Based on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when 1 of 3 (Cook A) staff members in the kitchen handled residents' food with no gloves on. The facility had a census of 47 with 47 of those residents receiving a tray from the kitchen. The findings include: Review of the undated facility policy titled, Handwashing Procedure for Dining Services, revealed .Hand hygiene continues to be the primary means of preventing the transmission of infection.some situations that require hand hygiene.Before and after eating or handling food.After handling soiled equipment or utensils.After removing gloves.In between glove changes.Between tasks. Observation in the kitchen on 7/21/2025 at 4:50 PM, revealed [NAME] A removed bread from the package without gloves. During an interview on 7/21/2025 at 4:59 PM, the Certified Dietary Manager confirmed that gloves should have been worn to remove the bread from the package. During an interview on 7/22/2025 at 3:00 PM, the Director of Nursing confirmed that staff should not use their bare hand to touch residents' food.

Based on policy review, observation, and interview, the facility failed to ensure proper infection control practices were followed when 1 of 9 staff members Certified Nursing Assistant (CNA) B failed to handle and serve food under sanitary conditions for 2 of 20 (Resident #14 and #45) residents observed during dining, and when 1 of 2 Registered Nurses (RN) C failed to perform hand hygiene for 3 of 5 (Resident #17, #47, and #55) residents observed during medication administration. The findings include: 1. Review of the facility policy titled, .Handwashing/Hand Hygiene . dated October 2023, revealed .This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections .Perform hand hygiene before applying non-sterile gloves .When removing gloves .Perform hand hygiene . Review of the facility policy titled, .Medication Administration, dated 6/21/2017, revealed .Preparing Medication for Administration .Never touch any of the medication with fingers . 2. Random observation during dining on 7/21/2025 at 12:21 PM, revealed CNA B assisted Resident #14 in the dining room, CNA B removed Resident #14's bread with her bare hand to apply mustard to Resident #14's sandwich. Random observation during dining on 7/21/2025 at 12:29 PM, revealed CNA B assisted Resident #45 with his meal and touched the Resident's sandwich her bare hands. The Director of Nursing (DON) informed CNA B that she couldn't touch the Resident's bread. During an interview on 7/22/2025 at 3:00 PM, the DON confirmed that staff should not use their bare hand and touch resident's food when assisting with meals. 3. Observation during medication administration on the A Hall on 7/22/2025 at 7:56 AM, revealed RN C prepared Resident #17's medications and donned gloves without performing hand hygiene, administered the medication, doffed (removed) gloves and did not perform hand hygiene. Observation during medication administration on the A Hall on 7/22/2025 at 8:16 AM, revealed RN C prepared Resident #55's medications, dropped multiple medications on top of the medication cart, picked up the medications with his bare hands, and placed the medications in the medicine cup. Observation during medication administration on A Hall on 7/22/2025 at 8:31 AM, revealed RN C prepared Resident #47's medication, dropped medication on top of the medication cart, picked up the medications with his bare hand and placed in the medicine cup, donned gloves, administered the medication, doffed gloves, and returned to medication cart without performing hand hygiene. During an interview on 7/22/2025 at 8:38 AM, RN C confirmed hand hygiene should have been performed before and after administering medications. RN C confirmed that he should not have picked up the medications with his bare hands. During an interview on 7/23/2025 at 8:50 AM, the DON confirmed medication should not be touched with bare hands and hand hygiene should have been performed before preparing medication, and when gloves are donned and doffed.

Based on interview, record review, facility policy, and facility document review, the facility failed to protect the resident's right to be free of physical abuse by a contracted staff member, Licensed Practical Nurse (LPN) #1. This failure affected 1 (Resident #1) of 4 sampled residents. On 08/18/2023, Certified Nursing Assistant (CNA) #2 observed LPN #1 take a sandwich from Resident #1's hand despite the resident's objection, hold the resident's hands, and forcefully pushed a spoonful of crushed medications into the resident's mouth through the resident's closed lips. Findings included: 1. A review of an undated facility policy titled, Freedom from Abuse and Neglect Policy, indicated the purpose of the policy was To prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of property. The policy indicated for protection 1. All residents will be protected from harm. 2. All allegation involving staff will necessitate suspension pending investigation. 2. A review of an admission Record revealed the facility readmitted Resident #1 on 06/06/2019. The resident had diagnoses that included palliative care, dysphagia, anorexia, need for assistance with personal care, unspecified dementia with agitation, schizoaffective disorder, major depressive disorder, and cognitive communication deficit. 3. A review of Resident #1's care plan with a revision date of 03/17/2023, revealed the facility identified a focus area for the potential for weight loss due to poor food intake and diagnoses of dysphagia, anorexia, and dementia. The care plan directed the staff to offer Resident #1 finger foods between meals. A review of a care plan focus area, revised on 02/20/2023, indicated Resident #1 exhibited verbal behaviors related to anxiety such as calling out, Help me, or Hey. The care plan directed the staff to provide opportunity for positive interactions. 4. A review of a facility Incident Reporting System report submitted to the state agency on 08/19/2023, indicated that on 08/18/2023 at 9:30 PM, the facility became aware of an incident of abuse perpetrated on Resident #1 by LPN #1. The allegation indicated CNA #2 observed LPN #1 take a sandwich out of the resident's hand and told the resident they could not have the sandwich until after the resident had taken medication. The allegation indicated that when the LPN took the resident's sandwich, Resident #1 began swatting at the nurse. LPN #1 then restricted the resident's arms. A review of Resident #1's August 2023 Medication Administration Record (MAR) revealed the resident's target behaviors of pacing, agitation, and restlessness did not increase after the 08/18/2023 incident. A review an Incident Reporting System report for the facility's five-day follow-up report to the state agency, undated, indicated there had been no residual emotional/mental harm to Resident #1. The Social Services Director (SSD) had interviewed the resident three times since 08/18/2023 and there were no negative findings. The report indicated the resident had been observed with slight redness to the right wrist that had dissipated by the following day. LPN #1 had been relieved of duties immediately after speaking with the Director of Nursing (DON). The report indicated that after speaking with floor staff on the night in question, the DON found it prudent to relieve LPN #1 of her duties. The facility report indicated the allegation was verified. A review of the shift timecard for LPN #1 indicated the nurse clocked out at 10:11 PM on 08/18/2023. A review of an eInteract Change in Condition Evaluation, with an effective date of 08/19/2023 at 10:00 PM, indicated Resident #1 had no change in behaviors and had minimal redness of the right hand in the wrist area. A review of an eInteract Change in Condition Evaluation, with an effective date of 08/20/2023 at 10:12 AM, revealed Resident #1 had no mental status nor function status changes and had minimal redness to the right wrist with no bruising noted. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/21/2023, revealed a Brief Interview for Mental Status (BIMS) score of 6, which indicated Resident #1 had severe cognitive impairment. The MDS also revealed Resident #1 had minimal difficulty hearing and impaired vision. The MDS indicated Resident #1 required limited supervision for eating. The MDS also revealed the resident did not exhibit any behavioral symptoms during the assessment period. 5. CNA #2 was interviewed on 10/09/2023 at 2:35 PM. CNA #2 stated that on the night of the incident, 08/18/2023 between 9:00 PM and 9:30 PM, Resident #1 was yelling they were hungry, and she got the resident a sandwich and a chocolate shake. CNA #2 stated she passed LPN #1 in the hallway and the LPN stated she had medication for Resident #1 and followed the CNA into Resident #1's room. CNA #2 stated she had given the sandwich to the resident and LPN #1 ripped the sandwich out of the resident's hand. CNA #2 stated the nurse then held the resident's hands down with her arms, placing weight on the resident's arms, and proceeded to shove a spoon of medications in the resident's mouth. CNA #2 stated that initially she said nothing due to being shocked at the entire situation. The CNA stated at the time this occurred, Resident #1 was in bed with the head of the bed raised. CNA #2 added the nurse did not ask the resident whether the medication was wanted. When CNA #2 questioned the LPN, the LPN told her that was the only way she could get Resident #1 to take medications. CNA #2 added that when LPN #1 took the sandwich from the resident, the resident started fighting and closed their lips and LPN #1 forced the spoon of medications between the resident's closed lips. CNA #2 stated Resident #1 told the nurse to stop, and the resident was hungry, and the nurse told Resident #1 they had to take the medication first. CNA #2 stated she spoke up and told the nurse not to treat Resident #1 that way. LPN #1 got an attitude and walked out of the resident's room. CNA #2 stated after the nurse walked out, she made sure Resident #1 was okay and walked outside. After speaking with LPN #3 about what happened, the CNA called the DON. CNA #2 stated when she spoke with the DON, she went back inside at the DON's instructions and had a three-way conversation with the DON and the Administrator. CNA #2 stated while she was making the call to the DON, CNA #4 stayed with Resident #1. CNA #2 stated she saw no injuries to Resident #1 and after the incident LPN #1 sat at the nurses' station and did not return to Resident #1's room. A telephone interview was held with CNA #4 on 10/09/2023 at 4:01 PM. She stated she had worked with CNA #2 on the night of 08/18/2023 when the incident occurred between LPN #1 and Resident #1. CNA #4 stated she and CNA #2 had been in the breakroom and heard Resident #1 yelling for help. She stated LPN #1 was also in the breakroom heating something in the microwave and cursed at Resident #1. CNA #4 stated she had not observed the incident, but CNA #2 reported to her what happened. CNA #4 stated CNA #2 told her she had given Resident #1 a snack and had observed LPN #1 hold the resident's arms down and shove a spoon of medication in the resident's mouth. CNA #4 stated when confronted by the CNAs about how she had treated Resident #1, LPN #1 replied she had to do it. CNA #4 stated she was in the hallway and was sure LPN #1 had not gone back into Resident #1's room after the incident and had been at the nurses' station until she left the building. A telephone interview was held with LPN #3 on 10/10/2023 at 10:20 AM. LPN #3 stated she was the other nurse in the building on 08/18/2023 when the incident occurred between Resident #1 and LPN #1. LPN #3 stated she was administering medications when she heard LPN #1 yelling at CNA #2 and CNA #4 because they had called the DON to report LPN #1. LPN #3 stated she had not witnessed the incident, but the CNAs had told her what happened. LPN #3 stated the DON called her and asked that she check on Resident #1. She stated Resident #1 was sleeping, and she saw no bruising on Resident #1. She stated LPN #1 was asked to leave the facility and as far as she knew the nurse had not returned to Resident #1's room. CNA #6 was interviewed on 10/10/2023 at 10:54 AM. She stated she worked with Resident #1 on day shift, and prior to the incident Resident #1 had no bruising. After the incident, the resident had redness on one wrist. CNA #6 stated there had been no change in Resident #1's behavior after the incident. The DON was interviewed on 10/10/2023 at 11:58 AM. The DON stated around 9:30 PM on 08/18/2023, she received a call from CNA #2 and CNA #4. The CNAs told her the resident was in bed yelling, as was normal for Resident #1. When CNA #2 checked on the resident, Resident #1 stated they were hungry, and the CNA got the resident a snack. The DON stated the CNA reported LPN #1 came in to give Resident #1 medications and told the resident they could not have the sandwich until the medication was taken. LPN #1 grabbed the sandwich out of the resident's hand. Resident #1 got angry and started swatting at the nurse. The DON stated the CNA told her the LPN roughly held the resident's hands down, shoved a spoonful of medication in the resident's mouth, handed the sandwich back to the resident, and left the room. She stated CNA #2 was disturbed by what happened and called the DON. The DON stated she also called the Administrator and asked for direction and was advised to call LPN #1 and ask for her side of the story. The DON stated LPN #1 denied the incident, but the nurse became angry and defensive, and she was sure the incident had occurred. She stated she called LPN #3 and asked her to assess the resident and then called LPN #1 back and instructed her to leave the premises. She stated she had not asked LPN #1 to leave the facility after the first phone call. Although she felt there was a high probability the incident occurred as reported, she felt she needed to ask a few more questions. The DON stated there were only two to three minutes between the first time she spoke with LPN #1 and the second call when she told the LPN to leave the facility. The DON stated although she did not know exactly what time LPN #1 left the facility, she was sure the nurse had not gone into the resident's room again. She stated the CNAs had told her two of them had stayed in the hall and the nurse was at the nurses' station. According to the DON, Resident #9 had heard LPN #1 yelling at the CNAs. Resident #9 was interviewed on 10/10/2023 at 12:54 PM and stated there was a night in mid-August that the resident had heard a nurse cursing at two CNAs. Resident #9 stated they heard the nurse say to the CNAs, I can't believe what you did. The resident stated the CNAs did not respond to the nurse but continued to stand in the hallway until the nurse left for the night. A telephone interview was held with CNA #7 on 10/10/2023 at 4:23 PM. She stated she had worked with Resident #1 on the night shift after the incident occurred between LPN #1 and Resident #1. The CNA stated she arrived at the facility at approximately 9:30 PM and found LPN #1 sitting at the nurses' station and was there until the LPN left the facility. The CNA stated LPN #1 had not gone into Resident #1's room nor the room of any other resident. The CNA stated during the night shift after the incident, Resident #1 was awake all night but added that was common. She stated it seemed to be harder to get Resident #1 to calm down. CNA #7 stated she gave the resident another sandwich and another shake on her shift and the resident had no difficulty eating and had no complaints of oral pain. LPN #8 was interviewed on 10/10/2023 at 4:56 PM and stated she had completed a skin assessment for Resident #1 on 08/19/2023 and found a reddened wrist but no swelling or pain were present. LPN #8 stated the redness resolved quickly and had not progressed to a bruise. LPN #8 stated she had worked day shift on 08/19/2023 and had not noticed anything different about Resident #1's behavior, adding Resident #1 always had a high anxiety level. The Administrator was interviewed on 10/10/2023 at 6:54 PM and stated he became aware of the 08/18/2023 incident between LPN #1 and Resident #1 when the DON called and informed him that a CNA had witnessed an agency nurse get frustrated and make the resident take medication. He stated he had been told the nurse took the resident's sandwich away but had not found about the nurse holding the resident down until the next day. The Administrator stated the two CNAs were vigilant in watching to make sure LPN #1 had not abused any other residents. He stated he considered the incident with Resident #1 abuse and that was why LPN #1 was instructed to leave the building. He stated he went in when LPN #8 assessed the resident on 08/19/2023, and LPN #8 told him the resident had no signs of distress.

Based on interviews, record review, facility documents, and facility policy review, the facility failed to ensure 1 (Resident #1) of 4 abuse/neglect investigations was reported and addressed in the facility's Quality Assurance and Performance Improvement (QAPI) program. Specifically, the facility's abuse/neglect policy required all substantiated allegations of abuse be review by the facility's QAPI Committee; however, the facility failed to ensure a substantiated abuse allegation for Resident #1 was reported to the committee. Findings included : 1. A review of the facility's Freedom from Abuse and Neglect Policy, undated, revealed 3. Substantiated allegations of abuse will be reviewed by the Facility's Quality Assurance and Performance Improvement Committee to detect potential patterns or trends, and for consideration of further interventions or training opportunities. The medical director should be notified and involved. 2. A review of an admission Record revealed the facility readmitted Resident #1 on 06/06/2019. The resident had diagnoses that included palliative care, dysphagia, anorexia, need for assistance with personal care, unspecified dementia with agitation, schizoaffective disorder, major depressive disorder, and cognitive communication deficit. A review of Resident #1's care plan with a revision date of 03/17/2023, revealed the facility identified a focus area for potential weight loss due to poor food intake and diagnoses of dysphagia, anorexia, and dementia. The care plan directed staff to offer Resident #1 finger foods between meals. A review of a care plan focus area revised on 02/20/2023 indicated Resident #1 exhibited verbal behaviors related to anxiety such as calling out, Help me, or Hey. The care plan directed the staff to provide opportunity for positive interactions. A review of an Incident Reporting System report, revealed on 08/18/2023 at 9:30 PM, Certified Nursing Assistant (CNA) #2 observed Licensed Practical Nurse (LPN) #1 take a sandwich out of Resident #1's hand and told the resident they could not have the sandwich until after the resident had taken medication. Resident #1 began swatting at LPN #1 and the nurse restricted the resident's arms. The report indicated the initial allegation of abuse was not reported to the state agency until the next day, on 08/19/2023 at 12:07 PM. A review an Incident Reporting System report for the facility's five-day follow-up report to the state agency, undated, indicated Resident #1 had slight redness to the right wrist following the incident. LPN #1 was relieved of duties immediately and the facility report indicated the allegation was verified. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/21/2023, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS also revealed Resident #1 had minimal difficulty hearing and had impaired vision. The MDS indicated Resident #1 required limited supervision for eating. The MDS also revealed the resident did not exhibit any behavioral symptoms during the assessment period. The Administrator was interviewed on 10/10/2023 at 6:54 PM and stated the QAPI committee met monthly. The Administrator stated the incident that occurred with Resident #1 was an isolated incident and the facility had relieved the LPN of her duties. The Administrator reviewed the QAPI minutes and stated the QAPI Committee had not discussed the incident that occurred with Resident #1 stated he had no rational explanation why the incident had not been taken through the QAPI program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of an admission Record indicated the facility admitted Resident #4 on 02/10/2023 with diagnoses that included cognitive communication deficits, major depressive disorder, anxiety disorder, chronic kidney disease, and peripheral vascular disease. The document further revealed a diagnosis of unspecified dementia was added with an onset date of 04/14/2023. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/29/2023, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS indicated the resident required supervision to limited staff assistance with activities of daily living assistance (ADLs). A review of Resident #4's care plan revealed a focus area with an initiation date of 02/10/2023 that indicated the resident had impaired cognition and thought processes. Interventions directed staff to allow the resident to verbalize feelings and fears, to approach in a calm, friendly, non-rushed manner, and to assist the resident with daily tasks. Review of the IRS [Incident Reporting System] report dated 10/09/2023, revealed Resident #4 had made an allegation of rape on the morning of 08/30/2023. The resident had alleged a middle-aged man came into their room, sat on the edge of the bed, and encouraged the resident to do the same. The resident then alleged the man pushed the resident to lie on the bed and began having sex with them. The report indicated the Administrator was notified of the alleged abuse allegation on 08/30/2023 at 6:35 AM. The initial report was submitted to the state agency on 08/30/2023 at 10:31 AM, which was not submitted to the state agency timely. It was submitted one hour and 56 minutes later than the required two-hour time frame. During an interview on 10/10/2023 at 5:17 PM, the Administrator confirmed the allegation should have been reported within two hours of the facility being made aware. He stated he did not report the allegation within two hours because he was waiting on the police department's investigation. Based on interviews, record review, facility documents, and facility policy review, the facility failed to report allegations of abuse to the state agency within the two hours for 2 (Residents #1 and #4) of 4 residents reviewed for allegations of abuse/neglect; and failed to report an allegation of neglect within 24 hours for 1 (Resident #2) of 3 residents reviewed for allegations of abuse/neglect. Findings included: 1. A review of an undated facility policy titled, Freedom from Abuse and Neglect Policy, revealed 1. Allegations will be reported to the Executive Director immediately. 2. The facility will report all alleged violations and substantiated incidents to the stage agency and to all other agencies as required and will take all necessary corrective actions depending on the results of the investigation. Further review of the policy revealed, Reports may be oral or written and must be made immediately upon knowledge of the occurrence of the suspected abuse, neglect, or exploitation of an adult. It may take up to 1 business day to process reports of abuse and neglect made through the web-based reporting process. If you believe the allegation requires action in less than 24 hours, contact [PHONE NUMBER]. The policy did not address the requirement for reporting not later than two hours when the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury to state officials and other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. 2. A review of an admission Record revealed the facility readmitted Resident #1 on 06/06/2019. The resident had diagnoses that included palliative care, dysphagia, anorexia, need for assistance with personal care, unspecified dementia with agitation, schizoaffective disorder, major depressive disorder, and cognitive communication deficit. A review of Resident #1's care plan with a revision date of 03/17/2023, revealed the facility identified a focus area for potential weight loss due to poor food intake and diagnoses of dysphagia, anorexia, and dementia. The care plan directed the staff to offer Resident #1 finger foods between meals. A review of a care plan focus area revised on 02/20/2023 indicated Resident #1 exhibited verbal behaviors related to anxiety such as calling out, Help me, or Hey. The care plan directed the staff to provide opportunity for positive interactions. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/21/2023, revealed a Brief Interview for Mental Status (BIMS) score of 6, which indicated Resident #1 had severe cognitive impairment. The MDS also revealed Resident #1 had minimal difficulty hearing, impaired vision, and required limited supervision for eating. The MDS indicated the resident did not exhibit any behavioral symptoms during the assessment period. A review of a facility Incident Reporting System report, submitted to the State Agency on 08/19/2023, indicated that on 08/18/2023 at 9:30 PM, Certified Nursing Assistant (CNA) #2 observed Licensed Practical Nurse (LPN) #1 take a sandwich out of Resident #1's hand and told the resident they could not have the sandwich until after the resident had taken medication. The allegation indicated that when the LPN took the resident's sandwich, Resident #1 began swatting at the nurse. LPN #1 then restricted the resident's arms. The report indicated the Administrator was notified of the incident on 08/18/2023 at 9:35 PM. A review of Section 12 of the report indicated the Administrator reported the initial allegation of abuse to the state agency the next day, on 08/19/2023 at 12:07 PM. The report indicated the Administrator had been out of town and was not able to report the incident. The DON was interviewed on 10/10/2023 at 11:58 AM and she stated she understood that all allegations of abuse were to be reported to the state agency within two hours. The DON stated the Administrator was the person responsible for reporting abuse to the state agency and he had completed the submission. The DON reviewed the initial report and the submission date and stated submitting the report to the state agency on 08/19/2023 at noon had not met the reporting requirements. The Administrator was interviewed on 10/10/2023 at 6:54 PM and stated he became aware of the abuse allegation on 08/18/2023 when the DON called him. The Administrator stated he was aware of the two-hour reporting window for allegations of abuse but stated it had taken 15 hours to report because he was out of town at a family member's house that was approximately 90 minutes from the facility. The Administrator stated that in August 2023 he was the only person in the facility with access to report allegations of abuse to the state agency and he had reported the allegation to the state agency when he arrived at the facility on 08/19/2023. 3. A review of an admission Record indicated the facility admitted Resident #2 on 05/05/2021 with diagnoses that included other nontraumatic intracerebral hemorrhage (bleeding on the brain), generalized anxiety disorder, recurrent major depressive disorder, and need for assistance with personal care. A review of a facility Incident Reporting System report revealed the facility became aware of an allegation of Deprivation of Goods and Services by Staff on 02/08/2023 at 10:00 AM, and the incident was reported to the Administrator. The report indicated the alleged victim was Resident #1; however, no other details regarding the allegation were included on the initial report. The report indicated the Administrator submitted the allegation to the state agency on 02/10/2023 at 3:27 PM, two days after the Administrator was notified of the allegation. A review of a care plan focus, with a revision date of 02/14/2023, indicated Resident #2 had a history of aggressive behavior, verbally cursed, and threatened physical harm of staff, was easily angered, and refused care and medications. The care plan also indicated the resident had a history of making false allegations toward staff and peers. According to the care plan, on 02/09/2023, Resident #2 reported an allegation of neglect. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/02/2023, indicated Resident #2's Brief Interview for Mental Status (BIMS) assessment was coded as 99, which indicated the resident was unable to complete the interview. The MDS indicated the Staff Assessment for Mental Status (SAMS) revealed the resident's long-term memory and short-term memory were okay, with Resident #2 able to recall events after five minutes and able to recall long past events. The MDS indicated Resident #2 required extensive assistance from staff with bed mobility, dressing, and personal hygiene; was totally dependent upon staff for transfer, locomotion, and toilet use; and required supervision for eating. A telephone interview was held on 10/10/2023 at 5:20 PM with Registered Nurse (RN) #9, who was the Director of Nursing (DON) when the incident occurred. She stated she was unable to remember who called her about Resident #2's allegations that they were not receiving incontinence care or baths at the facility. She was also unable to remember whether the report was received late on 02/07/2023 or early on 02/08/2023. RN #9 stated she considered Resident #2's statements allegations of neglect and reported the allegations to the Administrator. RN #9 stated the Administrator was responsible for submitting allegations of abuse/neglect to the state agency. The Administrator was interviewed on 10/10/2023 at 6:28 PM and after reviewing the facility's initial report for the allegation of neglect for Resident #2, stated that the reporting time had not met facility policy or regulations. The Administrator stated he was unsure when the allegation had been reported to him and was unsure why the allegation had not been submitted timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, facility policy, and facility document review, the facility failed to ensure allegations of abuse were thoroughly investigated for 3 (Residents #4, #3, and #2) of 4 residents reviewed for abuse. Findings included: 1. Review of the undated facility policy titled, Freedom from Abuse and Neglect Policy, indicated, Purpose: To prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of property. In the section titled Investigation, the policy indicated: 1. The facility will conduct an internal investigation and report the results of the investigation to the enforcement agency in accordance with state law including the state survey and certification agency within five working days of the incident or according to state law. 2. The facility will thoroughly investigate all alleged violations and take appropriate actions. 3. Investigations will be prompt, comprehensive and responsive to the situation and contain founded conclusions. The investigation will include, but is not limited to the following: a. Notification of physician and resident representative; b. Identification and removal of the alleged person or persons; c. Type of alleged abuse; d. Where and when the incident occurred; e. Interviews and /or written statements from individuals with first-hand knowledge of the incident; f. Follow-up resolutions; g. Measures to prevent repeat incidents; h. All material and documentation of the pertinent data to the investigation is collected, maintained, and safeguarded by the facility. 4. Actions taken during the investigation will be based on the outcome of the investigation. 5. The alleged perpetrator of abuse is suspended during the investigation process. 2. A review of the admission Record indicated the facility admitted Resident #4 on 02/10/2023, with diagnoses that included cognitive communication deficits, major depressive disorder, anxiety disorder, chronic kidney disease, and peripheral vascular disease. The document further revealed a diagnosis of unspecified dementia was added with an onset date of 04/14/2023. A review of Resident #4's care plan revealed a focus area with an initiation date of 02/10/2023 that indicated the resident had impaired cognition and thought processes. Interventions directed staff to allow the resident to verbalize feelings and fears, to approach in a calm, friendly, non-rushed manner, and to assist the resident with daily tasks. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/29/2023, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS indicated the resident required supervision to limited staff assistance with activities of daily living assistance (ADLs). Review of the IRS [Incident Reporting System] report dated 10/09/2023, revealed Resident #4 had made an allegation of rape on the morning of 08/30/2023. The resident had alleged a middle-aged man came into their room, sat on the edge of the bed, and encouraged the resident to do the same. The resident then alleged the man pushed the resident to lie on the bed and began having sex with them. Resident #4 was unable to give a description of the perpetrator. The report indicated the only two male employees were off work at 6:00 AM on the morning of 08/30/2023. Resident #4 was transported to the local medical center for a rape kit exam. The local sheriff's department, Adult Protective Services (APS), and the Ombudsman were notified according to the IRS report. A review of the facility's investigation folder provided by the facility revealed interviews with residents who had a BIMS score of over 8 with no concerns identified related to the allegation. All residents indicated they felt safe at the facility. The folder included forms titled Today's Staffing for two days, 06/18/2023 and 07/02/2023. The folder contained no staffing sheets for the dates 08/29/2023 and 08/30/2023. The folder included a typed interview with Certified Nursing Assistant (CNA) #6 that indicated as she was making morning rounds, Resident #4 told her a man came into the resident's room, put his hands over their mouth, and raped the resident. CNA #6 indicated she reported the incident to Licensed Practical Nurse (LPN) #10 and LPN #5. The folder included a typed interview with LPN #10. LPN #10's interview indicated she went to Resident #4's room and asked the resident what had happened, and the resident recounted the same story. LPN #10 indicated she saw no visible injuries and then reported the incident. The folder also included a typed interview with LPN #22 who indicated LPN #10 asked LPN #22 to go back to the room and interview Resident #4 together. LPN #22 interviewed Resident #4 and the resident recounted the same story, and LPN #22 reported the incident to the Director of Nursing (DON). The folder did not contain any other staff interviews or statements or a summary of the facility's investigation with conclusions and steps taken to prevent recurrence. Review of a Daily Assignment Sheet, dated 08/29/2023, revealed LPN #5 and Nursing Assistant in Training (NA/IT) #11, both male staff members, had worked on the nightshift the night of the alleged incident. The facility's investigation lacked evidence of interviews with LPN #5 and NA/IT #11. The facility's investigation also lacked evidence of interviews with any staff listed on the Daily Assignment Sheet as having worked on 08/29/2023. During an interview on 10/10/2023 at 4:37 PM, the Director of Nursing (DON) said she was not at work when Resident #4 made the allegation of rape and said the Administrator had completed the investigation. She stated they had one male nurse and a male CNA working at the time of the resident's allegation and she thought the Administrator had interviewed them but was not sure. During an interview on 10/10/2023 at 5:17 PM, the Administrator said he did not interview the male staff because they were not on shift when the resident reported the allegation. He said Human Resources (HR) #13 had contacted the male staff to suspend them until the investigation was completed, but once they had the hospital report back, they were allowed to return to work. He confirmed there were no additional interviews or witness statements for the investigation and could not provide a reason as to why there were no additional interviews or witness statements. 3. A review of the admission Record, revealed Resident #3 was admitted to the facility on [DATE], and was most recently readmitted on [DATE], with diagnoses including low back pain, generalized muscle weakness, major depressive disorder, and malignant neoplasm of the nasal cavity. The admission Record indicated on 07/07/2023, neoplasm of the parotid salivary glands was added as a diagnosis. A review of Resident #3's care plan focus statement, with an initiation date of 06/01/2023, indicated the resident exhibited verbal behaviors including false accusations about staff, confabulations. The care plan indicated the resident had the potential for further behaviors related to olfactory neuroblastoma. Interventions, with an initiation date of 06/01/2023, directed staff to assist the resident to develop more appropriate methods of coping and interacting, encourage the resident to express feelings appropriately, provide opportunities for positive interactions and attention, consult behavioral health services as needed, explain/reinforce why behavior was inappropriate and/or unacceptable, and monitor and document behavioral episodes and attempt to determine underlying cause. A review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 07/22/2023, revealed the resident scored 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. The MDS did not indicate the resident had behavioral symptoms. The MDS indicated the resident required extensive assistance with bed mobility and personal hygiene and was totally dependent upon staff for transfers, dressing, and toilet use; the resident was always incontinent of bowel and bladder. The MDS indicated the resident received antidepressant medication daily during the 7-day review period. A review of an Internal Reporting System [IRS] form, dated 10/09/2023, revealed that on 05/03/2023 at 3:15 PM, Physical Therapy Staff (PTS) #16 reported to the Administrator that Resident #3 accused a CNA named [name redacted] of being rough during personal care provided on the 10:00 PM to 6:00 AM shift. The reporting form indicated the facility did not employ a CNA named [name redacted] who worked on the 10:00 PM to 6:00 AM shift; however, a CNA who had been caring for the resident for years stated that the resident sometimes called them [name redacted] because the resident could not remember the CNA's name. This CNA did not match the resident's description and the resident reportedly did not have concerns regarding this CNA. The reporting form indicated 22 residents with a BIMS score of 8 or higher were interviewed and no residents reported similar issues and no caregivers who were interviewed reported any negative encounters with the resident. A review of the contents of the facility's investigation folder revealed undated handwritten notes by the Director of Nursing (DON) regarding an interview with Resident #3. The notes indicated that Resident #3 stated staff, specifically [name redacted], did not provide proper hygiene care and this resulted in the resident developing a urinary tract infection (UTI) and when [name redacted] provided incontinence care they threw the resident to the side and handled the resident roughly. The resident described [name redacted] as an individual of a particular height, race, and gender, who worked on third shift. The folder also included a handwritten statement by CNA #15 dated 05/05/2023. CNA #15 wrote that they had been taking care of the resident for years and the resident called CNA #15 by the name of [name redacted] because the resident could not remember the CNA's name. CNA #15's statement indicated a couple of nights prior, CNA #7 and CNA #15 were taking care of the resident and the resident said, Oh [name redacted], I'm glad it's you, that [description of a staff member of a particular gender and race] was mean and rough with me. The folder did not contain any other staff interviews or statements or a summary of the facility's investigation with conclusions and steps taken to prevent recurrence. The DON confirmed that there was no documented evidence indicating that steps were taken to protect the resident during the investigation. During an interview on 10/10/2023 at 12:37 PM, the DON said she did not have an investigative summary or any other documentation of the investigation, only her handwritten notes in the file. The handwritten paper included the notes she took when she and the Administrator interviewed the resident. The DON said she completed a full body audit and found no bruising. She talked with the CNAs who worked with the resident and got their written statements. The DON said the written statements were in the folder but when she looked in the folder, she did not see any statements. The DON said she knew she talked to CNA #7, and she wrote a statement. She did not know what happened to CNA #7's statement. She said administrative staff went through the list of employees who worked at the facility and looked at the assignment sheets and did not find anyone named [name redacted]. The DON said they finally spoke to CNA #15 who said the resident sometimes called them [name redacted]. Administrative staff did not think that CNA #15 was the CNA who the resident was talking about because CNA #15 did not match the resident's description. No further investigation into the allegation was documented. During an interview on 10/10/2023 at 5:17 PM, the Administrator stated the DON had the folder that included the documented investigation into Resident #3's allegation. The Administrator believed the allegation was made because the resident had an issue with people of a particular race. The Administrator said he did not see the need to do any other interviews since the facility did not employ anyone by the name of [name redacted]. He stated he understood staff should follow their policy when investigating allegations of abuse. 3. A review of the admission Record indicated the facility admitted Resident #2 on 05/05/2021 with diagnoses that included other nontraumatic intracerebral hemorrhage (bleeding on the brain), generalized anxiety disorder, recurrent major depressive disorder, and need for assistance with personal care. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/02/2023, indicated Resident #2's Brief Interview for Mental Status (BIMS) was coded as 99, which indicated the resident was unable to complete the interview. The MDS indicated the Staff Assessment for Mental Status (SAMS) revealed the resident's long-term memory and short-term memory were okay, with Resident #2 able to recall events after five minutes and able to recall long past events. The MDS indicated Resident #2 required extensive assistance from staff with bed mobility, dressing, and personal hygiene and was totally dependent upon staff for transfer, locomotion, and toilet use. Supervision was required for eating. A review of a care plan focus, for Resident #2, with a revision date of 02/14/2023, indicated the resident had a history of aggressive behavior, verbally cursing and threatening physical harm of staff, was easily angered, and refused care and medications. The care plan also indicated the resident had a history of making false allegations toward staff and peers. According to the care plan, on 02/09/2023 Resident #2 reported an allegation of neglect. A review of an emergency department (ED) psychiatric evaluation dated 02/06/2023 indicated the facility sent Resident #2 to the ED due to suicidal ideation; however, the resident denied any suicidal ideation. Resident #2 was very upset the resident was in the ED and repeatedly asked staff not touch the resident, and the resident was not cooperative with examinations. Resident #2 reported the resident could not get their strength back because the facility refused to provide therapy. A review of an Incident Reporting System report revealed the facility became aware of an allegation of Deprivation of Goods and Services by Staff on 02/08/2023 at 10:00 AM and the incident was reported to the Administrator. The report indicated the alleged victim was Resident #1; however, no other details regarding the allegation were included on the initial report. A review of undated Incident Report System documents revealed Resident #1 was transferred to a local ED on 02/07/2023 due to threats of self-harm and harm to others. The resident had a history of verbal and physical aggression and making false allegations against staff. While at the ED, the resident voiced concerns of poor care. A review of the facility's investigation revealed the facility documented Unwitnessed under the section of the investigation designated for a summary of interviews with witnesses of what was observed or their knowledge of the alleged incident and there was no documented evidence the facility interviewed staff assigned to care for Resident #1. The facility documented N/A (not applicable) under the section designated for a summary of interviews with staff responsible for oversight and supervision of the location where the alleged victim lived. Further review of the facility's report revealed a section designated to provide a summary of the resident's clinical record. The facility documented the resident's diagnoses and that the resident had a history of making false allegations; however, there was no documented evidence the facility reviewed the resident's record to determine whether poor care had been provided. Under Conclusion, the report indicated the allegation was not verified and added that Adult Protective Services (APS) was present and verbally stated Resident #2 was delusional. The report did not include any documentation or observations regarding the resident's appearance at the time of transfer to the ED nor any documentation or observation of the resident's appearance on return from the ED. The Director of Nursing (DON) was interviewed on 10/10/2023 at 11:24 AM and stated she was unaware of Resident #2's accusations of not receiving needed care, adding she started working at the facility in January 2023 but was not in the role of DON. A telephone interview was conducted with RN #9 on 10/10/2023 at 5:20 PM, who was the DON when the incident occurred. The RN stated she was unable to remember exactly when or from whom she had received Resident #2's concerns of poor care, but she considered those expressed concerns as neglect and had reported that to the Administrator. RN #9 stated she completed an investigation with follow-up audits consisting of interviews with residents who had a BIMS score of 8 or greater and skin audits of residents with a BIMS score of 7 or less, observing for general cleanliness, and found no concerns. The Administrator was interviewed on 10/10/2023 at 6:28 PM and stated that when an allegation of abuse was received, it was purely an allegation and a process had to be followed. The Administrator stated part of the process included reporting and investigation. The Administrator stated in this instance, there was not an investigation; however, all he could remember about the February 2023 event involving Resident #2 was the hoopla surrounding the resident's transfer to the ED and felt the events leading to the transfer overshadowed an investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to maintain or enhance residents' dignity and respect when an indwelling urinary catheter bag was not concealed in a privacy bag for 1 of 2 sampled resident (Resident #20) reviewed for an indwelling urinary catheter. The findings include: Review of the facility's policy titled, Resident's Rights and Quality of Life, dated May 1, 2012, revealed .It is the policy of .all residents have the right for a dignified existence . Review of the medical record, revealed Resident #20 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Acute Kidney Failure, Urinary Retention, and Psychotic Disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #20 had severe cognitive impairment and required limited to extensive assistance for ADLs (activity of daily living). Review of the Care Plan dated 7/13/2022, revealed .has Indwelling Catheter . Observations on 9/25/2022 at 10:20 AM and 3:26 PM, 9/26/2022 at 8:47 AM and 5:05 PM, 9/28/2022 at 10:20 AM and 3:19 PM, revealed Resident #20 had an indwelling urinary catheter uncovered. During an interview on 9/26/2022 at 5:55 PM, the Director of Clinical Operations was asked should an indwelling urinary catheter be in a privacy bag or covered. The Director of Clinical Operations stated, .am trying to find that .it is not in the Resident Rights .that policy for the catheter does not address dignity . The Director of Clinical Operations would not answer the question.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to accurately assess residents for Antibiotic, Opioid, and Diuretic use and tracheostomy care when 3 of 5 sampled residents (Resident #8, #47 and #51) reviewed for accuracy of Minimum Data Set (MDS) assessments. The findings included: Review of the policy titled, Minimum Data Set (MDS), dated September 2021, revealed .it is the policy of this center to use the MDS 3.0 RAI [Resident Assessment Instrument] Manual and associated documents to complete minimum data sets .Coding Instructions .Code medications according to the pharmacological classification .Record the number of days and .medication was received by the resident at any time during the 7-day look-back period ( .since admission/entry or reentry if less than 7 days) .Tracheostomy care .this item may be coded if the resident performs his .own tracheostomy care . Medical record review revealed Resident #8 was admitted to the facility on [DATE] with a readmission on [DATE] with a diagnoses of Hypertension, Tracheostomy, Malignant Neoplasm of Larynx, Acquired Absence of Larynx, and Severe Protein-Calorie Malnutrition. Review of admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 had a Brief Interview for Mental Status (BIMS) 14, which indicated he was cognitively intact and required supervision for ADL (activity daily living) care. The admission MDS was not coded for Tracheostomy care. Review of Progress Note dated 8/6/2022, revealed .Resident alert non verbal secondary to trach [tracheostomy] site . During an interview on 9/27/2022 at 11:28 AM, the Director of Nursing Services confirmed Resident #8 should be coded on the admission MDS for stoma/tracheostomy care. Review of the medical record, revealed Resident #47 was admitted on [DATE] with diagnoses of Dysphagia, Chronic Pain, Dementia, Hypertension, Anxiety Disorder, Chronic Obstructive Pulmonary Disease, and Diabetes Review of the quarterly MDS assessment dated [DATE], revealed Resident #47 had a BIMS of 15 indicating she was cognitively intact. Review of the quarterly MDS dated [DATE], revealed Resident #47 was not coded correctly for antibiotic and opioid on the 7-day look back period. Review of the medical record, revealed Resident #51 was admitted on [DATE], with diagnoses of Dysphagia, Chronic Pain, Diabetes, Atrial Fibrillation, Hypertension and Heart Failure. Review of the quarterly MDS assessment dated [DATE], reveal Resident #51 was not coded correctly for antidepressant, diuretic, and opioid on the 7-day look back period. Review of the quarterly MDS assessment dated [DATE], revealed Resident #51 was not coded correctly for opioids on the 7-day look back period. During an interview on 9/27/2022 at 10:49 AM, The MDS Coordinator confirmed residents should be coded correctly for each medication according to the RAI manual in the 7-day look back period.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to develop a Baseline Care Plan within 48 hours of admission that included the initial goals and needs for 1 of 3 sampled residents (Resident #205) reviewed. The findings include: Review of the medical record, revealed Resident #205 was admitted on [DATE] with diagnoses of Malignant Neoplasm of Small Intestine, Depression, and Dysphagia. Review of the medical record, revealed Resident #205 did not have a Baseline Care Plan developed within 48 hours of admission that addressed the initial goals and needs of the resident. A Comprehensive Care plan was developed on 9/20/2022. Facility was unable to provide a 48 hour baseline care plan. During an interview on 9/27/2022 at 4:13 PM, the Director of Nursing Services (DNS) was asked if Resident #205 had a baseline Care Plan. The DNS stated, .We have the baseline put in within 24 hours .I do not see one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to conduct Care Plan meetings which included the Interdisciplinary Team (IDT) for 2 of 13 sample resident (Resident #41 and #47) reviewed for care plan meetings. The Finding include: Review of the facility's policy titled, Care Plans and Baseline Care Plans, dated June 2017, revealed .Care plan meetings are also per the RAI [Resident Assessment Instrument] manual guidelines . Review of the facility's policy titled, Resident's Rights and Quality of Life, dated May, 1, 2012, revealed .it is the policy .that all residents have the right to a dignified existence, self-determination, and communication with an access to people and services inside and outside the facility .Participated in care planning . Review of the medical record, revealed Resident #41 was admitted on [DATE] with diagnoses of Dementia, Depression, Anxiety, and Epilepsy. Review of the medical record revealed there were no quarterly Care Plan meetings held for Resident #41 on 9/16/2021, 12/16/2021, 3/18/2022, 6/6/2022, and 8/31/2022. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #41 had a Brief Interview For Mental Status (BIMS) of 15 which indicated she was cognitively intact. Review of the Care Plan Conference Summary dated 9/23/2021, revealed only the Licensed Practical Nurse and Activity Director signed as attending the meeting. Review of the Care Plan Conference Summary dated 12/23/2021, revealed the form was blank. There was one staff member who signed the form. Review of the Social Service Care Plan Calendar revealed Resident #41 was scheduled for a Care Plan meeting in June 2022, and August 2022. During an interview on 9/25/2022 at 4:15 PM, Resident #41 confirmed she has not had a care plan meeting. The facility was unable to provide documentation the care plan meeting was held according to the RAI manual. Review of the medical record, revealed Resident #47 was admitted on [DATE] with diagnoses of Dysphagia, Chronic Pain, Dementia, Hypertension, Anxiety, Chronic Obstructive Pulmonary Disease, and Diabetes. Review of the medical record revealed there were no quarterly Care Plan meetings held for Resident #47 on 1/17/2022, 4/14/2022, 6/9/2022, and 9/9/2022 Review of the quarterly MDS assessment dated [DATE], revealed Resident #47 had a BIMS of 15 which indicated she was cognitively intact. Review of the Care Plan Conference Summary dated 1/20/2022, revealed the form was blank. There was one staff member who signed the form. Review of the undated Care Plan Conference Summary revealed the summary sheet was blank with only the LPN, Social Service Director and the Activity Director signature. Resident #47 or family member did not attend the meeting. Review of the Social Service Care Plan Calendar revealed Resident #47 was schedule for a Care Plan meeting in April 2022, and August 2022. During an interview on 9/26/2022 at 8:19 AM, Resident #47 confirmed she has not been invited to the care plan meeting. During an interview on 9/26/2022 at 4:14 PM, the Social Service Director confirmed the Care Plan meetings should be done quarterly along with the MDS schedule. The Social Service Director confirmed the meeting are held on Thursday and should be scanned into the computer software. The Social Service Director confirmed she keeps a monthly calendar of when the residents when they are scheduled for the Care Plan meetings. During an interview on 9/28/2022 at 10:28 AM, the Director of Nursing Services (DNS) was asked according to the RAI manual how often are the care plan meetings held. The DNS confirmed the meetings or held within 72 hours of admission, quarterly, change in condition and annually. The DNS confirm the care plan meeting should include the IDT (interdisciplinary team) members.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, the facility failed to ensure the completion of a discharge summary that included a recapitulation of resident's stay, physicians orders, the disposition status of the resident at the time of discharge and a post discharge plan of care for 1 of 2 sample resident (Resident #57) reviewed for discharge. The findings include: Review of the facility's policy titled, Transfer & [and] Discharge, dated November 1, 2016, revealed .Documentation Requirements .Before [Named Facility] initiates a .discharge for one of the reason set forth in this policy, the Center shall document in the Resident's record the following, and communicate the information .The basis for .Discharge .In accordance with Federal and State law, [Named Facility] will provide and document sufficient preparation and orientation to the Resident to ensure a safe and orderly .discharge from the Center . Review of the medical record, revealed Resident #57 was admitted on [DATE] with diagnoses of Pressure Ulcer Stage 4, Dysphagia, Atrial Fibrillation, and Malignant Breast Cancer. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #57 had a Brief Interview For Mental Status (BIMS) of 6 indicating she was cognitively impaired and required total care with bathing and Self-performance. Review of the Progress Note dated 8/10/2022 at 8:45 (AM), revealed .Notified [Name Son], of residents significant change r/t [related to] transfer home today. [Named Son] stated I will be there shortly to see her and will let us know his decision from there . Review of the Progress Note dated 8/10/2022 at 15:29 [3:29 PM] .Resident discharged . Review of the medical record, revealed the facility failed to complete a discharge summary to recapitulate the resident's stay at the facility, her disposition, and post discharge plan of care. During an interview on 9/27/2022 at 12:29 PM, the Director of Nursing Services confirmed Resident #57 should have physician's orders for discharge, documentation of the discharge, and a discharge summary completed in the residents chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility guideline, medical record review, observation, and interview, the facility failed to ensure a resident's skin condition was accurately assessed, treatments were documented as provided and care plan was updated for 1 of 2 sampled residents (Resident #26) reviewed with pressure ulcers. The findings include: Review of the facility's Skin Care Guideline, dated 7/2018 revealed .To provide a system for evaluation of skin and identify individual interventions to address risk and a process for care of changes/disruption in skin integrity DNS [Director Nursing Services] or designee will be responsible to implement and monitor the skin integrity program .The plan of care will address problem, goals and interventions directed toward prevention .When an open area is identified .complete new risk assessment, Braden scale to determine what risk factors may have changed .Update care plan to address change in skin condition including interventions .Document evaluation of wound in electronic medical record .including .Location and staging .Size .Exudate .Pain .Wound bed .Reassess, re-evaluate and revise interventions when progress is not noted within 14 days .If there is any deterioration of wound statuses initiate comprehensive re-evaluation . Review of the medical record, revealed Resident #26 was admitted to the facility on [DATE] with diagnoses of Spinal Stenosis, Dependence on Supplemental Oxygen, Cystitis, Dysphagia, and Malignant Neoplasm of Breast. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #26 had severe impaired cognition, was at risk for pressure ulcers, and had one unstageable - deep tissue injury which was not present upon admission. Review of a Care Plan dated 8/4/2021, revealed Resident #26 was at risk for skin breakdown, was revised on 8/17/2022 and had a suspected deep tissue injury of left heel. The resident's left heel developed into a stage 2 pressure ulcer on 8/30/2022 and the care plan was not revised until 9/25/2022 to reflect the stage 2 pressure ulcer. Review of the facility Braden Scale For Predicting Pressure Score Risk, dated 7/1/2022 revealed resident was at risk. The facility failed to completed a Braden Scale For Predicting Pressure Ulcers when Resident #26 developed a DTI on 8/17/2022, and a Stage 2 pressure ulcer on 8/30/2022. Review of Physician's Orders dated 9/13/2022, revealed Skin Prep Wipes .Apply to left heel topically every shift for DTI [Deep Tissue Injury] . Review of the Treatment Administration Record (TAR) dated 9/2022, revealed missed wound care treatments on 9/20/2022 on each shift, 9/23/2022 on each shift, 9/24/2022 each shift , 9/26/2022 day shift. Review of the facility Skin & [symbol for and] Wound Evaluation, dated 8/17/2022, revealed .Pressure .Deep Tissue Injury .Persistent non-blanchable deep red, maroon or purple discoloration .Left Heel .In-House Acquired .8/15/2022 .Length 1.8 cm [centimeters] Width 0.8 cm . Review of the facility Skin & Wound Evaluation, dated 8/24/2022, revealed .Pressure .Stage 1 .Non-blanchable erythema of intact skin .Left heel .In House . There was no measurement document for Resident #26's left heel. Review of the facility Skin & Wound Evaluation, dated 8/30/2022, revealed .Pressure .Stage 2 .Partial-thickness skin loss with exposed dermis .Left heel .Length 0.2 cm .Width 0.2 cm . Review of the facility Skin [symbol for and] Wound Evaluation, dated 9/7/2022, revealed Pressure .Stage 2 .Partial-thickness skin loss with exposed dermis .Left heel .Length 0.2 cm .Width 0.2 cm . Review of the facility Skin [symbol for and] Wound Evaluation, dated 9/14/2022, revealed .Pressure .Deep Tissue Injury .Persistent non-blanchable deep red, maroon or purple discoloration .Length 0.7 cm .Width 0.9 cm . Review of the facility Skin [symbol for and] Wound Evaluation, dated 9/21/2022 revealed Pressure .Stage 2 .Partial-thickness skin loss with exposed dermis .Left heel . Length 0.4 cm .Width 0.4 cm scab fell off wound in shower now Stage 2. Skin prep applied and dermafoam applied for protection .Keep boot on and float heels when in bed . Observation in the resident's room on 9/26/22 at 5:08 PM, revealed Licensed Practical Nurse (LPN) #1, performed wound care. Wound to left heel was observed to be approximately length 0.2 cm and Width 0.4 cm, no depth. Wound was pink in color, no redness or drainage. Wound was cleansed with wound cleanser and gauze and skin prep was applied. Foam boarder gauze dressing applied, socks and protective boot placed on resident. During an interview on 9/27/2022 at 11:44 AM, the Director of Nursing Services (DNS) confirmed there were missing treatments on the Treatment Administration Record on 9/20/2022. The DNS confirmed the care plan should have been updated when the Pressure Ulcer changed to a stage 2. During an interview on 9/27/22 at 3:44 PM, the DNS was asked if the assessments were accurate for wound staging. The DNS stated .the wound did not change .it was an error .It was a stage 2 .you cannot go back .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to accurately assess the nutritional status and to follow the Registered Dietician's (RD) recommendations to provide nutritional interventions for 1 of 3 sampled residents (Resident #16), failed to follow the facility's policy for monitoring weights for 1 of 3 sampled residents (Resident #16), and failed to properly label an enteral feeding for 1 of 1 sampled resident (Resident #205) reviewed for nutrition. The findings include: Review of the facility's undated policy titled, .Weight Plan/Guidelines 2021, revealed .admission weights and heights are obtained within 24 hours of admission and recorded .all new admissions and readmissions are weighed weekly for four weeks .All residents who trigger a significant weight change for 30 days should be weighed weekly for four weeks minimum .All new admit/readmit weights, residents with significant weight loss, and residents with decreased po [by mouth] intake should be reviewed weekly at minimum .Interventions should be developed and monitored by team and reviewed and evaluated for effectiveness .all recommendations should be implemented within 48 hours . Review of the medical record, revealed Resident #16 was admitted to to the facility on 3/29/2022 with diagnoses of Diabetes, Dementia, and Dysphagia. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #16's Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment, and required extensive assistance from staff for all activities of daily living (ADL's). Resident #16 was not coded for weight loss during this review period. The facility was unable to provide documentation of Resident #16's admission weight. Review of Resident #16's Dietary Progress Notes dated 6/8/2022, revealed .Weight 128.8 pounds .a decrease of 9% /[per]4 months . Review of Resident #16's Dietary Progress Notes dated 6/27/2022, revealed .-7.5%[percent] change . Patient is slowing regaining weight . Review of Resident #16's Dietary Progress Notes dated 9/14/2022, revealed .Will recommend a House shake once daily and to continue to assist as needed . Review of Resident #16's medical record, revealed no documentation of the Registered Dietician's (RD) recommendation for a nutritional supplement on 9/14/2022. During an interview on 9/27/2022 at 3:15 PM, the RD confirmed Resident #16 did not have an admission weight and did not have an order for her 9/14/2022 recommendation of a House Shake daily. The RD confirmed Resident #16 should have been weighed on admission and received additional calories per her recommendations. During an interview on 7/27/2022 at 5:11 PM, the Director of Nursing Services (DNS) confirmed resident's weights should be completed on admission and that the RD recommendations should be implemented within 48 hours. Review of the medical record, revealed Resident #205 was admitted to the facility on [DATE] with diagnoses of Malignant Neoplasm of Small Intestine, Depression, and Dysphagia. Review of the Care Plan dated 9/20/2022, revealed Resident #205 required tube feeding related to Dysphagia. Review of Resident #205's physician orders dated 9/15/2022, revealed .Continue Vital .1.2 continuous via [by way of ] J-tube [Jejunal tube for feeding directly into the small bowel] @ [symbol for at] 65cc [cubic centimeter]/hr[hour] with 90cc water flush q [every] 4 hours. May substitute Jevity 1.5 continuous at 52cc/hr with 90cc water flush q 4 hrs[hours] . Observation in Resident room on 9/25/2022 at 11:23 AM and 4:20 PM and on 9/26/2022 at 4:18 PM, revealed Resident #205 tube feeding was infusing and was not labeled. On 9/27/2022 at 10:55 AM, was not labeled with the type of formula and the resident identifier. During an interview on 9/27/2022 at 10:58 AM, with the DNS confirmed the enteral feeding and water needs to be labeled on the bag to show interal feeding, time, date, rate and initials.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide the necessary respiratory care and services for tracheostomy care and there were no physicians orders for oxygen for 2 of 2 sampled residents (Resident #8 and #205) reviewed for oxygen therapy and tracheostomy care. The findings include: Medical record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses of Hypertension, Tracheostomy, Malignant Neoplasm of Larynx, Acquired Absence of Larynx, and Severe Protein-Calorie Malnutrition. Review of admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15 indicating he was cognitively intact and required supervision for Activity Daily Living care and was coded for tracheostomy care. Review of the Physician's Orders dated 8/2/2022, revealed .Resident may have o2 [oxygen] via trach [tracheostomy] collar @ [at] 1 LPM [liters per minute] every 1 hours as needed for .hypoxia . Review of the Progress Noted dated 8/23/2022, revealed .Encourage to not be touching at stoma site and to do good hand washing . Review of the Physician Note dated 9/14/2022, revealed .Tracheostomy patent/clear .no Edema . Review of the care plan revised on 9/26/2022, revealed .BATHING/SHOWERING .Stoma is naturally cleaned during bathing and showering and PRN [as needed] by resident. Alert nurse of any redness around area or increased drainage . Review of the Medication Administration Records dated August and September 2022, revealed no treatments or monitoring of Resident #8's tracheostomy stoma. The facility could not provide documentation of the Resident #8's assessment to self-clean his stoma site. The facility was unable to provide the monitoring of the stoma site. During an interview on 9/27/2022 at 11:28 AM, the Director of Nursing Services (DNS) confirmed Resident #8 should have been care plan for tracheostomy care. The DNS confirmed she did not see anything that addressed the care and treatment of Resident #8's stoma/tracheostomy care prior to 9/26/2022. Review of the medical record, revealed Resident #205 was admitted to the facility on [DATE] with diagnoses of Malignant Neoplasm of Small Intestine, Depression, and Dysphagia. Review of the Order Summary Report dated 8/27/2022 through 9/27/2022, revealed, there was no order for Resident #205's oxygen therapy. Observation in the resident's room on 9/25/2022 at 11:23 AM and 4:20 PM, on 9/26/22 at 8:52 AM, and 4:18 PM, and on 9/27/22 at 9:49 AM, revealed Resident #205 was receiving oxygen at 2 liters per minute via (by way of) bi-nasal cannula. During an interview on 9/27/22 at 10:58 AM, the Director of Nursing Services (DNS) confirmed there was no physician orders or care plan for oxygen therapy. The DNS confirmed the Resident #205 should have orders and a care plan for oxygen therapy. The facility did not provide a policy as requested by the surveyor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when medications were found unattended and unsecured when 1 of 3 nurses (Registered Nurse (RN) #1) left medications unattended and unsecured on top of the medication cart, and when 2 of 6 medication storage areas (C Hall Medication Cart and the Treatment Cart) were left unlocked and unattended on the hallway. The findings include: Review of the facility's policy titled, Storage and Expiration of Medications, Biologicals, Syringes and Needles revised 10/31/2016, revealed .Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors . Review of the facility's policy titled, General Dose Preparation and Medication Administration, revised 1/1/2013, revealed .Facility should ensure that medication carts are always locked when out of sight or unattended . Observation on the B Hall on 9/25/2022 at 10:23 AM, revealed the Treatment Cart on the hallway was unlocked and unattended. During an interview on 9/25/2022 at 10:25 AM, Licensed Practical Nurse (LPN) #1 nurse confirmed the treatment cart should not be unlocked. Observation on the A Hall on 9/26/22 at 4:47 PM, revealed the Treatment Cart was unlocked and unattended. On 9/26/22 at 4:50 PM, the Director of Nursing Services (DNS) walked by and locked the treatment cart. Observation on the C Hall medication cart on 9/27/2022 at 8:03 AM, revealed RN #1 prepared the medications for Resident #36, placed the medication cart in front of the C Hall Nurses Station and walked down the hall into room [ROOM NUMBER] to talk to staff members, leaving the open medications in a cup on top of the C Hall medication cart with the medication cart unlocked and unattended in the hallway. During an interview on 9/28/2022 at 4:42 PM, the Director of Nursing Services (DNS) confirmed that the medication carts and treatment cart should be locked and the staff should not leave medication on top of the medication carts unattended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure 2 of 4 (Licensed Practical Nurse (LPN) #1 and 2) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 2 errors were observed out of 29 opportunities, resulting in an error rate of 6.89%. The findings include: 1. Medical record review revealed Resident #58 was admitted to the facility on [DATE] with diagnoses of Acute and Chronic Respiratory Failure with Hypoxia and Chronic Obstructive Pulmonary Disease. The physician's orders dated 8/1/19 documented, .Spiriva HandiHaler Capsule 18 MCG [Microgram] .2 puff inhale orally one time a day . Observations in Resident #58's room on 8/27/19 beginning at 8:27 AM, revealed LPN #1 administered the Spiriva Handihaler to Resident #58. Resident #58 inhaled 1 puff and handed the Handihaler back to LPN #1. LPN #1 stated, That's right, 1 puff. Interview with the Director of Nursing (DON) on 8/27/19 at 4:38 PM, in the DON office, the DON confirmed Resident #58 should have received 2 puffs of Spiriva. The failure of the nurse to administer 2 puffs of the Spiriva resulted in medication error #1. 2. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses of Dementia, Humerus Fracture, Hypertension, and Epilepsy. The physician's order dated 8/3/19 documented, .Flonase Suspension 50 MCG .2 spray in both nostrils one time a day . Observations in Resident #16's room on 8/27/19 at 8:44 AM, revealed LPN #2 administered Flonase Suspension to Resident #16 with 1 spray to each nostril. Interview with the DON on 8/27/19 at 4:40 PM, in the DON office, the DON confirmed Resident #16 should have received 2 sprays of Flonase to each nostril. The failure of the nurse to administer 2 sprays of the Flonase resulted in medication error #2. Interview with the DON on 8/27/19 at 4:40 PM, in the DON office, the DON confirmed Resident #16 should have received 2 sprays of Flonase to each nostril. The DON was asked if the nurses should administer medications as ordered. The DON stated, Yes, Ma'am.

Based on observation and interview, the facility failed to ensure infection control practices to prevent the potential spread of infection in 1 of 1 laundry room. The findings include: Observations in the clean linen room of the laundry room on 8/26/19 at 1:35 PM, revealed a dirty empty mop bucket with a black thick substance on the top and on the bottom of the mop bucket and black thick substance on the wringer of the mop bucket. Interview with the Environmental Manager on 8/26/19 at 1:40 PM, in the clean linen room of the laundry room, the Environmental Manger was asked if the mop bucket was dirty. The Environmental Manager stated, .Yes . The Environmental Manager was asked if the dirty mop bucket should have been stored in the clean linen room. The Environmental Manager stated, No. Observations in the washing machine room of the laundry room on 8/26/19 at 1:45 PM and 2:55 PM, and on 8/27/19 at 1:45 PM and 2:55 PM, revealed an exhaust fan with thick white and gray debris stuck to the fan. The gray debris was blowing over the clean, uncovered linen. Observations in the dryer machine room of the laundry room on 8/26/19 at 1:55 PM and 3:00 PM, revealed uncovered clean dry laundry piled in wire baskets. A clean sheet was hanging out of the basket touching the floor. Interview with the Environmental Manager on 8/26/19 at 3:04 PM, in the dryer room of the laundry room, the Environmental Manager was asked if the laundry in the wire baskets was clean. The Environmental Manager stated, Yes. Observations in the clean linen room of the laundry room on 8/27/19 at 1:40 PM, revealed a dirty empty mop bucket with a black thick substance on the rim of a mop bucket and on the bottom of the mop bucket. Interview with the Environmental Manager on 8/27/19 at 2:57 PM, in the drying machine room of the laundry room, the Environmental Manager was asked if the clothes in the uncovered baskets, and if the sheet touching the floor were clean. The Environmental Manager stated, Yes . the clean clothes should be covered and not touching the floor . Interview with the Environmental Manager on 8/27/19 at 3:03 PM, in the washing machine room of the laundry room, the Environmental Manager was asked what was on the exhaust fan, and what was blowing off of the fan. The Environmental Manager stated, .it's coated with dirt and dust, shouldn't be blowing in the room .