**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to assure that a resident received an accurate assessment by staff qualified to assess relevant care areas for 1 of 1 (Resident #15) sampled residents reviewed. The findings include: Review of the Resident Assessment Instrument (RAI) (a means of ensuring that residents receive the highest quality of care and can maintain the highest quality of life) dated 10/2023, revealed .Intent: The intent of this section is to record the frequency that the resident was restrained by any of the listed devices or an alarm was used, at any time during the day or night, during the 7- day look-back period. Assessors will evaluate whether or not a device meets the definition of a physical restraint or an alarm and code only the devices that meet the definitions in the appropriate categories .Proper interpretation of the physical restraint definition is necessary to understand if nursing homes are accurately assessing manual methods or physical or mechanical devices, materials or equipment as physical restraints and meeting the federal requirements for restraint use .The regulation specifically states, 'The resident has the right to be free from any physical or chemical restraints imposed for the purposes of discipline or convenience and not required to treat the resident's medical symptoms' (42 CFR 483.10(e)(1) and 483.12) .Prior to using any physical restraint, the nursing home must assess the resident to properly identify the resident's needs and the medical symptom(s) that the restraint is being employed to address. If a physical restraint is needed to treat the resident's medical symptom(s), the nursing home is responsible for assessing the appropriateness of that restraint .Residents who are cognitively impaired are at a higher risk of entrapment and injury or death caused by physical restraints. It is vital that physical restraints used on this population be carefully considered and monitored .When the interdisciplinary team determines that the use of physical restraints is the appropriate course of action, and there is a signed physician order that gives the medical symptom supporting the use of the restraint, the least restrictive manual method or physical or mechanical device, material or equipment that will meet the resident's needs must be selected .Steps for Assessment 1. Review the resident's medical record (e.g., physician orders, nurses' notes, nursing assistant documentation) to determine if physical restraints were used during the 7-day look-back period .2. Consult the nursing staff to determine the resident's cognitive and physical status/limitations .3. observe the resident to determine the effect the restraint has on the resident's normal function .4.Evaluate whether the resident can easily and voluntarily remove any manual method or physical or mechanical device, material, or equipment attached or adjacent to their body .5. Any manual method or physical or mechanical device, material or equipment should be classified as a restraint only when it meets the criteria of the physical restraint definition .6. Determine if the manual method or physical or mechanical device, material, or equipment meets the definition of a physical restraint as clarified .After determining whether or not an item listed in (P0100) is a physical restraint and was used during the 7-day look-back period, code the frequency of use . The facility uses the RAI manual in the place of a MDS policy. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Anxiety Disorder, and Seizures. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Review of the Quarterly MDS dated [DATE] revealed Resident #15 had a BIMS score of 2 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #15 was not coded for a restraint. Review of the Care plan dated 12/5/2024, revealed, .Interventions .1/13/2024 Have resident up in [Named chair] with activity table when awake near nurses [nurses'] station for closer observation . The care plan does not reflect the use of the physical restraint, the medical condition for the use, or when the restraint will be released as noted per the facility policy. Observation on 100/200 hall at the nurse's station on 6/11/2024 at 9:50 AM, 10:46 AM, 12:22 PM, 2:10 PM, 2:20 PM, 3:00 PM, 4:04 PM, and 4:45 PM revealed Resident #15 was sitting in a geriatric chair (a large padded supportive recliner that can be placed in upright position or reclined) with a connected tray across her. Observation at the 100/200 hall nurses' station on 6/12/2024 at 11:18 AM, revealed Resident #15 was sitting in the hallway in a geriatric chair with a tray across her. Resident #15 was unable to release the table tray and get up out of the geriatric chair without assistance. During an interview on 6/11/2024 at 4:20 PM, the MDS Coordinator stated Resident #15 received the geriatric chair a week after she came to the facility. The MDS Coordinator was asked what were the risk factors when placing Resident #15 in a geriatric chair with a tray secured over her. The MDS Coordinator stated, .it could be considered a restraint . The MDS Coordinator stated no one documented the tray had been released and had never known of her (Resident #15) asking to remove the tray. Continued interview revealed the facility had not completed a device assessment. During an interview on 6/12/2024 at 7:52 AM, the Director of Nursing (DON) was asked if the facility could physically restrain a resident at the family's request. The DON stated, No. The DON was then asked the medical symptom for the physical restraint. The DON stated Resident #15 had the geriatric chair for previous falls and behaviors upon admission. The DON was asked what the benefits of the physical restraint are. The DON stated it was for keeping Resident #15 safe and prevent falls. Further interview revealed the DON was unable to provide a physician's order, any assessments, consent for the use, or documentation of removal and timing of the release for the physical restraint. During an interview on 6/13/2024 at 10:10 AM, the MDS Coordinator was asked why the Quarterly MDS does not reflect the use of a chair that prevented Resident #15 from rising. The MDS Coordinator stated, .well she didn't have the tray on all the time . During an interview on 6/21/2024 at 1:15 PM, the MDS Coordinator stated she could not find any documentation related to an assessment, physician's order, or monitoring of the table tray connected to the geriatric chair of Resident #15. When asked if she went out to do the assessment of the restraint, the MDS Coordinator stated, I do not go out myself to do the assessment, I go by what is charted. During an interview on 6/21/2024 at 4:05 PM, the Regional [NAME] President (RVP) Clinical Services stated the facility did not have a MDS policy and the coordinator should follow the RAI manual for the MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to implement a comprehensive person-centered care plan with appropriate interventions for 5 of 6 (Residents #6, #7, #10, #15, and #18) sampled residents reviewed. The findings include: Review of the facility policy titled, Baseline Care Plan Assessment/Comprehensive Care Plans, revised 3/21/2021, revealed .The Comprehensive Care Plan will be reviewed and updated every quarter at a minimum. The facility may need to review the care plans more often based on changes in the resident's condition and/or newly developed health/psycho-social issues . Review of the facility policy titled, Guidelines for Physical Restraints/Seclusion, dated 5/17/2023, revealed, .The care plan must reflect the use of the physical restraint-to include medical conditions as well as releasing at least q 2 hours-and skin checks during use at time of application and removal-with nurse to assess skin as indicated . Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses which included Spastic Quadriplegia Cerebral Palsy, Bipolar Disorder, Aphasia, Anxiety Disorder, and Depression. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #6 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Review of the Comprehensive Care Plan dated 4/17/2024 for Resident #6 revealed no interventions were added to address sexual abuse when Resident #10 touched Resident #6's hair and rubbed her thigh without permission. During an interview on 6/12/2024 at 8:02 AM, Resident #6 stated she had issues with [Named Resident #10]. [Named Resident #10] keeps rubbing her leg. [Named Resident #10] reaches toward her to hold her hands. She stated she would tell him to stop, but he doesn't and just laughs. She stated she doesn't want another man touching her. He does it to other women. She stated that she reported the incidents to the Administrator and DON, and they told her they were going to handle it by getting [Named Resident #10] transferred. The first incident occurred last summer around June [2023] and continues to happen. Resident #6 stated she doesn't want to leave her room because [Named Resident #10] makes her feel uncomfortable, and she doesn't want to be around him. The Administrator and DON keep telling her they are working on doing something about the incidents. Resident #6 stated she doesn't want to keep talking about the incidents because she doesn't want to get kicked out the facility for seeming like she is causing problems due to reporting the incidents. Review of medical record revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Polyneuropathy, Parkinson's Disease, Anxiety Disorder, and Dementia. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 11 which indicated moderate cognitive impairment. Review of the Comprehensive Care Plan dated 5/2/2024 revealed no interventions were added to address sexual abuse when Resident #10 made nonconsensual sexual propositions with Resident #7, grabbed her hand, and rubbed her thighs. During an interview on 6/12/2024 at 7:52 AM, Resident #7 stated that she has had issues with [Named Resident #10]. Resident #7 stated that she doesn't remember the exact dates. Resident #6 stated [Named Resident #10] always reaches to hold her hand. She stated she would slap his hands away. Resident #7 stated that she reported the incident to the Administrator. Resident #7 stated she is unsure if they are doing anything about it. Resident #7 stated that [Resident #10] says the most inappropriate things sometimes, and that [Named Resident #10] makes her feel uncomfortable, and she doesn't want to be around him . Resident #7 was asked if she could share some of the comments Resident #10 had made. Resident #7 stated she would rather not go into detail about the comments. Resident #6 stated that [Named Resident #10] causes issues all the time during activities by trying to touch on other women and yelling at staff and other residents. Resident #7 stated that [Named Resident #6] is another woman here in the facility that Resident #10 has touched on. Review of medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses which included Chronic Diastolic (Congestive) Heart Failure, Morbid (Severe) Obesity Due to Excess Calories, and Anxiety Disorder. Review of the Quarterly MDS dated [DATE] for Resident #10 revealed a BIMS score of 15 which indicated no cognitive impairment. Review of the Comprehensive Care Plan for Resident #10 revealed, .[Named Resident #10] has an alteration in behaviors as evidenced by: yelling at staff and others at times. 4/19/23 [2023] verbally aggressive with others. 6/8/23 [2023] verbally loud and argumentative with staff and other residents. 2/8/24 [2024] verbally agitated with staff and residents. 2/21/24 [2024] throwing objects out of room into hallway, verbal threats. 3/17/24 [2024] cursing staff, throwing things in room, banging on his garbage can . Further review revealed no interventions for allegations of sexual abuse. During an interview on 6/13/2024 at 11:00 AM, Resident #10 stated, .I was sent out yesterday [6/12/2024] because I told [Named Resident #18] to give me a kiss on Tuesday [6/11/2024], and she told on me . Resident #10 was asked had he any issues before with residents. Resident #10 smirked and laughed, then stated, .I had a resident report that I was rubbing her hair . During an interview on 6/12/2024 at 11:06 AM, the Administrator stated [Named Resident #10]'s behaviors should be care planned. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Anxiety Disorder, and Seizures. Review of the admission MDS dated [DATE] revealed Resident #15 had a BIMS score of 3 which indicated severe cognitive impairment. Review of the Quarterly MDS dated [DATE] revealed Resident #15 had a BIMS score of 2 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #15 was not coded for a physical restraint (table tray). Review of the care plan revealed, .Interventions .[1/13/2024] Have resident up in [Named chair] with activity table when awake near nurses [nurse's] station for closer observation . The care plan did not reflect the use of the physical restraint, the medical condition for the use or when the restraint will be released as noted per the facility policy. During an interview on 6/11/2024 at 4:20 PM, the MDS Coordinator stated Resident #15 received the geriatric chair a week after she admitted into the facility. Resident #15 was trying to get up and kept falling. The MDS Coordinator was asked what risk factors are present when placing a resident in a geriatric chair with a tray secured over the resident. The MDS Coordinator stated the tray could be considered a restraint. During an interview on 6/12/2024 at 7:52 AM, the Director of Nursing (DON) stated the family requested for the table tray for Resident #15. The DON was asked if the facility could physically restrain a resident at the family's request, she stated, No. The DON was asked the medical symptom for the physical restraint. The DON stated it was for previous falls and behaviors upon admission. The DON was asked what the benefits of the physical restraint are. The DON stated to keep the resident safe and prevent falls. The DON was unable to provide an order, any assessments, consent for the use, or documentation of removal and timing of the release for the physical restraint. During an interview on 6/13/2024 at 9:05 AM, the Physical Therapy Director stated, .today is the first time I have evaluated [Named Resident #15] for a sitting device . During an interview on 6/13/2024 at 10:10 AM, the MDS Coordinator was asked why the Quarterly MDS does not reflect the use of a chair that prevents rising. The MDS Coordinator stated she did not have the table tray on at all times. Further interview revealed the MDS Coordinator could not find any documentation related to an assessment, monitor for a table tray or a physician's order for the table tray connected to the geriatric chair. Further interview revealed, the MDS Coordinator admitted Resident #15 had the geriatric chair with the tray table since approximately one week after she admitted . When asked if she went out to do the assessment of the restraint, the MDS Coordinator stated, I do not go out myself to do the assessment, I go by what is charted. Observation on 100/200 hall at the nurse's station on 6/11/2024 at 9:50 AM, 10:46 AM, 12:22 PM, 2:10 PM, 2:20 PM, 3:00 PM, 4:04 PM, and 4:45 PM revealed Resident #15 was sitting in a geriatric chair (a large padded supportive recliner that can be placed in upright position or reclined) with a connected tray across her. Observation at the 100/200 nurses' station on 6/12/2024 at 11:18 AM, Resident #15 was sitting in her geriatric chair with tray across the resident. Review of the medial record revealed Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Muscle Wasting and Atrophy Right Shoulder, Difficulty in Walking, and Muscle Wasting and Atrophy Left Shoulder. Review of the Quarterly MDS dated [DATE] revealed Resident #18 had a BIMS score of 15 which indicated no cognitive impairment. Review of the Comprehensive Care Plan dated 5/14/2024 revealed no interventions were added to address allegations of sexual abuse when Resident #10 attempted to kiss Resident #18. During an interview on 6/12/2024 at 6:35 PM, Resident #18 stated, .[Named Resident #10] came into my room and demanded I give him a kiss. Then, he proceeded to come toward me. I yelled for him to get out my room. [Resident #10] looked at me and laughed then left out my room. I will fight him if he tries that again in order to protect myself. I notified the Administrator, DON, and Activities Director of the incident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to follow physician's orders and ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 3 (Resident #15) residents reviewed. The findings include: Review of the facility's policy titled, GUIDELINES FOR PHYSICIAN ORDERS--(FOLLOWING PHYSICIAN ORDERS), dated 6/18/2023, revealed .Policy .It is the policy of the facility to follow the orders of the physician .Procedure .4) All physician orders received pertaining to the resident will be implemented and followed throughout the course of the resident's dtay in the facility as the orders are received . Review of the facility's undated policy titled, Medication Administration, revealed .Purpose: To ensure that resident medications are administrered in a timely manner and documentation is completed to substantiate administration . Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Anxiety Disorder, and Seizures. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #15 received an Antipsychotic [medication given for psychosis], Antianxiety [medication given for anxiety], Antidepressant [medication given for depression], and Opioid [medication given for severe pain] over the last 7 days. Review of the Quarterly MDS dated [DATE] revealed Resident #15 had a BIMS score of 2 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #15 received an Antipsychotic, Antianxiety, Antidepressant, and Opioid over the last 7 days. Review of the Medication Administration Record (MAR) dated 4/1/2024 - 4/30/2024 revealed an order for Lorazepam oral tablet 2 mg (milligram) give 1 tablet by mouth as needed for seizures, may give x 3 doses for seizure activity. Continued review of the MAR revealed Resident #15 received Lorazepam on 4/1/2024, 4/2/2024, 4/5/2024, 4/6/2024, 4/15/2024, and 4/19/2024. Review of the Progress Notes from 4/1/2024 to 4/30/2024 for Resident #15 revealed no documentation of seizure activity for the use of the Lorazepam. Review of the Progress Notes dated 4/4/2024 revealed, .resident observed anxious/restless in . chair in hall .resident unaware d/t current cognitive status . Review of the care plan dated 12/5/2023, revealed .Focus .Alteration in comfort related to .dx [diagnoses] includes seizures, anxiety .Focus .diagnosis of seizure disorder and is as [at] risk or [of] injury .Interventions .Observe for seizure activity .Staff to monitor for changes in level consciousness .Stay with resident if seizure activity occurs . Review of the MAR dated 5/1/2024 - 5/31/2024 revealed an order for Lorazepam oral tablet 2 mg give 1 tablet by mouth as needed for seizures, may give x 3 doses for seizure activity. Continued review of the MAR revealed Resident #15 received Lorazepam on 5/23/2024, 5/25/2024, 5/29/2024, 5/30/2024, and 5/31/2024. Review of the Progress Notes from 5/1/2024 to 5/31/2024 for Resident #15 revealed no documentation of seizure activity for the use of the Lorazepam. Continued review of the Progress Notes revealed, .5/23/2024 13:43 [1:43 PM] .Medication Administration .Lorazepam Oral Tablet 2 MG Give 1 tablet by mouth as needed for seizures May give x 3 doses for seizures activity .Pt [Patient] agitated pulling on staff and chair .5/29/2024 12:13 [PM] .Medication Administration .Lorazepam Oral Tablet 2 MG Give 1 tablet by mouth as needed for seizures .Pt agitated and trying to get out of chair hollering at staff .5/31/2024 13:12 [1:12 PM] .Medication Administration .Lorazepam Oral Tablet 2 MG Give 1 tablet by mouth as needed for seizures May give x 3 doses for seizures May give x 3 doses for seizures activity .Pt restless and pulling at chair and calling out . Review of the Progress Notes from 5/1/2024 to 5/31/2024 revealed no documentation of seizure activity for the use of the Lorazepam. Review of the MAR dated 6/1/2024 - 6/12/2024 revealed an order for Lorazepam oral tablet 2 mg give 1 tablet by mouth as needed for seizures, may give x 3 doses for seizure activity. Continued review of the MAR revealed Resident #15 received Lorazepam on 6/3/2024, 6/5/2024, 6/7/2024, 6/9/2024, 6/11/2024, and 6/12/2024. Review of the Progress Notes revealed 6/3/2024, .Lorazepam Oral Tablet 2 MG .pt [patient] showing signs of anixety [anxiety] .6/5/2024 .Lorazepam Oral Tablet 2 MG .Pt pulling at other Patients trying to get out of chair .6/7/2024 .Lorazepam Oral Table 2 MG . Resident anxious . Review of the care plan dated 12/5/2023, revealed .Focus .Alteration in comfort related to .dx [diagnoses] includes seizures, anxiety .diagnosis of seizure disorder and is as [at] risk or [of] injury .Interventions .Observe for seizure activity .Staff to monitor for changes in level consciousness .Stay with resident if seizure activity occurs . Review of the Progress Notes from 6/1/2024 to 6/12/2024 for Resident #15 revealed no documentation of seizure activity for the use of the Lorazepam. Review of the Progress Notes revealed 6/7/2024, .Lorazepam Oral Tablet 2 MG . Resident anxious . Continued review of the Progress Notes revealed on 6/9/2024, 6/11/2024, and 6/12/2024 Lorazepam was given, the Notes did not reveal any seizure activity. During a telephone interview on 6/14/2024 at 8:42 AM, Hospice Registered Nurse (RN) V stated, .I know of maybe 1 or 2 reported Seizures [Named Resident #15] has had .the Lorazepam order she has a standing order Hospice gives if a resident has a diagnosis of Seizures .it is a PRN [as needed] order and should only be given if the resident has a Seizure . The Hospice RN V was asked if she had any concerns with Resident #15's care at the facility. Hospice RN V stated, .Yes, inappropriate use of Lorazepam .I have educated the staff that the PRN Lorazepam is for Seizures .[Named Resident #15] will become anxious, and the facility has given her the Lorazepam . During a telephone interview on 6/18/2024 at 9:52 AM, Licensed Practical Nurse (LPN) JJJ was asked if she recalled giving Resident #15 Lorazepam. LPN JJJ stated, .It was change of shift .the nurse that gave me report said she [Resident #15] had been shaking a lot .I checked to see if she needed to go to the bathroom .took her [Resident #15] myself .put her back in the [named] geriatric chair .she became agitated .she began pulling away from the wall .increased agitation .I saw her behavior change .I gave the Ativan .she was shaking and coming out of the chair .I wasn't sure of the seizure protocol, so I gave it since she was shaking .she was care planned for behaviors .I did not call the MD .I wasn't sure of that protocol .I just knew it was given for seizures or agitation . During a telephone interview on 6/18/2024 at 10:07 AM, RN X was asked the reason for giving Resident #15 Ativan. RN X chuckled and replied, I gave it for agitation. That is the only time I would give this medication. When asked about the physician's order that read to give for seizure activity, RN X replied, [Named Resident #15] gets upset and her hands start shaking. That is the seizure activity, and that's when we give it. That's what hospice told me to do. I have learned since then; the activity usually happens when she needs to go to the bathroom. Now we do that first instead of giving the medicine right away. RN X was asked if the physician was notified if the resident was having seizure activity. RN X replied, No. I do not notify the physician about the seizures. Hospice said if we have to give her more than 2 or 3 doses a day, then we could give them a call. During a telephone interview on 6/18/2024 at 10:21 AM, the Pharmacist stated Resident #15 had an order for Lorazepam since 12/5/2023 and was prescribed by Hospice MD. When asked what the recommended mode of transmission for lorazepam would be related to seizures, the Pharmacist replied, .For seizures, generally it is injectable or cream. It would be hard to give a patient a PO [by mouth] lorazepam if they were having a seizure . The Pharmacist then stated the lorazepam 2 mg injectable would typically be available in the Cubex (a medication dispenser for controlled substances), however there was none available at that time per the Pharmacist. During a telephone interview on 6/18/2024 at 11:45 AM, the Hospice Medical Doctor [MD] stated she did order Lorazepam 2 mg for seizures but would be concerned if the nurses are not charting seizure activity when giving this medication. Continued interview revealed Resident #15 should have 3 active orders for Lorazepam. One for 2 mg for seizure activity, one for 2 mg for agitation, and one for 0.5 mg BID. During a telephone interview on 6/18/2024 at 2:50 PM, MD FF stated he signed off on some of the hospice orders. MD FF was asked if he felt lorazepam 2 mg PO was the correct mode of transmission for a resident with seizures. MD FF replied, .The lorazepam PO can be given after the seizure is over and not during the active phase . When asked if staff consistently charted 0 for a pain level, would prn pain meds need to be given. MD FF stated, If it consistently a 0, then no. However, if they are without the pain medication, the pain could come back and potentially become worse. The pain meds keep the patient comfortable. During a telephone interview on 6/20/2024, the facility Nurse Practitioner [NP] stated she was not notified about Resident #15's seizure activity, but the nurses would also call hospice for any concerns or request. When asked about giving Ativan 2 mg PO for seizures, the NP stated, Not for active seizures. It should be given IM in my professional opinion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, police report review, and interview, the facility failed to report allegations of sexual abuse to the State Survey Agency (SSA) for 3 of 4 (Residents #6, #7, and #18) sampled residents reviewed. On an unknown date, Resident #6, who had a diagnosis of Spastic Quadriplegia with Cerebral Palsy, stated Resident #10 made nonconsensual sexual advances toward her by touching her hair and rubbing her on the thighs without permission. Resident #6 stated Resident #10 continued to rub on her thighs and antagonized her during activities to the point where she is fearful and uncomfortable around Resident #10. On an unknown date, Resident #7 stated Resident #10 made nonconsensual sexual propositions, grabbed her hand, and rubbed her thighs. Resident #7 stated that she doesn't want Resident #10 around her or touching her without permission because he made her feel uncomfortable. On 6/11/2024, Resident #18 stated that she reported to the Activities Director, Administrator, and Director of Nursing (DON) that Resident #10 came into her room and demanded that she give him a kiss then motioned toward her. Resident #18 stated she yelled for Resident #10 to get out my room. The facility also failed to report an allegation of suspected neglect to the SSA for 1 of 4 (Resident #9) sampled residents reviewed. Family Member (FM) ZZ contacted law enforcement and requested they do a welfare check at the skilled nursing facility. When law enforcement arrived at the facility, Resident #9 was tearful and reported an allegation of neglect. Resident #9 alleged she had attempted to contact her nurse Licensed Practical Nurse (LPN) B for needed medications. Resident #9 felt she was not being adequately cared for and did not receive her medication as scheduled. The finding include: Review of the facility policy titled, Abuse Prevention Program, dated 10/22/2022 revealed, .It is the policy of this facility to prevent resident abuse, neglect, mistreatment .The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party .Staff should report their knowledge of allegations without fear of reprisal .employees are required to report any incident, allegation or suspicion of potential abuse, neglect or mistreatment they observe, hear about or suspect to the Administrator. The Administrator is the Abuse Coordinator .Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated .Upon learning of the report, the Administrator .shall initiate an incident investigation .the Administrator or designee utilizing the Incident Reporting System will immediately notify the Department of Health by the online system .All incidents will be documented, whether or not abuse occurred was alleged or suspected .The final investigation report will be completed within the required timeframe . Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses which included Spastic Quadriplegic Cerebral Palsy, Bipolar Disorder, Anxiety Disorder, and Depression. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Review of the Comprehensive Care Plan dated 4/17/2024 revealed no interventions to address allegations of sexual abuse. During an interview on 6/12/2024 at 8:02 AM, Resident #6 stated, .I had issues with [Named Resident #10]. [Named Resident #10] keeps rubbing my leg. [Named Resident #10] reaches towards me to hold my hands. I tell him to stop, but he doesn't and just laughs. I don't want another man touching me. He does it to other women. I have reported the incidents to the Administrator and DON, and they told me they were going to handle it. The first incident occurred last summer around June 2023 and continues to happen . Review of medical record revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's Disease, Anxiety Disorder, and Dementia. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 11 which indicated moderate cognitive impairment. Review of the Comprehensive Care Plan dated 5/2/2024 revealed no interventions to address allegations of sexual abuse. During an interview on 6/12/2024 at 7:52 AM, Resident #7 stated, .I have had issues with [Named Resident #10]. I don't remember the exact dates. He always reaches to hold my hand. I would slap his hands away. I reported the incident to the Administrator. I am unsure if they are doing anything about it . Review of medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses which included Chronic Diastolic (Congestive) Heart Failure, Morbid (Severe) Obesity Due to Excess Calories, and Anxiety Disorder. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated no cognitive impairment. Review of the Comprehensive Care Plan revealed, .[Named Resident #10] has an alteration in behaviors as evidenced by: yelling at staff and others at times. 4/19/23 [4/19/2023] verbally aggressive with others. 6/8/23 [6/8/2023] verbally loud and argumentative with staff and other residents. 2/8/24 [2/8/2024] verbally agitated with staff and residents. 2/21/24 [2/21/2024] throwing objects out of room into hallway, verbal threats. 3/17/24 [3/17/2024] cursing staff, throwing things in room, banging on his garbage can . Further review revealed no appropriate interventions for allegations of inappropriate sexual behaviors. During an interview on 6/13/2024 at 11:00 AM, Resident #10 stated, .I was sent out yesterday [6/12/2024] because I told [Named Resident #18] to give me a kiss on Tuesday [6/11/2024], and she told on me . Resident #10 was asked had he any issues before with residents. Resident #10 smirked and laughed, then stated, .I had a resident report that I was rubbing her hair . Review of the medial record revealed Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Muscle Wasting and Atrophy Right Shoulder, Difficulty in Walking, and Muscle Wasting and Atrophy Left Shoulder. Review of the Quarterly MDS dated [DATE] for Resident #18 revealed a BIMS score of 15 which indicated no cognitive impairment. Review of the Comprehensive Care Plan for Resident #18 revealed no interventions for allegations of sexual abuse. During an interview on 6/12/2024 at 6:35 PM, Resident #18 stated, .[Named Resident #10] came into my room and demanded I give him a kiss. Then, proceeded to come toward me. I yelled for him to get out my room.[Resident #10] looked at me and laughed then left out my room. I will fight him if he tries that again in order to protect myself. I notified the Administrator, DON, and Activities Director of the incident . During an interview on 6/11/2024 at 2:24 PM, The Ombudsman stated, .On 2/12/2024, [Named Residents #6 and #7] reported to me that they were having issues with [Named Resident #10] touching them without permission. Both [Named Residents #6 and #7] stated they had reported the incidents to the Adminitsrator and DON, but the issues with the unwanted touching continue. I spoke with the Administrator and DON regarding what was disclosed to me by [Named Residents #6 and #7]. The facility hadn't put anything in place to address the incidents that were reported to them by the residents [Named Resident #6 and #7]. The Administrator and DON also stated that the incidents weren't reported to the state . During an interview on 6/12/2024 at 9:48 AM, The DON stated, .Last year [2023] I believe there was incident between [Named Residents #6 and #10] about [named Resident #10] touching [Named Resident #6]'s ponytail. That is the only incident I can recall regarding [Named resident #10]. The incident wasn't reported to the state . During an interview on 6/12/2024 at 11:06 AM, the Administrator stated he was the abuse coordinator. The DON was his backup abuse coordinator. The Administrator stated, .I was aware of the incident between [Named Residents #6 and #10] regarding a ponytail being touched .[Named Resident #6] wanted [Named DON]'s help regarding [Named Resident #10] being rude and antagonizing her. The Ombudsman did inform me and the DON regarding [Named Resident #10]'s behaviors [sexual] toward [Named Residents #6 and #7]. [Named Resident #10]'s behaviors should be care planned. The Ombudsman did speak with me and the DON regarding concerns she had about 2 residents [Named Residents #6 and #7] having issues with [Named Resident #10] . The Administrator was asked what is the protocol when abuse is reported to him. The Administrator stated, .I follow the abuse policy, make sure the resident is safe, conduct an investigation, and report within 2 hours . The Administrator was asked if the incidents regarding Residents #6 and #7 were reported, and he stated no. During an interview on 6/12/2024 at 4:16 PM, the Activities Director stated, .I've been having issues with [Named Resident #10] for over a year now. During activities, he over talks residents and becomes very combative. [Named Resident #10] places his hands wherever he can on female residents such as hands, legs, and thighs. Then tells them you know you want it. I've witnessed those incidents during activities. Female residents are afraid of him. I reported everything that occurred to the Administrator and DON. I was told that as long as he doesn't hurt anyone there's nothing they can do. I witnessed [Named Resident #10] putting his hand on and rubbing [Named Resident #7]'s knee. I kept a log of the incidents involving [Named Resident #10] and gave it to the DON in a folder. I was told by the Administrator that I can't ask him to leave activities because he has a right to be there. It was also reported to me by [Named Resident #18] that [Named Resident #10] came into her room and demanded he kiss her. The Administrator and DON are well aware of the issues with [Named Resident #10] . During an interview on 6/13/2024 at 1:00 PM, the DON stated, .[Named Administrator] is the abuse coordinator. I would consider a resident attempting to kiss another resident without permission sexual abuse. [Named Resident #10] was sent out last night [6/12/2024] to the hospital for psychological evaluation due to behaviors . The DON was asked what type of behavior Resident #10 was sent out for. The DON responded, .I believe it was for attempting to kiss another resident . The DON was asked when did the incident occur involving the kiss. The DON stated the day before [6/11/2024]. The DON was asked if she would consider that a reportable incident. The DON stated, .Yes, the incident between [Named Resident #10 and #18] would be considered a reportable incident, but it was not reported to the state . Review of medical records revealed Resident #9 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses which included End Stage Renal Disease, Dependence on Renal Dialysis, Acquired Absence of Right Leg Above the Knee, and Type 1 Diabetes Mellitus. Review of the admission MDS assessment dated [DATE], revealed Resident #9 had a BIMS score was 15 which indicated no cognitive impairment. Continued review revealed Resident #9 requires the use of a wheelchair, had been occasionally incontinent of Bowel and Bladder, had a surgical wound, and required dialysis. Review of the undated Care Plan for Resident #9 revealed, Resident #9 was .at risk for an alteration in comfort related to diabetic polyneuropathy, chronic pain and Right AKA (above the knee amputation) .4/12/2024 surgical wound to right AKA .impaired visual function .legally blind . Review of the police report dated 4/29/2024 at 4:18 AM, revealed Resident #9 submitted a report alleging neglect of an Elderly or Vulnerable Adult.On 4/29/2024 Family Member (FM) ZZ called local law enforcement related to a welfare check at [named facility's address]. Resident #9 was crying .she feared retaliation from staff for speaking out against them [the staff]. Named Resident #9 attempted to contact her nurse [LPN B] started at midnight and she was not available no one else could access the medication. The nurse appeared shortly after the police had arrived at the facility .Resident #9 alleged the facility was the cause of her lower limb amputation . During an interview on 6/20/2024 at 12:24 PM, the Nurse Practitioner (NP) stated Resident #9 was a medically complex resident. Resident #9 was a brittle Diabetic, required dialysis and has had an amputation. Resident #9 psychologically had concerns with depression, anxiety and a lack of social support. The NP remembers being told about a time when Resident #9 had not been given her medication on the night shift but did not recall any pertinent details. During an interview on 6/17/2024 at 3:20 PM, LPN B stated Resident #9 had prescription for Vistaril (medication has been used for anxiety, nausea, vomiting and itching) that was requested more often than prescribed. LPN B said the technicians were intercepting Resident #9's phone calls for her because the medication was not available. LPN B stated the prescription had been changed from every 4 hours and Resident #9 was still requesting it be given that often. During an interview on 6/18/2024 at 10:00 AM. The Regional Director of Operations (RDO) stated he had reviewed the police report initiated by Resident #9 and noticed there was an allegation of neglect. The RDO stated the allegation should have been reported to the SSA within the 2-hour window. The RDO confirmed the allegation was not reported.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to provide sufficient staff to provide care and services in assisting residents to attain or maintain their highest practicable level of physical, mental, and psycho-social well-being for all residents at the facility. The findings include: Review of the facility policy titled, GUIDELINES STANDARD SUPERVISION, dated 5/17/2023, revealed, .6. Staff assignments are based on the resident needs as far as their acuity and their assessment results and their person-centered care planning. Therefore, the requirements of meeting those needs to include physical, emotional, psychosocial, social, and spiritual, will be accomplished by provision of as much hands on care as necessary. Further, supportive services to include staff from various departments in the facility and/or outside resources/vender services will be provided when indicated . Review of the Payroll Based Journal (PBJ) Staffing Data Report (A collection of data used to provide information on staffing levels) for 1/1/2023 to 3/31/2024, revealed, .Metric .One Star Staffing Rating .Result .Triggered .Definition .Triggered = Star Staffing Rating Equals 1 .Metric .Excessively Low Weekend Staffing .Result .Triggered .Definition .Triggered .Submitted Weekend Staffing data is excessively low . Continued review revealed, PBJ Staffing Data Report had triggered for Star Staffing Rating Equal 1 and Submitted Weekend Staffing data is excessively low for 1/1/2023 to 3/31/2023, 4/1/2023 to 6/30/2023, 7/1/2023 to 9/30/2023, and 10/1/2023 to 12/31/2023. Review of the FACILITY ASSESSMENT (designed for the facility to evaluate its resident population and identify the resources needed to provide the necessary services) dated 2/23/2024 revealed an average daily census between 72 and 80 residents. 95% - 100% of all residents required assistance with Activities of Daily Living (ADLs) with 1-2 person physical assistance. Review of the medical records revealed Resident #1 was admitted to the facility on [DATE], with readmission on [DATE], with diagnoses which included Generalized Osteoarthritis, Dysphagia and Major Depressive Disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #1, revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment. Continued review reveals Resident #1 required extensive assistance with bed mobility, transfers, locomotion on unit, dressing, eating, toilet use, and personal hygiene. Review of the care plan for Resident #1 revealed, . [6/2/2023] has potential for nutritional decline R/T [related to]: varied intakes, confusion/dementia, history of GI bleed .Requires extensive to total assist with meals . Review of the Nursing Home Licensure Checklist dated 6/11/2024, revealed a total of 2.58 Per Patient Day (PPD) for that day. Review of the Daily Scheduled Nursing dated 6/11/2024, revealed four (4) nurses and thee (3) CNAs scheduled for the day. Observation throughout the facility on 6/11/2024 at 9:30 AM, revealed four (4) nurses and three (3) CNAs at the facility. The nurses were passing medications, and the three (3) CNAs were assisting residents with breakfast. Meal carts remained on the halls with untouched trays on them, waiting to be taken to assisted diners. During an interview on 6/12/2024 at 10:02 AM, family member (FM) L stated she had been to the facility several times and Resident #1's meal was on her bedside table with no one assisting her. The staff have not been taking the time to comb Resident #1's hair. Review of medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses which included Chronic Diastolic (Congestive) Heart Failure, Morbid (Severe) Obesity Due to Excess Calories, and Anxiety Disorder. Review of the Quarterly MDS dated [DATE] for Resident #10, revealed a BIMS score of 15, which indicated no cognitive impairment. Continued review revealed Resident #10 required extensive assistance with bed mobility, transfers, locomotion on and off unit, dressing, toilet use, and personal hygiene. During an interview on 6/13/2024 at 11:10 AM, Resident #10 stated the facility needed more staff and had waited up to 45 minutes for assistance. Resident #10 was asked how he knew it took up to 45 minutes to answer the call light. Resident #10 responded, I have four (4) phones and a clock. I know how long I have to wait. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses which included Muscle Wasting and Atrophy, Multiple Sites, Type 2 Diabetes Mellitus without Complications, and Atherosclerotic Heart Disease of Native Coronary Artery. Review of the admission MDS assessment dated [DATE] for Resident #12, revealed a BIMS score of 11, which indicated moderate cognitive impairment. Continued review revealed Resident #12 required the use of a walker, required partial/moderate assistance with oral hygiene, showers/bath, upper and lower body dressing and putting on and taking off shoes, requires supervision and touch assistance with personal hygiene and required set up assistance with eating. During an interview on 6/12/2024 at 11:09 AM, Resident #12 stated he hardly ever seen a Certified Nursing Assistant (CNA) and sometimes had to wait for his call light to be answered for 45 minutes to an hour. When asked how he knew it took that long to answer the call light, Resident #12 stated, I watch the clock and I have a phone. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses which included Lack of Coordination, Urinary Tract Infection (UTI), and Muscle Wasting and Atrophy. Review of the admission MDS assessment dated [DATE] for Resident #13, revealed a BIMS score of 15, which indicated no cognitive impairment. Continued review revealed the use of a manual wheelchair, required set up assistance with eating, required partial/moderate assistance with upper/lower body dressing, shower/baths, putting on/taking off footwear, rolling left/right, sit to lying, lying to sit, sit to stand position changes, was frequently incontinent of bladder and always incontinent of bowel. During an interview on 6/12/2024 at 4:44 PM, FM III stated she had come into the facility several times and Resident #13 had been soaked with urine up to her shoulders. FM III stated Resident #13 would get changed between 8:00 PM and 10:00 PM but would not receive anymore care until the next morning. Continued interview revealed the weekend staff was low and the dining room was always closed. During an interview on 6/14/2024 at 1:12 PM, Resident #13 stated, .the facility is always short handed .I don't see anyone all night after they put me to bed .It does no good to put the light on because they will not come .I have to wait to be changed at night until right before the shift changes .sometimes it is only one person on this whole hallway . Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, Anxiety disorder, Adult Failure to thrive, Contracture of Muscle, unspecified lower leg, and Contracture of Muscle, unspecified upper arm. Review of the Quarterly MDS dated [DATE], revealed Resident #17 had a staff interview for mental status which indicated poor short term and long-term memory. Continued review revealed Resident #17 was dependent for oral, personal and toileting hygiene, was dependent for shower/bathing, upper and lower body dressing, and putting on and taking off footwear, and partial/moderate assistance with eating. Review of the Care Plan for Resident #17 revealed, .[11/17/2022] Alteration in nutritional status .He is receiving a mechanically altered diet. He requires extensive assistance with his feeding . Observation on 6/12/2024 at 5:30 PM, Resident #17 was being fed by a CNA at the nurses' station close to the 200 Hallway. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, Hemiplegia and Hemiparesis, and Vascular Dementia. Review of the Quarterly MDS dated [DATE], revealed Resident #19 had a BIMS score of 1, which indicated sever cognitive abilities. Continued review revealed Resident #19 required the use of a wheelchair, required substantial/maximum assistance with eating and upper body dressing, and had been totally dependent with oral, toilet, and personal hygiene, dependence for shower/bath, lower body dressing, and putting on/taking off footwear. Review of the Care Plan for Resident #19 revealed, .[1/10/2022] at risk for Alteration in Nutritional Status . Observation on 6/12/2024 at 5:30 PM, Resident #19 was being fed by a CNA at the nurses' station close to the 200 Hallway. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure with Hypoxia, and Acute and Chronic Diastolic (Congestive) Heart Failure. Review of the Quarterly MDS assessment dated [DATE] for Resident #20, revealed a BIMS score of 12, which indicated moderate cognitive impairment. During an interview on 6/12/2024 at 8:25 AM, Resident #20 stated her call light was left on for an hour and a half. She stated staff would come in the room and say they would come back but did not. Resident #20 stated, If they tell me they will be back, I expect them to. When asked how Resident #20 knew that she waited for an hour and a half for staff to assist her, she replied, I looked at the clock on the wall and pointed to it. Continued interview revealed, Resident #20 stated the weekends were awful and very short staffed and had to wait for even longer periods of time when she called for assistance. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] with diagnoses which included Muscle Wasting and Atrophy, Multiple Sites, Type 2 Diabetes Mellitus with Hyperglycemia, and Dysphagia, Oropharyngeal Phase. Review of the Quarterly MDS assessment dated [DATE] for Resident #21, revealed a BIMS score of 4 which indicated severe cognitive impairment. Continued review revealed Resident #21 required the use of a wheelchair, required partial/moderate assistance with upper body dressing, substantial/maximal assistance with eating, oral hygiene, shower/bath, lower body dressing, dependent for toileting, putting on/taking off footwear and personal hygiene. Review of the Care Plan for Resident #21 revealed, .[2/6/2023] Alteration in Nutritional Status as evidenced by: [named Resident #21] has a dx [diagnosis] pf CVA [Cerebral Vascular Accident], weakness, dysphagia [difficulty with swallowing]. She is on a modified diet with thickened liquids. Dx: Blind, feeding difficulties and requires assistance with meals . Observation on 6/13/2024 at 5:00 PM, Resident #17 was being fed by a CNA at the nurses' station close to the 200 Hallway. Observation of the facility on 6/11/2024 at 9:30 AM, revealed breakfast carts for all residents remained on the hallways. Residents remained in bed and were not being fed in a timely manner. Continued observation revealed three CNAs for 73 residents in the facility at that time. Observation on 6/11/2024 at 5:30 PM, revealed CNA F standing up, feeding a resident at the end of 100 Hall by the nurse's station. Observation of 200 Hallway on 6/12/2024 at 5:25 PM, revealed assisted diners being fed in the hallway by staff. During an interview on 6/12/2024 at 6:35 PM, CNA Z stated, .The dining room has always been closed for dinner since I been here. I believe it's due to not having enough staff in the building as the day progresses. The management staff is mostly gone so there isn't any extra help to be able to get residents to the dining room and assist with feeding . During an interview on 6/12/2024 at 5:20 PM, CNA F stated she fed in the hallway so she could watch the fall risk patients. When asked if she thought feeding in the hallway was because of a staffing issue, CNA F replied, Yes, it would be. During an interview on 6/14/2024 at 8:45 AM, the Staffing Coordinator was asked how many CNAs were present on the morning of 6/11/2024, the Staffing Coordinator responded, .There were 3 CNAs here . When asked if 3 CNAs would be considered sufficient staff to meet the needs of the residents, the Staffing Coordinator stated, No. During an interview on 6/14/2024 at 11:05 AM, the Administrator was asked about the staffing needs at the facility. When asked how he thought breakfast went on the morning of 6/11/2023, the Administrator stated, I imagine breakfast was rough that morning. During an interview on 6/14/2024 at 11:33 AM, Licensed Practical Nurse (LPN) O stated there were only 3 CNAs in the facility on the morning of 6/11/2024. Continued interview revealed LPN O was asked what a reasonable time for a call light to be answered and she replied, A call light should be answered within 5 minutes. During a telephone interview on 6/18/2024 at 2:50 PM, CNA KK was asked if the night shift had ever worked short before. CNA KK replied, .We have worked with 3 people at night before . When asked if she felt this was enough staff to care for the residents at night, CNA KK replied, No. It makes it very hard to care for all the residents and their needs. During an interview on 6/21/2024 at 10:31 AM, CNA LL stated there were more call outs on the weekend, which made it hard to find staff to come in.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to have sufficient staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 2 (Resident #1 and #15) of 7-sampled residents reviewed. The finding included: Review of the facility policy titled, Baseline Care Plan Assessment/Comprehensive Care Plans, dated [DATE], revealed, .The Comprehensive Care Plans will be reviewed and updated every quarter at a minimum. The facility may need to review the care plans more often based on changes in the resident's condition and/or newly developed health/psycho-social issues . Review of the facility policy titled, Guidelines for Physical Restraints/Seclusion, dated [DATE], revealed, .It is the policy of the facility to use physical restraint only as a last resort and only after every other alternative to a physical restraint (based on assessment) that seemed to have the potential for being used successfully, has been tried, and has failed .A physical restraint is NEVER to be used for staff convenience or for discipline .The resident must have a complete order for the restraint which includes the type of restraint and when it is to be applied/released. The restraint order must include the related medical condition. All physical restraints are to [be] released and the resident is to be repositioned at least every 2 hours .If the resident cannot remove the physical restraint device on command-and using the proper technique for removal-the device is considered a physical restraint .Procedure .Complete the initial Physical Restraint Assessment .Review contributing factors such as behaviors/mood/fall risk/medical signs and symptoms/diagnosis/cognition/communication and ADL performance abilities .IDT to evaluate alternatives to physical restraint use and least restrictive interventions for the least amount of time .Explain and document the risk and benefits of treatment options related to physical restraints/devices to the resident as well as the representative/POA [Power of Attorney] .Obtain a detailed and specific doctor's order for the physical restraint/device which includes the specific physical restraint/device as well as when it is to be applied and released .Complete a new Physical Restraint/Device Assessment at least quarterly or if there is a change in the resident's condition (or if the medical condition for which the physical restraint is being used changes) to see if a lesser restraint can be used .The care plan must reflect the use of the physical restraint-to include medical conditions as well as releasing at least q 2 hours-and skin checks during use at time of application and removal-with nurse to assess skin as indicated . Review of the facility policy titled, GUIDELINES FOR PHYSICIAN ORDERS-(FOLLOWING PHYSICIAN ORDERS), dated [DATE], revealed, .Policy: It is the policy of the facility to follow the orders of the physician .The facility will have orders to provide essential care to the resident, consistent with the resident's mental and physical status upon admission .Procedure: 1) c. Routine care to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan .2) As assessments are completed, orders will be received from the physician to address significant findings of the assessment .4) All physician orders received pertaining to the resident will be implemented and followed throughout the course of the resident's stay in the facility as the orders are received . Review of the Job Description for the Administrator dated [DATE], revealed .reporting to the Governing Body, the Administrator leads and directs the overall operations of the facility in accordance with resident needs, government regulations and company policies so as to maintain quality care for the residents while achieving the facility's business objectives. There are multiple role responsibilities such as: working with management while doing planning for facility operations, conducting rounds to ensure resident needs are being addressed, maintaining working knowledge to ensure compliance with all governmental regulations and company's Quality Assurance Standards and management of turn-over to ensure that adequate staffing through development of recruitment resources, training and education while addressing family and resident satisfaction. The Administrator should also have the ability to identify and respond appropriately to potential behavior outbursts and recognize, remove and/or report potential hazards . Review of the undated Job Description for Director of Nursing (DON) revealed he/she will be under the supervision of the Administrator.The DON has the authority, responsibility and accountability for the functions, activities, and training of the nursing services staff .In the absence of the Administrator, the DON assumes responsibility .Role Responsibilities .knowledge, skills and techniques necessary to care for residents .Ensures that a sufficient number of qualified supervisory and supportive nursing personnel are assigned for each unit/shift to meet the residents needs .makes rounds upon entering the building each day .review all Accidents and Incidents daily and develop an appropriate plan to prevent future accident and incidents . Review of the undated Job Description for Registered Nurse revealed, .POSITION SUMMARY: The Registered Nurse provides direct nursing care to the residents and supervises the day-to-day nursing activities performed by nursing assistants. The person holding this position is delegated the administrative authority, responsibility, and accountability for carrying out the assigned duties and responsibilities in accordance with, current existing federal and state regulations and established company policies and procedures to ensure that the highest degree of quality care is maintained at all times .Role Responsibilities .3. Receives telephone orders from physicians and record on the Physicians' Order Form .Transcribes physician's orders to resident charts, cardex [[NAME]], and medication cards, treatment/care plans, as required .5. Charts nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care .Drug Administration .1. Prepares and administers medications as ordered by the physician .8. Reviews medication cards for completeness of information, accuracy in the transcription of the physician's order .9. Notifies the attending physician of automatic stop orders prior to the last dosage being administered . Review of the medical records revealed Resident #1 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses which included Generalized Osteoarthritis, Dysphagia and Major Depressive Disorder. Continued review revealed Resident #1 was a full code status. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 revealed, a BIMS score of 00 which indicated a severe cognitive impairment. Review of Care Plan for Resident #1 revealed, a care plan with goals and interventions that included Advanced Directives .Full Code status on file . Review of the Progress Notes dated [DATE] at 1:30 PM, the DON documented don notified of resident expiring. call made to daughter to notify her. daughter upset with information given. daughter states that she will be here to see her mother soon. awaiting daughter's arrival for funeral arrangements There was no documentation that the physician had been contacted. During a phone interview on [DATE] at 10:08 AM, FM L was asked when she had been contacted by the facility on [DATE] and she stated she received a call when her (Resident #1) had passed and said that she had not been updated concerning her condition prior to her death on that day. During a phone interview on [DATE] at 12:24 PM, MD HH was asked whether she had received a call regarding a change in Resident #1's condition. After MD HH reviewed her notes, there had been no documentation that the facility had contacted her on that day. MD HH reviewed her schedule and stated she had not rounded that day [[DATE]]. During an interview on [DATE] at 12:35 PM, the Traveling DON for Named Consulting Company reviewed the Code Blue Record for Resident #1. The Traveling DON was asked what the expectation for the nursing staff was when a resident was observed with decreased heart rate and respiration, and no obtainable blood pressure and oxygen saturation. The Traveling DON responded, I would expect the nurse to get orders for oxygen, stay with the patient at the bedside and call 911. The physician should have been contacted immediately. During a phone interview on [DATE] at 1:04 PM, the DON stated if a resident had been found with vitals signs at the level noted in the Code Status form (Pulse of 38, 4-5 respirations per minute, and unattainable blood pressure and oxygen saturation), she would expect the crash cart to be gotten because a code blue would be imminent. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Anxiety Disorder, and Seizures. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #15 required substantial/maximal assistance to sit to stand, chair/bed to chair transfer, and partial/moderate assistance with walking 10 feet. Continued review of the MDS revealed Resident #15 received an Antipsychotic [medication given for psychosis], Antianxiety [medication given for anxiety], Antidepressant [medication given for depression], and Opioid [medication given for severe pain] over the last 7 days. Review of the Quarterly MDS dated [DATE] revealed Resident #15 had a BIMS score of 2 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #15 required substantial/maximal assistance to sit to stand, chair/bed to chair transfer, and walking 10 feet was not attempted due to medical conditions or safety concerns. Continued review of the MDS revealed Resident #15 received an Antipsychotic, Antianxiety, Antidepressant, and Opioid over the last 7 days. During a telephone interview on [DATE] at 8:42 AM, Hospice Registered Nurse (RN) V stated she knew of maybe 1 or 2 reported Seizures [Named Resident #15] has had. The Lorazepam order was a standing order Hospice gave for a diagnosis of Seizures. The Lorazepam was a PRN [as needed] order that should have only been given if the resident had a Seizure. The Hospice RN V was asked if she had any concerns with Resident #15's care at the facility. Hospice RN V stated, .Yes, inappropriate use of Lorazepam . RN V stated she had educated the staff that the PRN Lorazepam was for Seizures. Resident #15 would become anxious, and the facility had given her the Lorazepam. During a telephone interview on [DATE] at 9:52 AM, LPN JJJ was asked if she recalled giving Resident #15 Lorazepam. LPN JJJ stated the previous nurse that gave me report said Resident #15 had been shaking a lot. Resident #15 had increased agitation, began puled away from the wall, was shaking, and coming out of the chair. RN V stated she saw Resident #15's behavior changes and she gave the Ativan because she knew it was given for seizures or agitation. RN V stated she was not sure of the seizure protocol, so she gave it [Lorazepam] since she was shaking. RN V stated Resident #15 was care planned for behaviors. Continued interview revealed, RN V did not call the MD and was not sure of that notification protocol. During a telephone interview on [DATE] at 10:07 AM, RN X was asked the reason for giving Resident #15 Ativan. RN X chuckled and replied, I gave it for agitation. That is the only time I would give this medication. When asked about the physician's order that read to give for seizure activity, RN X stated Resident #15 got upset, her hands start shaking, and that was the seizure activity, so we gave it. RN X stated hospice had told staff to do that. Continued interview revealed, RN X stated she had learned since then; the seizure-like activity usually happened when Resident #15 needed to go to the bathroom. Now, staff did that first instead of giving the medicine right away. Further interview revealed RN X was asked if the physician was notified if the resident was having seizure activity. RN X replied, No. I do not notify the physician about the seizures. Hospice said if we have to give her more than 2 or 3 doses a day, then we could give them a call. During a telephone interview on [DATE] at 10:21 AM, the Pharmacist stated Resident #15 had been prescribed Lorazepam 2 mg by the Hospice MD as of [DATE]. When asked what the recommended route for Lorazepam would be related to seizures, the Pharmacist stated it would be hard to give Lorazepam PO [by mouth] during an active seizure. The Pharmacist recommended Lorazepam as an injectable or a cream. Continued interview revealed, the Pharmacist then stated the lorazepam 2 mg injectable would typically be available in the Cubex (a medication dispenser for controlled substances), however there was none available at that time per the Pharmacist. Review of the Physician's Orders dated [DATE] to [DATE], revealed Resident #15 did not have an order for a geriatric chair with a table tray connected. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #15 had a Brief Interview of Mental Status (BIMS) score of 2 which indicated severe cognitive impairment. Continued review revealed the MDS for Resident #15 was not coded for a restraint. Review of the care plan for Resident #15 dated [DATE], revealed no care plan for a restraint to the geriatric chair. Review of the Medication Administration Record (MAR) for Resident #15 dated [DATE] to [DATE], revealed no documentation of a physical restraint. Review of the Treatment Administration Record (TAR) for Resident #15 dated [DATE] to [DATE], revealed no documentation of a physical restraint. Review of the Weekly Wound Evaluation dated [DATE] revealed, a skin tear to the front of the right lower leg. Review of the TAR for Resident #15 dated [DATE] to [DATE], revealed no documentation of a physical restraint. Continued review revealed there was no documentation that treatments were performed daily on Resident #15's right leg skin tear. During an interview on [DATE] at 4:14 PM, Licensed Practical Nurse (LPN) O stated Resident #15 had the (named) geriatric chair since she had been working at the facility (7 months). LPN O stated Resident #15 could not remove the restraint from the geriatric chair and had never asked for it to be removed. LPN O stated Resident #15 would get angry and shake the table tray. Continued interview revealed LPN O could not find an assessment or an order for the geriatric chair or the table tray (restraint). During an interview on [DATE] at 4:20 PM, the MDS Coordinator stated, Resident #15 received the geriatric chair with a table tray about a week after she was admitted to the facility. When asked what risk factors were present when placing a resident in a geriatric chair with a tray secured over the resident, the MDS Coordinator stated it could be considered a restraint. Continued interview revealed the MDS Coordinator confirmed there was no documentation when the tray was released or a device assessment. Review of the medical record revealed no documentation of when the restraint was released. During an interview on [DATE] at 7:52 AM, the Director of Nursing (DON) stated, she could not verify staff had been trained related to the geriatric chair with a table tray. The DON stated the facility did not typically allow this type of chair, but the family had requested the geriatric chair with the table tray. The DON was asked if the facility could physically restrain a resident at the family's request and she stated, No. The DON was asked the medical symptom for the physical restraint. The DON stated Resident #15 had previous falls and behaviors upon admission. The DON stated the tray was not used as a restraint if it was used for activities. The DON was asked what the benefits of the physical restraint were. The DON stated the benefit was to keep Resident #15 safe and prevented falls. Continued interview revealed Resident #15 could not remove the table tray. Further interview revealed, the DON was unable to provide an order, any assessments, consent for the use, or documentation of removal and timing of the release for the physical restraint. During an interview on [DATE] at 8:15 AM, Registered Nurse (RN) X stated Resident #15 was unable to remove the tray and she was not aware of any documentation on the tray when it was released. During a telephone interview on [DATE] at 9:07 AM, Family Member (FM) Y stated the geriatric chair with the tray table was suggested to him by the DON. Further interview revealed FM Y did not know of any injuries Resident #15 had related to the chair. During an interview on [DATE] at 5:15 PM, LPN W stated Resident #15 could not remove the tray. During an interview on [DATE] at 9:05 AM, the Physical Therapy Director stated that this day was the first time Resident #15 had ever been evaluated for a sitting device [Rocking recliner wheelchair that can tilt back 30 degrees]. During an interview on [DATE] at 10:10 AM, the MDS Coordinator stated the Quarterly MDS did not reflect the use of a chair that prevented rising because Resident #15 did not have the tray in front of her at all times. During a telephone interview on [DATE] at 11:46 PM, Nurse Practitioner (NP) was asked if a table tray could be considered a restraint. The NP stated if a resident had the mental capacity to remove the tray themselves, it could be placed in front of a resident. When asked if Resident #15 had the mental capacity to remove a tray table, the NP replied, No, Resident #15 does not have the mental capacity to remove a table tray. During an interview on [DATE] at 12:40 PM, the Wound Care Nurse (WCN) stated Resident #15 sustained a skin tear to the front of the right lower leg when she tried to get up from the geriatric chair with a table tray connected. During an interview on [DATE] at 1:15 PM, the MDS Coordinator confirmed she was unable to find any documentation related to an assessment, physician's order, or monitoring of the table tray connected to the geriatric chair of Resident #15. Observation at the 100/200 nurses' station on [DATE] at 2:10 PM, revealed Resident #15 was sitting in the geriatric chair pulling on the tray with both hands and raising her buttocks off the seat. The staff failed to respond to Resident #15 pulling on the tray table and raising her buttocks off the seat. Observation in the dining room on [DATE] at 3:00 PM, revealed Resident #15 was sitting in the geriatric chair with a tray table across the resident during a movie. Resident #15 was observed pulling on the tray and lifting her buttocks off of the seat. No staff responded to the Resident #15.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, temperature log review, observation, and interview, the facility failed to minimize the potential for foodborne illness transmission by not properly cleaning and sanitizing the inner components of the ice machine for 73 of 73 residents. The facility failed to document refrigerator temperatures to ensure the food was kept at a safe level for 3 of 3 nourishment room refrigerators which has the potential to effect all residents. The facility failed to ensure that food was not left in the refrigerator beyond safe to use by dates in all Nourishment Room Refrigerators. The findings included: Review of the undated policy titled Physical Plant-Daily Inspection, revealed, .Refrigerators .Inspect .check for cleanliness and clean if needed and check for proper operation .Ensure a working thermometer is present inside the unit and temperature is taken daily . Review of the policy titled Food Brought into The Facility by Friends/Family/Others [Outside Sources] For Resident Policy, dated 11/28/2016, revealed, .Food/beverages brought in may be stored in the resident ' s personal refrigerator or in the facility ' s appropriate pantry or refrigerator freezer .Foods/beverages that are in the original manufacturer's container when brought in will be labeled appropriately, but will be discarded after the expiration date .Cooked and [prepared foods brought in for resident will .be appropriately labeled and dated when accepted for storage and discarded after 48 hours .All refrigerators in use in the facility have an internal thermometer to monitor temperature .All refrigerators have their internal temps recoded daily . Review of the undated policy titled Ice Machine Preventative Maintenance, revealed .the facility should be checked for proper ice level, if not at satisfactory level, check equipment operation. The facility should also look for any calcium, lime, or algae. Check to ensure it is in a clean and sanitized state. This includes all ice machines throughout the facility including Dietary . Review of (Named Dietetic Solutions) Nutritional Services/Operations Policy Use By Guidelines dated 6/12/2023, revealed, .Foods with a manufacturer's use by date will still require an opened on date once the item is opened . [Named nutritional supplement] opened and refrigerated should be discarded after 4 days and thickened liquid, opened should be refrigerated for no more than 7 days. Observation on 6/11/2024 at 12:14 PM, in the 400 Hall nourishment room, revealed a large bottle of mustard, 2 bottles of mayonnaise, and 1 bottle of ketchup, and 1 bottle of salad dressing were in the refrigerator with no resident name and no open date present. There were 2 open jars of Pure Cranberry juice labeled room [ROOM NUMBER] with no open date present and an opened container of thickened fruit punch with delivery date of 5/7/2024 but no open date or discard by date present. There were 2 unlabeled and undated partially eaten frozen ice cream items in the freezer. The refrigerator temperature log was labeled May 2024 and had two temperatures documented on the 13th and 14th and the remaining dates had no temperatures documented. Observation of the nourishment room between 100 and 200 Hall on 6/11/2024 at 12:20 PM, revealed a bottle of pineapple juice with no open date, an opened container of thickened fruit punch with delivery date of 5/7/2024 and no open/use by date, a bottle of apple juice and thickened tea, both with delivery dates of 4/2/2024 and no open/use by date present, and a container of [Named nutritional supplement] Vanilla Shake with delivery date of 4/30/2024, with no open/use by date present. There were multiple food items in plastic grocery bags with no label, no date and a bag of potatoes with no label and no date. Observation on 6/11/2024, in the 200 Hall nourishment room at 12:35 PM, revealed a container of [Named nutritional supplement] vanilla shake with delivery date of 4/30/2024 and opened Thickened Sweetened Tea with delivery date of 4/2/2024 with no open date. The refrigerator temperature log labeled May 2024 had 1 temperature recorded and 30 days with no temperature recorded. Observation and interview on 6/11/2024 at 1:35 PM, during a walking round with the Dietary Manager (DM), revealed outdated items were identified in 3 of the 3 nourishment rooms which included [Named nutritional supplement], thickened sweet tea, and fruit juice. The Dietary Manager stated those items should not have remained in the refrigerator. The ice machine in the 400 Hall nourishment room contained pink colored debris on the white surface inside the ice machine and this was confirmed present by the DM. Observation and interview on 6/11/2024 at 1:42 PM, was conducted in the Nourishment Room on the 400 Hall with the Director of Nursing (DON). The DON confirmed the debris in the ice machine and stated it should not have been there. Observation and interview on 6/11/2024 at 2:05 PM, revealed the Administrator was present in the 400 Hall nourishment room and the Maintenance Director walked in as well. The Administrator instructed the Maintenance Director to take the ice machine out of service. Observation on 6/14/2024 at 11:10 AM, revealed the refrigerator in the 200 Hall Nourishment Room had an open container of nutritional supplement with delivery date of 4/2/2024, with no open or use by date, and continued to have brown debris in the bottom of the refrigerator. Observation on 6/17/2024 at 10:25 AM, in the nourishment room located between the 100 and 200 Hall, revealed there was an open container of thickened sweet tea with delivery date of 6/2/2024 that had no open date and no use by date. Observation on 6/17/2024 at 10:30 AM, in the nourishment room behind the 200 Hall desk, revealed the brown debris continued to be at the bottom of the refrigerator. Observation on 6/17/2024 at 10:35 AM, revealed in the 400 Hall refrigerator there continued to be 4 opened condiment bottles with no label and no open or use by date on them. The ice scoop was observed in the ice chest. Observation on 6/17/2024 at 11:00 AM, revealed the refrigerator in the 200 Hall Nourishment Room remained soiled with the brown debris at the bottom under the drawers and had not been cleaned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observations, and interviews, the facility failed to ensure a safe and clean environment in 32 of 51 residents' rooms (101, 102, 103, 104, 105, 106, 110, 113, 201, 203, 204, 205, 208, 210, 211, 212, 213, 214, 301, 302, 306, 307, 308, 309, 311, 314, 403, 405, 406, 407, 409, 411) observed. The findings include: Review of the policy titled, General Cleaning Policies and Procedures, revealed, .To provide a clean, attractive and safe environment for residents, visitors, and staff .Remove general waste from the resident's room .Clean and disinfect the room furnishings .Clean bedside commodes, toilet, handrails, nurse call and cord, light switch and cover plate, safety bar, toilet paper holder, light cover, door frame, and door knobs .Clean and refill soap dispensers .Clean and refill the paper towel and toilet paper dispenser .Clean and reline the waste containers .Wet mop the resident room and bathroom floors .Clean and sanitize toilets . An observation on 8/14/2023 at 11:27 AM, in room [ROOM NUMBER], revealed dried debris on the floor and in the bathroom. An observation on 8/14/2023 at 11:27 AM, in room [ROOM NUMBER], revealed debris on floor and no hand sanitizer in dispenser. An observation on 8/14/2023 at 11:29 AM, in room [ROOM NUMBER], revealed dried debris on the floor and in the bathroom. An observation on 8/14/2023 at 11:32 AM, in room [ROOM NUMBER], revealed dried debris on the floor and in the bathroom. An observation on 8/14/2023 at 11:32 AM, in room [ROOM NUMBER], revealed used paper towels on the floor in the bathroom, a bag of laundry on the bathroom floor, and two spots of a dried red substance on the floor. An observation on 8/14/2023 at 11:35 AM, in room [ROOM NUMBER], revealed dried debris on the floor. An observation on 8/14/2023 at 11:35 AM, in room [ROOM NUMBER], revealed dark dried spots on the floor. An observation on 8/14/2023 at 11:37 AM, in room [ROOM NUMBER], revealed dried debris on the floor. An observation on 8/14/2023 at 11:40 AM, in room [ROOM NUMBER], revealed there was no hand sanitizer in the dispenser. An observation on 8/14/2023 at 11:40 AM, in room [ROOM NUMBER], revealed no toilet paper in bathroom and no hand sanitizer in dispenser. An observation on 8/14/2023 at 11:42 AM, in room [ROOM NUMBER], revealed a foul odor. An observation on 8/14/2023 at 11:42 AM, in room [ROOM NUMBER], revealed dried debris on the floor. An observation on 8/14/2023 at 11:46 AM, In room [ROOM NUMBER], revealed no trash bags in the trash cans and no hand sanitizer in the dispenser. An observation on 8/14/2023 at 11:50 AM, 300 Hall shower room had soiled gloves and used washcloths on the floor. An observation on 8/14/2023 at 11:51 AM, in room [ROOM NUMBER], revealed dark colored dried debris on B side of the room, a foul odor on the A side of the room and soiled linen present in bathroom and no toilet paper present. An observation on 8/14/2023 at 11:51 AM, revealed no hand sanitizer in Rooms 201, 204, 309, and 407. An observation on 8/14/2023 at 11:54 AM, in room [ROOM NUMBER] revealed loose dry debris on the floor and stained tiles. An observation on 8/14/2023 at 11:56 AM, in room [ROOM NUMBER], a graduate was unlabeled and unbagged in the bathroom and no hand sanitizer was in the dispenser. An observation on 8/14/2023 at 11:58 AM, in room [ROOM NUMBER], a graduate was unlabeled and unbagged in the bathroom. An observation on 8/14/2023 at 12:00 PM, in room [ROOM NUMBER], revealed debris on the floor and a bathroom with dried brown debris down the side of the toilet. An observations on 8/14/2023 at 12:00 PM, in room [ROOM NUMBER], revealed no gloves in the room, the uncovered positioning wedge was on the floor, A side had food on the floor, and there was no hand sanitizer. An observation on 8/14/2023 at 12:03 PM, in room [ROOM NUMBER], revealed there was no hand sanitizer. An observation on 8/14/2023 at 12:04 PM, in room [ROOM NUMBER], revealed dried debris on the floor of the bathroom. An observation on 8/14/2023 at 12:04 PM, in room [ROOM NUMBER], revealed there was no hand sanitizer. An observation on 8/14/2023 at 12:05 PM, in room [ROOM NUMBER], revealed there was no hand sanitizer. An observation on 8/14/2023 at 12:07 PM, in room [ROOM NUMBER], revealed there was no hand sanitizer. An observation on 8/14/2023 at 12:08 PM, in room [ROOM NUMBER], revealed dried debris on the floor and no hand sanitizer in the dispenser. An observation on 8/14/2023 at 12:43 PM, in room [ROOM NUMBER], revealed debris on the floor of the bathroom. An observation on 8/14/2023 at 12:45 PM, in room [ROOM NUMBER], revealed dried debris on the bathroom floor. An observation on 8/14/2023 at 12:48 PM, in room [ROOM NUMBER], revealed dried debris and food on the floor. An observation on 8/14/2023 at 12:55 PM, in room [ROOM NUMBER], revealed dried debris on the floor. An observation on 8/14/2023 at 1:00 PM, in room [ROOM NUMBER], revealed debris on the floor. An observation on 8/14/2023 at 1:05 PM, in room [ROOM NUMBER], revealed debris on the floor. An observation on 8/14/2023 at 1:12 PM, in room [ROOM NUMBER], revealed dried brown debris in the bathroom on the toilet. An observation on 8/14/2023 at 1:17 PM, in room [ROOM NUMBER], revealed debris on the floor. An observation on 8/14/2023 at 1:20 PM, in room [ROOM NUMBER], revealed food on the floor. During an interview on 8/14/2023 at 1:43 PM, the Assistant Director of Nursing (ADON) confirmed room [ROOM NUMBER] was dirty with dried brown debris on the toilet. Continued interview revealed the ADON stated this is not an acceptable practice for nursing home standards. An observation on 100 Hall on 8/14/2023 at 2:23 PM, revealed residents' rooms with dried debris on floor. An observation on 200 Hall on 8/14/2023 at 2:35 PM, revealed residents' rooms with dried debris on floor and in bathroom. An observation on 8/14/2023 at 2:38 PM, in room [ROOM NUMBER], revealed candy, an empty medicine cup, and dark dried substance on the floor. Further observation revealed no hand sanitizer in dispenser. During an interview on 8/14/2023 at 2:46 PM, the Director of Nursing (DON) confirmed there was an issue with an understaffed housekeeping department and the resident rooms should have already been cleaned. During an interview on 8/14/2023 at 3:03 PM, the Housekeeper stated the housekeeping department was understaffed and currently had only two staff members. She stated the two housekeepers had two halls each and did laundry too. Continued interview revealed the Housekeeper stated the housekeepers were responsible for toilet paper, paper towels, and soap in resident rooms. During an interview on 8/14/2023 at 3:55 PM, CNA #2 stated that during her rounds at the start of her shift, at the facility, on this day, she observed a soiled brief, with dried debris present, stuck to the floor in room [ROOM NUMBER] on the B side of the room. She stated there was also brown debris present on the bed and a soiled chuck present in the wheelchair. During an interview on 8/15/2023 at 1:46 PM, the DON confirmed the resident rooms were not cleaned the way they should be due to being short staffed in housekeeping.

**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 promote and protect the dignity of 1 of 39 sampled residents (Resident #2) reviewed. The findings include: Review of the facility's undated policy titled, Resident Rights, revealed, .As a resident of this facility, you have the right to a dignified existence and to communicate with individuals and representatives of choice .The facility must care for you in a manner and environment that enhances or promotes your quality of life .The facility will treat you with dignity and respect in full recognition of your individuality .You have the right to receive services with reasonable accommodations to individual needs and interests .The facility must provide a safe, clean, comfortable, home-like environment, allowing you the opportunity to use your personal belongings to the extent possible .The facility will provide housekeeping and maintenance services . Review of the medical record for Resident #2 revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Polyneuropathy and Atrial Fibrillation. Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #2 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Continued review revealed she required extensive assistance for transfer, toileting and hygiene. Review of the Care Plan for Resident #2 revealed, .Self care deficit related to: obesity, pain .she requires extensive assistance with bed mobility, transfers, toileting . Observation on 8/9/2022 at 7:15 AM, Certified Nursing Assistant (CNA) #1 provided incontinent/peri care for Resident #2, and did not pull the privacy curtain, nor close the door to the room. Several staff members, residents and visitors were observed passing by the room in the hallway. During an interview on 8/9/2022 at 7:30 AM with CNA #1, she confirmed she did not provide privacy for Resident #35 while performing incontinent care. She stated, I should have pulled the curtain and closed the door. During an interview on 8/9/2022 at 8:57 AM with the Director Of Nursing, she confirmed the staff must provide privacy when performing incontinent care for the residents by pulling the curtain and closing the room door.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to notify the physician when a resident refused gastrostomy supplemental feeding, blood glucose checks, and medication for 1 of 39 sampled residents (Resident #20) reviewed; the facility also failed to notify the family of a Resident to Resident interaction for 1 of 39 sampled residents (Resident #211) reviewed. The findings include: Review of the facility's undated policy titled, Change in Resident's Condition or Status, revealed, .it is the policy of the facility to ensure that the resident's attending physician and Representative are notified of changes in the resident's condition or status .resident is involved in an abuse situation or an allegation of abuse .a need to alter the resident's treatment plan significantly .resident repeatedly refuses treatment of meds [2 times consecutively or 3 times in a 7 day period] .the nurse will notify the resident's representative when .abuse situations or allegations of abuse . Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses which included End Stage Renal Disease, Chronic Pancreatitis, Type 2 Diabetes Mellitus, and Dependence on Renal Dialysis. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Continued review of the MDS revealed Resident #20 required extensive assistance with Activities of Daily Living (ADL). Review of Resident #20's July and August 2022 Medication Administration Record (MAR) revealed Resident #20 refused her Enteral feed 22 different times for Nepro 35 milliliters (ML)/hour (hr) for 4 hrs at 2200 [10:00 PM]. Continued review of Resident #20's July and August 2022 MAR also revealed numerous refusals of medications and blood glucose checks. During an interview on 8/10/2022 at 3:05 PM, the Director of Nursing (DON) reviewed Resident #20's medical record and confirmed she was unable to find any notifications to the Physician of the resident's refusals. Review of the medical record for Resident #16 revealed an admission date of 5/7/2022 with diagnoses of Hypertensive Heart Disease Without Heart Failure, Dementia without Behavioral Disturbances, and Seizures. Review of the admission MDS assessment dated [DATE] revealed Resident #16 had a BIMS score of 3, which indicated severe cognitive impairment. Review of the medical record for Resident # 211 revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Cholecystitis and Alzheimer's Disease. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #211 had a BIMS score of 8, which indicated moderate cognitive impairment. During a telephone interview on 8/9/2022 at 3:05 PM, Registered Nurse (RN) #1 stated she had notified Resident #16's family member about finding her in bed with Resident #211, but she did not notify Resident #211's family. During a telephone interview on 8/9/2022 at 4:33 PM, Resident #211's responsible party (family member #4) stated she had not been notified of any occurrences involving another resident being found in Resident #211's bed. She stated the resident was sent to the hospital on 8/2/2022 and the facility called her to let her know but no one told her about the incident. During an interview on 8/10/2022 at 7:15 PM, the Assistant Director of Nursing (ADON) stated there was no documentation in Resident #211's records to indicate the family was notified about Resident #16 being found in Resident #211's bed on 7/31/2022. She confirmed the family/responsible party should have been notified of the occurrence.

Based on facility policy review, observation, and interview, the facility failed to maintain patient confidentiality related to a computer screen open with resident health information in view with no staff in attendance. The findings include: Review of the undated facility policy titled, What Is HIPAA [Health Insurance Portability and Accountability Act of 1996] revealed, .It shall be the policy of the facility to protect and safeguard the PHI (Protected Health Information) created, acquired and maintained in accordance with the Privacy Regulation pursuant to the HIPAA . Observation of the 200 Hall medication cart on 8/8/2022 at 2:40 PM, revealed residents' heath information was displayed on the computer screen on the medication cart with no staff in attendance. Observation of the 200 Hall on 8/8/2022 at 2:43 PM, revealed 2 EMS (Emergency Medical Service) personnel and 2 facility staff walked by the 200 Hall medication cart with the computer screen open with residents' identifiable information in view. During an interview on 8/8/2022 at 2:43 PM, Licensed Practical Nurse (LPN) #2 confirmed she left the 200 Hall medication cart with the computer screen open with resident identifiable information in view. During an interview on 8/8/2022 at 2:45 PM, the Director of Nursing stated, Computer screens should be locked to protect the resident's health information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to promote a clean and sanitary homelike environment for 1 of 39 sampled residents (Resident #22). The findings include: Review of the facility's undated policy titled, General Cleaning Policies and Procedures, Resident Room-Clean, revealed, .Bedside tables-scrub all surfaces of the table including legs, base, stand, table top, and bottom . Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses which included Interstitial Pulmonary Disease, Hypertensive Heart Disease without Heart Failure and Atrioventricular Block. Observation in Resident #22's room on 8/8/2022 at 10:10 AM, 12:43 PM, and 2:41 PM, and again on 8/9/2022 at 12:29 PM and 12:36 PM revealed several flies on Resident #22's left shoulder and flying around the room. Continued observation revealed an bedside table with dark dried debris at the base of the table. Observation and interview on 8/9/2022 at 12:36 PM in Resident #22's room in the presence of Housekeeper #1, Housekeeper #2, and the Housekeeping Supervisor, all 3 confirmed there were flies in the room and dark dried debris to the base of bedside table.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, and interview, the facility failed to report a resident to resident interaction incident to the State Agency within the required time for Resident #16 and #211. The findings include: Review of the facility policy titled, Abuse Prevention Program, revealed, .It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property .The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party .employees are required to report any incident, allegation or suspicion of potential abuse, neglect or mistreatment they observe, hear about or suspect to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator .Supervisors shall immediately inform the Administrator or in the absence of the Administrator, the person in charge of the facility of all reports of incidents, allegations, or suspicion of potential mistreatment .Upon learning of the report, the Administrator, the person in charge of the facility shall initiate an incident investigation .All personnel must promptly report any incident or suspected incident of resident abuse, mistreatment or neglect, including injuries of unknown origin . Review of the medical record for Resident #16 revealed an admission date of 5/7/2022 with diagnoses of Hypertensive Heart Disease Without Heart Failure, Dementia without Behavioral Disturbances, and Seizures. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #16 revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Review of the progress notes for Resident #16 revealed, .7/31/2022 06:54 .Res [resident] was awake .Found her in [named Resident] #211's bed with other res .res just started fighting .hitting CNA [Certified Nursing Assistant] with both fists .Police came with EMT [Emergency Management Transportation]. Review of the medical record for Resident #211 revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Cholecystitis, Alzheimers Disease, and Aphasia. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #211 had a BIMS score of 8, which indicated moderate cognitive impairment. During an interview on 8/8/2022 at 3:24 PM, Resident #16's responsible party (family member #4) stated she had received a phone call about Resident #16 getting into bed and cuddling with another female resident. She stated she was informed Resident #16 became combative with the CNA when she tried to get her out of the bed and had to be sent to the ER to get her calmed down. She stated the next night at the facility, the resident was found in another bed and became combative again. She stated the resident had to be sent back to the ER again for her behavior. During a telephone interview on 8/9/2022 at 3:05 PM, Registered Nurse (RN) #1 stated Resident #16 wanders into rooms and has to be redirected frequently. She stated she had gotten into beds before and had to be redirected. She stated she was notified by the CNA on 7/31/2022 that Resident #16 had been found in bed with Resident #211. She stated Resident #16 became combative and attacked the CNA when she attempted to assist her out of the other resident's bed. She stated she notified the Director of Nursing (DON) and was told to send her out to the emergency room (ER). She stated the resident was sent to the ER and returned later that morning. During an interview on 8/10/2022 at 4:49 PM, the DON confirmed she had not reported the incident to the State Agency. During an interview on 8/10/2022 at 5:22 PM, the Administrator stated he was the abuse coordinator. He stated the facility did not report the occurrence between Resident #16 and Resident #211 to the State Agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, and interview, the facility failed to complete a thorough investigation of resident to resident interaction incident between Resident #16 and Resident #211. The findings include: Review of the undated facility policy titled, Abuse Prevention Program, revealed, .It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property .The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party .employees are required to report any incident, allegation or suspicion of potential abuse, neglect or mistreatment they observe, hear about or suspect to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator .Supervisors shall immediately inform the Administrator or in the absence of the Administrator, the person in charge of the facility of all reports of incidents, allegations, or suspicion of potential mistreatment .Upon learning of the report, the Administrator, the person in charge of the facility shall initiate an incident investigation .All personnel must promptly report any incident or suspected incident of resident abuse, mistreatment or neglect, including injuries of unknown origin . Review of the medical record for Resident #16 revealed an admission date of 5/7/2022 with diagnoses of Hypertensive Heart Disease Without Heart Failure, Dementia without Behavioral Disturbances, and Seizures. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Review of the progress notes for Resident #16 revealed, .7/31/2022 06:54 .Res [resident] was awake .Found her in [named Resident] #211's bed with other res .res just started fighting .hitting CNA [Certified Nursing Assistant] with both fists .Police came with EMT [Emergency Management Transportation] . Review of the medical record for Resident # 211 revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Cholecystitis, Alzheimers Disease, and Aphasia. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #211 had a BIMS score of 8, which indicated moderate cognitive impairment. During an interview on 8/8/2022 at 3:24 PM, Resident #16's responsible party (family member #4) stated she had received a phone call about Resident #16 getting into bed and cuddling with another female resident. She stated she was informed Resident #16 became combative with the CNA when she tried to get her out of the bed and had to be sent to the ER to get her calmed down. She stated the next night at the facility, the resident was found in another bed and became combative again. She stated the resident had to be sent back to the ER again for her behavior. During a telephone interview on 8/9/2022 at 3:05 PM, Registered Nurse (RN) #1 stated Resident #16 wanders into rooms and has to be redirected frequently. She stated she had gotten into beds before and had to be redirected. She stated she was notified by the CNA on 7/31/2022 that Resident #16 had been found in bed with Resident #211. She stated Resident #16 became combative and attacked the CNA when she attempted to assist her out of the other resident's bed. She stated she notified the Director of Nursing (DON) and was told to send her out to the emergency room (ER). She stated the resident was sent to the ER and returned later that morning. During an interview on 8/10/2022 at 4:49 PM, the DON stated she did not complete a thorough investigation related to the interaction involving Resident #16 and #211. During an interview on 8/10/2022 at 5:22 PM, the Administrator stated he was the abuse coordinator. He confirmed the facility did not thoroughly investigate the interaction between Resident #16 and #211.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to have quarterly care plan conference meetings with resident or resident's representative for 5 of 39 sampled residents (Residents #9, #15, #34, #36 and #47) reviewed for care plan conference meetings. The facility also failed to revise care plans for 3 of 39 sampled residents (Residents #11, #16 and #47) reviewed. The findings include: Review of the facility's undated policy titled, Baseline Care Plan Assessment/Comprehensive Care Plans, revealed, .The Comprehensive Care Plan will be finalized within 7 days of completion of the Full Comprehensive MDS assessments and corresponding CAAs [Care Area Assessments]. The Comprehensive Care Plan will include participation from the IDT [Interdisiplinary Team] members as well as a CNA(s) [Certified Nursing Assistant] who deliver hands on care by way of interview, some member of the food/nutritional service staff, restorative nursing team as applicable, as well as Social Services Worker .As the resident remains in the Nursing Home, additional changes will be made to the comprehensive care plan based on the assessed needs of the resident .The facility Social Service Director or designee will notify the resident's responsible party either by letter or a phone call to inform them of the scheduled Care Plan Conference to include the date and time. This notification will continue for subsequent Care Plan Conferences. These notifications will be documented for reference .The facility Social Service Director or designee will notify the resident of their scheduled Care Plan Conference and will invite and encourage the resident to attend .The Comprehensive Care Plan will be reviewed and updated every quarter at a minimum. The facility may need to review the care plans more often based on changes in the resident's condition and/or newly developed health/psycho-social issues . Review of medical record revealed, Resident #9 was admitted to the facility on [DATE] with diagnoses which included Spastic Quadriplegic Cerebral Palsy, Aphasia, Muscle Wasting, and Atrophy. Review of the Quarterly MDS assessments for Resident #9 completed on 2/17/2022 and 5/19/2022 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Review of Resident #9's Quarterly Care Plans on 2/23/2022 and 5/19/2022, revealed Care Plan Conferences were not held with Resident or Resident's Representative. No Care Plan Conference notes or documentation were found in the medical record within the last year. Review of Resident #9's Nursing Progress notes revealed no documentation of Care Plan Conference documentation. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses which included Cerebral Palsy Unspecified and Chronic Diastolic Congestive Heart Failure. Review of the Quarterly MDS assessments for Resident #15 completed on 3/22/2022 and 6/6/2022 revealed a BIMS score of 15, which indicated no cognitive impairment. Review of Resident #15's Quarterly Care Plans on 3/4/2022 and 6/3/2022, revealed Care Plan Conferences were not held with Resident or Resident's Representative. No Care Plan Conference notes or documentation were found in the medical record. Review of Resident #15's Nursing Progress notes revealed no documentation of Care Plan Conference documentation. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses which included Cerebral Ataxia and Chronic Pain Syndrome. Review of the medical record revealed Quarterly Minimum Data Set (MDS) assessments were completed for Resident #34 on 4/11/2022 and 7/5/2022. Review of the medical record for Resident #34 revealed there were no care conference meetings conducted with the resident or resident representative. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE] with diagnoses which included Traumatic Subdural Hemorrhage and Dementia. Review of the Quarterly MDS dated [DATE] for Resident #36 revealed a BIMS score of 0, which indicated severe cognitive impairment. Review of the medical record for Resident #36 revealed no Care Plan conference meetings. Review of the medical record for Resident #47 revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Cerebral Infarction, Hemiplegia, Hemiparesis, and Pneumonia. Review of the Quarterly MDS assessment for Resident #47 dated 7/19/2022, revealed a BIMS score of 15, which indicated no cognitive impairment. Continued review revealed she required extensive assistance with all Activities of Daily Living. During an interview in Resident #9 and #15's room on 8/8/2022 at 10:34 AM, Resident #9 stated, I haven't had any care plan meetings recently, and Resident #15 stated, I haven't participated in a care plan meeting in a long time. During an interview on 8/8/2022 at 10:45 AM with Resident #47, she stated she has been at the facility for over a year and has never been invited to a care plan meeting. During an interview on 8/9/2022 at 4:00 PM, the Regional Director of Nursing confirmed there were no Care Plan Conference meetings for Resident #47. During an interview with the Social Service Director on 8/9/2022 at 5:12 PM, she confirmed she had not completed care conference meetings with Resident #9, Resident #15, Resident #34, Resident #36, and Resident #47. During an interview with the Regional MDS Consultant on 8/10/2022 at 6:54 PM, she confirmed no Care Plan meetings were noted for Resident #36. Review of the medical record for Resident #11 revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Seizures, Frontal Lobe and Executive Function Deficit Following Cerebrovascular Disease. Review of the Quarterly MDS assessment for Resident #11 dated 5/26/2022, revealed a BIMS score of 00, which indicated severe cognitive impairment. Continued review revealed he required extensive assist of 1-2 persons for bed mobility, transfers, dressing, toilet use, personal hygiene, and total dependence for bathing and eating. Continued review revealed he had a urinary catheter and an ostomy; he received a tube feeding; and was at risk for developing pressure ulcers. Review of the Care Plan for Resident #11 revealed assessments/problems, goals, and interventions for, .[Named resident] comes in and out of activities including music and devotion and socials. He wheels self around the facility in his wheelchair. [Named resident] wanders into others rooms, stop signs are in place for redirection. His food during socials is purred [pureed] so he can enjoy with the other residents .[Named resident] is at risk for aspiration related to difficulty swallowing as evidenced by: history of aspiration, mechanically altered diet . Review of the medical record for Resident #16 revealed an admission date of 5/7/2022 with diagnoses of Hypertensive Heart Disease Without Heart Failure, Dementia without Behavioral Disturbances, and Seizures. Review of the admission MDS assessment for Resident #16 dated 6/3/2022, revealed a BIMS score of 3, which indicated severe cognitive impairment. Review of the Wandering Risk Scale for Resident #16 dated 5/27/2022, 5/30/2022 and 6/29/2022 revealed a score of 9, which indicated she was at risk to wander. Review of the Care Plan for Resident #16 revealed assessments/problems, goals, and interventions for, .Alteration in nutritional status as evidenced by: [Named resident] has a dx [diagnosis] of dementia and aphasia .Will not experience an undesired significant weight change greater than 5% in 30 days. or 10% in 180 days .Alteration in behaviors as evidenced by [Named resident] is resistant to care- hitting scratching staff, spitting on them, wanders in hallway . Continued review revealed the care plan was not updated with interventions for her behaviors after the wandering incidents that occurred on 7/31/2022 and 8/1/2022 which resulted in a hospital visit. Continued review revealed the care plan was not updated with interventions for significant weight loss documented 7/14/2022. Review of a Dietary Progress Note for Resident #16 dated 7/14/2022, revealed, .Resident triggers for following weight change: -5.0% change [Comparison Weight 6/1/2022, 127.2 Lbs, -5.2% , -6.6 Lbs] .Start fortified foods TID [three times a day] (677 kcal [kilocalories], 23g PRO [protein]) in effort to increase kcal/pro intake to prevent further weight loss . Review of progress notes for Resident #16 revealed, .7/31/2022 06:54 .cna [Certified Nursing Assistant] reported res [resident] was awake so I went to check on her as she gets out of bed .Found her in .bed with other res . Review of the medical record for Resident #47 revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Cerebral Infarction, Hemiplegia, Hemiparesis, and Pneumonia. Review of the Quarterly MDS assessment for Resident #47 dated 7/19/2022, revealed a BIMS score of 15, which indicated no cognitive impairment. Continued review revealed she required extensive assistance with all Activities of Daily Living. Review of the Care Plan for Resident #47 revealed assessments for current problems and included assessments for the use of anticoagulants, aspirin, antibiotics, and an active urinary tract infection. During an interview on 8/9/2022 at 3:50 PM, the Care Plan Coordinator stated the resident care plans are updated any time there is a change and quarterly. Upon reviewing Resident #47's Care Plan, she confirmed the care plan was not updated when the anticoagulant and aspirin were discontinued, when the urinary tract infection resolved, and when the antibiotic therapy was completed. During an interview on 8/10/2022 at 10:55 AM, the MDS Coordinator reviewed the care plan for Resident #16 and confirmed there were no revisions made to the care plan to reflect recent behaviors of getting into other resident's beds. Continued interview she confirmed there were no revisions to her care plan to reflect significant weight loss documented on 7/14/2022. During an interview on 8/10/2022 at 11:00 AM, the Care Plan Coordinator confirmed the care plan for Resident #11 should have been updated when he declined. She confirmed he no longer gets up in his wheelchair and is no longer on a pureed diet. During an interview on 8/10/2022 at 4:49 PM, the DON stated there were no new interventions or revisions updated to Resident #16's care plan to prevent more behaviors of wandering into other rooms and getting into bed with other residents. She stated the resident repeated the behaviors after being sent to the ER for further evaluations. She stated the resident probably needed one on one supervision.

**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 turn and reposition 2 of 39 sampled residents (Residents #11 and #51) and failed to obtain a doctor's order for 1 of 39 sampled residents (Resident #58) reviewed. The findings include: Review of the facility's undated policy titled, Turning/Repositioning Guidelines, revealed, .The risk for skin breakdown depends on the number and type of risk factors identified for the individual resident .One of the factors is immobility including in bed and/or in chair with the inability to move .If the resident cannot change position without the help of other(s) or cannot change position due to a splint or brace or other device the risk for skin breakdown is increased .Choosing a turn schedule, usually every 2 hours on odd or even hours . Review of the facility's undated policy titled, Physicians Orders- (Following Physician Orders), revealed, .It is the policy of the facility to follow the orders of the physician. At the time of admission the facility must have physician orders for the resident's immediate care. The facility will have orders to provide essential care to the resident, consistent with the resident's mental and physical status upon admission . Review of the undated facility policy titled, Oxygen Administration, revealed, .to provide oxygen to maintain levels of saturation to residents as needed and as ordered by the attending physician .Orders are entered into the clinical record under Medication Administration Record .tubing, humidifier bottles and filters will be changed, cleaned and maintained no less than weekly and PRN .Each will be labeled with date, time and initialed by staff completing this service to equipment . Review of the medical record for Resident #11 revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Seizures, Frontal Lobe and Executive Function Deficit Following Cerebrovascular Disease. Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #11 dated 5/26/2022, revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment. Continued review revealed he required extensive assist of 1-2 persons for bed mobility, transfers, dressing, toilet use, personal hygiene, and total dependence for bathing and eating. Continued review revealed he had a urinary catheter and an ostomy. Continued review revealed he received a tube feeding and was at risk for developing pressure ulcers. Review of the Care Plan for Resident #11 revealed assessments/problems, goals, and interventions for, .Self care deficit related to : [Named resident] has altered functional ability he requires extensive to total services all mobility related tasks .Oral care daily and as needed .Risk for Pressure Ulcer: [Named resident] is at risk for developing a pressure ulcer r/t [related to] altered mobility, weakness, history of stroke, expressive aphasia, seizure disorder, and incontinence of bowel and bladder .Assist PRN [as needed] to reposition/shift weight to relieve pressure . Review of the medical record for Resident #51 revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Carcinoma of the Liver, Severe Protein-Calorie Malnutrition, and Cerebral Infarction. Review of the Quarterly MDS assessment dated [DATE] for Resident #51 revealed a BIMS assessment could not be performed due to severe cognitive deficits. Continued review revealed he required extensive assistance for bed mobility, dressing, eating, toilet use, personal hygiene, and total dependence for bathing. Review of the Care Plan for Resident #51 revealed assessments/problems related to, .ADLs [Activities of Daily Living] Self care deficit related to: [Named resident] has altered mobility and cognition, Ca [cancer] Liver, Dementia/Alzheimer's diagnosis: Requires extensive to total assist with transfers, toileting, Bathing and dressing .Turn and reposition as indicated, shifting weight to enhance circulation .RISK FOR PRESSURE ULCER: [Named resident] is at risk for developing a pressure ulcer lack of coordination, requires staff to effectively relieve pressure, incontinence of bowel .Assist PRN [as needed] to reposition/ shift weight to relieve pressure . Observations in Resident #11's room on 8/8/2022 at 11:09 AM, 12:21 PM, and 3:05 PM, revealed he was laying in his bed on his back. His urinary catheter tubing was under his right back/arm. Observations on 8/9/2022 at 7:07 AM and 9:33 AM revealed Resident #11 laying on his right side, facing the window. Observation in Resident #51's room on 8/8/2022 at 11:04 AM, 12:22 PM, and 2:52 PM revealed he was laying in his bed on his back . Observation in Resident #11's room on 8/9/2022 at 7:06 AM, 8:44 AM, and at 9:33 AM, revealed he was laying on his side facing the window. Observation in Resident #51's room on 8/9/2022 at 7:07 AM revealed he was laying on his back. Continued observation at 8:45 AM revealed him laying on his back with head of bed elevated and was being fed by a staff member. Continued observation at 9:33 AM revealed him laying on his back. During an interview on 8/8/2022 at 3:10 PM in Resident #11 and Resident #51's room with the Director of Nursing (DON), she confirmed Resident #11 was laying on the urinary catheter tubing and Resident #51 was laying on his back, and they should have been turned and repositioned every 2 hours. During an interview on 8/9/2022 at 9:33 AM with the DON confirmed again, residents who are immobile are to be turned/repositioned at least every 2 hours. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE] with diagnoses which included Unspecified Protein-Calorie Malnutrition and General Anxiety Disorder. Review of the Annual MDS assessment dated [DATE] revealed the resident was not receiving oxygen therapy. Review of the Care Plan dated 7/30/2020 for Resident #58 revealed care plans which included, .complications with gas exchange .receives oxygen .date initiated 8/9/2022 . Review of the Order Summary Report dated for August 2022 revealed there were no oxygen orders. Observation and interview in Resident #58's room on 8/8/2022 at 10:22 AM, revealed a portable oxygen tank at Resident #58's bedside. Resident #58 stated she used oxygen every now and then. During an interview on 8/9/2022 at 12:10 PM, the DON confirmed she was unable to locate an order for Resident #58 to have oxygen prn (as needed).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to treat a stage 4 pressure ulcer upon admission for 4 days for 1 of 4 sampled residents (Resident #110) reviewed. The findings include: Review of the facility's undated policy titled, Pressure Ulcer Management: Treatment of Pressure Ulcers revealed .Once a Pressure Ulcer is established, the following must be investigated, established, documented, and addressed to resolution .Establish the root cause of the wound .Monitor for efficacy-treatments/cleanings/meds [medications]/debridement .Monitor and track nutrition/hydration and weight loss . Review of the medical record revealed Resident #110 was admitted to the facility on [DATE] with diagnoses which included Dementia without Behavioral Disturbances, Osteomyelitis, Sepsis, and Pressure Ulcer to Right Butt Stage 4. Review of the admission Minimum Data Set (MDS) assessment, dated 7/18/2022, revealed Resident #110 had a Brief Interview for Mental Status (BIMS) score of 2, indicating severe cognitive impairment. Continued review revealed Resident #110 was incontinent of bowel and bladder and required an indwelling urinary catheter. Continued review revealed Resident #110 had been admitted to the facility with a stage 4 pressure ulcer. Resident #110 required extensive assistance from 2 staff members for bed mobility. Review of the care plan dated 7/15/2022 revealed .Alteration in comfort related to: [named resident] has Rheumatoid arthritis, Osteomyelitis, Stage IV pressure ulcer right buttocks .Pain medication per order, observe effectiveness .Pressure reduction mattress to enhance comfort .Turn and reposition every 2 hours and prn [as needed] res [resident] request .Alteration in nutritional status as evidence by: dysphagia, malnutrition .Encourage P.O [by mouth ] intake. Offer substitutes if consume less than 75% . Review of the Medication Discharge Report dated 7/14/2022 revealed .Cefdinir (cefdinir 300 mg [milligram] oral capsule) 1 capsule By mouth Twice daily for 7 days .R [right]-gluteal Chronic stage 4 Dakin's wet to dry . Review of the Admission/readmission Screener dated 7/15/2022 revealed Resident #110 admitting diagnosis was, .Non-Healing R [right] gluteal wound . Review of the Order Summary Report dated 7/14/2022 revealed .Give 300 mg by mouth two times a day for abx [antibiotic] therapy . Continued review revealed no wound care orders upon admittance to the facility on 7/14/2022 . Review of the Weekly Wound Evaluation dated 7/15/2022, revealed the wound was a right gluteal stage 4 wound with measurements of 10 cm [centimeters] x 11.5 cm x 5 cm. Review of the Medication Administration Record (MAR) dated 7/2022 revealed no orders from 7/14/2022 to 7/18/2022 addressing wound care for the right gluteal. During an interview on 8/9/2022 at 12:30 PM, the Director of Nursing (DON) confirmed that when shown the MAR, she did not see where the nurses charted wound care treatment for five days from 7/14/2022 to 7/18/2022. During an interview on 8/9/2022 at 12:44 PM, the Assisted Director of Nursing (ADON) confirmed the orders to provide wound care were not reflected on the MAR for Resident #110 from 7/14/2022 to 7/18/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, and interview, the facility failed to ensure adequate supervision and interventions to prevent repetition of behaviors which include wandering into resident rooms and getting into unknown beds for 1 resident (Resident #16) reviewed for resident to resident interaction incidents. The findings include: Review of the undated facility policy titled, Accident Incident Reporting Policy, revealed, .Any accident/incident will be reported immediately to the nurse or appropriate person designated to be in charge. A written report will be completed for any individual (resident) involved in an accident or an incident while residing in the facility .Purpose: to ensure that accidents and incidents that occur with residents are identified, reported, investigated, and resolved. To provide a database to study the cause of accidents/incidents and to provide assistance in implementing corrective actions to prevent reoccurrence when possible . Review of the medical record for Resident #16 revealed an admission date of 5/7/2022 with diagnoses which included Hypertensive Heart Disease Without Heart Failure, Dementia without Behavioral Disturbances, and Seizures. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Review of the Care Plan for Resident #16 revealed assessments/problems, goals, and interventions for, .dementia .Observe for untoward side effects to Antipsychotics such as Tardive dyskinesia, drowsiness, agitation, insomnia, Headache, etc .Alteration in behaviors as evidenced by [Named resident] is resistant to care- hitting scratching staff, spitting on them, wanders in hallway . Continued review revealed the care plan was not updated with interventions for her behaviors after the wandering incidents that occurred on 7/31/2022 and 8/1/2022 which resulted in a hospital visit. Review of the Wandering Risk Scale for Resident #16 dated 5/27/2022, 5/30/2022, and 6/29/2022 revealed a score of 9, which indicated she was at risk to wander. Review of the Progress Notes for Resident #16 dated 7/31/2022 at 6:54 AM, revealed, .cna [Certified Nursing Assistant] reported res [resident] was awake so I went to check on her as she gets out of bed .Found .in bed with other res . res just started fighting .hitting cna with both fists, scratched both her arms and spit fully in her face .she went out 911 .at 00:40 [12:40] a.m . Review of the Progress Notes for Resident #16 dated 8/1/2022 at 6:17 AM revealed, .resident was in a bed on 400 hall when this nurse and cna on duty found her sleeping. this nurse and cna tried to talk resident into getting up and going back to her bed. cna on duty tried to assisted resident into her wheelchair when resident proceeded to kick cna on duty .this nurse called NP [Nurse Practitioner] and gave order to send her out. resident was pleasant when EMS [Emergency Medical Service] and cops arrived. Family DON [Director of Nursing] and NP [Nurse Practitioner] notified . Review of the Progress Notes for Resident #16 dated 8/10/2022 at 12:34 AM, revealed, .Resident was observed wandering into another resident's room .This nurse intervened and redirected resident from room [ROOM NUMBER] to her room; Resident was assisted into her bed while during transfer resident began to bite, spit and scratch this nurse .resident had multiple behaviors earlier in the shift where she was spitting at staff members; DON requested this nurse call NP or MD for order to send to ER for psych eval . During a telephone interview on 8/9/2022 at 3:05 PM, Registered Nurse (RN) #1 stated Resident #16 wanders into rooms and has to be redirected frequently. She stated she had gotten into beds before and had to be redirected. She stated she was notified by the Certified Nursing Assistant (CNA) on 7/31/2022 that Resident #16 had been found in bed with Resident #211. She stated Resident #16 became combative and attacked the CNA when she attempted to assist her out of the other resident's bed. She stated she notified the Director of Nursing (DON) and was told to send Resident #16 out to the emergency room (ER). She stated the resident was sent to the ER and returned later that morning. During an interview on 8/10/2022 at 4:49 PM, the DON stated there were no new interventions or revisions updated to Resident #16's care plan to prevent more behaviors of wandering into other rooms and getting into bed with other residents. She stated the resident repeated the behaviors after being sent to the ER for further evaluations. She stated the resident probably needed one on one supervision.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to label and date the oxygen equipment for 5 of 14 sampled residents (Resident #27, #40, #43, #54, and #58) who received respiratory therapy and failed to administer oxygen at the physician's prescribed rate for 2 of 14 sampled residents (Residents #35 and #44) who recieved respiratory therapy. The findings include: Review of the facility's undated policy titled, Oxygen Administration, revealed, .Tubing, humidifier bottles .will be changed, cleaned and maintained .each will be labeled with date, time and intialed by staff completing this service to equipment .check orders for adequate oxygen liter flow . Review of the facility's undated policy titled, Physician Orders-(Following Physician Orders), revealed, .It is the policy of the facility to follow the orders of the physician . Review of the medical record for Resident #27 revealed she was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), and Cardiac Pacemaker. Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #27 dated 6/20/2022 revealed she received oxygen while a resident at the facility. Review of the Medication Administration Record (MAR) for Resident #27 dated 8/1/2022 through 8/31/2022 revealed, .Oxygen 3L [liters] NC [nasal cannula] as needed for SOB [shortness of breath] PRN [as needed] . Review of the 8/2022 Physician's Orders revealed an order to administer O2 3 LPM per NC as needed for shortness of breath and order to change O2 tubing weekly every Sunday night. Observation in Resident #27's room on 8/8/2022 at 10:15, 1:00 PM, and at 5:23 PM, revealed she was wearing a nasal cannula attached to an oxygen concentratator that was delivering O2 at 2 Liters per minute (LPM). Further observation revealed Resident #27's O2 tubing and humidifier bottle were not dated or labeled. Observation and interview in Resident #27's room on 8/9/2022 at 7:45 AM, Assistant Director of Nursing (ADON) observed the O2 concentrator setting at 2 LPM and tubing. The ADON confirmed the Physician's Order for O2 was 3 LPM, and nasal cannula tubing should be dated and changed weekly. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Fibromyalgia, and Dysphagia. Review of the Physician's Orders for Resident #35 revealed, .9/10/2020 O2 LPM via NC every shift continously . Observation in Resident #35's room on 8/8/2022 at 11:00 AM, revealed she was wearing a nasal cannula attached to an oxygen concentrator that was delivering oxygen at 6 liters per minute. Observation and interview in Resident #35's room on 8/8/2022 at 4:28 PM, the Director of Nursing confirmed the oxygen concentrator was delivering 6 LPM of oxygen to the resident. She also confirmed the physician's order was for 2 LPM oxygen, and the concentrator should have been set to deliver 2 LPM oxygen. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses which included Hypertensive Heart Disease, Atrial Fibillation, and Morbid Obesity. Review of Resident #40's Physician's Order dated 8/2022, revealed an order to administer O2 at 2 LPM continously. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses which inclued Cerebrovascular Disease, Chronic Obstructive Pulmonary Disease, and Morbid Obesity. Review of Resident #43's Physician's Order dated 8/2022, revealed an order to administer O2 at 2 LPM as needed. Observation on 8/8/2022 at 11:30 AM and on 8/9/2022 at 1:00 PM in Resident #40 and Resident #43's room, revealed the resident's nasal cannulas were not labeled or dated. Observation and interview on 8/8/2022 at 11:45 AM in room [ROOM NUMBER], Assistant Director of Nursing (ADON) confirmed Resident #40 and Resident #43's O2 tubing were not dated. The ADON confirmed the O2 tubing should be changed weekly on Sunday. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with diagnoses which included Chronic Diastolic (Congestive) Heart Failure and Cardiomyopathy. Review of the current Physician's Order dated 8/2022, for Resident #44, revealed an order to administer O2 at 1 LPM continuously. Observation on 8/8/2022 at 10:44 AM, 2:49 PM, and 6:44 PM in Resident #44's room, revealed O2 at 2 LPM NC. Observation and interview on 8/8/2022 at 6:44 PM in Resident #44's room, Licensed Practical Nurse (LPN) #3 confirmed the resident was receiving O2 at 2 LPM per nc. She stated, The physician's order reads to administer O2 at 1 lpm per nc. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses which included Congestive Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease. Review of the Order Summary Report dated August 2022 for Resident #54 revealed .Oxygen every shift for CHF at 4LPM continuously per nasal cannula . Observation on 8/8/2022 at 10:58 AM, Resident #54's nasal cannula tubing and humidified bottle were not labeled or dated. Observation and interview on 8/8/2022 at 11:00 AM, LPN #1 confirmed the nasal cannula and humidifier bottle should be dated and changed weekly. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE] with diagnoses which included Unspecified Protein-Calorie Malnutrition and General Anxiety Disorder. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was not receiving oxygen therapy. Review of the Comprehensive Care Plan dated 7/30/2020 for Resident #58 revealed care plans which included, .complications with gas exchange .receives oxygen .date initiated 8/9/2022 . Observation and interview in Resident #58's room on 8/8/2022 at 10:22 AM, revealed Resident #58 had portable oxygen tank with undated tubing at her bedside. Interview revealed she stated she used oxygen every now and then. Observation and interview in Resident #58's room on 8/8/2022 at 10:59 AM, revealed LPN #1 stated the oxygen tubing connected to the portable oxygen tank was not dated. She confirmed the oxygen tubing should be dated and stored in a bag for resident to use as needed.

Based on facility policy review, facility record review and interview, the facility failed to ensure Registered Nurse (RN) coverage 8 consecutive hours a day 7 days a week for 6 days ranging from July 17, 2022 through August 7, 2022. The findings include: Review of the facility's undated policy titled, Registered Nurse Coverage revealed, .The person responsible for the nursing schedule will write the schedule to ensure that at least 8 consecutive hours of RN services are scheduled each 24 hour day, 7 days per week .If there is the potential for a 24 hour period at which time there would not be an RN to provide services for an 8 hour consecutive period in any given 24 hour period, the Director of Nursing and the Administrator will be immediately informed .to provide the required consecutive 8 hours of RN services for that specified 24 hour period . Review of the facility's Daily Posted Staffing Hours and Resident Census sheet dated 7/17/2022, 7/23/2022, 7/30/2022, 7/31/2022, 8/6/2022, and 8/7/2022, revealed the facility did not have the required 8 hours of RN coverage. During an interview in the conference room on 8/10/2022 at 9:09 AM, the Director of Nursing confirmed the facility only scheduled 6 hours of RN coverage, not the required 8 consecutive hours, for 7/17/2022, 7/23/2022, 7/30/2022, 7/31/2022, 8/6/2022, and 8/7/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses which included End Stage Renal Disease, Chronic Pancreatitis, Type 2 and Dependence on Renal Dialysis. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #20 had a BIMS score of 15 which indicated no cognitive impairment. Continued review of the MDS revealed Resident #20 required extensive assistance with Activities of Daily Living (ADL). Review of Resident #20's August 2022 MAR revealed Resident #20 did not receive her medications as ordered. Resident #20's 8/2022 MAR revealed 1 missed dose of Trazadone Hydrochloride (HCL) 150 mg tablet, 2 missed doses of Lantus Solution 100 Unit/Milliliters (ML) 5 units subcutaneously, 1 missed dose of Sevelamer Carbonate Packet 0.8 Gram (GM), 2 missed doses of Creon Capsule 6000 Units, 1 missed dose of Novolog Solution 100 Unit/ML inject 3 units subcutaneously, 4 missed doses Novolog Solution 100 Unit/ML Inject as per sliding scale and blood glucose checks were not performed 5 times. Continued review of Resident #20's July MAR revealed 1 missed dose of Trazadone HCL 150 mg tablet, 1 missed dose of Lantus Solution 100 Units/ML subcutaneously, 1 missed dose of Sevelamer Carbonate Packet 0.8 GM, 6 missed doses of Creon Capsule 6000 units, 8 missed doses of Novolog Solution 100 Unit/ML 3 units subcutaneously, Novolog Solution 100 Unit/ML inject per sliding scale 9000 Units, and blood glucose checks were not performed 8 times. During an interview on 8/10/2022 at 3:05 PM, Director of Nursing (DON) confirmed there should not be holes for administration on the MAR and stated, I would expect a nurse to chart that medications were given. Based on facility policy review, medical record review, and interview, the facility nurses failed to document medication administrations for 3 of 4 sampled residents (Resident #20, Resident #111, and Resident #112) reviewed. The findings include: Review of the undated facility's policy titled, Medication Administration, revealed .To ensure that resident medications are administered in a timely manner and documented is completed to substantiate administration . Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses which included End Stage Renal Disease, Chronic Pancreatitis, Type 2 Diabetes Mellitus, and Dependence on Renal Dialysis. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Review of Resident #20's August and July 2022 Medication Administration Record (MAR) revealed the MAR did not have completed documentation of administration for the following medications: Trazodone Hydrochloride (HCL) 150 mg tablet on 8/5/2022 at 9:00 PM, Lantus Solution 100 Unit/Milliliters (ML) 5 units subcutaneously on 8/3/2022 at 9:00 AM and 8/5/2022 at 10:00 PM, Sevelamer Carbonate Packet 0.8 Gram (GM) on 8/5/2022 at 10:00 PM, Novolog Solution 100 Unit/ML inject 3 units subcutaneously on 8/2/2022 at 4:00 PM, Novolog Solution 100 Unit/ML Inject as per sliding scale and blood glucose checks on 8/2/2022 at 11:00 AM, 8/3/2022 at 5:00 AM, 8/6/2022 at 9:00 PM, and 8/7/2022 at 5:00 AM, Trazodone HCL 150 mg tablet on 7/19/2022 at 9:00 PM, Lantus Solution 100 Units/ML subcutaneously on 7/19/2022 at 10:00 PM, Sevelamer Carbonate Packet 0.8 GM on 7/19/2022 at 10:00 PM, Creon Capsule 6000 units on 7/8, 7/11, 7/13, 7/14, 7/18, 7/20, and 7/28/2022 at 5:00 PM, Novolog Solution 100 Unit/ML on 7/8, 7/11, 7/12, 7/13, 7/14, 7/18, 7/20, 7/28/2022 at 4:00 PM, Novolog Solution 100 Unit/ML inject per sliding scale and blood glucose checks were not performed 7/8, 7/10, 7/11, 7/13, 7/14, 7/18, 7/20, 7/28/2022 at 4:00 PM, 7/1, 7/4, 7/14, 7/20, 7/22, 7/30/2022 at 5:00 AM, 7/19/2022 at 9:00 PM. During an interview on 8/10/2022 at 3:05 PM, Director of Nursing (DON) confirmed there should not be blanks for administration on the MAR. Review of the medical record revealed Resident #111 was admitted to the facility on [DATE] with diagnoses which included Fracture of Left Femur, Hypertensive Heart Disease, and Hyperlipidemia. Review of the admission MDS assessment dated [DATE] revealed Resident #111 had a BIMS score of 15 which indicated no cognitive impairment. Review of Resident #111's MAR dated 7/2022 revealed the MAR did not have completed documentation of administration for the following medications: Ascorbic Acid Tablet on 7/8/2022 and 7/14/2022 at 9:00 PM. Enoxaparin Sodium Solution Prefilled syringe 40 MG (milligram) /0.4 ml on 7/14/2022 at Bedtime. Furosemide 20 MG 1 time by mouth a day on 7/14/2022 and 7/15/2022 at 5:00 AM. Levothyroxine Sodium Tablet 88 MCG (micrograms) on 7/14/2022 and 7/15/2022 at 5:00 AM. Calcium Carbonate Tablet 500 mg Chewable twice a day on 7/13/2022 at 5:00 PM. Cholecalciferol Tablet 125 MCG give 1 tab by mouth twice a day on 7/14/2022 at 9:00 PM. Docusate Sodium 100 MG by mouth twice a day on 7/14/2022 at 9:00 PM. Omeprazole Capsule 60 MG by mouth twice a day on 7/14/2022 at 10:00 PM. During an interview on 8/9/2022 at 3:35 PM, the DON confirmed when shown the MAR there were days and nights the medications were not documented as administered or not given with a reason. The management staff were supposed to look at the MARs daily to check for discrepancies. Review of the medical record revealed Resident #112 was admitted to the facility on [DATE] with diagnoses which included Dementia without Behavioral Disturbances, Alzheimer's Disease, and Osteoarthritis. Review of Resident #112's MAR dated 8/2022 revealed the MAR did not have completed documentation of administration for the following medications: Donepezil HCl (hydrochloride) 10 MG give 1 tablet a day for Dementia on 8/3/2022 at 9:00 AM. Continued review revealed Donepezil HCl 10 MG give 1 tablet at bedtime with no documentation for administration on 8/6/2022 at 9:00 PM. Continued review revealed missed documentation for Meloxicam 15 MG 1 tablet by mouth a day for pain at 9:00 AM on 8/3/2022, 8/7/2022, and 8/10/2022. During an interview on 8/10/2022 at 5:49 PM, when shown Resident #112's MAR the DON confirmed Resident #112's medication was not documented on the MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to adequately monitor 2 of 2 sampled residents (Resident #40 and #52) receiving anticoagulant therapy. The findings include: Review of the facility's policy titled, Summary of Unnecessary and Psychotropic Medications, dated 9/30/2021, revealed .Each resident's entire drug/medication regimen is managed and monitored .sources of information to facilitate defining the monitoring criteria or parameters may include cautions, warnings and identified adverse consequences from .Pharmacists .Clinical practice guidelines or clinical standards of practice .Monitoring involves three aspects: Periodic planned evaluation of progress toward the therapeutic goals; continued vigilance for adverse consequences; and Evaluation of identified adverse consequences . Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses which included Hypertensive Heart Disease, Atrial Fibrillation, and Morbid Obesity. Review of the 5-day Minimum Data Set (MDS) assessment for Resident #40 dated 7/15/2022, revealed the resident received anticoagulants. Review of the Physician Orders for Resident #40 revealed, .Apixaban [an anticoagulant, a medication to prevent clotting] Tablet 5 mg Give 5 mg by mouth two times a day for Deep Vein Thrombosis [DVT] .7/7/2022 . Further review of the Physician's Orders revealed no monitoring for side effects of anticoagulant therapy, such as bruising or bleeding. Review of the 8/2022 Medication Administration Record (MAR) revealed Resident #40 was receiving Apixaban 5 mg two times per day without any monitoring for potential side effects of bleeding or bruising. Review of the medical record for Resident #52 revealed she was admitted to the facility on [DATE] with diagnoses which included Memory Deficit Following Nontraumatic Subarachnoid Hemorrhage and Cerebral Infarction. Review of the 5-day MDS assessment for Resident #52 dated 7/25/2022, revealed the resident received anticoagulants. Review of the Physician's Orders for Resident #52 revealed, .Plavix Tablet 75 MG (Clopidogrel Bisulfate) Give 75 mg by mouth one time a day for anticoagulant 7/22/2022 . Continued review revealed there was no order to monitor for the side effects for the use of an anticoagulant. Review of the 8/2022 MAR revealed Resident #52 was receiving Plavix 75 mg one time per day without any monitoring for potential side effects. During an interview on 8/10/2022 at 3:00 PM, the Director of Nursing (DON) confirmed any resident receiving an anticoagulant should be monitored for potential bleeding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to ensure accurate documentation in the medical records for 1 of 39 sampled residents (Resident #54) reviewed. The findings include: Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses which included Congestive Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease. Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #54 dated 7/24/2022, revealed the resident received oxygen therapy. Review of the Comprehensive Care Plan for Resident #54 dated 6/16/2022 revealed, .02 [oxygen] therapy per orders, change 02 tubing per facility protocol and as needed . Review of the Order Summary Report dated August 2022 for Resident #54 revealed .Oxygen every shift for CHF at 4LPM (liters per minute) continuously per nasal cannula . Review of the progress notes for Resident #54 revealed, .7/9/2022 12:20 .02 per NC [nasal canula] @ [at] 2L/min .7/8/2022 22:34 .Resident is on continuous 02 per NC @ 2L/min .7/8/2022 05:51 .Resident is on continuous 02 per NC @ 2L/min .7/7/2022 11:06 .Resident is on continuous 02 per NC @ 2L/min .7/7/2022 06:07 .Resident is on continuous 02 per NC @ 2L/min . Observation and interview on 8/10/2022 at 7:00 PM, the Assistant Director of Nursing (ADON) reviewed Resident #54's medical record. She stated the documentation of Oxygen administration in the progress notes on 7/7, 7/8, and 7/9/2022 was inaccurate according to the Physician's Orders. She stated she expected the nurses to document accurate information in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with diagnoses which included Muscle Wasting and Atrophy Not Elsewhere Specified Multiple Sites, Unspecified Atrial Fibrillation, and Type 2 Diabetes Mellitus without Complications. Review of the shower records for Resident #55 revealed he was scheduled to be given showers on Tuesday, Thursday, Saturday, and as requested during the second shift. Continued review revealed the resident was not given his scheduled shower on Saturday 8/6/2022. Observation and interview in Resident #55's room on 8/8/2022 at 11:26 AM, Resident #55 stated he had been requesting to get a shower since 8/4/2022. Resident #55 then pushed his call light, and the Administrator answered and told Resident #55 that he would send a tech down to let him know when he would be getting a shower. Observation and interview on 8/8/2022 at 12:44 PM and 3:41 PM, with Resident #55, he stated he had not received his shower as he had requested. During an interview on 8/9/2022 at 4:00 PM, the Staffing Coordinator confirmed residents were to receive showers 3 times a week and were to receive bed baths on the days they do not receive showers. Continued interview she stated staff were to notify the Registered Nurse (RN) to document any refusals. During an interview on 8/9/2022 at 5:12 PM, the Certified Nurse Aide (CNA) #2 confirmed residents were to receive showers 3 times a week and were to receive bed baths on the days they do not receive showers. Continued interview she stated the Registered Nurse (RN) would be notified to document any refusals. During an interview on 8/10/2022 at 10:27 AM the Director of Nursing (DON) reviewed Resident #55's bathing sheets and confirmed Resident #55 did not receive a scheduled shower on 8/6/2022. Review of the undated facility policy titled, Incontinence Care, revealed, .Policy of the facility to ensure that residents receive as much assistance as needed for cleansing the perineum and buttocks after an incontinent episode or with routine daily care .Frequency depends on bladder diary results and/or routine minimal q [every] 2 hour checks . Review of the medical record revealed Resident #58 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Horner's Syndrome, Generalized Muscle Weakness and Difficulty in Walking. Review of the Annual MDS assessment dated [DATE] revealed Resident #58 had a BIMS score 13 which indicated cognitively intact. Continued review revealed the resident required supervision to total dependence of one to two person physical assist with all ADLs. Resident #58 was occasionally incontinent of bladder and continent of bowel. Review of the Comprehensive Care Plan for Resident #58 revealed care plans which included difficulty with transfers and ADLs related to self-care deficit. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses which included Congestive Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had a BIMS score of 15, which indicated no cognitive impairment. Continued review revealed the resident required supervision to total dependence of one to two person physical assist with all ADLs. Resident #54 was always incontinent of bowel and bladder. Review of the Comprehensive Care Plan for Resident #54 revealed care plans which included ADLs related to self-care deficit. Review of the medical record for Resident #52 revealed she was admitted to the facility on [DATE] with diagnoses which included Memory Deficit Following Nontraumatic Subarachnoid Hemorrhage, and Cerebral Infarction. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #52 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Continued review revealed she required extensive assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, total dependence with bathing and supervision with eating. Continued review revealed she is frequently incontinent of bladder and always incontinent of bowel. Review of the Care Plan for Resident #52 revealed care plans which included ADLs (Activities of Daily Living) related to self care deficit. Observation and interview in room [ROOM NUMBER] on 08/08/22 at 12:00 PM, revealed, Resident #52 sitting in a wheelchair (wc)at bedside. The resident had a strong odor of urine. She stated she had been brought back to her room about an hour ago by therapy. She stated she told the CNA #3 at that time she needed to use the bedpan. She stated CNA #3 told her she would be back to help her, and she had not been back. She stated the staff often cuts off her call light and says they will be back, only to not come back to help. She stated she will urinate in her brief before anyone comes back, and it makes her angry as hell. She stated she had com plained to the nurse many times about the call lights and staff not providing assistance. Observation on 8/8/2022 at 12:20 PM, revealed Resident #52 told the DON, who was in the room delivering a lunch tray to A bed, that she had to be changed. The DON told the resident she would let the CNA know and they would be back in to change her before she eats. The ADON then delivered the resident's lunch tray and the resident shrugged her shoulders and stated I guess I will have to wait. Observation and interview on 8/8/2022 at 1:30 PM, revealed CNA #3 in room making the bed and Resident #52 sitting in wc at bedside. Resident stated she had not been changed since coming back from therapy. CNA #3 stated she was going to change the resident after making the bed. Resident #52 stated she has to wait over an hour most of the time to be changed. During an interview in room [ROOM NUMBER] A on 08/08/22 at 10:22 AM, Resident #58 stated she required assistance with the use of a bedside commode (BSC). She stated she calls the CNA to empty the BSC after she finishes using the bathroom. She stated there are times when she had to call for assistance with transfering to the BSC. She stated staff often took hours to come in and empty the BSC. She stated she had been incontinent on a few occasions because she needed help getting to the BSC and staff took too long to answer her call light. Observation and interview in room [ROOM NUMBER] B on 08/08/22 at 10:35 AM, revealed Resident #54 in bed with a personal gown on. There was a strong odor of urine present in the room. She stated she was waiting for the CNA to come back to change her because she was wet. She stated she had put on her call light and the CNA came in, cut the light off, and told her she would be right back. She stated the staff sometimes takes up to 2 to 4 hours at night to answer her call light. She states the weekends are worse. She stated had told the nurse about the call lights and the nurse told her they were short staffed. During an interview on 8/8/2022 at 10:40 AM, CNA #3 stated she did turn off the call light in room [ROOM NUMBER] B. She stated she told the resident she would be back after completing care for another resident. During an interview on 8/8/22 at 12:43 PM, family member #3 stated she came in to visit at 11:00 AM today. She stated Resident #54 was soaked in urine and the bed was wet needing a complete linen change. She stated the resident had feces dried on her and her brief. She stated she put the call light on and the Human Resource person assisted her in changing the resident and her linens. She stated the Human Resource person told her she would speak to the DON about the poor care. She stated she had talked to the nurse, about her concerns with pericare and some of the CNA's. She stated she was here to visit on 8/5/2022 early and the resident put on her call light several times to be changed. She stated the nurse came in and turned off the call light multiple times and told her she would let the CNA know. She stated it was just before shift change at 2:30 PM before anyone came in to assist her. During an interview on 8/8/22 2:22 PM, the Human Resource person stated she had an active CNA license, and she helped familiy member #3 clean up Resident #54. She stated the resident had feces that looked dry and had saturated her brief and had to have her bed changed. She stated the daughter explained to her that the resident had waited all night to be changed. She stated she told the ADON about the situation. During an interview on 8/9/2022 at 2:45 PM, the Assistant Director of Nursing (ADON) stated she expected call lights to be answered in a timely manner. She stated residents should not have to wait hours to have a call light answered. Based on facility policy review, medical record review, observation, and interview, the facility failed to provide Activities of Daily Living (ADL) care for 8 of 39 sampled residents (Residents #2, #11, #18, #47, #52, #54, #55, #58, and #111) reviewed. The findings include: Review of the facility's undated policy titled, Activities of Daily Living (Routine Care), revealed, .Residents are given routine daily care and HS [bedtime] care by a C.N.A. [Certified Nursing Assistant] or a Nurse to promote hygiene, provide comfort and provide a homelike environment. ADL care is provided throughout the day, evening and night as care planned and/or as needed .ADL care of the resident includes: Assisting the resident in personal care such as bathing, showering, dressing, eating, hair care, oral care, nail care, appropriate skin care .Providing privacy and personal space . Review of the facility's undated policy titled, Incontinence Care, revealed, .It is the policy of the facility to ensure that resident's receive as much assistance as needed for cleansing the perineum and buttocks after an incontinent episode or with routine daily care. Frequency depends on bladder diary results and/or routine minimal q [every] 2 hour checks as well as care planning . Review of the facility's undated policy titled, Oral Hygiene and Denture Care, revealed, .It is the policy of the facility to assist the residents as much as necessary to see that they have good oral hygiene. This includes removing food and debris from their teeth and mouth . Review of the medical record for Resident #2 revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Polyneuropathy, Atrial Fibrillation, and Morbid Obesity. Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #2 dated 8/4/2022, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15, which indicated no cognitive impairment. Continued review revealed she required extensive assistance for toilet use and personal hygiene. Continued review revealed she was always incontinent of bowel and bladder. Review of the Care Plan for Resident #2 revealed assessments/problems, goals, and interventions for, .Self care deficit related to: obesity, pain, right shoulder total reverse, she requires extensive assistance with bed mobility, transfers, toileting, and meals, r/t [related to] altered ROM [range of motion] and weight bearing status .Assist to bathroom as needed. Provide incontinence care as indicated . Review of the medical record for Resident #11 revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Seizures, Frontal Lobe and Executive Function Deficit Following Cerebrovascular Disease. Review of the Quarterly MDS assessment for Resident #11 dated 5/26/2022, revealed a BIMS score of 00, which indicated severe cognitive impairment. Continued review revealed he required extensive assistance of 1-2 persons for bed mobility, transfers, dressing, toilet use, personal hygiene, and total dependence for bathing and eating. Review of the Care Plan for Resident #11 revealed assessments/problems, goals, and interventions for, .Self care deficit related to : [Named resident] has altered functional ability he requires extensive to total services all mobility related tasks .Oral care daily and as needed . Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses which included Aphasia, Atherosclerotic Heart Disease (ASHD), and Dementia. Review of the Quarterly MDS dated [DATE], revealed Resident #18 required extensive assistance of 2 staff for bed mobility, dressing, toileting, personal hygiene, and total assistance required for bathing. Review of the Care Plan for Resident #18 revealed assessments/problems, goals, and interventions for, .Self care deficit related to : [Named resident] requires extensive assist with bed mobility, grooming, eating, and transfers .bowel incontinence .provide incontinence care after incontinence episodes .prn[as needed] . Review of the medical record for Resident #47 revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Cerebral Infarction and Hemiplegia and Hemiparesis. Review of the Quarterly MDS assessment for Resident #47 dated 7/19/2022, revealed she had a BIMS score of 15, which indicated no cognitive impairment. Continued review revealed she required extensive assistance for toileting and hygiene. Continued review revealed she is always incontinent of bowel and bladder. Review of the Care Plan for Resident #47 revealed assessments/problems, goals, and interventions for, .Self care deficit related to: [Named resident] requires extensive assistance for her bed mobility, transfers, toileting and bathing needs. She has back pain, Parkinson disease .Provide incontinence care as indicated .Alteration in elimination due to bowel incontinence. [Named resident] is frequently incontinent of bowel and bladder requires staff with all toileting and hygiene needs .Provide incontinence care after incontinence episodes PRN . Review of the medical record for Resident #52 revealed she was admitted to the facility on [DATE] with diagnoses which included Memory Deficit Following Nontraumatic Subarachnoid Hemorrhage, and Cerebral Infarction. Review of the 5-day MDS assessment dated [DATE], revealed Resident #52 had a BIMS score of 15, which indicated no cognitive impairment. Continued review revealed she required extensive assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, total dependence with bathing, and supervision with eating. Continued review revealed she is frequently incontinent of bladder and always incontinent of bowel. Review of the Care Plan for Resident #52 revealed care plans which included ADLs related to self care deficit. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses which included Congestive Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #54 had a BIMS score of 15, which indicated no cognitive impairment. Continued review revealed the resident required supervision to total dependence with all ADLs. Continued review revealed Resident #54 was always incontinent of bowel and bladder. Review of the Comprehensive Care Plan for Resident #54 revealed care plans which included ADLs related to self-care deficit. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with diagnoses which included Muscle Wasting and Atrophy Not Elsewhere Specified Multiple Sites, Unspecified Atrial Fibrillation, and Type 2 Diabetes Mellitus without Complications. Review of the shower records for Resident #55 revealed he was scheduled to be given showers on Tuesday, Thursday, Saturday, and as requested during the second shift. Continued review revealed the resident was not given his scheduled shower on Saturday 8/6/2022. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Horner's Syndrome, Generalized Muscle Weakness, and Difficulty in Walking. Review of the Annual MDS assessment dated [DATE] revealed Resident #58 had a BIMS score 13 which indicated the resident was cognitively intact. Continued review revealed the resident required supervision to total dependence with all ADLs. Resident #58 was occasionally incontinent of bladder and continent of bowel. Review of the Comprehensive Care Plan for Resident #58 revealed care plans which included difficulty with transfers and ADLs related to self-care deficit. Review of the medical record revealed Resident #111 was admitted to the facility on [DATE] with diagnoses which included Fracture of Left Femur, Hypertensive Heart Disease, and Hyperlipidemia. Review of the admission MDS assessment dated [DATE] revealed Resident #111 had a BIMS score of 15 indicating no cognitive impairment. Continued review revealed Resident #111 required extensive assistance with bathing with two staff. Review of Resident #111's care plan dated 8/9/2022 revealed .Self care deficit related to dx [diganosis]: fx [fracture] femur, anemia. Requires extensive assistance with bed mobility, toileting, transfers, dressing. Shower 2-3 times a week and as needed . Review of the Bathing Activities dated 7/2022 revealed Resident #111 had one doumented bed bath on 7/12/2022 on the 7 AM to 3 PM shift. Review of Occupational Therapy (OT) Notes dated 7/13/2022 revealed Resident #111 was assisted with a light bath by the Occupational Therapist. Review of the OT Notes dated 7/20/2022 revealed Resident #111 was assisted with a shower by the Occupational Therapist. Observation and interview in room [ROOM NUMBER] B on 8/8/2022 at 10:35 AM, revealed Resident #54 in bed with a personal gown on. There was a strong odor of urine present in the room. She stated she was waiting for the CNA to come back to change her because she was wet. She stated she had put on her call light and the CNA came in, cut the light off, and told her she would be right back. She stated the staff sometimes takes up to 2 to 4 hours at night to answer her call light. She stated the weekends are worse. She stated she had told the nurse about the call lights and the nurse told her they were short staffed. During an observation and interview in Resident #2's room on 8/8/2022 at 10:42 AM, she stated she she was wet with urine and has been waiting all morning to be changed, The room had a strong smell of urine. During an observation and interview in Resident #47's room on 8/8/2022 at 10:45 AM, revealed a strong odor of urine. Resident #47 stated, I put my call light on at 6:30 (AM) this morning so I could be changed, and they haven't come in yet. I am soaking wet. Observation in Resident #11's room on 8/8/2022 at 11:09 AM, 2:23 PM and again on 8/9/2022 at 7:07 AM, and 9:33 AM, revealed he had white/tan dried crusty substance on his lips. Observation and interview in Resident #55's room on 8/8/2022 at 11:26 AM, Resident #55 stated he had been requesting to get a shower since 8/4/2022. Resident #55 then pushed his call light, and the Administrator answered and told Resident #55 that he would send a tech down to let him know when he would be getting a shower. Observation and interview in room [ROOM NUMBER] on 8/8/2022 at 12:00 PM, revealed, Resident #52 sitting in a wheelchair (wc) at bedside. The resident had a strong odor of urine. She stated she had been brought back to her room about an hour ago by therapy. She stated she told CNA #3 at that time she needed to use the bedpan. She stated CNA #3 told her she would be back to help her, and she had not been back. She stated the staff often cuts off her call light and says they will be back, only to not come back to help. She stated she will urinate in her brief before anyone comes back. She stated she had complained to the nurse many times about the call lights and staff not providing assistance. Observation on 8/8/2022 at 12:20 PM, revealed Resident #52 told the Director of Nursing (DON), who was in the room delivering a lunch tray to A bed, that she had to be changed. The DON told the resident she would let the CNA know and they would be back in to change her before she eats. The Assistant Director of Nursing (ADON) then delivered the resident's lunch tray and the resident shrugged her shoulders and stated I guess I will have to wait. Observation and interview on 8/8/2022 at 12:44 PM and 3:41 PM, with Resident #55, he stated he had not received his shower as he had requested. Observation and interview on 8/8/2022 at 1:30 PM, revealed CNA #3 was in Resident #52's room making the bed and Resident #52 was sitting in her wheelchair at bedside. Resident #52 stated she had not been changed since coming back from therapy. CNA #3 stated she was going to change the resident after making the bed. Resident #52 stated she has to wait over an hour most of the time to be changed. During an observation of medication administration with Licensed Practical Nurse #2 on 8/9/2022 at 9:50 AM, Resident #18 was found to have a soiled gown and pad that had soaked onto the left arm of her gown. Resident #18's incontinent pad was covered with a large amount of black wet substance, with a large light brown ring around the parameters of the pad. LPN #2 stated, Oh no, she has to have a shower, she is in a mess. The DON was asked to come to the room and at 10:00 AM she confirmed the resident should not be in this kind of condition. LPN #2 raised Resident #18's cloth pad which revealed a brown dried ring on the fitted sheet under the incontinent pad. Resident #18's room had a foul odor and 4 flies were on the resident and 3 other flies were noted on her roommate. During an interview in room [ROOM NUMBER] A on 8/8/2022 at 10:22 AM, Resident #58 stated she required assistance with the use of a bedside commode (BSC). She stated she calls the CNA to empty the BSC after she finishes using the bathroom. She stated there are times when she had to call for assistance with transfering to the BSC. She stated staff often took hours to come in and empty the BSC. She stated she had been incontinent on a few occasions because she needed help getting to the BSC and staff took too long to answer her call light. During an interview on 8/8/2022 at 10:40 AM, CNA #3 stated she did turn off the call light in room [ROOM NUMBER] B. She stated she told the resident she would be back after completing care for another resident. During an interview in Resident #2's room on 8/8/2022 at 12:25 PM, she stated, I finally got changed after 4 1/2 hours of waiting. During an interview on 8/8/2022 at 12:43 PM, Resident #54's family member #3 stated she came in to visit at 11:00 AM today. She stated Resident #54 was soaked in urine and the bed was wet needing a complete linen change. She stated the resident had feces dried on her and her brief. She stated she put the call light on and the Human Resource person assisted her in changing the resident and her linens. She stated the Human Resource person told her she would speak to the DON about the poor care. She stated she had talked to the nurse about her concerns with pericare and some of the CNAs. She stated she was here to visit on 8/5/2022 early and the resident put on her call light several times to be changed. She stated the nurse came in and turned off the call light multiple times and told her she would let the CNA know. She stated it was just before shift change at 2:30 PM before anyone came in to assist her. During an interview on 8/8/2022 at 2:22 PM, the Human Resource person stated she had an active CNA license, and she helped familiy member #3 clean up Resident #54. She stated the resident had feces that looked dry and had saturated her brief and had to have her bed changed. She stated Resident #54's family member explained to her that the resident had waited all night to be changed. She stated she told the Assistant Director of Nursing (ADON) about the situation. During an interview on 8/8/2022 at 2:23 PM in Resident #11's room, the DON confirmed the resident had white/tan dried crusty substance on his lips. When asked if he had mouth care performed that day, she stated, It looks like he hasn't had mouth care today, and he certainly should have. During a telephone interview on 8/8/2022 at 7:24 PM, the Complainant stated Resident #111 was only given a shower one time during her stay at the facility. During an interview on 8/9/2022 at 7:11 AM with LPN #1, she confirmed Resident #11 had white/tan dried crusty substance on his lips. During an interview on 8/9/2022 at 2:45 PM, the ADON stated she expected call lights to be answered in a timely manner. She stated residents should not have to wait hours to have a call light answered. During an interview on 8/9/2022 at 4:00 PM, the Staffing Coordinator confirmed residents were to receive showers 3 times a week and were to receive bed baths on the days they do not receive showers. Continued interview she stated staff were to notify the Registered Nurse (RN) to document any refusals. During an interview on 8/9/2022 at 5:12 PM, CNA #2 confirmed residents were to receive showers 3 times a week and were to receive bed baths on the days they do not receive showers. Continued interview she stated the RN would be notified to document any refusals. During an interview on 8/10/2022 at 10:27 AM the DON reviewed Resident #55's bathing sheets and confirmed Resident #55 did not receive a scheduled shower on 8/6/2022. During an interview on 8/10/2022 at 1:28 PM with the DON confirmed, If a resident is incontinent of urine or bowel, they should be provided incontinent care within a reasonable amount of time, like 15 minutes. She confirmed a resident should never go 4 1/2 hours without being provided incontinent care. During an interview on 8/9/2022 at 3:35 PM, the DON stated Resident #111 had assistance with showers by the Occupational Therapist. She confirmed the Resident could have either a shower or bed bath 3 days a week and on the days she was not scheduled for shower or bed bath the resident she could clean herself such as wash her face and wash certain body parts. The DON stated We don't do bed baths when they are not scheduled for a shower.

Based on facility policy review, observation, and interview, the Dietary Department failed to label, date, dispose of expired food, and failed to maintain dietary equipment in a sanitary manner on 2 of 5 observations. The findings include: Review of the facility's policy titled, Storage Periods, Use-By Guidelines, dated 12/3/2020, revealed, .Food will be stored properly and used within the appropriate time period to ensure safe and high quality food is served .In some cases, [named Dietetic Solutions] guideline is for 3 days. Expired Food items will be disposed of . Review of the facility's policy titled, Food Storage, dated 11/25/2019, revealed, .Food is stored and prepared in a clean safe sanitary manner that complies with state and federal guidelines . Review of the facility's policy titled, Cleaning Rotation, dated 2017, revealed, .Equipment and utensils will be cleaned according to the following guidelines, or manufacturer's instructions .Items cleaned daily: stove top, grill, exterior of large appliances . Observation in the Dietary Department on 8/8/2022 at 9:55 AM, with the Certified Dietary Manager (CDM), revealed one full pitcher of fruit punch dated 7/27/2022-7/30/2022, 1/2 opened and unlabeled 16.9 ounce bottle of water, 1-5 pound bag of salad mix with 1/2 bag full of brown contents dated 8/2/2022, 1/2 gallon of chocolate milk that was 1/4 full, expiration date 7/23/2022, 1/2 canister full of pimento cheese dated 7/31/2022 with use by date 8/7/2022, 2 boiled eggs in a bowl unlabeled and undated, 1 small bowl of peaches unlabeled and undated, and 2/3 container full of white beans dated 8/2/2022. During an interview on 8/8/2022 at 10:00 AM, the CDM confirmed the fruit punch, opened bottle of water, 5 pound bag of salad mix, chocolate milk, pimento cheese, eggs, peaches, and white beans were to be labeled and/or discarded by the specified dates or 3 days after opened/prepared. Observation in the Dietary Department on 8/8/2022 at 10:10 AM and 12:05 PM, with the CDM, revealed the stove drip pan had a moderate amount of dark tan and black debris. During an interview on 8/8/2022 at 10:11 AM, the CDM confirmed the stove drip pan had a moderate amount of dark tan and black debris. She stated the drip pan needed to be cleaned and did not know when the drip pan was last cleaned. Observation in the Dietary Department on 8/8/2022 at 10:10 AM and 12:08 PM, with the CDM, revealed moderate amount of dried tan debris on the right side and top of the steamer, on the grill, backsplash behind the grill, stove, large backsplash on the right side of the stove and 11 large baking pans with moderate amount of dark tan debris and one stove rack sitting on the floor. During an interview on 8/8/2022 at 12:10 PM, the CDM confirmed a large amount of dried tan debris on the right side and top of the steamer, on the grill, backsplash behind the grill, stove, large backsplash on the right side of the stove and 11 large baking pans with moderate amount of dark tan debris and the stove rack was sitting in the floor. She stated, The whole kitchen needed to be cleaned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Medical Record Review and Interview the facility failed to complete a Pre-admission Screening and Resident Review (PASRR) for 1 (#46) of 20 residents reviewed. The findings include: Medical record review revealed Resident #46 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses which included Antisocial Personality Disorder, Schizoaffective Disorder and Dementia. Medical record review of Resident #46's Notice of Pre-admission Screening and Resident Review Level I (one) Screen Outcome dated 8/21/18 revealed, .Your Level I screen has been cancelled by Ascend .The screen was cancelled because your health care professional did not complete either the Level I screening form and/or submit requested information within the required timeframe .If you want to go to a nursing home, the nursing home must send a new Level I screening form to Ascend . Interview with the Assistant Director of Nursing (ADON) on 8/6/19 at 11:23 AM in the conference room when asked to review Resident #46's PASRR Level I Screen Outcome dated 8/21/18 confirmed there was no PASRR completed for Resident #46.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview the facility failed to label and date oxygen tubing for 2 (#18 and #45) of 21 residents reviewed receiving respiratory therapy. The findings include: Facility policy review, Oxygen Therapy/Administration, revised 11/2015 revealed .Disposable equipment needs to be changed at a minimum of every 14 days .Discard all disposable supplies every 14 days and as needed . Medical record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses which included Neuralgia and Neuritis, Chronic Obstructive Pulmonary Disease and Heart Failure. Medical record review of Resident #18's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident received oxygen therapy. Medical record review of Resident #18's Order Summary Report revealed .Change Oxygen Tubing Weekly every night shift every Sunday . Medical record review of Resident #18's care plan revised on 4/29/19 revealed .Change oxygen tubing every 2 weeks and as needed . Medical record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease and Chronic Kidney Disease Stage 3. Medical record review of Resident #45's admission MDS dated [DATE] revealed the resident received oxygen therapy. Medical record review of Resident #45's care plan revealed .administer oxygen as ordered and needed .change oxygen tubing every 2 weeks and as needed . Observation on 8/5/19 at 9:44 AM and at 11:01 AM in Resident #18's room revealed the resident's oxygen tubing was dated 7/21/19. Observation on 8/5/19 at 9:47 AM and at 11:02 AM in Resident #45's room revealed the resident's oxygen tubing was dated 7/4/19 closest to the concentrator and again dated 7/22/19 closer to the resident. Observation and interview on 8/5/19 at 11:09 AM in Resident #18's room with Registered Nurse (RN) #1 and the Assistant Director of Nursing (ADON) present confirmed the resident's oxygen tubing was dated 7/21/19. Continued interview RN #1 stated it's [the oxygen tubing] dated wrong. Observation and interview on 8/5/19 at 11:11 AM in Resident #45's room with RN#1 and the ADON present when asked to look at the resident's oxygen tubing, RN #1 stated it's dated wrong, it is to be changed every 2 weeks, it needed to be changed on the 18th [July] and then again on August 1st [2019].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, medical record review, observation and interview the facility failed to ensure oxygen tubing was stored in a sanitary manner related to oxygen tubing with the nasal cannula lying on the floor in a resident's room for 1 (#18) of 21 residents reviewed receiving respiratory therapy. Facility policy review, Infection Prevention and Control - Policy and Procedure, undated, revealed .It is the policy of the facility to ensure that a comprehensive system is in place that prevents, identifies, investigates reports, records and controls infections and prevent the development and transmission of communicable disease process .to determine the most effective practices to reduce infection rates as well as identifying ways to integrate these practices into the everyday workday to create a culture of safety as related to Infection Control . Facility policy review, Standard Precautions, undated, revealed .Standard precaution principals are designed to reduce the risk of transmitting microorganisms from both recognized and unrecognized sources of infection . Medical record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses which included Neuralgia and Neuritis, Chronic Obstructive Pulmonary Disease and Heart Failure. Medical record review of Resident #18's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident received oxygen therapy. Observation on 8/5/19 at 11:01 AM in Resident #18's room revealed the resident's oxygen concentrator was on and not in use by the resident. Continued observation revealed the oxygen tubing stretched across the concentrator and the nasal cannula was lying on the floor. Observation and interview on 8/5/19 at 11:09 AM in Resident #18's room with Registered Nurse (RN) #1 and the Assistant Director of Nursing (ADON) present confirmed the resident's oxygen tubing was stretched across the oxygen concentrator and the nasal cannula was lying in the floor. Continued interview with RN #1 when asked the procedure for handling oxygen tubing when not in use by the resident she stated, we turn the concentrator off and place the tubing in a bag and this one was not put in a bag. Interview with the ADON on 8/6/19 at 8:47 AM in her office when asked concerning infection control procedures related to oxygen tubing she stated, we don't have a specific infection control policy for the oxygen tubing; we use standard precautions; if the tubing is on the floor it's contaminated and dirty.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview the facility failed to ensure 1 of 69 residents (Resident #49) reviewed, had clean and groomed finger nails. Findings include: Review of facility policy Grooming of Residents, dated 1/89 revealed .special attention will be given to nails at least weekly following the bath . Medical record review revealed the facility admitted Resident #49 on 4/28/17 with diagnoses including Unspecified Dementia, Muscle Weakness, Unspecified Sequelae of Unspecified Cerebrovascular Disease, Dysphasia, Gastrostomy Status, Seizures, and Shortness of Breath. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #49 had a Brief Interview of Mental Status (BIMS) score of 3 indicating Resident #49 was severely cognitively impaired. Further record review revealed the resident required total assistance with bathing and personal hygiene. Medical record review of Resident #49's comprehensive care plan dated 4/8/18 revealed the resident required extensive assistance with all activities of daily living. Observations of Resident #49 on 6/11/18 at 9:55 AM and at 1:25 PM in the 200 hall way; on 6/11/18 at 4:02 PM at the 200 hall nurse's station; on 6/12/18 at 12:37 PM in Resident #49's room revealed Resident #49's finger nails had brown debris under nails on bilateral hands. Interview with Licensed Practical Nurse (LPN) #3 on 6/12/18 at 12:40 PM in Resident #49's room confirmed Resident #49's nails were dirty and ungroomed. LPN #3 stated I've told everyone to do their nail care, I've been telling my techs to do nail and mouth care, I would expect nail care to be done, and his wasn't done. Further interview with LPN #3 revealed resident nail care was to be performed with showers and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview the facility failed to ensure 1 of 12 sampled residents (Resident #12) reviewed received a follow up vision appointment. Findings include: Medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction, Muscle Weakness, Type Two Diabetes, Major Depressive Disorder, and Anxiety Disorder. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #12 had a Brief Interview Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. Medical record review of the Care Plan dated 10/18/16 revealed .Impaired visual function, as evidenced by requires large print to read, wears glasses, blind in left eye . Further review revealed an intervention of .Refer to social services to see ophthalmologist/optometrist as needed or desired . Medical record review of the Request for Eye Evaluation form dated 2/26/18, the day of the eye exam, confirmed a one month follow up examination with the Ophthalmologist. Interview with Resident #12 on 6/12/18 at 2:45 PM in her room revealed her desire to move forward with cataract surgery. Further interview revealed the last time she saw the ophthalmologist was in February 2018. Interview with Licensed Practical Nurse (LPN) #4 on 6/12/18 at 2:53 PM at the nurse station revealed the Social Service Director (SSD) handled all follow up appointments for the residents. Interview with the SSD on 6/13/18 at 9:17 AM in her office confirmed the facility failed to provide a follow up appointment with the ophthalmologist for Resident #12. Further interview with the SSD revealed, I completely missed it. I will set it up and make sure I get it set up today. I won't lie, I missed it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview the facility failed to remove 4 expired Meclizine (antihistamine) 12.5 mg (milligram) bottles from 1 of 3 medication storage rooms observed. Findings include: Observation of the medication storage room on [DATE] at 10:30 AM on the 400 Hall with the Assistant Director of Nursing (ADON) revealed 4 Meclizine 12.5 mg unopened bottles with an expiration date of 3/2018 were available for administration to residents. Observation and interview with the ADON on [DATE] at 10:30 AM confirmed the facility failed to remove expired medication from the med storage room.

Based on observation and interview the facility failed to keep dumpster doors closed and failed to keep the dumpster area free from debris and medical garbage. Findings include: Observation with the Certified Dietary Manager (CDM) present on 6/12/18 at 2:30 PM of the facility dumpster revealed both side doors of the dumpster were open. Continued observation of the right side of the dumpster revealed multiple pairs of used plastic gloves and multiple plastic medicine cups lying on the ground. Interview with the CDM on 6/12/18 at 2:31 PM confirmed the dietary department and nursing department share the same dumpster. Further interview confirmed the facility failed to keep the dumpster doors closed and failed to maintain the dumpster area free from garbage debris.

Based on observation and interview the facility failed to maintain the walk in cooler for the dietary department in a safe, operating condition. Findings include: Observation of the walk in cooler for the dietary department located outside behind the building on 6/11/18 at 9:00 AM with the Certified Dietary Manger (CDM) present revealed the inside thermometer read 42 degrees Fahrenheit (F). The CDM was notified it should read 41 degrees F or lower and she acknowledged the temperature. Observation of the walk in cooler on 6/12/18 at 2:40 PM with the CDM present revealed the inside thermometer read 44 degrees F. The CDM verified the reading at that time. Observation of the walk in cooler door on 6/12/18 at 2:53 PM with Maintenance and the CDM present revealed the gasket on the last 6-8 inches of the walk in cooler door was torn, and loose. Continued observation revealed when Maintenance attempted to allow the door to close, the top door closer was not strong enough to pull the door completely closed and latch. Interview with Maintenance on 6/13/18 at 7:20 AM in the conference room revealed Maintenance provided a copy of a statement from a company that provided gaskets for the facility walk in cooler that stated, .If your refrigerator gasket is dirty or torn, you risk unsafe holding temperatures . Interview with Maintenance on 6/12/18 at 2:55 PM with the CDM present by the door of the walk in cooler confirmed the gasket and top door closer were not working correctly and needed to be replaced. Maintenance stated. That's what's allowing the heat to get inside. Continued interview confirmed the facility failed to maintain the dietary departments walk in cooler in a safe, operating condition.