) in his room yesterday (5/1/2023). He stated he did not have any injuries or bruising and felt safe. During an interview on 5/2/2023 at 2:11 PM, CNA #4 stated he overheard the incident that occurred on 4/30/2023 between 10:45 AM-11:30 AM, between CNA #3 and Resident #147. CNA #4 stated he was charting at the desk and heard Resident #147 call out to use the bathroom. He stated CNA #3 went into the room to answer the call light. CNA #4 stated while walking by Resident #147's bathroom he heard CNA #3 speaking loudly stating you need to do it yourself, if you want to go home. CNA #4 stated he entered the room to see if they needed assistance. CNA #4 stated Resident #147 was upset, and he informed CNA #3 he would take over care of the resident. CNA #4 then stated he reported the event to Registered Nurse (RN) #3. He stated he reported that CNA #3 was being rough and loud with Resident #147. CNA #4 stated Resident #147 appeared mad that CNA #3 was in his room and asked for her not to come back in his room; he was not tearful and did not act fearful of CNA #3. CNA #4 stated he did not witness any physical abuse, only CNA #3 speaking loudly with Resident #147. During an interview on 5/2/2023 at 2:25 PM, the Nurse Manager stated she and the Social Services Coordinator (SSC) were in Resident #147's room conducting a care conference with Resident #147 and his wife on 5/1/2023. Resident #147 then informed her and the SSC about the events that occurred on Sunday (4/30/2023). The Nurse Manager stated the care conference on 5/1/2023 was the first time she heard of the events that occurred on 4/30/2023. The Nurse Manager stated when RN #3 was asked if she reported the incident she stated, no. The Nurse Manager stated she immediately reported to the Director of Nursing (DON) (1 day after the occurance). During an interview on 5/2/2023 at 2:32 PM, the SSC stated she was made aware of the incident that occurred on Sunday 4/30/2023, while she and the Nurse Manager were having the care plan meeting with Resident #147 and his wife on 5/1/2023. The wife informed the SSC and the Nurse Manager that Resident #147 had reported CNA #3 was mean to him and hurt his hip while getting him out of bed. Resident #147 stated he reported the incident to CNA #4. The SSC stated she immediately reported the incident to the DON and the Administrator (1 day after the occurance). During an interview on 5/2/2023 at 2:41 PM, the DON stated she became aware of the incident that occurred on 4/30/2023 between 10:45 AM-11:30 AM on 5/1/2023 at 11:00 AM, when the SSC informed her that Resident #147 had made an allegation of abuse. The DON was told that CNA #4 had reported to a nurse that Resident #147 stated CNA #3 had been mean to him and hurt him. The DON stated Resident #147 was flustered and upset during the interview and it bothered him the way he was spoken harshly to and how quickly CNA #3 moved his body. He stated he did not want CNA #3 back in his room. The DON stated when she questioned RN #3 why the incident was never reported to administration, she stated she thought it was gossip among the CNAs and she thought the incident had already been handled, since CNA #3 was no longer caring for Resident #147. The DON confirmed the allegation of abuse had not been reported timely to Administration. During a telephone interview on 5/2/2023 at 3:17 PM, RN #3 stated she was informed by CNA #4 on Sunday 4/30/2023 that CNA #3 had been very direct and blunt with Resident #147. She stated CNA #4 did not report to her that Resident #147 was upset. She stated she thought it was gossip between the CNAs. She stated CNA #3 is very direct and blunt spoken, and some people take offense to her. RN #3 stated she did not report the incident; she did not feel it was abuse. She thought it was more of a disagreement between the resident and the CNA. She thought the situation had already been handled since she had been told CNA #3 would no longer be caring for Resident #147. RN #3 confirmed she had not reported the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy review, medical record review, and interviews, the facility failed to investigate an allegation of abuse timely for 1 resident (#147) of 25 residents reviewed for abuse. The findings include: Review of the facility's policy titled, Abuse And Neglect-Rehab/Skilled, therapy & Rehab, revised 12/23/2023, showed .If an employee received an allegation of abuse .the employee will then report the allegation to a supervisor .The .nurse will be notified immediately, assess the situation .complete an initial investigation . Resident #147 was admitted to the facility on [DATE] with diagnoses including Left Hip Fracture, Chronic Kidney Disease, Dementia, and Cerebral Infarction. Review of the admission Minimum Data Set (MDS) dated [DATE] showed Resident #147 scored 15 on the Brief Interview for Mental Status, indicating the resident was cognitively intact. Review of a Care Plan note dated 4/18/2023, showed .up with extensive assist X 2 [times 2] with a stand aid .alert and oriented .Resident is able to verbalize his needs . Review of an Incident note dated 5/1/2023, showed Resident #147 reported yesterday (4/30/2023) around 10:00 AM, Certified Nursing Assistant (CNA) #3 came into his room and told him to .Get up . Resident #147 informed CNA #3 .I can't . The resident stated CNA #3 stated .Well figure it out .jerked his legs to the side and it hurt . Resident #147 stated CNA #4 came in afterwards and took care of him. Resident #147 stated CNA #3 worked yesterday (4/30/2023) and was working today (5/1/2023). CNA #3 was asked to leave the floor and placed on administrative leave until investigation concluded. During an interview on 5/2/2023 at 1:57 PM, Resident #147 stated he was able to recall the events that occurred on Sunday 4/30/2023. He stated he was lying in the bed on his back and CNA #3 came in and told him he needed to get out of bed. He was unable to give CNA #3's name, but stated she worked yesterday with CNA #4. He informed her that he couldn't get out of bed without assistance. CNA #3 told him he would have to do it on his own. He stated CNA #3 then grabbed his knees and twisted his legs and feet off the bed. Resident #147 stated he did not call out for help and did not tell CNA #3 to stop. He then stated CNA #4 came into the room and he reported what happened to him. Resident #147 stated no one came to speak with him about the events that happened on Sunday (4/30/2023) until he reported the incident to the Social Services Coordinator (SSC) and Nurse Manager (NM) in his room yesterday (5/1/2023). Resident #147 stated it made him angry the way he was talked to and handled roughly. He stated he did not have any injuries or bruising and felt safe. Resident #147 stated CNA #3 had not been back in his room since Sunday (4/30/2023). During an interview on 5/2/2023 at 2:11 PM, CNA #4 stated he overheard the incident that occurred on 4/30/2023 between 10:45 AM-11:30 AM, between CNA #3 and Resident #147. CNA #4 stated he reported the event to Registered Nurse (RN) #3. He stated he reported that CNA #3 was being rough and loud with Resident #147. CNA #4 stated CNA #3 did not provide care to Resident #147 the rest of the shift on Sunday. CNA #4 stated he did not witness any physical abuse, only CNA #3 speaking loudly with Resident #147. During an interview on 5/2/2023 at 2:25 PM, the NM stated she and the SSC were in Resident #147's room conducting a care conference with Resident #147 and his wife on 5/1/2023. Resident #147 then informed her and the SSC about the events that occurred on Sunday (4/30/2023). During an interview on 5/2/2023 at 2:32 PM, the SSC stated she was made aware of the incident that occurred on Sunday 4/30/2023, while she and the NM were having the care plan meeting with Resident #147 and his wife on 5/1/2023. The wife informed the SSC and the NM that Resident #147 had reported CNA #4 was mean to him and hurt his hip while getting him out of bed. The SSC stated she immediately reported the incident to the Director of Nursing (DON) and the Administrator. She then came back to Resident #147's room to start the investigation. The SSC stated the Administrator, the DON, and she were the Abuse Coordinators for the facility; it was a shared responsibility, and we work together as a team. The SSC stated it was her responsibility to interview the resident. When she interviewed Resident #147, he was not tearful. She stated Resident #147 denied being fearful of any staff members or of CNA #3. During an interview on 5/2/2023 at 2:41 PM, the DON stated she became aware of the incident that occurred on 4/30/2023 between 10:45 AM- 11:00 AM on 5/1/2023, when the SSC informed her that Resident #147 had made an allegation of abuse. An investigation was started on 5/1/2023 at 11:00 AM, once she and the Administrator were made aware of the allegation of abuse. The DON stated CNA #3 did not care for Resident #147 the rest of the shift. The DON stated it was her expectation that any reports of abuse be reported immediately to the next person in charge or administration. An initial investigation should be started with formal investigation to begin the following day. She confirmed the investigation of the abuse was not started until administration was made aware of the allegation on 5/1/2023 (one day after the incident occurred). During a telephone interview on 5/2/2023 at 3:17, PM, RN #3 confirmed she had not initiated an investigation after she was informed of the allegation of abuse of Resident #147.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to implement a wound care intervention for 1 resident (Resident #7) of 3 residents reviewed for wounds. The findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses including Dementia, Adult Failure to Thrive, Diabetes Mellitus, and Palliative Care. Review of a 5-day Minimum Data Set (MDS) assessment dated [DATE], showed Resident #7 had severe cognitive impairment and was at risk for pressure ulcers. Further review showed the resident had 0 pressure ulcers on admission. Review of the comprehensive care plan initiated 11/1/2022 showed .potential for pressure ulcer development .nutritional problem r/t [related to] FTT [Failure to Thrive], T2DM [Type 2 Diabetes Mellitus] .hospice care . Intervention added on 11/14/2022 included .provide pillows to float heels while in bed .bilateral heel boots while in bed . Review of an order summary report for Resident #7 dated 11/14/2022, showed .Cleanse left inner foot wound with saline or wound cleanser. Apply medi-honey [gel medication used for management of wounds], cover with foam dressing . Dressing changes were ordered to be performed daily. Review of a Pressure Ulcer Monthly Report dated 11/14/2022, showed Resident #7 had an unstageable left foot wound. Wound measurements were documented as L (length) 2.0 centimeters (cm) x W (width) 3.0 cm x D (depth) 0 cm. Review of the Treatment Administration Record dated 11/2022 -5/2023, showed Resident #7 received wound care as ordered. Review of the quarterly MDS assessment dated [DATE], showed Resident #7 had severe cognitive impairment and had 1 unstageable pressure ulcer. Review of a Pressure Ulcer Monthly Report dated 5/1/2023, showed Resident #7 had an unstageable left foot wound. Wound measurements were documented as L 2.0 cm x W 2.0 cm x D 0 cm. During multiple observations on 5/1/2023-5/2/2023 of Resident #7's room, there were no pillows to float heels and bilateral heel boots were not in place. During an interview on 5/2/2023 at 4:14 PM, the Wound Care Nurse confirmed the heel pillows and bilateral heel boots were not in place in the resident's room. During an interview on 5/3/2023 at 9:46 AM, the Director of Nursing (DON) stated it was her expectation interventions were to be implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to implement interventions to prevent accidents for 1 resident (Resident #20) of 3 residents reviewed for accidents. The findings include: Resident #20 was admitted to the facility on [DATE] with diagnoses including Dementia, History of Falling, and General Anxiety Disorder. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] showed Resident #20 had moderate cognitive impairment and required extensive assistance of 2 staff with bed mobility, transfers, dressing, and toilet use. Resident #20 had a history of 1 fall since the last assessment. Review of Resident #20's care plan dated 2/17/2023 showed the resident was at risk for falls with interventions of a pad alarm to bed and tab alarm to chair to be used to alert staff and prevent accidents. During observation on 5/1/2023 at 12:16 PM, Resident #20 was observed in a common room for lunch, seated in a wheelchair with no alarms. During an observation and interview on 5/2/2023 at 8:00 AM, in Resident #20's room, Certified Nursing Assistant (CNA) #1 confirmed there was not a pad alarm on the bed. During an observation and interview on 5/2/2023 at 1:25 PM, in the dining room, Licensed Practical Nurse (LPN) #1 confirmed there was no tab alarm on Resident #20's wheelchair. During an observation and interview on 5/2/2023 at 1:30 PM, CNA #1 stated there was not a pad alarm in the resident's bed. CNA #1 stated she made the bed every day she cared for the resident and she hadn't seen an alarm pad in a while. During an interview on 5/2/2023 at 2:28 PM, the DON confirmed that staff had not implemented the interventions to prevent accidents for Resident #20.

Based on facility policy review, observation, and interview, the facility failed to ensure medications were secured in 1 of 4 medication carts and in 1 of 4 treatment carts observed. The findings include: Review of the facility's policy titled, .Medications: Acquisition Receiving Dispensing and Storage, dated 3/2/2023, showed, .Medications will be stored in a locked medication cart, drawer, or cupboard . During an observation on 5/2/2023 at 7:48 AM, Registered Nurse (RN) #1 had left the medication cart unattended, with stock medications stored on top of the medication cart, while going to administer medications. During an observation and interview on 5/2/2023 at 8:10 AM, RN #1 had left the medication cart unattended, with medications stored on top of the medication cart, while going to administer medications. RN #1 stated she stored stock medications on top of the cart to prevent wear and tear on the medication cart drawers and to save time. RN #1 stated she felt like the stock medications on top of the cart was secure because she was at the medication cart most of the time. RN #1 stated she had not realized stock medications could not be stored on top of the medication cart. During an interview on 5/2/2023 at 8:12 AM, the Director of Nursing (DON) observed with surveyor medications were stored on top of the medication cart. The DON confirmed RN #1 had not followed the facility's policy on medication storage. The DON confirmed medications stored on top of the medication cart were not secured. During an observation and interview on 5/2/2023 at 9:50 AM, a treatment cart located in the common area on the Nandina Pod Hall was not locked or secured. During an interview on 5/2/2023 at 10:01 AM, the Wound Care Nurse stated she had completed treatments at 9:00 AM, however she had not used the treatment cart located on the Nandina Pod hall. The Wound Care Nurse stated the treatment cart located in the common area on the Nandina Pod hall had prescription medication creams and wound care supplies inside. The Wound Care Nurse confirmed the treatment cart was unlocked and the contents were not secured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #20 was admitted to the facility on [DATE] with diagnoses including Dementia, History of Falling, and General Anxiety Disorder. Review of a Physician Orders for Scope of Treatment (POST) form dated 7/29/2020 showed Resident #20 wished to be a Do Not Resuscitate (DNR). Review of physician's orders dated 7/24/2020 showed Resident #20 had an order for DNR. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] showed Resident #20 had moderate cognitive impairment. Review of a comprehensive care plan dated 4/29/2023 showed end of life wishes for Resident #20 had not been addressed. Resident #9 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease and Dysphagia. Review of a POST form dated 8/4/2022 showed Resident #9 wished to be a DNR. Review of physician's orders dated 8/4/2022 showed DNR, allow natural death. Review of the comprehensive care plan dated 5/1/2023 showed end of life wishes for Resident #9 had not been addressed. During an interview on 5/2/2023 at 4:06 PM, the MDS Coordinator confirmed there was no end of life plan of care on Resident #20 or #9's care plan. During an interview on 5/3/2023 at 8:45 AM, the Social Services Coordinator stated end of life care was an integral part of the resident's care and it should be included in the care plan. Resident #13 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Dementia, Atherosclerotic Heart Disease, Repeated Falls, Hemiplegia and Hemiparesis, Cognitive Communication Deficit, Unspecified Convulsions, and Muscle Weakness. Review of the POST form for Resident #13 dated 8/13/2021 showed a DNR. Review of a comprehensive care plan dated 4/27/2023 showed end of life wishes were not addressed for Resident #13. Resident #16 was admitted to the facility on [DATE] with diagnoses including Heart Failure, Alzheimer's Disease, Dementia, Major Depressive Disorder, and Anxiety. Review of the Durable Power of Attorney (POA) for Health Care dated 8/21/2012, showed the daughter was granted POA to make health care decisions for Resident #16 and end of life was addressed. Review of the POST form dated 1/7/2022, showed Resident #16 wished to be a DNR, with limited additional interventions, and defined trial period of artificial nutrition by tube. Review of Resident #16's comprehensive care plan, last updated 4/27/2023, showed the resident's end of life wishes were not addressed on the care plan. Resident #27 was admitted to the facility on [DATE], with diagnoses including Dementia, Alzheimer's Disease, Delusional Disorders, and Chronic Kidney Disease. Review of the POST form dated 12/16/2022, showed Resident #27 wishes were to be a full code. Review of the comprehensive care plan revised 4/7/2023 showed end of life wishes had not been addressed for Resident #27. Resident #34 was admitted to the facility on [DATE], with diagnoses including Dementia, Heart Failure, Retention of Urine, Neuromuscular Dysfunction of Bladder, Urogenital Implants and Atrial Fibrillation. Review of the POST form dated 4/8/2022, showed Resident #34 wished to be a DNR. Review of the annual MDS assessment dated [DATE], showed Resident #34 did not have a hearing aid. Review of the comprehensive care plan revised 4/25/2023 showed Resident #34's hearing impairment, interventions to accommodate for the hearing loss, and end of life wishes had not been addressed. During an interview on 5/3/2023 at 9:16 AM, the Social Services Coordinator revealed .I know that she [Resident #34] has a hearing deficit . During an interview and record review on 5/3/2023 at 3:44 PM, the Licensed Practical Nurse (LPN) Admissions Nurse confirmed Resident #34's care plan had not addressed the hearing deficit, and it would be her expectation for the hearing loss to be addressed in the care plan. During an interview on 5/3/2023 at 8:05 AM, the DON confirmed the residents' care plans did not address end of life wishes or code status. Based on facility policy review, record review, and interview, the facility failed to develop and implement a comprehensive person-centered care plan to address end of life care for 6 residents (Residents #20, #9, #13, #16, #27, and #34) and hearing loss for 1 resident (Resident #34) of 17 residents reviewed. The findings include: Review of the facility's policy titled, Care Plan-R/S, LTC, Therapy & Rehab, dated 9/22/2022, showed .Each resident will receive and be provided the necessary care and services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment. Each resident will have an individualized, person-centered, comprehensive plan of care .will be modified to reflect the care currently required/provided for the resident .will emphasize the care .of the whole person .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a facility policy, medical record review, facility investigation review, observation and interview, the facility failed to prevent abuse of 2 residents (#5, #6) of 7 residents reviewed for abuse. The findings included: Review of a facility policy Abuse and Neglect Rehab/Skilled, Therapy & Rehab last reviewed 3/31/2022 showed .the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .residents must not be subject to abuse by anyone, including, but not limited to, location employees, other residents, consultants or volunteers, employees of other agencies serving the resident, family members or legal guardians, friends or other individuals . Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Chronic Kidney Disease, Delusional Disorders, Alzheimer's Disease, and Protein-Calorie Malnutrition. Review of Resident #5's comprehensive care plan dated 12/16/2022 showed .resident has behavioral symptom R/T [related to] dementia E/B [evidenced by] refusing showers, brushing teeth, not wanting to be alone .intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, remove from situation and take to alternate location, prefers .diversional activities watching game shows, [NAME] Show, folding towels, sorting books magazines .introduce to other residents make sure she can be within eye vision distance of nursing staff . Review of Resident #5's 5-day Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. The resident required supervision with 1-person assist for toilet use, personal hygiene, supervision with set up for bed mobility, transfer, walking, locomotion, dressing, eating, and was always continent of both bowel and bladder. No behaviors were noted during the assessment period. Review of a facility investigation dated 1/18/2023 at 5:15 PM, showed Resident #6 was seated at his normal position at the dinner table when Resident #5 got up from her spot at the dinner table and went and sat in front of the television in the dining room and began to change the channel. Resident #6 wheeled his wheelchair over beside Resident #5 and they began to argue over the television channels. Nursing staff reported they heard yelling back and forth. A CNA responded to where both residents were sitting and asked Resident #5 for her remote and about the time the CNA obtained the remote, Resident #6 took the remote he had in his right hand and hit Resident #5 in the right upper arm. The residents were separated and Resident #5 was taken to her room by the staff and Resident #6 took himself back to his room. Medical record review of Resident #5's comprehensive care plan revised on 1/18/2023 showed .SS [Social Services] to provide visits 3 X [times] a week X one month due to recent altercation . Medical record review of Resident #5's comprehensive care plan revised on 1/23/2023 showed .resident has delusional disorder or an acute confusional episode R/T Dementia EB anxiety, confusion, paranoia, forgetfulness, and increased aggression .resident enjoys chores (washing dishes, folding laundry according to family). A basket of clean laundry is in the TV room and there are plastic dishes for her to wash, attempt this as redirection activity if she becomes agitated .Monitor mood and behavior . Medical record review of Resident #5's Progress Note dated 1/28/2023 at 5:09 PM, showed .resident heard raising her voice in common area at another resident by this nurse exclaiming loudly, 'I was watching that, turn it back!' resident was found to be in front of [Resident #6] who had changed the TV channel with his personal remote. [Resident #5] was asked to step away from [Resident #6] and talk about the situation. [Resident #5] kept exclaiming, 'No turn it back he just came up and changed it, that's ignorant.' [Resident #6] did not respond to this instance and backed away and closed his eyes. Channel was changed back to previous channel that [Resident #5] was watching and situation defused. [Resident #6] took himself back to his room to eat dinner meal. [Resident #5] was asked to ask for assistance next time a situation similar arose and stated, 'no he shouldn't do that and he's ignorant.' Residents now separated but calm . Medical record review of Resident #5's Progress Note dated 2/6/2023 showed .resident found extremely agitated at other residents at meals today. Found yelling to one male resident and one female resident at dinner. Redirection attempt failed . Medical record review of Resident #5's Social Service Progress Note dated 2/8/2023 showed .resident experiencing increased aggression in the evening hours. Through the day, resident appears calm and cooperative, but in the evening, she becomes aggressive toward other residents. She's had three events of yelling at other residents and nursing intervened to keep everyone safe . Medical record review of Resident #5's Progress Note dated 2/8/2023 at 3:24 PM showed .resident stated she was bored to activities staff. Staff gave resident options of different activities available; cards, painting, crafts, puzzles, folding laundry. Resident declined all . Medical record review of Resident #5's Progress Note dated 2/8/2023 at 3:47 PM showed .Resident asked nurse 'what time are you going home? I need a ride home.' Nurse explained that resident lives here, resident begins yelling 'I don't live here. I don't want to have to walk all the way home.' Nursing attempted to reorient resident. Resident continues roaming around unit asking staff for a 'ride home' . Medical record review of Resident #5's Progress Note dated 2/8/2023 at 6:00 PM .following conversation with MD about recommendations for medication changes, daughter .verbally consents for nursing to administer one time dose of Ativan and scheduled HS [hour of sleep] Zoloft per MD . Medical record review of Resident #5's Progress Note dated 2/8/2023 at 6:40 PM .Resident tells staff that she will call 911 if no one will take her home. Resident found in 2 other resident rooms asking resident and family members if they will give her a ride to her apartment .Resident followed MD and nurse manager into another patient rooms and demanded someone take her away from this place. Redirection and diversion attempts, unsuccessful throughout the evening .wander guard in place . Review of a facility investigation dated 2/13/2023 showed the Social Service Director (SSD) entered the dining room and observed Resident #5 and Resident #6 arguing and fist swinging. [Resident #6] had a remote control in his right hand and [Resident #5] had a remote control laying on the table. The SSD stopped the interaction and directed the residents to separate areas. The SSD interviewed Resident #5 and the resident stated she was watching TV and Resident #6 came up and changed the channel. Then she had changed it back and the argument followed. Resident #5 stated, 'he can't be hitting me' .The dining room TV was unplugged but each resident had access to TV in his/her room. The Director of Nursing Services (DNS) and Administrator reviewed the video surveillance tape and observed both residents making contact with each other. Medical record review of Resident #5's comprehensive care plan revised on 2/13/2023 showed .remove triggers that cause behaviors such as TV in dining room. Resident may watch TV in her personal room . Medical record review of Resident #5's Incident Progress Note dated 2/13/2023 at 12:20 PM, showed .Late Entry .Per camera and social service director description. Resident [Resident #5] watching TV in common area when male resident [Resident #6] attempted to change the channel. Resident then changed the TV channel back. Both residents with increased agitation. Male resident [Resident #6] attempted to remove the remote from this resident's [Resident #5] hand and this resident [Resident #5] hit male resident [Resident #6] in his left upper arm. Male resident [Resident #6] then hit resident [Resident #5] in her right upper arm . Observation of Resident #5 on 3/29/2023 at 1:30 PM, in the common area of her hallway, showed the resident seated in a chair. She was awake and alert, dressed in street clothes and covered with a blanket. A staff member asked her if she would like to go outside for a while and she responded, no I am cold. No anxious, or aggressive behaviors were observed. Resident #6 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis, Aphasia, Apraxia, Epilepsy, Dysphagia, and Adjustment Disorder with Anxiety. Medical record review of Resident #6's comprehensive care plan dated 8/6/2018 showed .Resident has a communication problem R/T slight hearing loss and CVA [cerebrovascular accident] E/B expressive aphasia .monitor/document physical/non-verbal indicators of discomfort or distress .resident prefers to communicate face to face so he can hear everything you say .Ensure available and functioning of adaptive communication equipment . Review of Resident #6's quarterly MDS dated [DATE] showed a staff assessment was completed for mental status showing mild cognitive impairment. The resident required extensive assistance with 1-person assist for bed mobility, transfer, toilet use, dressing, personal hygiene, supervision with set-up for locomotion on and off unit and eating. Resident #6 was frequently incontinent of bladder, and occasionally incontinent of bowel. Review of Resident #6's Progress Note dated 1/18/2023 at 7:46 AM showed .Late Entry .nursing heard two residents yelling at each other in the dining room. CNA observed the 2 residents fighting over the current TV channel. Each resident had a remote and was attempting to change the channel. CNA removed the remote from the female resident's [Resident #5] hand and at that time this resident [Resident #6] took his remote in his hands and hit female resident [Resident #5] in the right arm with the remote. Male resident [#6] denied hitting the female. Female resident [#5] said 'I'm okay, he hit my arm, and now it is all over with.' Immediately both residents were moved away from each other. [Resident #6] went back to his room as well as [Resident #5]. Both residents assessed for injury. No injury noted . Medical record review of Resident #6's comprehensive care plan revised on 1/18/2023 showed .the resident has a mood and behavior symptom R/T adjustment disorder with anxiety E/B anxiety/agitation/increased depression, resident to resident altercation .Social Services to visit with resident 3X a week X 1 month, educate resident/family on successful coping and interaction strategies, if reasonable discuss resident's behavior. Explain/reinforce to resident why behavior is inappropriate and/or unacceptable, consult with MD for medication review and check BMP [basic metabloic panel] and Urinalysis, Agitation: Positive interaction, remove from source . Medical record review of Resident #6's comprehensive care plan revised on 1/23/2023 showed .resident has mild impaired cognitive function or impaired thought processes R/T mild cognitive impairment E/B aphasia, increased agitation, anxiety, confusion .Monitor/document/report to health care provider any changes in cognitive function .reduce any distractions-turn off TV, radio, close door etc .attempt non-pharmacological interventions of reorientation, reassurance, redirection, assist with ADL's [activities of daily living], pain control, sleep hygiene, reduce risk, if puppy is a at [facility] provide puppy visit . Medical record review of Resident #6's comprehensive care plan revised on 1/26/2023 showed .minimize potential of resident behavior problems by modifying environmental factors and daily routine . Medical record review of Resident #6's Incident Progress Note dated 2/13/2023 showed .Late Entry .Per camera and social service director description. Resident watching TV at his normal table in dining room. Female resident [Resident #5] already using the common room TV, resident attempted to change the channel to a program he preferred. [Resident #5] changed TV back to her channel. Agitation increased. [Resident #6] attempted to remove remote from female resident. She hit him in the left upper arm, and he returned the hit to her right upper arm. Residents separated from each other. [Resident #6] returned to his room . Medical record review of Resident #6's comprehensive care plan revised on 2/13/2023 showed .remove triggers that cause behaviors such as TV in the dining room. Resident may watch TV in his personal room . Observation of Resident #6 on 3/27/2023 at 1:45 PM, in his room, showed the resident seated in a wheelchair, he was awake, alert and well-groomed. The resident was pleasant, no agitation, aggression, or negative behaviors were observed. During an interview with Licensed Practical Nurse (LPN) #2 on 3/28/2023 a 8:05 AM, she stated .I was here for the 2nd incident .[Resident #6] would bring his remote out of his room with him and it worked with the TV in the dining room. I came out of a room and heard yelling in the dining room, and SSD had just gotten in the dining room she was separating the residents, she [Resident #5] was yelling 'he hit me he hit me' . During an interview with the Social Service Director on 3/28/2023 at 1:40 PM, she stated .this was the second event with these two residents .I was coming into the dining room, the residents were both sitting in front of the TV, I heard some commotion like someone was slapping their hand on the table, I could tell they were angry. When I walked in [Resident #5] had a remote on the table and [Resident #6's] remote was in his right hand. She [Resident #5] hit him at least once that I saw. He [Resident #6] struck back at her but I couldn't tell if he made contact or not .I just saw the motion of his hand I couldn't tell if it was open handed or a fist .she did not respond with any emotion indicating she had been hit .I got between them and said 'whoa, whoa we can't do this, we need to stop' .the nurse came up and we separated them. Both of the residents had brought their remote into the dining room, from their rooms . During an interview with the Social Service Director on 3/28/2023 at 2:25 PM, she stated regarding the 1/28/2023 incident .the nurses notified me after the fact they had already separated the 2 residents. I returned to the facility to do the investigation. I interviewed both residents [Resident #6] denied hitting [Resident #5] with the remote. [Resident #5] minimized the effect of the hit, but she had been hit on her right arm by [Resident #6] with the remote. I asked her if she was afraid of [Resident #6] and she said 'no but he can't just be hitting me' .I did speak to the nurses, they reported the residents had started arguing over the TV the nurses went over [Resident #5] had the remote in her hand, the nurse took the remote and laid it on the table [Resident #6] picked up the remote off the table and struck [Resident #5] on the right arm with the remote .He was agitated and kept denying he had hit her but within a short time he was back to his baseline. I assured both of them our goal was to maintain a peaceful area and keep everyone safe .the next day she had difficulty recalling what happening, she never acknowledged that she was antagonizing him .he can't speak I think he just got flustered and struck out .The immediate intervention was for the nurse to keep the TV remote in the med cart, and operation of the TV was to be the nursing staff responsibility . During an interview with the DNS on 3/29/2023 at 11:40 AM, she stated .the residents did have an altercation on 1/18/2023, and a verbal disagreement on 1/28/2023 again over the TV program and changing of the channel. The nurse did intervene with no altercation occurring .we attempted to put a second television in the common area, but the cable box was not wired .No further incidents or encounters occurred after 1/28/2023 and on the 28th [Resident #6] didn't respond to her he just left the dining room. But on 2/13/2023 Social Services came up to me and reported she had witnessed [Resident #5] and [Resident #6] arguing and arms and fists swinging. She reported that [Resident #6] had the remote in his right hand [Resident #5] had her remote laying on the table. She stopped the interaction and directed them to separate areas. She did ask [Resident #5] what happened, and she said she was watching TV and [Resident #6] came up and changed the channel. She then changed the channel back and the argument started. [Resident #5] said 'he can't be hitting me'. The SSD could not tell if both parties had made contact or not but when we reviewed the video footage we were able to determine both residents had made physical contact with the other .[Resident #5] did make the first physical contact striking his [Resident #6's] left upper arm with the TV remote, then with him following with making physical contact with her [Resident #5's] right upper arm with his remote .neither resident was viewed as showing any indication of pain after being struck .The TV was unplugged immediately and removed from the sitting area later the same day . During the interview the DNS confirmed the facility failed to prevent abuse of Resident #5 and Resident #6. During an interview with the Administrator on 4/6/2023 at 11:45 AM he stated .after the second incident we did remove the television to prevent further incidents, we were doing interventions with the female resident to prevent further incidents after the first incident, however the interventions were unsuccessful, and a second physical altercation did occur .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a facility policy, medical record review, observation and interview, the facility failed to report an allegation of neglect to supervisory staff timely so that the allegation of abuse was reported within the required 2-hour time frame to the State Survey Agency for 1 Resident (#3) of 7 residents reviewed for abuse. The findings included: Review of a facility policy Abuse and Neglect Rehab/Skilled, Therapy & Rehab last reviewed 3/31/2022 showed .the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .residents must not be subject to abuse by anyone .alleged or suspected violations involving any mistreatment, neglect, or exploitation or abuse .will be reported immediately to the Administrator .Designated agencies will be notified in accordance with state law .if there is an allegation of abuse .it will be reported immediately, but not later than two hours after the allegation is made . Resident #3 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Dysphagia, Congestive Heart Failure, and Hypotension. Medical record review of Resident #3's Incident Report dated 10/3/2022 showed .resident reported to nursing staff a CNA [Certified Nursing Assistant] [#2] had answered her call light this morning and had refused to assist resident to the bathroom. CNA told resident it was too early, and she would need to wait. Resident Description: I have to go to the bathroom and CNA comes in and says its only 4 O'clock it's not time to get up, you will have to wait till 5 or 6 O'clock. This is the second time she said no you can't get up its not time . Medical record review of Resident #3's quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The resident required extensive assistance of 1-person assist with bed mobility, transfer, dressing, toilet use, limited assistance of 1-person assist with personal hygiene, supervision with setup for eating, occasionally incontinent of bladder, always continent of bowel. During an interview with CNA #2 on 3/27/2023 at 11:00 AM, she stated . If I remember correctly I was in the middle of my round, changing and toileting my residents, she asked to get up and I told her she would have to wait until I finished my round and I would be back to get her up. She does take a long time, so I needed to wait until my round was finished. I never heard her ask to go to the bathroom, or I would have had to get her up and taken her to bathroom, and put her in her chair, and then gone back and gotten her ready for the day .but she did not tell me she had to go to the bathroom . Observation of Resident #3 on 3/27/2023 at 1:30 PM, in her room, showed the resident seated in a recliner, she was awake, alert, well-groomed, dressed in street clothes appropriate for the inside temperature. No concerns or behaviors of fearfulness, withdrawn, or tearfulness were observed. During an interview with Resident #3 on 3/27/2023 at 1:30 PM, she stated .I called in the night she said it was 1:00 in the morning you can't go to the bathroom. Told her my bladder didn't know what time it was .I've not had any problems since .she hasn't been here in a long time .I held it I have never had an accident .my briefs are always dry .I don't think she misunderstood. I tried to make it clear .I did have to wait, and I did .everything has been okay after that . When questioned about how many times staff had refused to assist her with her needs, she stated just that one time. During an interview with the Director of Nursing Services (DNS) on 3/27/2023 at 4:45 PM, she stated .the fact that someone asked to be toiled and the CNA supposedly told the resident they would have to wait is borderline abuse/neglect that is why I had reported it when I received the allegation. I started the investigation when I received knowledge of the incident. However, the night nurse did not report it to me or the Administrator, she told the day nurse in report, who then later reported it to the unit manager [Registered Nurse (RN) #1]. During an interview with Licensed Practical Nurse (LPN) #5 on 3/28/2023 at 6:00 AM, she stated .I was the nurse the night [Resident #3] made the allegation .that morning [Resident #3] rang her light, it was during final rounds, so sometime between 4:00 AM, and 4:30 AM, she was sitting on the side of her bed she said 'thank goodness you came I have to go to the bathroom,' she told me she had been told she had to wait or it was too early something along those lines I can't remember verbatim. So, I took the resident myself. I told her you never have to wait if anything like this happens you need to tell us because that is not okay .[CNA #2] had been giving a shower, I asked her why she had not toileted the resident and she said because she had to do the shower. She did not deny telling the resident she would have to wait at least not to me .That morning at shift change I told dayshift what happened and day shift reported it to management .I didn't report it immediately, but I did mention it around 6:00 AM, while we were rounding .I suppose I could have called the DNS when it happened or the Administrator .I didn't think it was appropriate but I don't think she meant it to be neglect .I did tell her 'hey you can't tell them to wait like that' . During an interview with LPN #2 on 3/28/2023 at 7:30 AM, she stated .I got in report that [Resident #3] had called and [LPN #5] answered the light. She stated [CNA #2] told her she would have to wait a minute turned off the call light and left the room. So, she didn't get to go to the bathroom a few minutes later she put her call light on again and [LPN #5] the nurse answered the light that is when the resident reported it to her .at some point during the morning, I told [Registered Nurse RN #1/Unit Manager]. I don't know at what point that was, but it was in the morning sometime. I mentioned it again to her in the evening because I wanted to make sure it was reported .I had a conversation with the resident and her friend about the incident. The resident reported to me [CNA #2] wouldn't let her go to the bathroom .she was upset, and she was emotional, but any time anything happens she gets emotional, it was not out of her baseline of her emotional status .The resident is very vocal .I did tell [RN #1/Unit Manager] that morning but I don't know what time it was .I know now I have should have reported it immediately .I do feel like this was a neglectful situation .I do think it should have been reported immediately by [LPN #5] when the resident reported it to her . During an interview with RN #1/Unit Manager on 3/28/2023 at 2:55 PM, she stated .I do not recall [LPN #2] notifying me of the incident until the afternoon. I do not recall her telling me that morning. As soon as I was notified, I said 'hold on I have to go tell the DNS [Director of Nursing Services] .she told me and [LPN #6] .to go interview the resident. She reported to us she was told it wasn't time to get up she would have to wait, and you could tell she was upset about it .not tearful just aggravated .After we interviewed her, I reported to the DNS what she had said. At that point she had called the CNA [#2] to tell her she couldn't come in until the investigation was complete .the resident did report this was the second time [CNA #2] had told her it was too early to get up, but I could not get any information from the resident about the 2nd time .during our interview she did calm down and was not upset . During an interview with the DNS on 4/3/2023 at 12:15 PM, she stated .the incident was not reported timely. I was not made aware of the allegation until the afternoon on 10/3/2022 and I began my investigation and submitted the report to the state .When I spoke to the CNA [#2], she reported resident called and requested to get up, and the CNA responded 'I am doing my rounds and I will come get you up when I get done with my rounds.' She reported resident took a long time to get up and she never asked to go to the bathroom .It appeared she had not slowed down enough to hear the resident ask to go to the bathroom. It did not appear intentional .but it was an allegation of neglect and should have been reported immediately, and should have been reported to the state within 2 hours . Observation on 4/3/2023 at 11:25 AM, showed Resident #3 to be sitting in a wheelchair at a dining room table. She was well groomed, dressed appropriately for the inside temperature and location. No odors or signs of incontinence were observed. The resident was smiling, and pleasantly conversing with other residents. During an interview with the Administrator on 4/6/2023 at 9:05 AM, he stated .the DNS notified me of the allegation, and she did keep me informed. At the end of the investigation, we were unable to substantiate neglect had occurred. Based on the investigation findings it was an allegation of neglect and should have been reported when the incident occurred .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to adequately monitor and report an irregularity to the physician for 1 resident (#27) of 6 residents reviewed for unnecessary medications. The findings include: Medical record review revealed Resident #27 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Dementia without Behavioral Disturbance, Restless Leg Syndrome, Type 2 Diabetes Mellitus, and Anxiety Disorder. Medical record review of the Order Summary Report, dated 11/13/19, revealed .mirtazapine [an antidepressant medication used to stimulate the appetite] tablet 7.5 mg [milligrams] .order date .4/24/19 . Medical record review of the Quarterly Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #27 was cognitively intact. Further review revealed the resident received an antidepressant daily. Medical record review of a Nutritional Status note, dated 8/30/19, revealed .[current weight] 126.5# [pounds] .116% [percent] IBW [ideal body weight] .has experienced a significant wt [weight] gain of +6.61% x [in] ~30 days .Resident receives mirtazapine which may increase appetite . Medical record review of the Monthly Consultant Pharmacist Report dated 8/1/19 - 8/31/19 revealed Resident #27's medication regimen was reviewed with no recommendations. Medical record review of a Nutritional Status note, dated 9/20/19, revealed .[current weight] 129 [pounds] .118% IBW .has experienced a significant wt [weight] gain of +5.4% x [in] ~30 days .Resident receives mirtazapine which may increase appetite . Medical record review of the Monthly Consultant Pharmacist Report dated 9/1/19 - 9/30/19 revealed Resident #27's medication regimen was reviewed with no recommendations. Medical record review of a Nutritional Status note, dated 10/29/19, revealed .[current weight] 133.5 [pounds] .122% IBW .has experienced a significant wt [weight] gain of +11.25% x [in] ~90 days .Resident receives mirtazapine which may increase appetite . Medical record review of the Monthly Consultant Pharmacist Report dated 10/1/19 - 10/31/19 revealed Resident #27's medication regimen was reviewed with no recommendations. Medical record review of a Consultant Pharmacist Progress note, dated 10/21/19, revealed .medication regimen review completed . Further review revealed no recommendations. Phone interview with the Consultant Pharmacist on 11/14/19 at 12:52 PM, revealed QAPI [Quality Assurance and Performance Improvement meeting held by facility department heads monthly] had recently had a discussion about the continued use of mirtazapine in light of significant weight gain. Further interview confirmed he was unaware of Resident #27's weight fluctuations and significant weight gains. Continued interview confirmed there was no evidence the mirtazapine was re-evaluated for continued need and effectiveness, as would have been appropriate. Further interview confirmed I did not make a recommendation [to the physician] on the mirtazapine .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 resident (#17) of 28 residents sampled. The findings include: Medical record review revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Dementia, and History of Falls. Medical record review of the Weights and Vitals Summary revealed a weight on 7/27/18 of 118 pounds and a weight on 8/20/18 of 111.5 pounds ( a 5.51 percent weight loss). Medical record review of the Care Plan dated 7/31/18 and revised 8/13/18 revealed .The resident has altered nutrition related needs .Resident has experienced a wt [weight] loss of -8.5% [percent] x [times] 17 days . Medical record review of a nutritional status progress note dated 8/13/18 revealed the resident had a significant weight loss of 8.5% x 17 days. Medical record review of the 30 day MDS dated [DATE] revealed the resident had a weight of 112 pounds and no significant weight loss (loss of 5% or more in the last month) had been documented. Interview with the MDS Coordinator on 10/2/18 at 3:46 PM, in the conference room, confirmed the resident had a weight loss of greater than 5% within 30 days. Continued interview confirmed the 30 day MDS dated [DATE] did not indicate the resident's significant weight loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to administer medication as ordered for 1 resident (#19) of 28 residents reviewed. The findings include: Review of the facility policy Medication Errors revised 5/1/16 revealed .Medication errors consist of the following .Omission of medication ordered .Transcription Error .Inaccurate transcription of an order . Medical record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including Dementia, Alzheimer's Disease, Pseudobulbar Affect (involuntary laughing and crying), Psychotic Disorder with Hallucinations, Depressive Episodes, and Anxiety Disorder. Medical record review of a Psychiatric Evaluation dated 8/28/18 for Resident #19 revealed, .Nuedexta (medication used for central nervous system outburst of involuntary laughing and crying in people with neurological disorders) 20/10mg [milligram] 1PO [by mouth] qhs [every night] x [times] 7 days then increase to one BID [twice daily] . Medical record review of the Physician Recapitulation Orders dated 8/31/18 revealed .Nuedexta Capsule 20-10MG give 1 capsule by mouth one time a day related to Pseudobulbar Affect for 7 days .start date 8/31/18 . Medical record review of the electronic Medication Record and interview with Registered Nurse (RN) Unit Manager on 10/3/18 at 11:35 AM, in the Nandina Common Area/Activity Room, confirmed Resident #19 had received Nuedexta Capsule 20-10MG 1 capsule by mouth one time a day from 8/31/18 through 9/6/18. Medical record review of the Physician Recapitulation Orders dated 8/31/18 revealed .Nuedexta Capsule 20-10MG give 1 capsule by mouth two times a day related to Pseudobulbar Affect .start date 9/7/18 . Medical record review of the electronic Medication Record dated 9/7/18 revealed an X was electronically placed in the box for the AM [morning] space, indicating Resident #19 had not received the AM dose of Nuedexta as ordered by the physician. Interview with RN Unit Manager on 10/3/18 at 11:35 AM, in the Nandina Common Area/Activity Room, confirmed . Nuedexta was started on 8/31/18 for 7 days and then increased .September the 7th to BID [twice daily] but it was only given in the PM on the 7th . RN Unit Manager revealed she had transcribed the order for the Nuedexta. Further interview confirmed, .I didn't set the start date for the 7th AM dose for some reason .No the nurse didn't give this on the 7th in the AM because he would not have known to give the medication .because I would have to put it in the system [electronic Medication Record] correctly . The facility failed to administer the morning dose of Nuedexta on 9/7/18 due to the incorrect transcription into the electronic Medication Record.

Based on review of the two previous annual survey results, review of facility policy, and interview the facility failed to maintain compliance related to food safety requirements for 3 consecutive years. The findings include: Review of the 8/2016 annual survey results revealed the facility failed to properly store opened food items to maintain food quality and prevent cross contamination, failed to properly discard leftovers, failed to discard food items by the use by date, failed to ensure kitchen equipment/non-food contact surfaces were clean, and failed to properly air dry and store pans. Review of the 8/2017 annual survey results revealed the facility failed to ensure head and facial hair were covered in the kitchen preparation area, thermometers were present in all coolers and freezers, failed to ensure opened refrigerated and frozen foods were closed securely, failed to ensure plates were stored in a sanitary manner, failed to ensure staff and resident food items were stored separately, and failed to maintain clean kitchen equipment. Review of the facility's policy Food Temperature Monitoring, revised 9/2017, revealed .Time/temperature Control for Safety (TCS) food - A food that requires time/temperature control to limit pathogenic microorganism growth or toxin formation. Proper holding temperature - Temperature required for food safety .hot food > [greater than] 135 degrees Fahrenheit .TCS hot foods should be served at 135 degrees Fahrenheit or higher . During the current survey, conducted from 10/1/18 through 10/3/18, observations of the tray line revealed the facility failed to maintain appropriate food temperatures on 2 of 3 units affecting 38 of 45 residents who resided in the facility. Interview with the Director of Nursing and the Quality Coordinator on 10/3/18 at 2:00 PM, in the Quality Coordinator's Office confirmed the facility's performance improvement plan had not been effective to maintain compliance with food safety regulations. Refer to F812

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to ensure expired supplies were not available for use in 2 of 3 medication rooms. The findings include: Review of the facility policy Nursing Care Equipment AND Supplies revised 12/2015 revealed .Supplies that are soiled, outdated or suspected to be unsafe will not be used. Dispose of these supplies properly or according to code requirements . Observation of the Lily Unit medication room with Registered Nurse (RN) #1 on [DATE] at 11:11 AM, revealed 1 container of bleach wipes in the cabinet available for use with an expiration date of 8/2018. Observation of the Nanadina unit medication room with RN #2 on [DATE] at 11:41 AM, revealed 1 container of bleach wipes in the cabinet available for use with an expiration date of 2/2018. Interview with the Director of Nursing on [DATE] at 12:37 PM, in the admissions office, confirmed the 2 containers of bleach wipes were expired and had not been disposed of per facility policy.

Based on facility policy review, observation, and interview, the facility failed to maintain appropriate food temperatures, on the tray line, on 2 of 3 units affecting 38 of 45 residents who resided in the facility. The findings include: Review of the facility's policy Food Temperature Monitoring, revised 9/2017, revealed .Time/temperature Control for Safety (TCS) food - A food that requires time/temperature control to limit pathogenic microorganism growth or toxin formation. Proper holding temperature - Temperature required for food safety .hot food > [greater than] 135 degrees Fahrenheit .TCS hot foods should be served at 135 degrees Fahrenheit or higher . Observation on 10/1/18 at 12:30 PM of the meal tray line on the Tulip unit, revealed the temperatures of the beef burgers were 125 degrees Fahrenheit (F) and the seasoned zucchini was 130 degrees F. Observation on 10/1/18 at 12:40 PM, of the meal tray line on the Nandina unit revealed the following food temperatures: veal 124 degrees F; puree veal parmesan 128 degrees F; mechanical veal 132 degrees F; beef patty 118 degrees F; puree zucchini 134 degrees F; squash 128 degrees F; and mashed potatoes 122 degrees F. Interview with the Certified Dietary Manager on 10/1/18 at 12:40 PM, on the Nandina Unit, confirmed the food items were not maintained at the proper holding temperature.