**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual Version 1.19.1 review, medical record reviews, and interviews the facility failed to ensure MDS assessments were accurate for 3 residents (Resident #33, #40, and #55) of 18 residents reviewed for MDS assessments. The findings include: Review of the MDS 3.0 RAI Manual, dated 10/2024, revealed .Health-related Quality of Life .residents covered by Level II PASRR [Pre-admission Screening and Resident Review] process may require certain care and services provided by the nursing home .Steps for Assessment .Code .yes if PASRR Level II screening determined that the resident has a serious mental illness .Determination of Pressure Ulcer/Injury Risk .Pressure ulcers/injuries occur when tissue is compressed between a bony prominence and an external surface .Steps for Assessment .Review the medical record, including skin care flow sheets or other skin tracking forms, nurses' notes, and pressure ulcer/injury risk assessments .Examine the resident and determine whether any ulcers, injuries, scars .are present. Assess key areas for pressure ulcer/injury development .sacrum .coccyx .Check A [yes] if resident has .a scar over bony prominence .Special Treatments, Procedures, and Programs .Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs .Dialysis .Code .renal dialysis which occurs at the nursing home or at another facility . Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Insomnia, Seizures, Delusional Disorders, and Anxiety. Review of the PASRR Level Two Outcome for Resident #33 dated 1/30/2020, revealed the PASRR screening determined the resident had a serious mental illness. Review of the annual MDS assessment dated [DATE], revealed Resident #33 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact and the resident was not identified to have a serious mental illness. During a record review and interview on 3/25/2025 at 3:45 PM, MDS Licensed Practical Nurse (LPN) B and MDS LPN C stated Resident #33 had a serious mental illness and confirmed the annual MDS assessment dated [DATE] was inaccurate. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease, Peripheral Vascular Disease, High Potassium Blood Levels, and Hypertension. Review of the comprehensive care plan for Resident #40 revised 5/27/2024, revealed the resident received dialysis. Review of a quarterly MDS assessment for Resident #40 dated 3/1/2025, revealed the resident scored a 15 on the BIMS assessment which indicated the resident was cognitively intact and the resident did not receive dialysis. During an interview on 3/24/2025 at 2:00 PM, Resident #40 stated she received dialysis on Tuesdays, Thursdays, and Saturdays. During a telephone interview on 3/25/2025 at 3:10 PM, Dialysis Nurse D stated Resident #40 received dialysis treatments. During an interview on 3/25/2025 at 4:15 PM, the Director of Nursing (DON) stated Resident #40 received dialysis treatments and confirmed the quarterly MDS assessment dated [DATE] was inaccurate. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Adult Failure to Thrive, and Difficulty Walking. Review of the skin assessment for Resident #55 dated 2/4/2025, revealed the resident had a wound over a sacral scar. Review of the quarterly MDS assessment for Resident #55 dated 2/5/2025, revealed the resident scored a 4 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further review revealed the resident did not have a sacral scar or wound over a bony prominence. During an observation and interview on 3/24/2025 at 9:25 AM, with the wound care nurse revealed Resident #55 had a wound over a sacral scar. The wound care nurse confirmed the wound had slough (dead tissue) and depth. During an interview on 3/25/2025 at 3:45 PM, MDS LPN B and MDS LPN C stated Resident #55 had sacrum scarring with a wound which was over a bony prominence and confirmed the quarterly MDS assessment dated [DATE] was inaccurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record reviews, and interviews the facility failed to refer 2 residents (Resident #15 and Resident #32) to the state designated Pre-admission Screening and Resident Review (PASRR) agency after a new mental health diagnosis of 7 residents reviewed for PASRR. The findings include: Review of the facility's policy titled, Behavioral Health Services, undated, revealed .Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care .Residents who do not display symptoms of, or have not been diagnosed with, mental, psychiatric, psychosocial adjustment, substance abuse, or post-traumatic disorder(s) will not develop behavioral disturbances .any assessment that reveals .mental health disorders (PASRR ) will be addressed . Review of a PASRR Level One Screen Outcome for Resident #15 dated 2/5/2024, revealed the resident had 3 mental health conditions which included Schizoaffective Disorder, Depression, and Anxiety. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including Dementia, Depression, Schizoaffective Disorder, Anxiety, and Insomnia. Review of a quarterly Minimum Data Set (MDS) assessment for Resident #15 dated 12/28/2024, revealed the resident scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the medical record revealed on 10/18/2024, Resident #15 was diagnosed with Adjustment Disorder, a new mental health condition. Further review of the medical record revealed the resident had not been referred to the state designated PASRR agency after a new mental health diagnosis was identified. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including Sleep Terrors, Insomnia, Depression, Anxiety, and Hallucinations. Review of a PASRR Level One Screen Outcome for Resident #32 dated 12/7/2021, revealed the resident had 4 mental health conditions which included Major Depression, Anxiety Disorder, Depression, and Insomnia with Night Terrors. Review of the medical record revealed on 10/18/2024, Resident #32 was diagnosed with Psychotic Disorder, a new mental health condition. Further review of the medical record revealed the resident had not been referred to the state designated PASRR agency after a new mental health diagnosis was identified. Review of a quarterly MDS assessment for Resident #32 dated 1/17/2025, revealed the resident scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. During a record review and interview on 3/25/2025 at 4:15 PM, the Director of Nursing (DON) confirmed Resident #15 and Resident #32 were diagnosed with a new mental health condition and the facility failed to refer Resident #15 and Resident #32 to the state designated PASRR agency after a new mental health diagnosis was identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interviews the facility failed to revise the care plan timely for 1 resident (Resident #28) of 18 residents' care plan reviewed. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed .The comprehensive, person-centered care plan .describes the services that are to be furnished .care plans are revised as information about the residents and the residents' condition change .the Interdisciplinary team reviews and updates the care plan .at least quarterly, in conjunction with the required quarterly MDS [minimum data set] assessment . Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, Difficulty Swallowing, Communication Deficit, Difficulty Speaking, and Gastrostomy Status [a surgical entry into the stomach to deliver feeding]. Review of the comprehensive care plan for Resident #28 dated 9/3/2022, revealed the resident received enteral feeding [by a tube inserted into the stomach]. Review of a quarterly MDS assessment for Resident #28 dated 3/1/2025, revealed the resident scored a 00 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review of the quarterly MDS assessment revealed the resident did not receive nutrition by a tube. During an observation on 3/23/2025 at 3:20 PM, revealed Resident #28 was laying in bed and no enteral feeding was observed. During an interview on 3/24/2025 at 8:00 AM, Licensed Practical Nurse (LPN) A stated Resident #28 previously received enteral feedings, and stated the resident had not received enteral feedings .for a long time . During an observation on 3/24/2025 at 8:10 AM, revealed Resident #28 was seated in a wheelchair and no enteral feeding was observed. During an interview on 3/25/2025 at 2:00 PM, LPN Supervisor stated the resident previously received supplemental enteral tube feedings and stated the enteral tube feedings were discontinued related to the resident's appetite increase. The LPN supervisor stated the enteral tube feedings were discontinued .a while back . During an interview on 3/25/2025 at 3:45 PM, MDS LPN B stated Resident #28 did not currently receive enteral feedings and confirmed the comprehensive care plan had not been revised when the enteral feedings were discontinued.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation review, and interviews, the facility failed to prevent physical abuse for 1 resident (Resident #1) of 8 residents reviewed for abuse. The findings include: Review of the facility policy titled, Resident Rights, dated 2/2021, revealed .Federal and state laws guarantee certain basic rights to all residents of this facility .include the resident's right to .be free from abuse . Review of the facility policy titled, Abuse, Neglect, Exploitation, Misappropriation Prevention Program, dated 10/2022, revealed .It is the policy of the facility to maintain an environment where residents are free from abuse .Abuse includes but is not limited to .physical .residents have the right to be free from abuse .Protect residents from abuse .by anyone including .facility staff . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Hypertension, and Generalized Muscle Weakness. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 15 on the Brief Interview of Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the facility's investigation documentation for Resident #1 dated 7/11/2024 at 5:15 PM, revealed Certified Nursing Assistant (CNA) D answered Resident #1's call light, the resident stated her back was hurting. Resident #1 stated that she wanted to be put on her side and pillows placed between her legs. CNA D started to put the head of the bed down and Resident #1 started screaming at CNA D to stop. CNA D stopped and explained to Resident #1 she needed to lay flat to be able to turn the resident onto her side. Resident #1 raised herself up and put her finger in CNA D's face and screamed at the CNA. CNA D asked Resident #1 to stop yelling but the resident continued to scream and had her face in CNA D's face. CNA D then touched Resident #1's chin and asked the resident to stop. CNA D stated that she knew what she had done (touching the resident's chin) was wrong, immediately left the room and told Licensed Practical Nurse (LPN) B what had happened. LPN B instructed CNA D to wait in the conference room for further instructions. LPN B went immediately to Resident #1's room and assessed the resident's face. LPN B stated Resident #1 did not have any marks or bruising to face. Resident #1 thanked LPN B for checking her and stated she felt safe in the facility. LPN B assigned another CNA to Resident #1 and notified the Supervisor (LPN E) of what had happened. LPN E immediately went to assess Resident #1 and there were no red areas or bruising to the resident's face. LPN E immediately called the Director of Nursing (DON) and Administrator. CNA D was placed on suspension pending an investigation. CNA D was terminated on 7/12/2024 (1 day after the event) as the result of facility's findings during investigation. Review of the Progress Note for Resident #1 dated 7/11/2024 5:15 PM, revealed . CNA REPORTED TO THIS NURSE THAT SHE TOUCHED PTS [patient's] [Resident #1's] CHEEKS.THIS NURSE WENT TO ASSESS PT [patient] [Resident #1]. SKIN C/D/I. [clean, dry, intact] NO REDNESS OR BRUISING NOTED AT THIS TIME .NO S/S [signs or symptoms] OF DISTRESS OR DISCOMFORT NOTED. SUPERVISOR NOTIFIED. DON NOTIFIED. ADMINISTRATOR NOTIFIED . Review of the facility document titled, admission Skin Assessment form, for Resident #1 dated 7/11/2024, revealed .no skin issues noted with skin . Review of the Local Police Department Initial Incident Report for Resident #1 dated 7/11/2024, revealed, .spoke with [Resident #1] who stated that [CNA D] had grabbed her chin .no visible injuries noted . Review of the Progress Note for Resident #1 dated 7/12/2024, revealed, .SS [Social Services] met with resident this morning in her room to follow up with event on 7/11 [7/11/2024] .calm throughout conversation with no signs or symptoms of distress noted .stated that she did not remember anything happening yesterday .confirmed that she feels safe in facility and denied any current needs. SS will continue to f/u (follow up) with resident for all SS needs . Review of the Progress Note for Resident #1 dated 7/13/2024, revealed, .lying in bed with eyes open .No s/s ( signs and symptons) of acute distress has been noted or reported .Mood and affect pleasant . Review of the Progress Note for Resident #1 dated 7/16/2024, revealed, .monitor mental status and provide psychotherapy as indicated .resident states she is very tired .she stated she is ok but did not elaborate on anything .did not mention the abuse allegation until asked if there was anything new that had happened .asked if she was feeling better and she said yes . During an observation and interview on 10/7/2024 at 1:05 PM, revealed Resident #1 lying on her left side in bed with the head of the bed elevated. Resident #1 stated she had been at the facility about 6 months, the staff were good to her, and she felt safe in the facility. Resident #1 further stated there was an incident with an associate (CNA D) in the past, the incident had been taken care of, and the resident did not want to talk about the incident anymore. During an interview on 10/7/2024 at 3:04 PM, LPN B stated on 7/11/2024 CNA D alerted LPN B that Resident #1 and CNA D had an altercation in Resident #1's room. CNA D told LPN B that Resident #1 asked to be rolled onto the back related to discomfort. CNA D told LPN B she proceeded to lower Resident #1's head of bed to reposition the resident. Resident #1 became belligerent and yelled at CNA D .don't lower me down, that's not how you do it . the resident continued to yell and point her finger at CNA D. CNA D stated she then squeezed Resident #1's cheeks and told the resident to not speak to her like that. CNA D immediately left Resident #1's room and reported what happened to LPN B. LPN B instructed CNA D not to go into any residents' rooms and to sit in conference room. LPN B went to Resident #1's room and asked the resident how she was doing. Resident #1 responded she was fine but wanted to report CNA D for squeezing her face. LPN B assessed Resident #1's face and there was no red areas or bruising noted. LPN B stated she repositioned Resident #1 while in the room. LPN B stated she asked Resident #1 again if she was okay and informed the resident that her safety was her biggest priority. Resident #1 stated she was fine and thanked LPN B for checking on her. LPN B notified the Supervisor (LPN E) of what had been reported. During an interview on 10/7/2024 at 3:18 PM, LPN E stated on 7/11/2024, LPN B reported to LPN E that CNA D had squeezed Resident #1's face. LPN E immediately assessed Resident #1's face and did not observe any red areas or bruising to the resident's face. LPN E further stated Resident #1 told LPN E that CNA D had squeezed her face. LPN E stated the DON and the Administrator was notified of the event. CNA D was placed on suspension pending and investigation and was sent home. During an interview on 10/8/2024 at 9:15 AM, Social Services Director (SSD) revealed she spoke with Resident #1 on 7/12/2024 and the resident stated she felt safe at the facility. During an observation, interview, and review of the facility investigation on 10/8/2024 at 12:20 PM, with the DON revealed on 7/11/2024 CNA D was providing care to Resident #1 and the resident became aggressive towards CNA D. CNA D touched Resident #1's face. CNA D immediately left the resident's room and told LPN B what happened. LPN B immediately assessed Resident #1's face for any injuries and did not observed red areas or bruising to the resident's face. The DON stated CNA D was asked to write a statement about the event. CNA D was placed on suspension pending an investigation, and the DON instructed CNA D to immediately leave the facility after the witness statement had been completed. During an interview on 10/8/2024 at 1:30 PM, The Executive Director confirmed physical abuse towards Resident #1 had taken place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to protect a resident's rights to be free from misappropriation and/or exploitation when money totaling $400.00 was taken from 1 resident (Resident #3) of 4 sampled residents reviewed for misappropriation. The findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, reviewed on 10/2022, revealed .It is the policy of the facility to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident property . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Type 2 Diabetes Mellitus, Malignant Neoplasm of Base of Tongue, and Adult Failure to Thrive. Continued review revealed the resident expired in the facility on [DATE] on hospice services. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the facility investigation documentation dated [DATE], revealed Resident #3 reported he was missing $400.00 from his bedside table/nightstand. Resident #3 had stated he had last counted his money on [DATE]. He did not take his money with him on [DATE] when he left his room to go out to a doctor's appointment. Review of a police report dated [DATE], revealed .on [DATE] .received a call to a theft from building .[name of facility] .upon receiving call, the administrator .stated that a resident named .[Resident #3] .wanted to make a report regarding a suspected theft from his room of $400.00 cash .the victim further stated that he had no idea who had taken the money from his room, and did not suspect anyone in particular . During an interview on [DATE] at 3:05 PM, Licensed Practical Nurse (LPN) B stated she was approached by LPN A who stated Resident #3 notified her of the $400.00 missing. Continued interview with LPN B notified the Administrator who had instructed her to go and check the resident's room with his permission for the missing money. The LPN stated the money was not found. During an interview on [DATE] at 9:05 AM, LPN A confirmed she was the first-person Resident #3 had notified about the missing money. Continued interview confirmed both herself and LPN B searched the resident's room for the missing money and the money was not found. During an interview on [DATE] at 1:00 PM, the Administrator confirmed the facility substantiated the allegation of misappropriation for Resident #3. The Administrator stated the $400.00 was reimbursed to Resident #3 by the facility. The Administrator further confirmed the facility could not determine who was responsible for the misappropriation of Resident #3's property.