**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, observation and interview, the facility failed to provide privacy of personal care information for 1 resident (Resident #28) of 80 residents reviewed. The findings include: Review of the facility's policy titled, Dignity, dated 9/30/2022, showed .Each resident has the right to be treated with dignity and respect .Facility must treat each resident with respect and dignity .recognizing each resident's individuality .promote the rights of the resident .Staff should not .document .records where others can see a resident's information . Resident #28 was admitted to the facility on [DATE] with diagnoses including, Contracture of Left Knee and Atherosclerosis of Native Arteries of Left L with Ulceration of Lower Leg. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #28 had a Brief Mental Status Score (BIMS) of 15, which indicated the resident was cognitively intact, and required extensive assistance of 2 staff members with bed mobility and transfers. During an observation and interview in the resident's room on 11/14/2022 at 11:30 AM, Resident #28 was lying in the bed with the bed against the wall on the resident's left side, and a hand-written sign was taped to one of the resident's pictures. The sign read, .[Resident #28] .Please reposition Left Lower outer leg to where its [it's] not touching bed or pillow .can place pillow under L [left] hip/thigh. Thanks [Wound Care nurse] . The resident stated the wound care nurse put the sign there, did not ask if she could hang the sign, and the resident did not want the sign there. During an observation and interview in Resident #28's room on 11/15/2022 at 10:15 AM, Licensed Practical Nurse (LPN) #1 confirmed the position of the sign and its contents, the sign displayed resident's personal care information and was visible to anyone entering the room. During an interview on 11/15/2022 at 10:25 AM, the Director of Nursing (DON) confirmed the sign in Resident #28's room was personal care information, was visible to anyone that entered the room, and the sign did not protect her privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to protect 1 resident (Resident #16) from verbal abuse of 24 residents reviewed for abuse. The findings include: Review of the facility policy titled, Protection of Residents: Reducing the Threat of Abuse & Neglect, revised 8/2021, showed .Each resident has the right to be free from abuse .It is the policy and practice of this facility that all residents will be protected from all types of abuse .It is the policy of the facility to maintain an environment where residents are free from abuse .Residents must not be subjected to abuse by anyone .includes but is not limited to: staff, other residents . Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Mild Intellectual Disabilities, Cognition Communication Deficit, and Chronic Kidney Disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 12 indicating the resident had moderate cognitive impairment. Review of the behavior Monthly Flow Record dated 11/2022, showed Resident #16 had a behavior of arguing with roommate which occurred on 11/1/2022, 11/2/2022, 11/3/2022, 11/6/2022, 11/7/2022, and 11/8/2022 with staff intervention of redirection with 1 on 1 (1:1 - one staff member supervision of resident) on those dates. Resident #73 was admitted to the facility on [DATE] and readmitted [DATE] with Diagnoses including Major Depressive Disorder, Cerebrovascular Disease, Hyperlipidemia, and Adult Failure to Thrive. Review of an admission MDS dated [DATE], showed Resident #73 had a BIMS score of 15 indicating the resident was cognitively intact. Review of the behavior Monthly Flow Record dated 10/2022 and 11/2022, showed Resident #73 had a behavior of arguing with roommate which occurred on 10/7/2022, 10/8/2022, 10/9/2022, and 11/11/2022, with staff intervention of redirection with 1:1 on those dates. Review of a Care Plan for Resident #73 dated 10/21/2022 and revised 10/24/2022, revealed .The resident is/has potential to be physically aggressive and verbally aggressive/threatening with staff and residents. Curses at staff and residents; attempts to hide medication under bed sheet; pulls hand back in motion to hit staff members .Assess and anticipate resident's needs .provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated .Document observed behaviors and attempted interventions in behavior log . Review of a Nursing Progress note dated 10/24/2022 and documented by Licensed Practical Nurse (LPN) #3, showed .Resident [#73] verbally aggressive with staff, and roommate [Resident #16] this shift. Resident stated he was going to 'kick that damn man over there's ass [Resident #16] .that he wasn't nothing but a stupid idiot'. Resident calling CNA's [Certified Nursing Assistant] bitches and demanding to see a DR [Doctor] .resident [#73]stated 'to get these damn bitches and that idiot over there [Resident #16] to leave him alone' .Will report behaviors to oncoming shift nurse . During an interview on 11/15/2022 at 2:23 PM, when Resident #16 was asked if anyone had been mean to him, the resident replied Get me ice cream. During an interview on 11/15/2022 at 3:57 PM, CNA #2 stated Resident #73 and Resident #16 were roommates and did not get along. During interview on 11/16/2022 at 9:13 AM, with CNA #6 stated Resident #73 made comments about Resident #16 liked everything his way and he got annoyed with Resident #16's music. The CNA stated Resident #16 could communicate his needs and concerns. Interview with the MDS Coordinator on 11/16/2022 at 9:38 AM revealed Resident #73 was care planned for the potential to be physically aggressive, had threatened to hit a nurse, and was physically and verbally aggressive. The MDS Coordinator confirmed a nursing note stated Resident #73 was cursing at his roommate, Resident #16. She stated the roommates had conflicts over the TV and radio. The MDS Coordinator stated the incident on 10/24/2022 was the only incident she was aware of where Resident #73 cursed Resident #16. During an interview on 11/15/2022 at 4:07 PM, LPN #3 stated Resident #73 she heard Resident #73 fussing at his roommate, Resident #16, telling him to shut up. LPN #3 stated she did not remember what night it was, but she walked in Resident #73 and #16's room, and Resident #73 said they needed to move dumb retarded roommate. She also stated there was an instance when Resident #16 came out of the room and said he wanted another room because his roommate, Resident #73, was cussing him, but the LPN was unable to recall the date of the occurrence. During an interview on 11/16/2022 at 12:53 PM, the Director of Nursing (DON) stated she was aware of one issue where Resident #73 was calling the nurses names and talking about his roommate, Resident #16. The DON confirmed the nurses note dated 10/24/2022 stated Resident #73 was verbally aggressive to staff and his roommate. The DON confirmed the note stated 'kick that damn man over there's ass [Resident #16's] .that he wasn't nothing but a stupid idiot'. The DON confirmed the resident-to-resident altercation was abuse. The DON stated she was not aware Resident #16 had requested another room due to his roommate's behavior. During an interview on 11/16/2022 at 3:30 PM, Resident #16's Family Member #2 stated if he (Resident #16) said he wanted to be moved, then that would be his wishes. She stated if he (Resident #16) heard someone say get that idiot out of here he would understand that as a derogatory remark.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to report allegations of abuse for two residents (Resident #73 and Resident #16) of 24 residents reviewed. The findings include: Review of the facility policy titled, Protection of Residents: Reducing the Threat of Abuse & Neglect, revised 8/2021, showed .Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency . Resident #73 was admitted to the facility on [DATE] and readmitted [DATE] with Diagnoses including Major Depressive Disorder, Cerebrovascular Disease, Hyperlipidemia, and Adult Failure to Thrive. Review of an admission Minimum Data Set (MDS) dated [DATE], showed Resident #73 had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Review of the behavior Monthly Flow Record dated 10/2022 and 11/2022, showed Resident #73 had a behavior of arguing with roommate which occurred on 10/7/2022, 10/8/2022, 10/9/2022, and 11/11/2022, with staff intervention of redirection with 1 on 1 (1:1 - one staff member supervision of resident) on those dates. During an interview on 11/14/2022 at 10:32 AM, Resident #73 stated he has had some problems with staff.Two nights ago my catheter was bothering me and the CNA [Certified Nursing Assistant] said there is nothing wrong with your catheter; go to sleep and shut your mouth . Resident #73 stated he did not recall the CNA's name but he reported the incident to CNA #2. Resident #73 reported he also had an issue with CNA #6 approximately 3 months ago calling him stupid and lazy .they don't let her come in here anymore .she still works here down the hall . During an interview on 11/15/2022 at 2:30 PM, with Licensed Practical Nurse (LPN) #4 stated she had observed behaviors from Resident #73.One night shift a few months ago he was extremely loud with a CNA [CNA #6] . She stated she heard CNA #6 trying to get him up and the resident was rude, yelled and refused to get up. During an interview on 11/15/2022 at 3:57 PM with CNA #2 she stated Resident #73 reported CNA #6 was hateful with him. CNA #2 stated it occurred months ago and CNA #6 was not allowed in Resident #73's room. CNA #2 stated she did not report the incident to anyone after she was told by Resident #73. During an interview on 11/16/2022 at 10:18 AM, with CNA #6 she stated Resident #73 alleged she called him stupid and a dumbass and did not want her in his room. CNA #6 stated Registered Nurse (RN) #1 called her and advised her it was probably not a good idea to go back in Resident #73's room a couple of months ago. CNA #6 stated RN #1 was the only person who ever discussed any issues regarding Resident #73's care with her. CNA #6 had not been assigned to provide care to Resident #73 since that time but did provide care for the roommate. Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Mild Intellectual Disabilities, Cognition Communication Deficit, and Chronic Kidney Disease. Review of a quarterly MDS assessment dated [DATE], showed Resident #16 had a BIMS score of 12 indicating the resident had moderate cognitive impairment. Review of a Nursing Progress note dated 10/24/2022 and documented by Licensed Practical Nurse (LPN) #3, showed .Resident [#73] verbally aggressive with staff, and roommate [Resident #16] this shift. Resident stated he was going to 'kick that damn man over there's ass [Resident #16] .that he wasn't nothing but a stupid idiot'. Resident calling CNA's [Certified Nursing Assistant] bitches and demanding to see a DR [Doctor] .resident [#73]stated 'to get these damn bitches and that idiot over there [Resident #16] to leave him alone' .Will report behaviors to oncoming shift nurse . During an interview on 11/15/2022 at 4:07 PM, LPN #3 stated she heard Resident #73 fussing at his roommate, Resident #16, telling him to shut up. LPN #3 stated she did not remember what night it was, but she walked in Resident #73 and #16's room, and Resident #73 said they needed to move dumb retarded roommate. She also stated there was an instance when Resident #16 came out of the room and said he wanted another room because his roommate, Resident #73, was cussing him, but the LPN was unable to recall the date of the occurrence. LPN #3 stated she notified the DON and charted it in the behavior book. Interview with the MDS Coordinator on 11/16/2022 at 9:38 AM revealed Resident #73 was care planned for the potential to be physically aggressive, had threatened to hit a nurse, and was physically and verbally aggressive. The MDS Coordinator confirmed a nursing note stated Resident #73 was cursing at his roommate, Resident #16. She stated the roommates had conflicts over the TV and radio. The MDS Coordinator stated the incident on 10/24/2022 was the only incident she was aware of where Resident #73 cursed Resident #16. The MDS Coordinator stated the incident on 10/24/2022 was the only incident she was aware of where Resident #73 cursed Resident #16. She stated she updated the care plan after she saw the progress note and the behaviors were discussed in the Interdisciplinary Team (IDT) meeting. The MDS Coordinator stated received verbal abuse training and considered the incident to be verbal abuse that should have been reported immediately. The MDS Coordinator stated the Assistant Director of Nursing (ADON) and Social Services was aware of the allegations. The MDS nurse stated the facility policy stated to report allegations of abuse immediately. During an interview on 11/16/2022 at 12:53 PM, the DON stated she was aware of one issue where Resident #73 was calling the nurses names and talking about his roommate, Resident #16. The DON confirmed the nurses note dated 10/24/2022 stated Resident #73 was verbally aggressive to staff and his roommate. The DON confirmed the note stated 'kick that damn man over there's ass [Resident #16's] .that he wasn't nothing but a stupid idiot' and that was considered abuse. The DON stated she was not aware Resident #16 had requested another room due to his roommate's behavior. The DON confirmed the facility did not report the allegations of abuse to the State Survey Agency within 2 hours. The DON confirmed the resident-to-resident altercation was abuse. She stated the allegation of staff calling Resident #73 names should have been reported to Administration and the State Survey Agency. The DON confirmed the instances of verbal abuse by a staff member for Resident #73 and the allegation of resident-to-resident abuse for Resident #6 was not reported to the State Survey Agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to investigate allegations of abuse for 2 residents (Resident #73 and Resident #16) of 24 residents reviewed. The findings include: Review of the facility policy titled, Protection of Residents: Reducing the Threat of Abuse & Neglect, revised 8/2021, showed .In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must .Have evidence that all alleged violations are thoroughly investigated . Resident #73 was admitted to the facility on [DATE] and readmitted [DATE] with Diagnoses including Major Depressive Disorder, Cerebrovascular Disease, Hyperlipidemia, and Adult Failure to Thrive. Review of an admission Minimum Data Set (MDS) dated [DATE], showed Resident #73 had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. During an interview on 11/14/2022 at 10:32 AM, Resident #73 stated he has had some problems with staff.Two nights ago my catheter was bothering me and the CNA said there is nothing wrong with your catheter; go to sleep and shut your mouth . Resident #73 stated he did not recall the CNA's name but he reported the incident to another (CNA #2). Resident #73 reported he also had an issue with CNA #6 approximately 3 months ago calling him stupid and lazy .they don't let her come in here anymore .she still works here down the hall . During an interview 11/15/2022 at 3:57 PM CNA #2 stated Resident #73 reported to CNA #2 that CNA #6 was hateful with him. CNA #2 stated it occurred months ago and CNA #6 was not allowed in Resident #73's room. CNA #2 stated she did not report it to anyone. During interview with CNA #6 on 11/16/2022 at 10:18 AM, she stated Resident #73 did not want her in his room. She stated she was told he alleged she called him stupid and a dumbass. CNA #6 stated Registered Nurse (RN) #1 called her and told her it was probably not a good idea to go back in Resident #73's room a couple of months ago. CNA #6 stated RN #1 was the only person who ever discussed any issues regarding Resident #73's care with her. CNA #6 had not been assigned to provide care to Resident #73 since that time but did provide care for the roommate. Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Mild Intellectual Disabilities, Cognition Communication Deficit, and Chronic Kidney Disease. Review of a quarterly MDS assessment dated [DATE], showed Resident #16 had a BIMS score of 12 indicating the resident had moderate cognitive impairment. Review of a Nursing Progress note dated 10/24/2022 and documented by Licensed Practical Nurse (LPN) #3, showed .Resident [#73] verbally aggressive with staff, and roommate [Resident #16] this shift. Resident stated he was going to 'kick that damn man over there's ass [Resident #16] .that he wasn't nothing but a stupid idiot'. Resident calling CNA's [Certified Nursing Assistant] bitches and demanding to see a DR [Doctor] .resident [#73]stated 'to get these damn bitches and that idiot over there [Resident #16] to leave him alone' .Will report behaviors to oncoming shift nurse . During an interview on 11/15/2022 at 4:07 PM, LPN #3 stated she heard Resident #73 fussing at his roommate, Resident #16, telling him to shut up. LPN #3 stated she did not remember what night it was, but she walked in Resident #73 and #16's room, and Resident #73 said they needed to move dumb retarded roommate. She also stated there was an instance when Resident #16 came out of the room and said he wanted another room because his roommate, Resident #73, was cussing him, but the LPN was unable to recall the date of the occurrence. LPN #3 stated she notified the DON and charted it in the behavior book. Interview with the MDS Coordinator on 11/16/2022 at 9:38 AM revealed Resident #73 was care planned for the potential to be physically aggressive, had threatened to hit a nurse, and was physically and verbally aggressive. The MDS Coordinator confirmed a nursing note stated Resident #73 was cursing at his roommate, Resident #16. She stated she updated the care plan after she saw the progress note and the behaviors were discussed in the Interdisciplinary Team (IDT) meeting. The MDS Coordinator stated received verbal abuse training and considered the incident to be verbal abuse that should have been reported immediately. The MDS Coordinator stated the Assistant Director of Nursing (ADON) and Social Services was aware of the allegations. The MDS nurse stated the facility policy states to report allegations of abuse immediately. During an interview on 11/16/2022 at 12:53 PM, the DON stated she was aware of one issue where Resident #73 was calling the nurses names and talking about his roommate, Resident #16. The DON confirmed the nurses note dated 10/24/2022 stated Resident #73 was verbally aggressive to staff and his roommate. The DON confirmed the note stated 'kick that damn man over there's ass [Resident #16's] .that he wasn't nothing but a stupid idiot' and that the incident was considered abuse. The DON stated she was not aware Resident #16 had requested another room due to his roommate's behavior. The DON confirmed the allegation of verbal abuse by a staff member for Resident #73 and the allegation of resident-to-resident abuse for Resident #16 was not investigated by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, observation and interview, the facility failed to provide restorative therapy services for 1 resident (Resident #42) of 12 residents reviewed for limited range of motion (ROM). The findings include: Review of the facility's policy titled, Restorative Nursing, dated 9/19/2022, showed .To promote the resident's optimum function .Restorative programs may be initiated by .therapy .resident is given the appropriate treatment and services to .improve his or her ability to carry out the activities of daily living [ADLs] .Restorative Nursing does not require a physician order . Resident #42 was admitted to the facility on [DATE] with diagnoses including Hemiplegia (paralysis on 1 side of the body) and Hemiparesis (muscle weakness on 1 side of the body) and Left Above the Knee Amputation (AKA). Review of the annual Minimum Data Set (MDS) assessment dated [DATE], showed Resident #42 required extensive assistance of 2 staff for bed mobility and transfers and extensive assistance of 1 staff for toileting. Review of a PT Discharge summary dated [DATE], showed Resident #42 was discharged from PT services that were provided from 9/14/2021 to 10/11/2021, and the summary showed Discharge Recommendations .Restorative Range of Motion Program .Balance in sitting .ROM exercises . Review of the quarterly MDS assessment dated [DATE], showed Resident #42 required extensive assistance of 2 staff for bed mobility and transfers and extensive assistance of 1 staff for toileting. During an interview on 11/15/2022 at 1:42 PM, the Rehab Manager revealed Resident #42 was admitted with an amputation below the left knee that was later revised to an amputation above the knee. The resident received Physical Therapy (PT) services from 9/14/2021 to 10/11/2021. At discharge from PT, there was a referral to restorative therapy. The restorative therapy referral was communicated to nursing staff through a Restorative Nursing Communication Tool document. During an interview on 11/15/2022 at 2:20 PM, the RCNA stated she had not provided restorative services to Resident #42 in almost 2 years. During an interview on 11/16/2022 at 12:30 PM, the Rehab manager confirmed that PT #1 discharged Resident #42, and the PT recommended restorative therapy, but therapy was not provided for Resident #30. During an interview on 11/16/2022 at 1:25 PM, the DON stated that it was her expectation restorative therapy would start immediately after a recommendation was made by PT and confirmed Resident #42 did not receive the restorative services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, observation, and interview, the facility failed to implement an intervention after a fall for 1 resident (Resident #9) of 3 residents reviewed for accidents. The findings include: Review of the facility policy titled, Fall Management, undated showed .promote patient safety .reduce .falls by .care planning and monitoring .fall indicators .with any fall event .fall risks .will identify appropriate interventions to minimize the risk of injury related to falls . Resident #9 was admitted to the facility on [DATE], readmitted on [DATE] with diagnoses including Right Femur Fracture, Contusion of Eyeball, Osteopenia, Atrial Fibrillation, Congestive Heart Failure, Osteoarthritis, Repeated Falls, and Open-Angle Glaucoma. Review of the of the comprehensive care plan initiated 5/26/2022 and revised 10/28/2022, showed Resident #9 was at risk for falls related to weakness and impaired mobility. Interventions included assistance with activities of daily living and soft touch call light within reach. The resident had an actual fall with injury with an intervention which included a fall mat to bedside on 10/22/2022. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #9 had moderate cognitive impairment. The resident required limited assistance of 1 staff person with walking in corridor and toileting. Resident #9 required supervision of 1 staff person with walking in room. No falls were documented during the look back period. Review of the facility's Incidents Follow-up & Recommendation Form dated 10/22/2022, showed the nurse entered the room and observed Resident #9 lying on floor by bed (with walker flipped beside her). The intervention put in place after the fall included a fall mat to the bedside. Review of Significant Change MDS assessment dated [DATE], showed Resident #9 required extensive assistance of 1 staff person with toileting and personal hygiene. Resident #9 had several falls since last assessment which included 1 fall with no injury, 1 fall with minor injury, and 1 fall with major injury (right hip fracture-nondisplaced) which did not require surgery. During an observation on 11/16/2022 at 8:32 AM, in Resident #9's room showed no fall mat located at the bedside. During an observation and interview on 11/16/2022 at 9:27 AM, in Resident #9's room with Licensed Practical Nurse #2 and the MDS Coordinator they confirmed there was no fall mat at the bedside. During an interview on 11/16/2022 at 12:51 PM, the Director of Nursing stated interventions on the care plan were to be put in place.

**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 verify a medical justification or diagnosis for the use of an indwelling urinary catheter for 1 resident (Resident #79) of 6 residents reviewed for indwelling urinary catheter. The findings include: Review of the facility policy titled, Indwelling Urinary Catheter (Foley) [type of catheter] Management, reviewed 8/22/2022, showed .The facility will ensure that residents admitted with a urinary catheter, or determined to need a urinary catheter for a medical indication will have the following areas addressed .Timely and appropriate assessments related to the indication for use of an indwelling catheter .Identification and documentation of clinical indications for the use of a catheter; as well as criteria for the discontinuance of the catheter when the indication for use is no longer present .A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary .Examples of Appropriate Indications for Indwelling Urethral Catheters .Patient has acute urinary retention or bladder outlet obstruction .Need for accurate measurements of urinary output in critically ill patients .To assist in healing of open sacral or perineal wounds in incontinent patients .To improve comfort for end of life care if needed .Additional care practices related to catheterization .Attempts to remove the catheter as soon as possible when no indications exist for its continuing use . Resident #79 was admitted to the facility on [DATE] with diagnoses including Hemiplegia (paralysis of one side of the body) following a Cerebrovascular Accident, Urinary Tract Infection, Type 2 Diabetes Mellitus, Muscle Weakness, and Chronic Kidney Disease. The medical record did not reflect a diagnosis or medical justification for the use of an indwelling urinary catheter. Review of Discharge Documentation from the hospital dated 10/17/2022 showed .Due to her [Resident #79] grossly bed-bound status, patient will discharge [to the facility] with [indwelling urinary catheter] in place, due to risk of skin breakdown . Review of the comprehensive care plan dated 10/27/2022 showed the resident had an indwelling urinary catheter related to Obstructive Uropathy and Urinary Retention (the medical record did not reflect the diagnosis documented in the care plan). Review of the 5-day Minimum Data Set (MDS) dated [DATE] showed Resident #79 was not able to complete a Brief Interview for Mental Status (BIMS), as the resident was rarely or never understood. The MDS showed the resident had an indwelling urinary catheter. Review of the physician's orders dated 11/1/2022 showed change indwelling urinary catheter to straight drainage 14 French with 10 cubic centimeter (cc) bulb (size of catheter) as needed (a rationale or diagnosis was not provided). During observations on 11/14/2022 at 10:43 AM; 11/15/2022 at 2:00 PM; and on 11/16/2022 at 1:15 PM, Resident #79 was lying in bed with an indwelling urinary catheter in place and was draining urine to a bed side drainage bag. During an interview on 11/15/2022 at 4:15 PM, the Director of Nursing (DON) stated the diagnosis of obstructive uropathy with urinary retention was documented in error on the comprehensive care plan for the resident. The DON confirmed Resident #79 did not have a diagnosis for the continued use of an indwelling urinary catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #68 was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure, Sepsis, Chronic Kidney Disease, and Dementia. Review of an Order Summary Report for Resident #68 showed .Full code . with a start date of [DATE] and no end date indicated. Review of the POST form for Resident #68 dated [DATE], showed .DNR .no CPR . Review of Resident #68's comprehensive care plan initiated [DATE], showed Resident #68 was .Full Code . During an interview and observation on [DATE] at 3:35 PM, the Director of Nursing (DON) confirmed the physician order and the comprehensive care plan for Resident #23 and Resident #68's code status was inaccurate. Based on facility policy review, medical record review, observation, and interviews, the facility failed to maintain an accurate medical record for 2 residents (Resident #23 and Resident #68) of 24 medical records reviewed. The findings include: Review of a facility policy titled, Advance Directives and Advance Care Planning, reviewed [DATE], .it is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical treatment .and to formulate an advanced directive .the resident's choices will be documented in the resident's medical record . Resident #23 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Delusional Disorders, Major Depressive Disorder, and Dementia. Review of an Order Summary Report for Resident #23 showed, .Full code . with a start date of [DATE] and no end date indicated. Review of Resident #23's comprehensive care plan revised [DATE], showed .Full Code . Review of a Tennessee Physician Orders for Scope of Treatment (POST) dated [DATE], showed .Do Not Attempt Resuscitation .DNR .no CPR[cardiopulmonary resuscitation] .

Based on observations and interviews the facility failed to maintain cleaniness and sanitary conditions for 2 of 2 microwaves available for patient use in 2 of 2 Nourishment Rooms potentially affecting 76 of 80 residents. The findings include: During an observation and interview on 11/16/2022 at 1:12 PM, of the B Wing Nourishment Room with the Registered Dietician (RD) and the Executive Director (ED) showed splattered and crusty dried debris with a white film covering the whole inside of the microwave. The RD and the ED stated nursing staff were responsible for cleaning the microwaves and the microwave were to be cleaned after each use. The ED confirmed the microwave was dirty and available for patient use. During an observation and interview on 11/16/2022 at 1:30 PM, of the Secure Unit Nourishment Room with the RD and the ED showed splattered and crusty dried debris covering the whole inside of the microwave. The RD and the ED stated nursing staff were responsible for cleaning the microwaves and the microwave were to be cleaned after each use. The ED confirmed the microwave was dirty and available for patient use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of facility protocol, medical record review, observation and interview the facility failed to maintain a medication error rate less than 5 percent as evidenced by 2 medication errors out of 32 medication administration observations resulting in a medication error rate of 6.25 percent. The findings include: Review of the facility policy, Administration of Medications, dated 4/24/19 revealed .All medications are administered safely and appropriately per physician order . Review of a facility protocol revealed, .Common Oral Dosage Forms That Should Not Be Crushed .DR .delayed-release .ER .extended-release .Pantoprazole sodium .Delayed release . Medical record review revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including Encephalopathy, Diabetes, Anemia, Dysphagia, and Chronic Kidney Disease. Medical record review of a Physicians Recapitulation Order dated 6/7/19 revealed Pantoprazole Sodium (medication to treat high levels of stomach acid) 20 milligrams (mg) DR Give 1 tablet by mouth two times a day for ulcer. Medical record review of a Physicians Recapitulation Order dated 8/23/19 revealed Potassium Chloride (medication used to treat low potassium levels) ER Tablet Extended Release 10 milliequivalents per liter (meq)(concentration or strength of pharmaceutical products) Give 1 tablet by mouth two times a day for low potassium level. Observation on 9/3/19 at 9:55 AM, with Licensed Practical Nurse (LPN) #3 on the 200 hallway revealed LPN #3 prepared the following medications for administration: -Potassium 20 meq ER on e half tablet -Pantoprazole S 20 mg DR tablet. Further observation revealed LPN #3 crushed the medications and administered the medications with pudding to Resident #63. Interview with the Director of Nursing on 9/4/19 at 9:45 AM, in the conference room confirmed extended release, or delayed release medications are not to be crushed. Interview with the Consultant Pharmacist on 9/4/19 at 10:00 AM, by telephone, confirmed Potassium Chloride ER and Pantoprazole DR are not to be crushed.

**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 routine dental services were provided for 1 resident (#15) of 4 residents reviewed for dental services of 31 sampled residents. The findings include: Review of the facility policy revised 7/2017 revealed .facility is responsible for assisting the patient in obtaining needed dental services, including routine dental services .arrangements will be made promptly for routine .dental services . Medical record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including Huntington's Disease, Muscle Spasms, Encephalopathy, Anxiety, and Depression. Medical record review revealed the Consent for Dental Treatment, signed by the family, dated 4/10/17. Observation and interview of Resident #15 on 9/17/18 at 10:20 AM, in the resident's room, revealed the resident complained of tooth pain and pointed to the upper teeth. Continued interview revealed the resident had not been seen by dental services since admission. Observation and interview of Resident #15 on 9/18/18 at 9:30 AM, in the resident's room, revealed the resident complained of tooth pain and pointed to the upper teeth. Interview with the Social Service Director on 9/18/18 at 2:30 PM, in the Conference Room, confirmed the dentist visits the facility every 3 months and the resident had not received dental care. Further interview confirmed the facility does not ask residents prior to the dental visit if they needed to see the dentist. Interview with the Director of Nursing on 9/18/18 at 3:20 PM, in the Conference Room, confirmed Resident #15 did not have the opportunity to have her teeth evaluated and cleaned by the dentist since admission to the facility on 4/10/17.

Based on facility policy, observation, and interview, the facility failed to remove expired food supplies readily available for resident use, potentially affecting 70 of 72 residents. The findings include: Review of facility policy Food Safety last revised 11/28/17 revealed .Food is stored and maintained in a clean, safe and sanitary manner . Observation and interview with the Dietary Manager on 9/17/18 at 9:50 AM, at the reach in cooler located in the kitchen, revealed 6 strawberry banana yogurts available for resident use dated 8/23/18. Continued interview confirmed the facility failed to discard the expired yogurts.