**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 residents (Resident #1), reviewed for pharmaceutical services. The facility failed to ensure that Resident #1 was administered her 2 tablets of Acetaminophen 325 MG crushed due to her diagnosis of Dysphagia and difficulty swallowing. The medication administered by RN B (2 tablets of acetaminophen non-crushed) caused the resident to cough uncontrollably. This failure could place residents at risk for not receiving medications as ordered, aspiration, psychosocial harm/fear, and decreased quality of life. The findings included: Review of Resident #1's face sheet dated 05/27/25 revealed a [AGE] year old female admitted to the facility on [DATE] with diagnosis that included hemiplegia (paralysis on one side of the body) and hemiparesis (one sided muscle weakness) following cerebral infarction (stroke) affecting right dominant side, dysphagia (difficulty swallowing) following cerebral infarction (stroke), generalized anxiety disorder (condition characterized by excessive worry), and major depressive disorder-recurrent-moderate (condition characterized by persistent feeling of sadness and loss of interest). Review of Resident #1's Quarterly MDS assessment reflected a BIMS score of 10 indicating moderate cognitive impairment. Section GG for functional abilities reflected Resident #1 was dependent-helper does ALL of the effort, resident does none of the effort to complete activity or the assistance of 2 or more helpers is required for the resident to complete the activity which was marked as such for oral hygiene, toileting hygiene, shower/bathe, dressing, personal hygiene, sit to lying and lying to sit, toilet transfer, tub/shower transfer, and chair to bed transfer. Section I for active diagnosis reflected Resident #1 was identified as having a diagnosis of a stroke, non-Alzheimer's dementia, and hemiplegia/hemiparesis. Review of Resident #1's care plan last revised 05/27/25 reflected a focus area swallowing problem related to Dysphagia, coughing or choking swallowing meds, swallowing assessment results with interventions all staff to be informed of residents special dietary and safety needs: CRUSH MEDICATION. Review of Resident #1's swallow study physician consult summary dated 01/16/25 reflected: Diagnosis- dysphagia, dysphagia following cerebral infarction, dysphagia following unspecified cerebral vascular disease. Chief complaint: coughing, feeding difficulties, difficulties swallowing. Recommendations: Meal Diet: Pureed, thin liquids Strategies for pills: Choking risk- crush meds. Pertinent positive swallowing history: Current diet: Solids- Pureed, Liquids-thin. Indication for Dysphagia consultation- life limiting or threatening dysphagia disorder with: feeding difficulties, complaints of difficulty or pain when swallowing, coughing, determine safe diet, determine least restrictive diet. Modified Barium Swallow Study Results: Strategies for pills: choking risk- crush meds Pill trial not provided due to choking risk. Review of Resident #1's EMR undated face sheet special instructions capture on 05/27/25 reflected Special instructions: crush medication as well as Diet: REGULAR diet, PUREED texture, THIN LIQUIDS consistency. Review of Resident #1's EMR undated face sheet special instructions capture on 05/28/25 reflected, Special instructions: **CRUSH MEDS** as well as Diet: REGULAR diet, PUREED texture, THIN LIQUIDS consistency. Review of Resident #1's physician orders reflected an order dated 09/22/22, may crush meds prn, empty capsules & mix with applesauce or Jello as indicated/desired/needed. Review of Resident #1's physician orders reflected an order dated 05/27/25, Crush meds, empty capsules & mix w/ applesauce or pudding unless contraindicated. Review of Resident #1's physician orders reflected an order dated 04/04/24, acetaminophen tablet 325 mg- Give 2 tablets by mouth every 4 hours as needed for pain. Review of Resident #1's medication administration note dated 05/27/25 at 11:18 AM entered by RN B reflected, acetaminophen tablet 325 mg- give 2 tablets by mouth every 4 hours as needed for pain 1-10 do not exceed 3G/day. Resident was complaining of pain in her right shoulder where she has a fracture and administered acetaminophen per orders. Arm in sling for comfort. Will continue to monitor. In an observation on 05/27/25 at 11:18 AM RN B was observed providing pain medication to Resident #1 and walked in her room with a clear pill container that contained 2 tablets not crushed. RN B asked Resident #1 if she required crushed medications, Resident #1's response to RN B was not heard. RN B provided the medication to Resident #1 and then Resident #1 was heard immediately coughing forcibly and uncontrollably. RN B was heard asking Resident #1 continuously if she was ok and if she required more water, attempted to provide her more water which Resident #1 refused as she continued to cough to clear her throat. In an interview and observation on 05/27/25 at 12:11 PM with RN B, he stated he did not know if Resident #1 required crushed medication. He stated he doesn't usually work this building. RN B stated he would have to check Resident #1's chart and was then observed logging into Resident #1's chart. RN B stated that Resident #1 did require her medications to be crushed as stated in the special instructions located on top of the face sheet/ medical record which is where he said he would look to find that information. He stated the special instructions give you the important stuff as soon as you log into the residents' chart, as an alert located at the top being one of the first things you see. RN B stated the last time he worked with Resident #1 was 6 months ago. He stated the medication he gave which were 2 acetaminophen tablets are able to be crushed and should have been. RN B stated he did not look at the chart to determine if Resident #1 required crushed medications prior to the administration of the acetaminophen tablets but should have done so to verify correct administration. RN B stated a potential negative outcome of not providing crushed medications to Resident #1 is the resident has the potential to choke on the medication. In an interview on 05/27/25 at 12:40 PM with the DON, she stated that if residents require crushed medications its communicated through special instructions on the residents chart. The DON stated that if the special instruction say to crush medications its her expectation that medications are crushed when provided to the resident. The DON stated that any staff member that is here can see the special instructions and said, PRN staff members, CNAs, everyone know its there, its quick and it shows up at the top so they can see it. The DON stated that a negative outcome to not reviewing the chart prior to providing care, staff could provide something that is not part of their plan of care. She stated failing to crush medication for a resident that required it has the potential to result in the resident not being able to swallow the medication appropriately. The DON stated Resident #1 has good recall but that she did not believe Resident #1 had the cognition to answer the question appropriately if asked if her medication needed to be crushed instead of her chart being reviewed by staff. In an interview on 05/27/25 at 01:14 PM with Resident #1 she stated she preferred her medication to be crushed. Resident #1 stated that when she was administered the medication in the morning, when she started to choke and cough it made her scared. In an interview on 05/27/25 at 04:04 PM in a follow up interview again with Resident #1, she was once again asked about the morning medication administration and stated she recalled the incident. Resident #1 stated it made her feel terrible. In an interview on 05/27/25 at 04:09 PM with SW, she stated she believed Resident #1 would be able to say if she was in pain or scared. She said if Resident #1 said she was scared she would take it seriously but would question if Resident #1 fully understood what that meant. She stated given Resident #1's cognitive stance she is more likely to recall events tied to a strong emotion like fear or pain. In an interview on 05/28/25 at 11:10 AM with ST, she stated that when there are concerns with a residents ability to swallow they will do a bedside swallow test or have a swallow study done. ST stated that after the swallow study is completed if there is anything on the residents chart that needs to be updated, they will do so based on the swallow study providers recommendations which comes from the third party provider. ST stated since Resident #1 is on a pureed diet there is a risk of choking to occur so they will recommend pills to be crushed as a precaution. ST stated that they have attempted a mechanical soft diet in the past with Resident #1 such as with pleasure feedings but she requires a lot of cueing and would still cough. ST stated that she has worked with Resident #1 for a while and that even with the pureed diet she appears to cough a lot and looks like she's choking which can appear scary. ST stated that Resident #1 has not done well enough on pleasure feedings with a mechanical soft diet to be upgraded from a full pureed texture. ST stated that based on the swallow studies and their work with her crushed medications would go down easier and be safer for her. In an interview on 05/28/25 at 02:31 PM with the DON she stated she made the updates to Resident #1's chart pertaining to the order from may crush medications to crush medications unless contraindicated in order to ensure more consistent care. In an interview on 05/28/25 at 02:55 PM with the ADM, he stated it was his expectation that physician orders and special instructions in a resident's medical record were reviewed prior to the administration of medication. He stated a potential negative outcome of not reviewing the chart prior to providing medications is there could be a medication error. The ADM stated that a negative outcome of not following a providers recommendation related to the swallow study would be it would depend on the order or recommendation provided. Record Review of the undated Medication and Treatment Administration policy reflected: Residents shall be identified prior to the administration of a medication or treatment. Record review of the Resident Rights policy last revised 2023 reflected: You have a right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, it was determined that the facility failed to ensure residents have the right to receive visitors of his or her choosing at the time of his or her choosing for 1 (Resident #1) of 10 Residents reviewed for resident rights. The facility did not allow Resident #1 to visit with a family member. This failure could place residents at risk of isolation, decreased emotional wellbeing, and diminished quality of life. Findings included: 1. Review of Resident #1's face sheet dated 09/25/2024 reflected that Resident #1 was a [AGE] year-old male admitted on [DATE] with diagnoses of alcoholic polyneuropathy (a neurological disorder in which peripheral nerves throughout the body malfunction simultaneously), Wernicke's encephalopathy (a type of brain injury), chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs), alcohol dependence (being unable to stop drinking without experiencing symptoms of withdrawal), in remission, and other psychoactive substance abuse (refers to the harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs). Review of Resident #1's quarterly MDS dated [DATE] reflected the resident had a BIMs score of 15 which indicated no cognitive impairment. Review of Resident #1's care plan revised on 02/05/2024 reflected that resident had verbally abusive behaviors towards staff related to substance use disorder. Approach for this care plan included assess resident's coping skills and support system. Resident #1 was at risk for unexpected weight loss or gain related to new admission, malnutrition, diabetes, depression, and other medical conditions. Interventions included encourage snacks between meals, honor resident rights to make personal dietary choices, monitor and report to doctor as needed for any symptoms of decreased appetite or unexpected weight loss, and monthly weights if stable. Care plan did not include any information regarding visitation limitations or concerns from the facility or Resident #1. Review of Resident #1's progress notes dated 07/26/2024 through 09/26/2024 did not include any information regarding visitation limitations or concerns from the facility or Resident #1. Review of Resident #1's progress notes dated 07/26/2024 through 09/26/2024 reflected no conversations with ADM regarding visitors/visitation. Review of Resident #1's psychological services progress note dated 09/04/2024 completed by LCSW, revealed Resident #1 reported feeling depressed because he had not seen his family member in several days and was worried because the family member was homeless. Review of Resident #1's psychiatric initial assessment dated [DATE] completed by PMHNP, revealed Resident #1 endorsed depression, sadness, loss of interest, fatigue, and guilt because his family member was banned from the facility, and he did not know why. Review of Resident #1's electronic medical record did not include any information regarding visitation limitations or concerns from the facility or other residents regarding Resident #1's family member. Review of Resident #1's weight records showed stable weight with no weight loss. During an interview on 09/24/2024 at 1:20 PM, the Ombudsman stated Resident #1 was upset because his family member could not visit him. Resident #1 stated that the ADM told him they had on video that the family member brought Resident #1 drugs and alcohol. Resident #1 denied this and had asked to see the video, but that request was denied. The Ombudsman stated that she talked to the ADM on 09/06/2024, who stated that Resident #1's family member had been banned from the facility because he was bringing drugs and alcohol into the facility. The ADM further stated that the family member was homeless, and Resident #1 had allowed family member to sleep in his bed, which was not allowed. The ADM told the Ombudsman that he called the police, but the family member left, and the police did not respond and there was not a no trespass order. The Ombudsman asked the ADM for proof or documentation of disruptive behaviors or suspected drug, and none was provided. The Ombudsman stated the ADM refused to allow supervised visitation between Resident #1 and the family member. The Ombudsman stated the ADM told her Resident #1 could transfer to another facility if he wanted to visit with his family member; otherwise, the ADM would start the discharge process because Resident #1 was not following the facility rules. During an interview on 09/25/2024 at 10:05 AM, LVN A stated family members can visit at any time. LVN A stated he observed Resident #1 at the nursing station complaining about his family member not being allowed to visit. LVN A had not seen Resident #1's family member in a few weeks and did not know why. LVN A had never seen Resident #1's family member bring alcohol or drugs into the facility, be disruptive, or aggressive. LVN A stated Resident #1 would allow the family member to sleep in resident's bed during the daytime when Resident #1 was not using the bed. LVN A stated the facility had a lot of social activities and family members came often to visit and engage in these activities. LVN A stated since Resident #1's family member had not been allowed to visit, Resident #1 appeared quieter and more withdrawn. LVN A stated he was not aware Resident #1's family member had been banned from the facility. During an interview on 09/25/2024 at 10:59 AM, Resident #1 stated the facility limited his visitors and that he was unable to visit with his family. Resident #1 stated he missed his family member and would like to see him. Resident #1 stated the ADM banned his family member from the facility because he had a video of the family member giving the resident alcohol. Resident #1 stated this was not true and he asked the ADM to view the video and his request was denied. Resident #1 stated he could get his own alcohol. He denied his family member being disruptive or causing any problems. Resident #1 stated he allowed his family member to sleep in his bed, during the daytime, never at night. Resident #1 stated the ADM never offered him supervised visitation with his family member or provided him anything in writing about the family member being banned. Resident #1 stated not allowing visits from his family member went against the facility's mission statement and against his resident rights. Resident #1 stated since his family member had been banned from the facility, he had lost his appetite, and was depressed as hell. Resident #1 stated since the family member was banned, he could not visit Resident #2 either. During an interview on 09/25/2024 at 12:00 PM, LVN B stated she was Resident #1's nurse. LVN B recalled an incident with Resident #1's family member about two months ago when Resident #1's family member yelled at her, Do you have a problem with me? You have a problem with me!. LVN B reported this to the ADM and the ADM stated he would talk to the resident and family member about this. LVN B had never observed any disruptive behaviors from Resident #1's family member prior to this and never had a problem with family visiting Resident #1. LVN B stated this was an isolated incident. LVN B stated she was never told Resident #1's family member was banned from the facility, and she does not know what the ADM did to address the situation. During an interview on 09/25/2024 at 12:15 PM, the OT stated that she had seen Resident #1's family member visit Resident #1, but not recently. The OT stated that she heard Resident #1's family member was not supposed to visit, but she did not know why. The OT had not observed any disruptive behaviors from Resident #1's family member. The OT stated that residents could have family member visit, but there might be restrictions on visiting hours. During an interview on 09/25/2024 at 12:20 PM, CNA B stated he found alcohol in Resident #1's backpack in his room and thought it might have been brought into the facility by Resident #1's family member. CNA B stated Resident #1's family member was always mad and yelled at staff, but he could not give specific dates of incidents or names of staff involved. He stated Resident #1's family member would sleep in Resident #1's bed and ate the food at the facility. CNA B stated he had not seen Resident #1's family member recently. During a telephone interview on 09/27/2024 at 8:35 AM Resident #1's family member A stated her family was mourning that family member B was not allowed to visit Resident #1 and Resident #2. She believed both Resident #1 and Resident #2 benefited from visits from family member B. Family member A stated she had never observed family member B be disruptive or disrespectful. She does not believe family member B would bring in alcohol or drugs into the facility as that was not the kind of person he was. Family member A stated she talked to both Resident #1 and family member B and they both denied family member B brought alcohol or drugs into the facility or was being disruptive and she believed them. 2. Review of Resident #2's face sheet dated 09/25/2024 revealed a [AGE] year-old female admitted on [DATE] with primary diagnoses of Huntington's Disease (an inherited disorder that causes nerve cells (neurons) in parts of the brain to gradually break down and die), Alcoholic cirrhosis (liver damage caused by chronic alcohol use) of the liver with ascites (buildup of fluid in the stomach), dysarthria (a speech disorder caused by problems controlling the muscles used for speech) and anarthria (the most severe form of dysarthria where the individual in unable to speak at all). Special instructions listed the resident enjoys spending time with her family. Review of Resident #2's quarterly MDS dated [DATE] reflected Resident #2 BIMS score selection was not completed. Resident was completely dependent for all functional abilities. Resident's speech was unclear and her ability to make herself understood and understand others was marked as sometimes. The cognitive patterns section had blanks and was not scored. Most items on the MDS were not scored. Review of Resident #2's care plan revised on 06/29/2023 reflected Resident #2 was identified as being at risk for delirium and impaired cognitive function/dementia due to Huntington's disease. Resident #2 was at risk for a communication problem related to hearing deficit, dementia, and aphasia. Under Activity Preferences, it was noted that resident would maintain involvement in cognitive stimulation such as outings with family and interventions included: Resident needed 11 beside/in-room visits and activities if she was unable to attend activities out of her room. Review of Resident #2's progress notes dated 08/26/2024 to 09/26/2024 reflected no conversations or requests regarding visitors/visitation. During an observation on 09/25/2024 at 3:05 PM, Resident #2 was observed lying in bed. Resident #2 was non-verbal but did respond to the surveyor calling her name and reached her hand out to shake the surveyor's hand. During an interview on 09/25/2024 at 12:57 PM, family member C stated Resident #2 was related to family member B. She had seen family member B at the facility when she went to visit Resident #2 and had not observed any disruptive behaviors. Family member C had never heard of facility staff or other residents complaining about Resident #1's family member. Family member C stated family member B primarily visited Resident #1, but also Resident #2. Family member C stated about a month ago, the ADM called her to inform her that Resident #1's family member had been banned from the facility. Resident #1 told her that the ADM had a video of family member B taking Resident #1 to buy alcohol. Family member C stated she had no concerns with family member B visiting Resident #2 and thought it was good for Resident #2 to see familiar family faces. She also had no concerns with the family member B visiting Resident #1. During an interview on 09/25/2024 at 9:46 AM, CNA A stated family members can visit all times of the day and she was not aware of any restrictions of family visiting residents. CNA A had not observed any disruptive family members or heard any complaints from residents about family members visiting. During an interview on 09/25/2024 at 11:37 AM, the SW stated residents could have family members visit any time 24 hours a day. The SW stated a potential negative outcome of a family member not being able to visit a resident was a change to their mental health. The SW stated Resident #1's family member was a regular visitor to Resident #1 until recently. The SW stated Resident #1's family member was suspected of bringing alcohol into the facility and he made LVN B feel uncomfortable and had been banned from the facility. The SW stated she had seen Resident #1's family member visiting and had never observed any disruptive behaviors. The SW described the family member as calm. The SW had observed Resident #1's family member sleeping in Resident #1's bed or on the floor during the daytime, but never at night. The SW stated residents could not have family members sleep overnight, but she was not aware of any policy that would prohibit that during the day. The SW stated Resident #2 was also impacted by Resident #1's family member not visiting, but she had never seen this family member visit Resident #2. There was one occasion when Resident #1 was upset after a visit from his family member and said they argued, and Resident # 1 did not want his family member to visit. The facility had a sign in sheet for the visitors, but it is not used or enforced or regulated. During an interview on 09/25/2024 at 1:15 PM, the DON stated that residents could have family members visit any time with no restrictions. Potential negative outcome of a family member not being able to visit a resident was psychosocial. The DON observed Resident #1's family member yelling at staff and sleeping in Resident #1's bed. The DON stated that based on family member B's presentation of red eyes and slurred speech, she thought he was under the influence of something. The DON stated that the ADM had spoken to both Resident #1 and family member B about these concerns and the facility restricted family member B's visitation for the safety of residents and staff. The DON stated that the ADM provided verbal discussion and that this was not documented anywhere. The DON was not aware of any documentation regarding family member B being banned from the facility. During an interview on 09/25/2024 at 1:35 PM, the ADM stated residents could have visitors 24 hours a day, but they could restrict visits if a visitor was disruptive to protect the safety of residents. Potential negative outcome of a family member not being able to visit was psychosocial harm. Resident #1 was very high functioning and would sign himself out on pass daily and when he would return to the facility, he appeared intoxicated. When Resident #1's family would visit, the resident appeared more intoxicated and would yell at staff. The ADM stated there were residents at the facility that did not want family member B to visit, and he needed to protect their rights. The ADM stated family member B would yell at the nurse or demand services (such as cleaning the room). The ADM talked to Resident #1 about not having his family member bring in substances. The ADM stated family member B was homeless and came into the facility to live there by sleeping on the bed and eating the food during the day when Resident #1 was not in the facility. The ADM educated Resident #1 on visitation rights and that the services were for residents and not his family. These conversations were not documented. The ADM stated family member B brought alcohol into the facility because he heard glass bottles when family member B walked by. The ADM denied having video or other proof that family member B brought in alcohol but suspected he had brought in illegal substances. The ADM stated family member B yelled at him because of this accusation, and he called the police, but family member B left the facility, and the ADM told the police not to respond. The ADM stated they did not have a police report or file number. The ADM stated he had not made any law enforcement referrals. The ADM stated he offered Resident #1 supervised visits with his family, but Resident #1 refused. The ADM stated the facility does not have a policy about family bringing alcohol into the facility nor about family members drinking alcohol while in the facility. Residents can drink alcohol in the facility but need a doctor's order. The ADM stated Resident #1's family member was also a family member of Resident #2. Family member B stated that he would go visit Resident #2 when he was at the facility. The ADM stated Resident #2's family did not want family member B to visit Resident #2. The ADM stated Resident #1 could leave on pass to visit his family member outside of the facility. The ADM stated he banned family member B from the facility and from visiting Resident #1 and Resident #2 because of these behaviors. The ADM stated he had not put any of this in writing or documented it anywhere. The ADM did not know family member B's name. The ADM stated staff had not been trained or given notice that family member B had been banned. The ADM could not recall when family member B was banned or how long that ban would last. The ADM stated that all of this was not documented in Resident #1 or Resident #2's electronic medical record nor anywhere else, because it was a family member and not a resident. During an interview on 09/25/2024 at 2:53 PM, the local Police Department stated they did not have any incident records for Resident #1 or his family member for the last two months. They did not have any records on file. During an interview on 09/25/2024 at 3:00 PM, CMA stated Resident #2's family visits often but had not seen family member B in a while and had never seen any problems with family member B's behavior. Review of facility grievance logs dated 06/03/2024 through 09/23/2024 revealed no complaints about visitation with family members. Review of facility policy titled Resident Rights and Responsibilities, Notice of dated November 2016 and revised in December 2023 reflected, It is the policy of the facility to inform the resident both orally and in writing of their rights as a resident, as well as the rules and regulations governing the resident's conduct and responsibilities during their stay in the facility. Review of facility policy titled Residents Rights dated 07/13/2017 reflected residents had the right to receive visitors of your choosing at the time of your choosing, subject to your right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident. Further review reflected residents had the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language you understand. Review of facility policy titled Visitation Rights of Residents dated November 2016 and revised in December 2023, reflected It is the policy of the facility to inform each resident and/or resident representative of the rights to receive visitors based on their preferences and any clinical or safety restrictions or limitations on these rights. The facility will respect the rights of a resident to consent to receive visitors of their choosing at the time of their choosing and the right to deny or withdraw consent for visitation at any time, when applicable, and in a manner that does not impose on the rights of another resident. Visitation will not be restricted, limited, or denied based on race, color, national origin, religion, sex, gender identity, sexual orientation, or disability. Further review reflected the resident had the right of immediate access to immediate family and visitation would be person-centered, consider the psychosocial well-being of the resident, and support their quality of life. Policy included The facility will ensure all visitors enjoy full and equal visitation privileges consistent with resident preferences. And Notify resident and/or their representative of the facility policy regarding visitation, to include the resident right to consent to, withdraw consent for, or deny visitors and any potential limitation or restrictions for visitation. Further review reflected, Reasonable clinical and safety restrictions include a facility's policies, procedures, or practices that protect the health and security of all residents and staff. These may include, but are not limited to: o Denying access to individuals who are inebriated or disruptive; 1. If the resident exhibits signs or symptoms or triggers of illegal substance use, ask the resident whether they possess or have used an illegal substance. 2. If the facility determines illegal substances have been brought into the facility by a visitor: Make a referral to law enforcement. The facility may need to provide additional monitoring or supervision or resident and/or visitation restrictions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents had the right to neglect for one (Resident #1) out of three residents reviewed for neglect, in that: The facility failed to pick up Resident #1 from his chemo treatment until three plus hours after his treatment had ended. Resident #1 had to wait outside while the facility was not answering his phone calls. He experienced increased frustration, humiliation, exhaustion, and harm to his psychosocial well-being. He stated he still felt frustrated and neglected. This failure placed residents at risk of experiencing humiliation, dehydration, and a decrease of self-worth. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acute respiratory failure, chronic heart failure, type II diabetes, chronic pain, major depressive disorder, stage II pressure ulcer of sacral region, and COPD (persistent respiratory symptoms like progressive breathlessness and cough). Review of Resident #1's quarterly MDS assessment, dated 07/29/23, reflected a BIMS of 15, indicating he was cognitively intact. Section I (Active Diagnoses) reflected he had a diagnosis of cancer. Section O (Special Treatments, Procedures, and Programs) reflected he was receiving chemotherapy treatments. Review of Resident #1's quarterly care plan, revised 08/02/23, reflected he had chemotherapy related to pancreatic cancer with an intervention of giving medications and treatments as ordered. Review of Resident #1's oncology notes, dated 04/18/23, reflected the following: 1. Pancreatic Cancer - Approximately 3 x 4 cm ill-defined hypo enhancing lesion at the head of the pancreas with associated narrowing of the pancreatic duct and portal vein confluence and sub centimeter adjacent lymph nodes, highly suspicious for malignancy (cancer). Review of Resident #1's oncology notes, dated 05/01/23, reflected the following: My Diagnosis: Primary pancreatic cancer My Stage at Diagnosis: Stage IIB Current Status of Disease: Metastatic (advanced or late-stage) Therapy Goal: Cure Prognosis: guarded Recommended Treatment: Abraxane D1 (on day one), 8 (on day 8), 15 (on day 15) + Gemcitabine D1, 8, 15 Q28D (for every 28-day cycle) Expected Response: shrinkage of tumor During an interview on 09/03/23 at 9:11 AM, Resident #1 stated he arrived at his chemotherapy appointment on 08/31/23 around 8:50 AM - 9:00 AM and his appointment was scheduled for 9:30 AM. He stated the facility did not send an aide to go with him as they normally did for the past couple of months. He stated he thought the van driver was going to stay with him at the appointment, but she left and never came back. He stated his treatment was completed around 3:00 PM, and he went to the parking garage to wait to be picked up. He stated he repeatedly called the facility without getting any answer. He stated he was extremely hot, sweaty , exhausted, and increasingly frustrated that he could not get ahold of anyone. He stated around 4:30 PM, the receptionist at the facility answered but she did not know what was going on with his transportation. He stated he finally got ahold of LVN A at the nurse's station, and she too had no idea what was going on with his transportation. He stated the staff at the Oncology clinic noticed him still waiting outside around 5:20 PM and brought him inside because they felt sorry for him. He stated he finally got ahold of the van driver on her cell phone around 6:00 PM. He stated she sounded very annoyed because she had to go back to the facility to get the van and then to the clinic to pick him up. He stated he went back outside once the clinic closed at 6:00 PM. He stated he was finally picked up by the van driver around 6:30 PM and brought back to the facility. He stated the whole situation made him extremely pissed off, embarrassed, and frustrated when he could not get ahold of anyone and no one knew what was going on. He stated the situation truly felt like it caused him mental anguish . He stated he did not suffer any physical ailments, such as dehydration, from the incident. Tearfully, he stated he still felt frusterated and upset over that sitation and was fearful the neglect he endured would happen again in the future. During an interview on 09/03/23 at 9:50 AM, the ADM stated she had not been informed of anything that occurred from Resident #1's last chemotherapy appointment on 08/31/23. She stated it would depend on the resident if they sent a staff member to accompany the resident to an appointment. She stated if a resident was cognitively impaired and not able to handle the process, a staff member would be sent with to assist. She stated, to her knowledge, no one accompanied Resident #1 to his appointments because he had a BIMS of 15. During an interview on 09/03/23 at 10:28 AM, the VD stated she stayed with residents at their appointments if she was able. She stated if their appointment was over two hours and she had to get another resident to their appointment, she would not be able to stay. She stated Resident #1 had been receiving chemotherapy one time a week for a few months now. She stated Resident #1's chemotherapy treatments usually last 2.5 - 3 hours. She stated they normally utilized a contracted transportation agency to transport him to his appointments and an aide always accompanied him. She stated she transported Resident #1 to his appointment on 08/31/23 because he notified her last minute of his appointment, and she did not have time to set up transportation with their contracted agency. She stated on 08/31/23 she had multiple resident appointments, so she reached out to the ADM and asked if they could get Resident #1 a (rideshare) to pick him up from his appointment. She stated she assumed it was taken care of until she received a call from Resident #1. She stated she picked him up from his appointment around 6:30 PM on 08/31/23. During an interview on 09/03/23 at 11:25 AM, the ADM stated the VD texted him on 08/31/23 at 2:36 PM asking if a (rideshare) could be arranged for Resident #1's pick-up. He stated he responded to her at 3:05 PM stating that he was out at a meeting and could not arrange one, but someone from the facility could arrange one as long as they met the (rideshare) at the clinic to ensure Resident #1 was picked up safely. He stated he did not have any further communication with the VD. He stated it was unacceptable that Resident #1 had to wait at the clinic for that long before getting picked up. A telephone call was made to LVN A on 09/03/23 at 11:39 AM. LVN A was Resident #1's nurse on 08/30/23 from 6:00 AM to 6:00 PM. A returned telephone call was not received prior to exiting the facility. A telephone call was made to LVN B on 09/03/23 at 11:42 AM. LVN B was Resident #1's nurse from 6:00 PM on 08/30/23 to 6:00 AM on 09/01/23. A returned telephone call was not received prior to exiting the facility. A telephone call was made to the Monday - Friday Receptionist on 09/03/23 at 11:45 AM. A returned telephone call was not received prior to exiting the facility. During an interview on 09/03/23 at 1:40 PM, the DON stated it was extremely important to ensure residents were dropped off and picked up in a timely manner for appointments. Shee stated the VD was ultimately responsible for ensuring that it happened. She stated it was inexcusable that Resident #1 had to wait at the clinic for over three hours after his chemotherapy treatment. She stated it could have caused him to become dehydrated, over-heated, or he could become so weak and exhausted that he could have fallen out of his wheelchair. She stated the only policy they had related to transportation, was a policy on transportation arrangements for dialysis. Telephone calls were made to the SW at the oncology clinic on 09/03/23 at 9:37 AM and 09/05/23 at 2:59 PM. A returned telephone call was not received prior to exiting the facility. Review of the facility's invoices from their contracted transportation agency, from 06/20/23 - 09/03/23, reflected they transported Resident #1 to/from his chemotherapy appointments on the following days: 06/22/23, 06/30/23, 07/07/23, 08/17/23, and 08/24/23. Review of the facility's undated Abuse, Neglect, and Exploitation policy, reflected the following: Neglect is the failure of the Facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.