**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to report allegations of sexual abuse for 1 of 4 (Resident 165) residents reviewed. The findings include: 1. Review of the facility policy titled Compliance with Reporting Allegations of Abuse/Neglect Exploitation dated 2/19/2025, revealed It is the policy of this facility to report all allegations of abuse .are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations .Sexual Abuse is the non-consensual sexual contact of any type with a resident .the facility will report all alleged violations and all substantiated incidents to the state agency .Abuse: The willful infliction of injury .intimidation .It includes .sexual abuse .is the non-consensual sexual contact of any type with a resident .Alleged violation: A situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment .Investigation: The facility will investigate all allegations and types of incidents .Reporting .The facility will report all alleged violations and all substantiated incidents to the state agency and to all other agencies required .The licensed/Registered Nurse will: Respond to the needs of the resident and protect him/her from further incident .Remove the accused employee from resident care areas .Notify the attending physician, resident's family/legal representative and Medical Director . Review of the Policy titled Abuse, Neglect and Exploitation, dated 2/19/2025 revealed .It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse .'Sexual Abuse' is non-consensual sexual contact of any type with a resident .Identification of Abuse, Neglect and Exploitation .Resident, staff or family report of abuse .The facility will make efforts to ensure all residents are protected from physical and psychological harm . 2. Review of medical records revealed Resident #165 was admitted to this facility on 10/6/2022, with diagnoses which include Type 2 Diabetes Mellitus, Major Depressive Disorder, and Bipolar Disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #165 was cognitively intact. Review of the Care Plan revealed 3/25/2024 Resident #165 had .Behavioral Symptom r/t [related to] emotional outbursts .noted to place herself on the floor .history if telling stories that are not exactly accurate .history if making sexual inappropriate statements and making sexual advances towards staff . Review of Resident Progress Notes dated 4/10/2024 at 12:30 PM, revealed Social Service Director (SSD) documented Resident making false accusations about staff/care received. Review of Resident Progress Notes dated 4/12/2024 at 7:11 AM, SSD documented Resident #165 .Recently exhibited increase in socially inappropriate behaviors related to male staff members and making false allegations . Review of Progress Notes dated 4/14/2024, revealed Resident #165 was seen by the Medical Director. Review of TIBRS (Tennessee Incident Based Reporting System) Narrative dated 4/12/2024 at 10:28 AM, revealed The Director of Nursing (DON ) .stated the staff was made aware of the allegations by a resident of the facility [Named Resident #165] on Wednesday April 10, 2024, and began looking into the allegations .there was an allegation that [Named LPN H] had inappropriate sexual contact with [Named Resident #165] on Tuesday 4/9/2024 during an examination of her pelvic and buttocks region due to complaints of hurting in the area. The DON stated [Named Resident #165] had a growth on her pelvic region that requires them to have 2 staff with peri care. Law enforcement reported Resident #165 was confused and was on the phone when she was interviewed. [Named Resident #165] reported to law enforcement she had been raped by [Named LPN H]. [Named Resident #165] allegedly reported she was asleep and knew he had sex with her.After getting information for a report I left the facility. I was contacted a short time later by [Named DON] and advised that after I left Named Resident [Resident #165] requested to speak with her. [Named Resident #165] informed the [named DON] that what she told did not happen. She stated she lied about it because she was mad. Named DON stated [Named Resident #165] had called her friend [Named FM I] and told her it was all a lie. [Named FM I] also stated she was on the phone with [Named Resident #165] when I [law enforcement] was speaking with her and she told me something totally different than she told her. Due to [Named Resident #165] stating she lied about the allegations this report is closed as unfounded . The Administrator was asked on 3/19/2025 to supply a copy of the URIS report mentioning Resident #165 and was unable to provide. An email was sent to the Ombudsman on 3/19/2025 at 8:59 AM, asking whether she had been notified of the allegation of sexual abuse by Named Resident #165 and the Ombudsman stated, she had not been notified. During an interview on 3/20/2025 at 4:45 PM, the Director of Nursing (DON) was asked whether education was done after the allegation of abuse by Resident #165, and she responded No. The DON was asked when this incident was reported to the state agency and she stated, it was not reported to the state agency. During an interview in the Conference Room on 3/20/2025 at 5:15 PM, the Administrator was asked if she was the Abuse Coordinator, and she responded that she was, and the DON would fill in when she was absent. The Administrator was asked when should abuse be reported and the Administrator responded, immediately. The Administrator was asked whether she reported the incident between Resident #165 and LPN H to the State Agency and she responded, I did not because the investigation was completed with the 2-hour window. A follow up question was asked . The Administrator stated, [Named LPN H] was suspended pending investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observations and interviews the facility failed to provide adequate personal hygiene and bathing to 4 of 8 (Resident #8, #13, #19, and #32) sampled residents reviewed for Activities of Daily Living. The findings include: 1. Review of the facility policy titled, Activities of Daily Living (ADLs), revised 1/2025, revealed .Care and services will be provided for the following .Bathing, dressing, grooming .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good .grooming, and personal and oral hygiene . Review of the facility policy titled Nursing Services and Sufficient Staff, dated 1/23/2025 revealed, .It is the policy of this facility to provide sufficient staff .to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident . 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Type 2 Diabetes, and Hypertensive Heart Disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 12, which indicated Resident #8 had moderate cognitive impairment and required substantial/maximal assistance with bathing. Review of the care plan revised 2/10/2025, revealed .Problem .has an ADL [Activities of Daily Living] self-care performance deficit r/t [regarding to] CVA [cerebrovascular accident] w/ [with] residual deficits, functional impairments .The resident will improve current level of function in ADL's through the review date .Approach .The resident requires substantial/maximal assistance by x1 [times 1] staff with bathing/showering . Review of Point of Care History dated 1/29/2025 - 3/18/2025, revealed .how did the resident bathe .activity did not occur . for dates 1/30/2025, 2/1/2025, 2/3/2025, 2/4/2025, 2/5/2025, 2/6/2025, 2/7/2025, 2/10/2025, 2/11/2025, 2/12/2025, 2/13/2025, 2/15/2025, 2/16/2025, 2/19/2025, 2/20/2025, 2/21/2025, 2/26/2025, 2/27/2025, 3/1/2025, 3/2/2025, 3/4/2025, 3/5/2025, 3/9/2025, 3/10/2025, 3/11/2025, 3/13/2025, 3/14/2025, 3/15/2025, 3/16/2025, 3/17/2025, and 3/18/2025. Resident #8 is documented to have received a shower on 2/18/2025 only. Review of Progress notes dated 1/30/2025-3/18/2025 does not reveal documentation of Resident refusing showers. During observation and interview in the resident's room on 3/17/2025 at 9:55 AM, revealed the resident sitting in her wheelchair at the sink brushing her hair and wearing a red and black plaid pajama top and bottom. Resident stated that it had been two weeks since she had a shower and asked to speak later. During an interview on 3/17/2025 at 11:14 AM, Resident #8 confirmed that the last time she had shower was on last Wednesday (3/12/2025) with therapy and that she was supposed to get a shower every Tuesday and Thursday. During observation and interview in the resident's room on 3/18/2025 at 8:11 AM, revealed the resident in lying in bed wearing a red and black plaid pajama shirt. Resident #8 confirmed she has not changed clothes and that she has been wearing the same socks for several days. During an interview on 3/18/2025 at 9:51 AM, Certified Nursing Assistant (CNA) NN confirmed there is a shower list that lists which rooms get showers on which days and they are to fill out a shower sheet and document the shower in the computer. CNA NN was asked where the shower sheets are kept. CNA NN stated, I believe we do have a book. CNA NN was asked to provide the book. CNA N stated, Give me just a second. Observation in the hallway on 3/18/2025 at 10:25 AM revealed Resident #8 was up in wheelchair wearing red and black plaid pajama top and bottoms. The resident confirmed she was going to ask staff if she could have a shower. 3/18/2025 11:00 AM facility unable to provide any shower sheets on Resident #8. Observation in the resident's room on 3/18/2025 at 3:33 PM, revealed the resident wearing red and black plaid pajama top and bottoms. Resident #8 confirmed she asked CNA EE if she could have a shower and was told staff would try to. During an interview on 3/18/2025 at 3:36 PM, the Assistant Director of Nursing (ADON) was asked who is responsible for showers on the hall, she stated, .the tech on this hall that is responsible for that room . During an interview on 3/19/2025 at 9:35 AM, CNA PP was asked if she knew when the residents she took care of received showers. CNA PP stated, I look in our book. Where do you chart that, CNA PP stated, .Matrix .I can put what kind of bath in here . CNA PP was asked if Resident #8 ever refuse. CNA PP responded, No. During an interview on 3/19/2025 at 10:53 AM, the ADON acknowledged the staff is expected to document showers in the computer and on the shower sheet. During an interview on 3/20/2025 at 4:44 PM, the DON was asked how often residents should get bathed, the DON stated, Depending on their preference but usually 2 to 3 times per week . 3. Review of medical records revealed Resident #13 was admitted to the facility on [DATE], with diagnoses which include Secondary Malignant Neoplasm, Essential Hypertension and Chronic Atrial Fibrillation. Review of the admission MDS assessment dated [DATE], revealed a score of 13, which indicated Resident #13 was cognitively intact. Observation on 3/18/2025 at 8:48 AM, revealed Resident #13, a female resident, had facial hair on top lip and chin. Observation on 3/18/2025 at 3:20 PM, revealed Resident #13 remained in bed with bed clothes on and facial hair continued to be present on top lip and chin. Observation and interview in Resident #13's room on 3/19/2025 at 9:42 AM, revealed Resident #13 continued to have facial hair on top lip and chin. Resident #19 was asked whether she liked the facial hair removed and she stated, I get it shaved when somebody does it for me and I need this hair done to. During an interview on 3/19/2025 at 11:06 AM, CNA E was asked how often the female residents have their facial hair trimmed. CNA E stated, I usually shave their face on shower day. 4. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses including Alzheimer's, Bipolar Disorder, Anxiety, and Major Depressive Disorder. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated Resident #19 was cognitively intact, uses wheelchair for mobility and required substantial to maximal assist for shower/bath and supervision or touching assist needed for personal hygiene. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 12, which indicated Resident #19 was moderately cognitively impaired, required substantial to maximal assist needed for shower/bath and transfers, and supervision or touching assist needed for personal hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical records review, observations, and interviews the facility failed to follow physician orders and failed to obtain timely skin treatment orders for 2 of 20 (Resident #7 and #8) sampled residents. The findings include: 1. Review of the facility policy titled, Medication Orders, revised 2/2025, revealed .Medications should be administered only upon the signed order of a person lawfully authorized to prescribe .The charge nurse on duty at the time the order is received should note the order and enter it on the physician order sheet or electronic format . Review of the facility policy titled, Oxygen Administration, revised 1/23/2025, revealed .Oxygen is administered to residents who need it, consistent with professional standards of practice . Review of the facility policy titled, Wound Treatment Management, revised 3/2024, revealed .Wound treatments will be provided in accordance with physician orders .Treatments will be documented on the Treatment Administration Record . 2. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Depression, Anxiety, and Chronic Pain Syndrome. Review of the quarterly MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated she had no cognitive impairment, was dependent on staff for all care, always incontinent. Resident received Antianxiety, Antidepressants, Anticoagulants, and Anticonvulsants, and received Oxygen. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed a BIMS score of 12, which indicated she had moderate cognitive impairment. Resident was dependent on staff for all care and was always incontinent. Resident received Antianxiety, Antidepressants, and Anticonvulsants, and received Oxygen and Hospice care. Review of the care plan dated 10/9/2024, revealed .has altered respiratory status/difficulty breathing related to chronic respiratory failure .elevate head of bed .O2 per MD orders . Physician's Orders dated 10/22/2024 revealed .O2 [Oxygen] at 4 LPM [liters per minute] BNC [binasal cannula-a medical device to deliver supplemental oxygen through the nostrils] PRN [as needed] SOB [shortness of breath . Observation in the resident's room on 3/17/2024 at 9:56 AM and at 03/18/25 09:14 AM, revealed the resident's oxygen set to 2 liters. During an interview on 3/18/2025 at 9:22 AM, LPN F Confirmed that Resident #7's oxygen order was for 4 liters, and stated, .I will change that right now . During an interview on 3/20/25 at 4:44 PM, the Director of Nursing confirmed that physician's orders be followed regarding oxygen settings. 3. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Diabetes, and Hypertensive Heart Disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 12, which indicated Resident #8 had moderate cognitive impairment and is at risk for pressure ulcers/injuries. Review of the care plan revised 2/10/2025, revealed .Resident will not exhibit skin breakdown .Apply moisture barrier to skin .Report any signs of skin breakdown . Review of the facility's form titled, Skin Integrity Events, dated 3/14/2025, revealed .MASD [Moisture-Associated Skin Damage] to right and left buttock .zinc cream [used to protect skin from being irritated and wet] twice a day . Review of the Physicians Orders dated 3/14/2025- 3/18/2025, revealed no order for zinc cream. Review of the Progress Notes dated 3/14/2025 - 3/18/2025, revealed no documentation regarding the resident's skin condition. Review of the Physicians Orders dated 3/19/2025, revealed .Zinc to bil. bouttucks [bilateral buttocks] BID [twice a day] . Review of the progress note dated 3/19/2025 at 1:49 PM, the Advanced Practice registered Nurse Practitioner (APRN NP) documented, .Seen today for evaluation of MASD. The resident has skin irritation, redness to b/l [bilateral] buttocks .consult wound care. cleanse area with wound cleanser, apply zinc oxide to affected area BID until healed . During an interview in the resident's room on 3/17/2025 at 11:47 AM, the resident confirmed she has an open spot on her bottom and the staff is aware. During an interview on 3/19/2025 at 10:53 AM, the ADON was asked what the process is when a resident has a new skin condition, she stated, .document in progress note .who we contacted .implement those verbal orders .enter the order in the computer . The ADON acknowledged there was not a physician's order from 3/14/2025 - 3/19/2025 for treatment of the MASD. The ADON was asked if any treatments were provided from 3/14/2025-3/19/2025, she stated, .I do know she was getting the zinc applied . Observation in the resident's room on 3/19/2025 at 3:09 PM with the ADON revealed MASD to buttocks as described in event note. During an interview on 3/20/2025, at 4:44 PM, the DON was asked what should be done when a skin issue is identified, she stated, .notify the md [Medical Doctor] .look at it .do an event .notify family .get an order for treatment . The DON acknowledged that an identified skin issue should be documented in the medical record, should receive an order on the day a skin issue is identified, and that nursing staff cannot treat a skin issue without an order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility assessment review, medical record review, facility ADL (Activities of Daily Living) documentation review, facility staffing time punch review, observations, and interviews, the facility failed to maintain adequate staffing levels to meet the ADL needs (bathing/showers, grooming, and skin care) for 5 residents (Residents #7, #8, #13, #19, and #32) of 20 residents reviewed for ADL care. The findings include: 1. Review of the facility assessment dated [DATE], revealed . Average Daily Census (ADC) .50 .Registered Nurse Hours per Resident Day . 18.76 .Licensed Nurse Hours per Resident Day .55.20 .Nurse Aide Hours per Resident Day .55.01 .Total Nursing Hours per Resident Day .128.97 . 2. Review of the facility policy titled Nursing Services and Sufficient Staff, dated 1/23/2025, revealed .The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents .nurse aides . Review of the facility policy titled, Facility Assessment, last revised on 1/25/2025, revealed .The facility conducts and documents a facility-wide assessment to determine what resources are necessary to care for our residents . The facility assessment will, at a minimum, address or include .the facility's resident population .The care required by the resident population .The facility will use the facility assessment to . Inform staffing decisions to ensure there are a sufficient number of staff .Consider specific staffing needs for each resident unit .each shift .and adjust as necessary based on any changes to its resident population .The facility assessment will be reviewed and updated as necessary and at least annually .based on changes to resident population . 3. Review of Licensure Staffing Requirements for 2/15/2025- 3/14/2025, revealed the facility census average for that period was 65. Review of Licensure Staffing Requirements for 2/15/2025- 3/14/2025, revealed on 2/15/2025, 2/22/2025, and 2/23/2025 the Aide hours were below the facility's assessment of 1.1 nurse aide hours per resident. Continued review revealed on 2/15/2025 nurse aide hours per resident were 0.73. Review revealed on 2/22/2025 nurse aide hours per resident were 1.08. Review revealed on 2/23/2025 nurse aide hours per resident were 1.04. Review of the Federal requirement for 483.35(b) Registered nurse, 483.35(b)(1), and 483.35(b)(3) for F727 revealed, . Except when waived under paragraph (e) or (f) of this section, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week .483.35(b)(3) The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents . 4. Review of the clock in and clock outs for 2/15/2025 from 7:32 AM until 6:51 PM (11 hours 19 minutes) [named Certified Nursing Assistant CNA #E] was the only CNA in the facility. Review of the clock in and clock outs for 3/15/2025 from 10:30 PM until 3/16/2025 at 7:06 AM (8 hours 36 minutes) revealed CNA #Q was the only CNA in the facility. 5. The facility failed to provide adequate personal hygiene and bathing Activities of Daily Living for Resident #8, #13, #19, and #32. 6. The facility failed to obtain timely skin treatment orders for Resident #8. 7. The facility failed to maintain Registered Nurse (RN) coverage for 8 consecutive hours a day 7 days a week. 8. During an interview on 3/19/25 at 11:11 AM, CNA A stated, .I am taking care of 20 residents today .the hospitality aides answer call lights, help with activities, pass ice, they cannot give any direct care because they are uncertified . During a telephone interview on 3/19/2025 at 6:03 PM, CNA B was asked about staffing for the facility. CNA B stated, .it is bad .I work night shift 7 PM to 7 AM, there have been numerous nights I have come in and meals are still not passed out and I have to feed residents on the hall .I know it's going to be a bad night if the trays are still on the hall .the nurses are having to work the floor as CNAs at times because we don't have enough help .baths are not getting done . CNA B was asked if she was able to complete incontinence care, turning and repositioning every 2 hours. CNA B stated, .when we come in and trays are still out it maybe 8:30 [8:30 PM] or 9:00 [9:00 PM] before we can ever start our turns by that time the residents are soaked .residents are left up in their chairs all day and when I go to get them out of the chair with the lift, the urine will get on me .I know of several days that only 1 CNA in the whole building .there are times I don't get to sit down to do any charting until 12:00 [12:00 AM] .I have expressed my concerns to nursing and they tell me just take a break for a little while .If you raise any concerns about the resident care the management staff will say your being aggressive .they want that point of care charting to be 100% .resident with skin issues, rashes, UTI's [Urinary Tract Infections] and it is because they are sitting in s . for hours .residents that really need 2 person assist you have to find help because they are so fragile I am afraid I might hurt them and that is hard when you are on the hall by yourself .there are 3 areas where you can chart showers either on paper or when you go in the computer you click on a link for ADLs and you either chart shower or bath . During an interview on 3/20/2025 at 9:08 AM, CNA N was asked why most CNA's have 20 residents a piece to care for CNA N stated, We have been short staffed this week. During an interview on 3/20/2025 at 8:20 AM, Licensed Practical Nurse (LPN) L confirmed she tries to assist staff with rounds when she can but her duties as a nurse often consume all her time. LPN L stated that there were 2 CNAs on her hall but now it is 1 and it is a lot for them to do. During an interview on 3/20/2025 at 8:27 AM, Registered Nurse (RN) J was asked how many CNAs usually work during the day. RN J stated, .We like to run 5-6, but we've had a lot of sickness over the last month. Most days we have had 4 people, this week has been harder, mostly 3 this week . During an interview on 3/20/2025 at 4:46 PM, the Director of Nursing (DON) was asked if a CNA could give adequate care to 20 residents. The DON stated that they could if they have support from the nurses, and that the nurses could assist with giving showers and doing ADLs between med passes. The DON confirmed the morning medication pass takes 2 to 3 hours and nurses give medications throughout the day, assist with meals, provide wound care, communicate with family and physicians, deal with events such as falls, and occasionally do lab draws. Refer to F677, F684, F727

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy, Facility Assessment review, Chapter 1000-02 Rules and Regulation of the Licensed Practical Nurses Rules and Regulations review, employee file review, medical record review, observation and interview, the facility failed to ensure all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely for 2 of 2 (Resident #50 and Resident #63) sampled residents with PICC lines (Peripherally Inserted Central Catheter inserted into the arm and threaded into a large vein near the heart). The findings include: 1. Review of the facility policy titled, Nursing Services and Sufficient Staff, dated 1/23/2025 revealed, .It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident .The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for resident's needs as identified through resident assessments and described in the plan of care . 2. Review of the facility policy titled, Facility Assessment, revised 1/25/2025 revealed, .The facility assessment will, at a minimum, address or include .care required by the resident population, using evidence-based, data-driven methods .staff competencies and skill sets that are necessary to provide the level and types of care needed . 3. Review of CHAPTER 1000-02 RULES AND REGULATIONS OF LICENSED PRACTICAL NURSES dated 10/2024, revealed 1000-02-.02 (3), .Licensed Practical Nurses shall not administer the following fluids/medication/agents or drug classifications in the context of intravenous therapy .Titrated medication and dosages calculated and adjusted by the nurse based on patient assessment and/or interpretation of lab values . and 1000-02-.02 (4) (a) 1.The Licensed Practical Nurse administers IV [Intravenous] push medications in peripheral lines [flexible tube inserted into a vein in the arm, hand, leg, or foot] only . 4. Review of the medical record revealed Resident #50 admitted on [DATE] and readmitted on [DATE] with diagnoses which included Osteomyelitis of Vertebra (bone infection of the spinal column), lumbar region. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #50 was receiving IV medications over the last 7 days. Review of the Physician Order Report dated 2/20/2025-3/20/2025 revealed an order for PICC line for Antibiotic (ATB) infusion with start date 3/12/2025. Continued review revealed an order for Vancomycin (Antibiotic given that may require blood levels to monitor dosage) 1,250 mg (milligram) intravenous with start date of 1/28/2025 and Ceftriaxone (antibiotic) 2 gm (gram) intravenous with start date of 2/27/2025. Review Hospital #1's Discharge Instructions dated 2/27/2025 for Resident #50 revealed, .You [Resident #50] are going home with a peripherally inserted central catheter (PICC) . Review of the Medication Administration History dated 3/1/2025-3/20/2025 revealed Daptomycin (Vancomycin) and Ceftriaxone (Rocephin) 2 gm was administered intravenously via PICC line by Licensed Practical Nurse (LPN) LPN L on 3/7/2025, 3/13/2025, 3/15/2025 and LPN M administered Daptomycin and Ceftriaxone intravenously via the PICC line on 3/15/2025 and 3/19/2025. 5. Review of the medical record revealed Resident #65 was admitted to the facility on [DATE], with diagnoses which included Osteomyelitis, unspecified and Charcot's (a progressive condition causing the bones and joints in the foot to degenerate) joint, right ankle and foot. Review of the MDS dated [DATE] revealed Resident #65 had an IV access over the last 7 days. Review of the Physician Order Report dated 2/20/2025 - 3/20/2025 revealed an order for PICC line dressing change per RN (Registered Nurse) every 3 days. Continued review revealed and order for Vancomycin 750 mg intravenous per venous catheter every 12 hours with start date of 3/15/2025. Review of the Medication Administration History dated 3/1/2025-3/20/2025 revealed Vancomycin 750 mg was administered intravenously through PICC line by LPN L on 3/17/2025 and 3/18/2025 and LPN M administered Vancomycin via the PICC line on 3/19/2025 and 3/20/2025. During an observation and interview on 3/19/2025 at 8:45 AM LPN M stated, .[Named Resident #50] has a PICC line and receiving Rocephin 2 gm, she has been here for 3 weeks, she is receiving the medication for Osteomyelitis of her Spine post her surgery . During the interview a lab tech informed LPN M she was unable to obtain the Vancomycin trough (lowest level of the drug in the resident's body to monitor the antibiotic) on Resident #65, the nurse informed the lab tech to let the Director of Nursing (DON) know on her way out so the DON could try and draw the lab from her PICC line. The LPN stated, .the lab comes every Wednesday to draw troughs . The LPN was asked if she could access a PICC line and she stated, .Yes I can hang the IV, but I can't draw blood from the port . The nurse put on her protective gown prior to going into the room to hang the Rocephin, she prepared the IV medication to hang on IV pole, flushes the tubing line and uses a dial a flow to set the rate, the nurse flushed the PICC line port with 10 ml [milliliters] of normal saline flush per a 10 ml syringe, hung the Rocephin, verified the IV antibiotic was dripping and the resident was ok. During an interview on 3/20/2025 at 8:52 AM, LPN L was asked if she had administered Vancomycin through [Named Resident #50 and Resident #65]'s PICC line. LPN L confirmed she had accessed the PICC line and ?performed the Vancomycin ?for [Named Resident #50 and Resident #65]. LPN L was asked if she had been through an IV certification course. LPN L stated, .I haven't gone anywhere for that. I don't remember any extra training I received here at the facility? .? During an interview on 3/20/2025 at 5:00 PM, the DON was asked if LPNs could access PICC lines and hang IV antibiotics. The DON stated, .LPNs can do anything but hang blood products or push medications. They can and have been trained. I have skill check offs; we provide training and skill check offs . 6. Review of Licensed Practical Nurse (LPN) M's employee file revealed training for Peripheral IV Insertion dated 7/19/2024 with the observer's signature of Registered Nurse (RN) C. No specialized IV (intravenous) training for PICC lines [thin tube inserted into a vein in the arm and threaded to a large vein near the heart] was found in the employee file. Review of LPN L's employee file revealed training for Peripheral IV Insertion dated 8/8/2024, with the observer's signature as LPN O. LPN L's employee file revealed no specialized IV training. 7. The Regional Nurse came to the conference room on 3/20/2025 at 6:07 PM and presented a copy of Chapter 1000-02 Rules and Regulation of Licensed Practical Nurses and stated, .Nothing says they cannot . referring to accessing a PICC line.

Based on facility policy review, record review, and interviews, the facility failed to maintain Registered Nurse (RN) coverage for 8 consecutive hours a day 7 days a week. The findings included: 1. Review of the facility policy titled Nursing Services and Sufficient Staff, dated 1/23/2025 revealed, .It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment .The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for resident's needs as identified through resident assessments and described in the plan of care .Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week .The Director of Nursing [DON] may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents . 2. Review of the facility's licensure information revealed the facility has 4 RNs. Review of the staffing clock in and out punches for 2/15/2025, and 2/22/2025 revealed no RN coverage for 8 consecutive hours. Review of the staffing clock in and out punches for 3/6/2025, revealed no RN coverage for 8 consecutive hours. Director of Nursing (DON) worked 8.5 hours; facility census was 64. Review of the facility's Daily Nurse Staffing Form dated 3/6/2025, revealed there were no RNs scheduled that date. 3. During an interview on 3/20/2025 at 4:46 PM, the DON confirmed there must be RN coverage for 8 consecutive hours every day and that the DON cannot serve as a charge nurse if the facility's average daily occupancy is greater than 60.

Based on facility policy, observation and interview the facility failed to store all drugs in accordance with currently accepted professional principles for 1 of 4 medication storage areas. The findings include: 1. Review of the facility policy titled, Medication Storage, with revision date 9/2024 revealed, .It is the policy to this facility to ensure all medications housed on our premises will be stored in accordance to .External Products .drugs for external use are stored separately from internal .medications .Internal Products: Medications to be administered by mouth are stored separately from other formulations ( .eye drops .). 2. During an observation and interview on 3/19/2025 at 10:56 AM, Registered Nurse (RN) L was working on the White medication cart. RN L was asked to open the medication cart so surveyor could review the storage of medications. Continued observation revealed a bottle of antacid chewable tablets stored with eye drops and an ear wax removal bottle stored with the topical Lidocaine (topical pain medication) and Nicotine (transdermal patch used to quit smoking) patches. RN L was asked if these medications should be stored together and she stated, No. During an interview on 3/20/2025 at 4:45 PM, the Director of Nursing (DON) was asked if oral medications should be stored with the eye drops; she stated, No. The DON was asked should an ear wax removal kit be stored with topical patches and she stated, No.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, document review, record review, and interview, the facility failed to ensure staff reported an incident of alleged abuse to administrative staff and to the state survey agency for 1 of 3 (Resident #7) residents reviewed for abuse. Findings included: 1. Review of the facility policy titled, Abuse, Neglect, and Exploitation, with a revision date of 08/30/2022, revealed It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Further review revealed, VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. 2. Review of Resident Progress Notes, dated 01/27/2023, revealed Resident #7 was initially admitted to the facility. Review of the Resident Progress Notes, dated 01/29/2023 at 5:12 PM, revealed Resident #7 was sent to the hospital emergency room (ER) for evaluation. Review of Resident #7's Resident Face Sheet revealed the resident was readmitted to the facility on [DATE] with diagnoses that included Urinary Tract Infection and Unspecified Dementia. Further review of the Resident Face Sheet indicated the facility discharged the resident on 02/12/2023 and the resident did not return to the facility. A review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/10/2023, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident was moderately cognitively impaired. The MDS indicated Resident #7 exhibited other behavioral symptoms not directed toward others four to six days during the seven-day review period. The MDS indicated the resident required extensive assistance from staff for toilet use and personal hygiene and was always incontinent of urine and bowel. A review of Resident #7's Care Plan History, dated 02/06/2023 that indicated the resident had cognitive loss/dementia. Another problem statement, with a start date of 02/06/2023, indicated the resident used psychotropic medication. Approaches directed staff to assess if the resident's behavioral symptoms presented a danger to the resident and/or others. A third problem statement, dated 02/06/2023, indicated the resident was at risk for developing pressure ulcers related to incontinence. Approaches directed staff to provide incontinence care after each episode of incontinence. Review of a nursing Progress Note, dated 01/29/2023 at 5:12 PM, indicated that while incontinence care was being provided Resident #7 hit one certified nursing assistant (CNA) across the face and struck another CNA in the chest. After care was provided, Resident #7 got out of bed and struck their roommate in the shoulder with their fist. The Progress Note indicated the resident was placed in a wheelchair in the line of sight of staff and was later sent to the emergency room (ER) for evaluation. Review of a nursing Progress Note, dated 02/02/2023 and written by the DON, indicated the resident was admitted to the hospital on [DATE] and was diagnosed with a urinary tract infection and pneumonia. The Progress Note indicated, that during an interview with staff members working at the time of the incident on 01/29/2023, Resident #7 thought a staff member was a man that rubbed their [genitalia] too hard during care. Review of a nursing Progress Note, dated 02/03/2023 at 6:20 PM, indicated the resident was transferred back to the facility from the hospital. The Progress Note indicated Resident #7 had redness and irritation in the genital area and was scratching the area and causing it to worsen. Review of a file provided by the Administrator on 09/20/2023, revealed that an investigation was conducted following the incidents that occurred on 01/29/2023 (the allegation by Resident #7 that a male staff member touched them roughly during care and the resident-to resident altercation between Resident #7 and their roommate). The file included statements dated 01/30/2023 from CNA #7 and Licensed Practical Nurse (LPN) #9, resident interviews, and a Care Management Progress Note from the hospital for Resident #7 (dated 01/29/2023 with a print date of 01/31/2023). Further review of documentation in the file indicated that staff in-servicing was provided on 01/30/2023 that included Abuse Investigating and Reporting, Signs of Abuse, Behavior Monitoring and the facility's policy related to behavior management plans and the Behavior Management Program Flowchart. Review of the phone interview statement made by CNA #7 and dated 01/30/2023 at 12:15 PM, indicated Resident #7 was assisted to use the toilet by two female CNAs (CNA #7 and CNA #8) on 01/29/2023. When CNA #8 wiped the resident's perineal area the resident hit CNA #8; CNA #7 said to the resident, Please don't hit us, and then Resident #7 struck CNA #7. According to the phone interview statement, Resident #7 later pointed at CNA #7 and stated, She's a part of the issue and that man that rubbed my [genital area] too hard, and pointed at CNA #8. The statement indicated that the CNAs noted Resident #7's perineal area was red, and that the area hurt when they touched the resident during perineal care. The statement also indicated that CNA #7 stated the CNAs did not report the incident to the nurse before Resident #7 hit their roommate but would be sure to report any similar incident next time. In an interview on 09/20/2023 at 12:24 PM, CNA #7 stated Resident #7 thought a man was rough with them during perineal care. CNA #7 stated there were no male staff working the night of 01/29/2023 and only she and CNA #8 were providing care for Resident #7. CNA #7 recalled that the Administrator and DON interviewed other residents on the hall where Resident #7 resided the next day to ask them about abuse and care. CNA #7 said she did not report Resident #7 stating that a man rubbed them too hard, to the DON until the next day. She stated she did not consider it abuse because they were trying to clean Resident #7 and change their brief when the resident made the comment. In an interview on 09/20/2023 at 1:30 PM, the Administrator stated the facility did not report the allegation made by Resident #7 to the state survey agency. He stated they did not report the allegation as abuse because it was determined to be a care issue since the resident was referring to the female CNA and stating she was a man, and staff had been conducting an adult brief change at the time. The Administrator stated there were no male staff members working during that shift. The Administrator stated the staff were in-serviced on abuse reporting in response to the allegation because the staff involved did not inform anyone about the allegation until the DON collected witness statements related to the resident becoming combative. The Administrator stated the facility had not reported the resident-to-resident altercation to the state survey agency either because when there was a resident-to-resident altercation, the facility reviewed whether the altercation was willfully intended toward the resident. He said in this case, Resident #7 was unaware of what they were doing, was sent to the hospital, and was diagnosed with a urinary tract infection that was likely associated with the combativeness. In an interview on 09/21/2023 at 12:00 PM, the Administrator reiterated that the allegation had not been reported because he knew from family conversations that Resident #7 had a history of making similar false allegations and the CNA that Resident #7 was referring to as a man was a female CNA who was trying to provide perineal care at the time the allegation was made. The Administrator stated he also took into account the fact that Resident #7 likely had pain in the perineal area due to being excoriated and had a chronic urinary tract infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, grievance log, medical record review, and interview, the facility failed to follow their grievance policy for 3 of 11 sampled residents (Resident #17, #41, and #258) interviewed. The findings include: 1. Review of the facility policy titled, Filing Grievances/Complaints updated 1-16-19, showed, .Our facility will help residents, their representatives (sponsor), other interested family members, or resident advocates file grievances or complaints when such requests are made .The facility will maintain evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision . 2. Review of the March, May, and July 2019 Grievance/Complaint Log showed there were no grievances documented for Resident #17, #41, and #258. The facility was unable to provide a Grievance/Complaint Log for August, September, October, November, and December 2019. 3. Medical record review showed Resident #17 was admitted to the facility on [DATE] with diagnoses of Vascular Dementia with Behavioral Disturbances, Schizoaffective Disorder, Paranoid Schizophrenia, and Depression. Review of the annual Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact for decision making. During an interview on 12/16/19 at 3:24 PM, Resident #17 stated, .had a christmas ball [ornament] stolen out of my room that my sister brought me .I told [Named Administrator] and they looked through my drawers .it had my name on it . During an interview on 12/17/19 at 4:50 PM, the Administrator stated, .she just told me this afternoon, today .someone brought her to my office and she told me .she has two sons but no sisters or daughters .usually I talk with the resident to see if the item is misplaced .Grievance/complaint form is filled out when I determine whether something has actually been stolen . The Administrator was asked how long it takes for a complaint to be resolved. The Administrator stated, .5 business days .I haven't started my typical stuff for [named Resident #17] yet .I haven't filled out a grievance form yet . 3. Medical record review showed Resident #41 was admitted to the facility on [DATE] with diagnoses of Congestive Heart Failure, Anxiety Disorder, Depression, and Chronic Obstructive Pulmonary Disease. The Annual MDS dated [DATE] showed a BIMs of 15. During an interview on 12/17/19 at 8:22 AM, Resident #41 confirmed that she had 2 crosses broken by a member of housekeeping staff while cleaning her room. The resident confirmed she had notified the Administrator 6-7 months ago. The resident stated, .He [Administrator] glued them together but they won't stay .just in pieces .I just wrapped it in a napkin and put it in my drawer. During an interview on 12/17/19 at 5:00 PM, the Administrator confirmed that Resident #41's broken items were not placed on the Grievance Log. 4. Medical record review revealed Resident #258 was admitted to the facility on [DATE] with diagnoses of Diabetes Mellitus, Congestive Heart Failure, and Anxiety Disorder. Th admission MDS dated [DATE] documented Resident #258 had a BIMs score of 14. The undated INVENTORY OF PERSONAL EFFECTS form labeled with Resident #258's name showed the resident had a .Cell phone . on admission. During an interview on 12/16/19 at 3:47 PM, in Resident #258's room, the resident was asked if he ever had any missing personal property. The resident stated, My telephone charging cord is missing. I have told everyone . During an interview on 12/17/19 at 5:23 PM, the Administrator confirmed no grievances had been placed on the log since July. The Administrator stated, .Sometimes I think it's the severity of what's missing .if it's money that's different .I hate to say that . The Administrator was asked when he should be notified of grievances. The Administrator stated, .Policy is they notify me immediately .