**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one (1) of one resident reviewed for transfer and discharge rights. (Resident #1) The facility failed to make arrangements for a safe discharge for Resident #1. This failure could place residents at risk for not receiving care and services to meet their needs upon discharge. Findings included: Review of Resident #1's Face Sheet reflected a [AGE] year-old male admitted [DATE] with diagnoses of unspecified systolic congestive heart failure (the left ventricle loses its ability to contract normally. The heart can't pump with enough force to push enough blood into circulation), essential primary hypertension (abnormally high blood pressure that not caused by a medical condition), major depressive disorder (persistent low mood and loss of interest in activities that people enjoy), and insomnia (a sleep disorder that makes it hard to fall asleep, stay asleep, or get quality sleep). Review of Resident #1's Quarterly MDS dated [DATE] reflected a BIMS score of 15 indicating no cognitive impairment. Resident #1 required set up or clean up assistance in the areas of eating, oral hygiene, upper body dressing, and personal hygiene, Resident #1 required partial/moderate assistance in the areas of lower body dressing and shower/bathe self. Resident #1 required substantial/maximal assistance in the areas of toileting hygiene and putting on/taking off footwear. Review of Resident #1's care plan dated 12/10/24, revealed Resident #1 was care planned for the following: Resident #1 wished to be discharged to an apartment. Review of Resident #1's 30-day discharge letter dated 10/09/24, revealed Resident #1 was given the 30-day discharge letter on the same date (10/09/24) he was discharged to the psych facility. Review of Resident #1's Interdisciplinary Discharge Summary date 10/11/24, revealed Resident #1 was sent to the psychiatric facility for evaluation and treatment. During an interview on 12/10/24 at 1:20 p.m., the SW stated that the resident was having several behaviors such as putting the remote to the tv in his pants, threatening other residents, and forced his roommate to watch gay porn. The SW stated Resident #1's former roommate was discharged from the facility as well but provided the investigator his face sheet with a phone number attached. The SW stated that the facility got an Application for Emergency Apprehension and Detention warrant for Resident #1 to be seen at a psychiatric facility. The SW stated that Resident #1 was given his 30-day discharge notice on 10/09/24 with a discharge date of 11/09/24. SW stated Resident #1 discharged from the psychiatric facility to another facility on 10/30/24. The SW stated that she nor anyone else was involved in the process of assisting with finding a new facility for Resident #1 once he left the psychiatric facility. During an interview on 12/10/24 at 2:35 p.m., the BOM stated that she was not involved in the transfer process when Resident #1 was sent to the psychiatric facility. The BOM stated Resident #1 was aware that he was going to the psychiatric facility on 10/09/24. The BOM stated that she gave Resident #1 his 30-day discharge letter on 10/09/24 with a discharge date of 11/09/24. The BOM stated that she thought that the SW, the DON, and the ADM had placement for Resident #1 once he was discharged from the psychiatric facility. During an interview on 12/10/24 at 4:00 p.m., Resident #1 stated that he was doing fine and was safe at his new facility. Resident #1 stated that the psychiatric facility referred him to the new facility. Resident #1 stated that he was very happy and pleased at his new facility and expected to get his own apartment after discharge. During an interview on 12/10/24 at 4:30 p.m., the DON stated she was not working at the facility at the time of the incident. The DON stated that the facility should have coordinated a transfer for Resident #1 due to him coming from their facility. The DON stated that she was not sure who was responsible to assist with coordinating a safe transfer due to her being new at the facility. The DON stated the failure could affect the resident by not having a safe place to discharge after discharging from the psychiatric facility. During an interview on 12/10/24 at 4:55 p.m., the ADM stated that Resident #1 was sent to the psychiatric facility on her first day working at the facility. The ADM stated that she thought the facility and coordinated a facility for Resident #1 to go to after he left the psychiatric facility. The ADM stated she was not involved in the discharge process for Resident #1. The ADM stated that IDT team was responsible for discussing the needs to ensure a safe discharge/transfer occurs and the SW was responsible for coordination with the psychiatric facility about finding a new placement for the resident. The ADM stated the failure could have affect the resident by not having a safe discharge. Review of facility's Transfer or Discharge Notice policy dated Revised January 2023 reflected Residents and/or representatives are notified in writing, and in a language and format they understand, at least (30) days prior to a transfer or discharge. Policy, Interpretation, and Implementation 1. Transfers and discharge includes movement of a resident from a certified bed in the facility to a non-certified bed in another part of the facility, or to a non certified bed outside the facility. Transfer and discharge does not refer to movement to a bed within the same certified facility, Specifically: a. Transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility; and b. Discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected. 3. Except as specified below, the resident and his or her representative are given a thirty (30) days advance written notice of the impending transfer or discharge from this facility. 4. Under the following circumstances, the notice is given as soon as is it practicable but before the transfer or discharge: a. The safety of individuals in the facility would be endangered; b. The health of individuals in the facility would be endangered; c. The resident's health improves sufficiently to allow a more immediate transfer or discharge; d. An immediate transfer or discharge is required by the resident's urgent medical needs; e. The resident has not resided in the facility for thirty (30) days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 6 residents (Resident #1) reviewed for a clean and homelike environment. The facility failed to ensure Resident #1's urinal was emptied appropriately on 09/04/24. This failure placed residents at risk of decreased feelings of self-worth and a diminished quality of life. Findings included: A record review of Resident #1's face sheet dated 09/04/24 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnoses included personal history of traumatic brain injury (someone who had a previous traumatic brain injury), muscle wasting and atrophy (loss of muscle tissue), major depressive disorder (persistent low mood and loss of interest in activities that people enjoy), epileptic seizures (a sudden burst of electrical activity in the brain that cause symptoms such as jerking and shaking), primary essential hypertension (high blood pressure that doesn't have a known secondary cause), and muscle weakness (loss of muscle strength). A record review of Resident #1's Quarterly MDS assessment, dated 08/12/24, reflected Resident #1 had a BIMS score of 13, which indicated cognitively intact. Resident #1's Quarterly MDS Section GG Functional Abilities and Goals reflected that Resident #1 required substantial/maximal assistance in the area of toileting hygiene and partial moderate assistance in the areas of eating, oral hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. A record review of Resident #1's care plan, dated 09/04/24, reflected Resident #1 was care planned for ADL self-care performance deficit r/t disease process TBI, limited physical mobility r/t TBI, and impaired cognitive function/dementia or impaired thought process r/t neurological symptoms. During an observation on 09/04/24 at 9:20am, Resident #1's urinal had yellowish liquid in it that appeared to be urine. During an observation on 09/04/24 at 11:28am, Resident #1's urinal appeared to have yellowish liquid in it that appeared to be urine. During an observation on 09/04/24 at 1248pm, Resident #1's urinal appeared to have yellowish liquid in it that appeared to be urine. During an observation on 09/04/24 at 2:42pm, Resident #1's urinal appeared to have yellowish liquid in it that appeared to be urine. During an interview on 09/04/24 at 9:20am, Resident #1 stated that the urinal had been on his nightstand for a long time. Resident #1 stated the CNAs only empty his urinal during the night shift. Resident #1 stated that his urinal was not emptied the night before. During an interview on 09/04/23 at 1:00pm, LVN A stated that CNAs should make rounds at least every two hours. LVN A stated that CNAs should be looking to see if a resident needs assistance, ensuring call lights were within reach, and making sure all residents were comfortable. LVN A stated that it's anyone's responsibility that walked into the resident's room to ensure that the urinal was emptied appropriately. LVN A stated that if a resident's urinal was not emptied appropriately then that would be a resident's rights issue, the resident's room would have a foul smell, or the resident could knock over the urinal creating a slippery floor. During an interview on 09/04/23 at 3:30pm, the DON stated that CNAs should ensure that the resident's urinals have been emptied when rounds were made. The DON stated anyone who entered the resident's room should ensure the resident's urinal was emptied appropriately. The DON stated if a resident's urinal was not emptied appropriately that would be a resident's right violation, and an infection control issue. During an interview on 09/04/23 at 4:00pm, the ADM stated that CNAs should ensure that the resident's urinals have been emptied when rounds were made. The ADM stated anyone who entered the resident's room should ensure the resident's urinal was emptied appropriately. The ADM stated if a resident's urinal was not emptied appropriately that would be a resident's right violation, there would be an odor from the urinal, and an infection control issue. Review of the facility's Bedpan/Urinal, Offering/Removing policy, revised February 2018, reflected, Purpose: The purpose of the procedure is to provide the resident with bedpan and/or a urinal assistance. Preparation 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. General Guidelines 1. Check to see if the resident is on intake and output before discarding the urine and feces. 2. Do not allow the resident to sit on a bedpan for extended periods. This is not only uncomfortable to the resident, it also causes skin breakdown. 3. If the resident prefers to keep a urinal at his bedside, check if frequently. Empty and clean it as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the communication system which allows residents to call for staff assistance was within reach for 5 (Resident #4, Resident # 21, Resident # 31, Resident #26, and Resident #20) out of 17 residents reviewed for call system placement. The facility failed to ensure Resident #4, Resident #21, Resident #31, Resident #26 and Resident #20's call light was within reach. The failure could place residents at risk for being unable to call for assistance from staff. Findings include: Review of Resident #4's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of hemiplegia (paralysis or severe weakness in one side of the body) and cerebral infarction (stroke). Review of Resident #4's Optional MDS, dated [DATE], reflected a BIMS score of 11 indicating moderate cognitive impairment. MDS further reflected resident required substantial assistance with sitting on side of bed and transferring to the toilet. Review of Resident #4's Care Plan, dated 05/13/2024, reflected resident requires staff assistance for meeting needs. Care plan reflected resident had an ADL self-care performance deficit and required extensive 2-person transfer and dependence for toileting needs. Interventions included to encourage resident to use call bell to call for assistance. Observation and interview on 08/20/2024 at 09:15 AM, revealed Resident #4 lying in bed by the window with the call bell hanging from the back wall out of the resident's reach. Resident #4 stated he did not know where the call bell was and shrugged his shoulders when asked further questions. 2. Review of Resident #21 face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), personal history of traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head), an anxiety disorder (feelings of worry, anxiety or fear). Review of Resident #21's MDS, dated [DATE], reflected a BIMS score of 13 indicating resident was cognitively intact. MDS further reflected resident required moderate assistance with eating and substantial assistance with toileting. Review of Resident #21's Care Plan, dated 05/13/2024, reflected resident had an ADL self-care performance deficit and required assistance with transfers, eating and toileting. Interventions included to encourage resident to use call bell to call for assistance. Observation and interview on 08/20/2024 at 09:45 AM, revealed Resident #21 sitting in wheelchair alone in his room with call bell hanging against back wall and behind furniture. Resident #21 stated he did not know where the call bell was and that he never uses it. He stated he goes out of the room to get someone if he needs something. 3. Review of Resident #31's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with readmission on [DATE] with diagnoses of nontraumatic intracerebral hemorrhage (bleeding in the brain that occurs without surgery or trauma), encephalopathy (brain disease that alters brain function), hemiplegia and hemiparesis (weakness and paralysis on one side of the body). Review of Resident #31's MDS, dated [DATE], reflected a BIMS score of 03 indicating severe cognitive impairment. MDS reflected resident was dependent on staff for toileting and hygiene needs. Review of Resident #31's care plan, dated 07/08/2024, reflected resident had an ADL self-care performance deficit and required assistance with transfers, eating and toileting. Interventions included to encourage resident to use call bell to call for assistance. Observation and interview on 08/20/2024 at 10:00 AM, revealed Resident #31 alone in the room, lying in bed with the call bell draped across the chair on the other side of the room. Resident # 31 was difficult to understand but stated he did not know about his call bell. 4. Review of Resident #26's face sheet reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of metabolic encephalopathy (brain dysfunction caused by a chemical imbalance in the blood from an underlying condition that affects metabolism), Alzheimer's disease (progressive disease that destroys memory and other mental functions), and transient cerebral ischemic attack (mini stroke). Review of Resident #26's MDS, dated [DATE], reflected a BIMS of 10 indicating moderate cognitive impairment. MDS indicated resident required moderate assistance with toileting and showering. Review of Resident #26's Care Plan, dated 07/09/2024, reflected resident had an ADL self-care performance deficit and required assistance with transfers, eating and toileting. Interventions included to encourage resident to use call bell to call for assistance. Observation and interview on 08/20/2024 at 10:15 AM, revealed Resident # 26 alone in room lying in bed by the window with the call bell across the room out of reach. Resident #26 stated he never has a call bell where he can reach it. 5. Review of Resident #20's face sheet reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (progressive disease that destroys memory and other mental functions), Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and Dementia (impairment of brain functions such as memory loss and judgement). Review of Resident #20's MDS, dated [DATE], reflected a BIMS of 04 indicating severe cognitive impairment. MDS reflected resident required supervision with toileting and shower. Review of Resident #20's Care Plan, dated 06/09/2024 reflected resident had an ADL self-care performance deficit and required assistance with toileting and supervision/setup with eating and transfers. Interventions included to encourage resident to use call bell to call for assistance. Observation on 08/2024 at 11:00 AM, revealed Resident #20 resting in bed with her call bell out of reach, hanging from back wall onto the floor. Resident was not interviewable. In an interview on 08/22/2024 at 3:51 PM, CNA C stated it was the nursing staff's responsibility to ensure the residents call bell was within reach or it could place the resident at risk for falls. She stated the nurses at the nurses station would only be able to hear some of the residents if they were to cry out for help. In an interview on 08/22/2024 at 4:10 PM, LVN A stated it was everyone's responsibility to ensure the call bells are within the residents reach and to tell the residents to call if they need anything. She stated a resident could fall while trying to get up and reach the call bell. She stated the nurses at the nurse station would only be able to hear some residents if they were to holler for help. In an interview on 08/22/2024 at 5:30 PM, Interim DON stated the call bells should be within reach at all times. She stated the staff have received in-services on call bells and she has started making rounds in the facility to monitor compliance. She stated when the call bell is not within reach it places the resident at risk for injury and not being able to get what they need. Review of in-service training, dated 03/27/2024, reflected call lights are everyone's responsibility and something anyone can help with. The training reflected the staff are to make sure call bells are within reach every time the staff enter and exit the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 4 of 8 (Resident #12, Resident #18, Resident #25, and Resident #28) residents reviewed for ADL care. 1. The facility failed to ensure Resident # 12, Resident #18, Resident #25, and Resident #28 nails were cleaned and did not have any rough edges. These failures placed residents at risk of a decline in their hygiene, loss of dignity and decreased quality of life. Findings included: 1. Record review of Resident # 12's Face Sheet dated, 08/22/2024, reflected a [AGE] year-old male admitted on [DATE] with diagnoses of type 2 diabetes mellitus without complications (high levels of blood glucose can damage the blood vessels and nerves that control the heart), lack of coordination (a problem with movement that can manifest in a variety of ways, such as difficulty with fine motor skills), anxiety disorder (worry endlessly over everyday issues such as health, money, family problems-even if the person realizes there's little cause for concern). Record review of Resident #12's Quarterly MDS Assessment, dated 07/19/2024, reflected the resident had a BIMS score of 07 indicated his cognition was severely impaired. Resident #12 required assistance with personal hygiene, dressing, transfers, and showers/bathing. Resident #12 had a behavior problem of picking at skin on his hand. Record review of Resident #12's Comprehensive Care Plan, dated 08/14/2024 reflected Resident #12 had an ADL self-care performance deficit. Intervention: Resident required assistance with personal hygiene, dressing, transfers, bed mobility, and toileting. Observation on 08/20/2023 at 10:50 AM, Resident # 12's nails was rough around the edges on his right hand. He also had blackish substance underneath his nails on his middle and ring fingers on his right hand. Resident was sitting in wheelchair in his room. There was an odor of feces on residents' fingers. In an interview on 08/20/3034 at 10:53 AM, Resident #12 stated he sometimes scratched his bottom at night and he got poop ( a word for feces) on my fingers. He stated he asked someone to clean it last night and the lady said she would come back and clean his fingers. Resident #12 said no one came back to his room. He did not respond to questions about his fingernails being rough around the edges. 2. Record review of Resident # 18's Face Sheet dated, 08/22/2024, reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] diagnoses of : type two diabetes mellitus without complications (high levels of blood glucose can damage the blood vessels and nerves that control the heart), muscle weakness- generalized (loss of muscle strength), combined forms of age-related cataract, bilateral ( when the lens in both eyes becomes cloudy from age, injury or disease), other lack of coordination (a problem with movement that can manifest in a variety of ways, such as difficulty with fine motor skills), hemiplegia , unspecified affecting left non dominant side ( left side paralysis- the loss ability to move). Record review of Resident #18's Quarterly MDS Assessment, dated 07/18/2024, reflected Resident #18 had a BIMS score of 10 indicated her cognition was moderately impaired. She required assistance from staff with personal hygiene, dressing, transfers, eating and bathing. Record review of Resident #18's Comprehensive Care Plan, dated 07/31/2024, reflected Resident #18 wished to have long fingernails. Intervention: keep fingernails smooth and clean. Monitor for any skin impairments related to long fingernails. Resident #18 makes poor safety choices. Intervention: Attempt to monitor Resident #18 in regard to safety choices that place resident at risk. Educate Resident #18 on risks associated with poor safety choices. Resident #18 had an ADL self-care performance deficit. Intervention: Resident #18 was dependent on staff for personal hygiene. Observation on 08/20/2024 at 11:15 AM, Resident #18 was in her room sitting in wheelchair. Resident #18 nails were approximately 1-2 inches long on both hands. Resident #18's left hand had nails on her ring finger, middle finger, and fore finger rough around the edges. In an interview on 08/202/2024 at 11:17 AM, Resident #18 stated she preferred her nails long but wanted her nails to be filed so they would not be so uneven and rough. She stated she always had a lot of pride in her fingernails and loved them long but did not prefer them to be unkept with not being filed. Resident #18 stated she was not able to file her nails any longer. She stated she asked someone on Saturday and on Sunday to file her nails and both of the ladies that worked at this facility told her that was not their job she would need to speak to the person who does activities she was the only staff that filed nails. Resident #18 stated she scratched her arm a little with one of her nails as she pointed to her right arm. Observed on 08/20/2024 at 11:19 AM, Resident #18's right arm and there was a small scratch, however, it was not a skin tear. 3. Record review of Resident #25's Face Sheet, dated 06/17/2024, reflected a [AGE] year-old male admitted on [DATE] with a diagnoses of lack of coordination (a problem with movement that can manifest in a variety of ways, such as difficulty with fine motor skills), age-related physical debility ( frail patients often present with symptoms including weakness, fatigue, medical complexity, and reduced tolerance to medical and surgical interventions), muscle weakness (loss of muscle strength), muscle wasting and atrophy, not elsewhere classified, other site ( muscle atrophy - the wasting or thinning of muscle mass, muscle wasting- weakening, shrinking, and loss of muscle caused by disease or lack of use), and anxiety disorder due to known physiological condition ( when anxiety symptoms (startle easily and can't relax) are a direct result of a physical health problem). Record review of Resident #25's admission MDS Assessment, dated 06/21/2024, reflected Resident #25 had a BIMS score of 9 indicated Resident cognition was moderately impaired. He required assistance with personal hygiene, showers, dressing and toileting hygiene. Record review of Resident #25's Comprehensive Care Plan, dated 07/12/2024, reflected Resident #25 had an ADL self-care performance deficit. Intervention: Resident #25 required assistance with personal hygiene, toileting hygiene, showers, and dressing. Resident #25 was resistive to care related to anxiety (startle easily and can't relax) he will refuse turning and repositioning and repositioning to offload areas and therapy participation sometimes. Intervention: Allow Resident #25 to make decisions about treatment regimen, to provide sense of control. Resident #25 had a communication problem related to aphasia ( a language disorder that affects a person's ability to understand and express language, including reading and writing). Resident #25 had a mood problem anxiety related to disease process of CVA ( a medical conditions that occurs when blood flow to the brain is suddenly cut off - this diagnosis was not listed on the face sheet) Intervention: Monitor/record/ report to medical doctor as needed acute episode feelings or sadness; feelings of worthlessness or guilt or change in psychomotor (movement-oriented activities that require practice and involved characteristics such as coordination, strength, speed and flexibility). Observation on 08/20/2024 at 11:30 AM, Resident #25 was lying in bed. His nails were approximately three inches long on all fingers on both hands. All of his fingernails on the left hand were rough around the edges. His right hand had blackish substance of a bowel movement (the process of moving waste through the intestines after eating or drinking) odor. There was a blackish substance on the tips of his middle and forefinger on his right hand. Resident #25 had a blackish substance underneath his nails on his fore finger, middle finger, and ring finger of the right hand. Attempted interview on 08/20/2024 at 11:34 AM, Resident #25 did not want to be interviewed. Attempted interview on 08/20/2024 at 3:05 PM, Resident #25 did not want to be interviewed. 4. Record review of Resident # 28's Face Sheet, dated, 08/22/2024, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of type 2 diabetes mellitus without complications (high levels of blood glucose can damage the blood vessels and nerves that control the heart), lack of coordination (a problem with movement that can manifest in a variety of ways, such as difficulty with fine motor skills), muscle weakness (loss of muscle strength), muscle wasting and atrophy, not elsewhere classified, other site ( muscle atrophy - the wasting or thinning of muscle mass, muscle wasting- weakening, shrinking, and loss of muscle caused by disease or lack of use), unspecified dementia, unspecified severity, with anxiety ( a condition in which a person loses the ability to think and solve problems. Unspecified severity- a medical classification for dementia that does not have a specific diagnosis and does not have a specified severity. Anxiety with dementia- often related directly to worries about coping with the condition and what the future holds). Record review of Resident #28's admission MDS Assessment, dated 07/27/2024, reflected Resident #28 had a BIMS score of 6 indicated his cognitive status is severely impaired. He required assistance with bathing, dressing, personal hygiene, and transfers. Record review of Resident #28's Comprehensive Care Plan, dated 08/14/2024, reflected Resident #28 needed had an ADL self-care performance deficit. Intervention: Resident #25 required assistance with personal hygiene, toileting hygiene, showers, and dressing. Observation on 8/20/2024 at 1:03 PM, reflected Resident # 28 was sitting in his wheelchair in his room. He had approximately 2-3 inches of long nails on his right and left hand. Resident #28's forefinger nail had a sharp nail only in the corner of the finger on his left hand. Resident #28's ring finger, thumb, small finger, and middle fingernails on his left hand was rough around the edges. Resident #28 had a very long nail approximately 4 inches long on his right hand. Resident #28 right hand had a sharp nail and rough around the edges in the corner of his ring finger. His right-hand fingernails on his middle finger and fore finger had a blackish substance underneath these nails. There was an odor of bowel movement (the process of moving waste through the intestines after eating or drinking) odor. In an interview on 08/20/2024 at 1:06 PM Resident #28 stated when he nails gets long and he can not find anyone to cut his nails, he will bend his nails until they break. He stated that is why you see that sharp nails in the corners. Resident #28 also stated when he bends his nails they don't break smoothly and causes a sharp point on some of his nails. He stated if someone does not want to cut his nails he will do it himself. Resident #28 stated he was a diabetic (high levels of blood glucose can damage the blood vessels and nerves that control the heart), and he knew his nails may become infected if his nails was not cut properly. Resident #28 stated he did have to use the bathroom last night and did have poop (a slang word for feces- waste matter from the bowels after food had been digested) to come out his bottom. Resident #28 stated he did scratch his bottom and got poop on his hands and he tried to get most of it off his hand (he raised his right hand when he was discussing where the poop was located). In an interview on 08/22/2024 at 1:30 PM, ADON G stated if a resident had rough edges around the nail there was a possibility the resident may scratch themselves or someone else and develop a skin tear. She stated if a resident ingested blackish substance on their fingers or underneath their fingernails, there was a possibility the substance may be some type of bacteria. She stated a resident may develop a stomach illness with symptoms of diarrhea and vomiting. ADON G stated it was according to what the bacteria was to determine if a resident would become ill. ADON G stated the nurses completed all nail care for residents with a diagnosis of diabetes (high levels of blood glucose can damage the blood vessels and nerves that control the heart). She stated if a staff was not certain if they were to file someone nails the staff was expected to ask their nurse supervisor. ADON G stated all residents was expected to receive nail care during showers and as needed. She stated it was the nurse supervisor responsibility to monitor nail care. ADON G stated she would need to review the electronic medical record to determine if any residents refused nail care. In an interview on 08/22/2024 at 4:45 PM, CNA K stated the nurses completed all diabetic (high levels of blood glucose can damage the blood vessels and nerves that control the heart) fingernails and the CNAs were responsible for all other residents' nails. CNA K stated the CNAs were responsible to complete nail care such as trimming, filing, and cleaning the nails during showers and as needed. CNA K stated if a resident had blackish substance underneath their nails, it was probably some type of bacteria such as bowel movements (the process of moving waste through the intestines after eating or drinking). She stated if a resident swallowed bacteria it was a potential the resident may become ill and may develop major stomach problems such as diarrhea or vomiting. CNA K stated if a resident became severely ill the resident may need to be transferred to emergency room for more care. She stated she worked with Resident #12, Resident #18, Resident #25, and Resident #28. CNA K stated the only resident she knew resisted care was Resident #25. CNA K stated Resident #25 resisted being turned or repositioned she was not aware of him refusing nail care. and Resident #31, and she was not aware of them refusing nail care. She stated if a resident's nails were rough around the edges there was a possibility the resident may scratch themselves and develop a skin tear, or possibly scratch their eye and cause a tear on their eyeball. CNA K stated she had been in-service on nail care but did not remember the date of the in-service. In an interview on 08/22/2024 at 5:05 PM, CNA C stated the CNAs was responsible for cleaning, trimming, and filing all residents' nails except for the residents with diagnosis of diabetes (high levels of blood glucose can damage the blood vessels and nerves that control the heart) and the nurses was responsible for residents with diabetes. CNA C stated the nurses was responsible for all residents' nails with diagnosis of diabetes. CNA C stated if a resident had a rough nails or their nails were dirty, nail care was expected to be completed as needed. CNA C stated if a resident nails was rough around the edges there was a possibility a resident may scratch themselves or another resident. CNA C stated the scratch may develop into a skin tear. CNA C stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill with stomach issues such as vomiting. She stated she worked at this facility as needed. CNA C also stated she had given care to Resident # 28, Resident #12, Resident #18, and Resident #25. She stated she was not aware of any of these residents refusing nail care. She stated she had been in-serviced on nail care but did not recall the date. In an interview on 08/22/2024 at 5:35 PM, LVN A stated the nurses and the CNAs were responsible for nail care. She stated the nurses were responsible to trim and clean all resident's nails with a diagnosis of diabetes (high levels of blood glucose can damage the blood vessels and nerves that control the heart). LVN A stated it was the CNAs responsibility to clean and trim all other residents' nails. She stated she was not aware of Resident #10, Resident #28, Resident #12 or Resident #25 refused nail care. She stated Resident # 25 would refuse to be turned or off load his heels but not nail care. LVN A stated if there was a blackish substance underneath the residents' nails, there was a possibility the substance had bacteria underneath the residents' nails. She stated if a resident swallowed the bacteria there was a possibility a resident may become extremely ill with stomach issues such as diarrhea and vomiting. LVN A stated if a resident scratched themselves with rough nails there was a potential a resident may develop a skin tear and there was a possibility the resident may scratch another resident and cause a skin tear on another resident. She stated she had been in-serviced on nail care but did not recall the date of the in-service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored, individual activities, independent activities, designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident , encouraging both independence and interaction in the community for 3 of 8 residents ( Resident #10, Resident #19, and Resident #25) reviewed for activities. The facility failed to develop an activity program based on preferences of Resident #10, Resident #19, Resident #25 during the months of July to August 2024. These failures placed residents at risk of boredom, depression, increased behaviors, and diminished quality of life. Findings include: 1. Record review of Resident #10's Face Sheet, dated 08/22/2024, reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis depression unspecified (used when a person's symptoms do not clearly align with a specific mental disorder or where there is insufficient information for a more definitive diagnosis), other secondary parkinsonism ( caused by brain injuries or brain disorders), and cognitive communication deficit (can effect both verbal and nonverbal communication, such as speaking, listening, reading, writing, and social interaction skills). Record review of Resident #10's Annual MDS Assessment, dated 01/30/2024, reflected Resident #10 was rarely/never understood. She had poor short (unable to recall after 5 minutes and long (unable to recall long past memories) term memory recall. Resident #10 does not have speech (absence of spoken words). Resident #10 activity preferences was listening to music and participating in religious activities or practices. Record review of Resident #10s Quarterly MDS Assessment, dated 07/30/2024, reflected Resident #10 had poor short (unable to recall events after 5 minutes) and long-term memory recall (unable to recall past events). Resident #10 was rarely/ never understood or rarely/never understands others. Record review of Resident 10's Comprehensive Care Plan, dated 08/14/2024, reflected Resident #10 required staff assistance for meeting emotional, intellectual, physical, and social needs related to disease process and immobility. Intervention: Resident #10 needed in-room visits and activities. Record review of Resident #10's in room activity participation record in the electronic medical record reflected Resident #10 did not have any documentation of receiving in room activities or attending group activities. The record review was completed with the Activity Director M. She stated she did not have any participation records on Resident #10. Observation on 8/20/2024 at 10:31 AM. Resident #10 was sitting in the lobby asleep. Observation on 08/20/2024 at 4:00 PM, Resident #10 was in bed. Her door to her room was slightly opened. Resident #10 was awake there was no lights on in her room. Television was not on and did not observe any radio in her room which music was her favorite activity. Resident #10's room was dark and she was moving her eyes side to side. Resident had sad expression (forehead wrinkled and eyebrows were brought together -signs of sad expression). In an interview on 8/20/2024 at 4:05 AM, Resident #10 was not interview able. Observation on 08/21/2024 at 7:45 AM, Resident #10 was in bed. Her door to her room was slightly opened. Resident #10 was awake and there were no lights on in her room and no stimulation such as a radio in her room which is her favorite activity listening to music. Resident #10 did not have television on in room. In an interview on 8/21/2024 at 8:15 AM, Activity Director M stated she did not have any in room or group participation records for the month of July 2024 and August 2024 for Resident #10. She stated she would print all of the in-room participation records for the months of July 2024 and August 2024 In an interview on 08/21/2024 at 8:45 AM, Activity Director M stated after the activity in room participation records were printed Resident #10 did not have any in room or group participation records for the months of July 2024 or August 2024. She stated she did not know if she received in room activities or attended group activities during the months of July 2024 and August 2024. Activity Director M stated if a resident had a diagnosis of depression and was not physically able to do activities without assist from another person, there was a possibility Resident # 10 may become more depressed and may become very lonely. She stated Resident #10 quality of life may decrease. She stated Resident #10 does sit in the lobby but sleeps most of the time and she was not receiving any activities in the lobby. She stated it was her responsibility to ensure all residents received activities according to their past and current interest. 2. Record review of Resident #19's Face Sheet, dated 08/22/2024, reflected a 94- year-old female admitted to the facility on [DATE] with diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a condition in which a person loses the ability to think and solve problems. Unspecified severity- a medical classification for dementia that does not have a specific diagnosis and does not have a specified severity), major depressive disorder ( feelings of guilt or worthlessness, lack of energy, agitation ( unable to stay calm) and /or sleep disturbances), and unspecified glaucoma (a group of eye diseases that cause increased pressure in the eye, which can damage vision). Record review of Resident #19's admission MDS Assessment, dated 10/18/2024, reflected Resident #19 had a BIMS score of a 15 indicated her cognition was intact. Resident #19's activity preferences were the following: go outside and get fresh air when weather permitted, participate in religious services or practices, listen to music, reading such as: books, newspapers, and magazines. Participating in groups activities was not very important to Resident #19. Record review of Resident #19's Quarterly MDS Assessment, dated 07/17/2024, reflected Resident #19 had a BIMS score of 15 indicated her cognition was intact. Resident #19 had moderately impaired vision- not able to see newspaper headlines but can identify objects. She was assessed to feel down, depressed, or hopeless. Resident #19 also felt tired and bad about herself, had difficulty concentrating on things such as: reading or watching television. Record review of Resident #19's Comprehensive Care Plan, dated 07/31/2024, reflected Resident #19 required staff assistance for meeting emotional, intellectual, physical, and social needs related to immobility. Intervention Resident #19 needed in room visits and activities if unable to attend out of room events. Resident was resistive to care related to adjustment to nursing home and dementia (a condition in which a person loses the ability to think and solve problems). Resident #19 refused to get out of bed. Intervention: All Resident #10 to make decisions about treatment regime, to provide sense of control. Resident #19 had impaired cognitive function/dementia (a condition in which a person loses the ability to think and solve problems). Intervention: Reminisce with Resident #19 using photos of family and friends. Observation on 8/20/2024 at 11:30 AM, Resident #19 was in her room lying in bed. The door to her room was barely opened and she did not have television on and did not see a radio or other stimulation in her room. Resident #19 had sad expression on her face such as (forehead wrinkled, and eyebrows were brought together -signs of sad expression). Resident #19 was staring toward the ceiling. In an interview on 08/202/2024 at 11:33 AM, Resident #19 stated she was lonely and there was not anything for her to do except watch television and she was tired of television. She stated she did not receive in room visits or activities from anyone and she did not know what in room visits or in room activities was until now. Resident #19 stated she never heard of in room activities. Resident #19 stated she did not prefer to attend group activities it made her feel uncomfortable being around others in a group. She stated if someone would just bring her a radio or something for her to listen to music. Resident #19 stated she loved Gospel music and liked country music. She stated if there was gospel or country music on television she never knew about it or ever saw it on television. Resident #19 stated music was her favorite thing to do. She stated she never liked to read very much due to her vision. Resident #19 stated her neighbor had books on tape and her neighbor would listen to different types of books. Resident #19 stated she might enjoy listening to books but she would need to try it before she made decision if she liked to listen to books. Resident #19 stated no one had ever offered her anything to read and with her poor vision it would need to be very large print. Resident #19 stated she did like to go outside in the spring and fall sometimes. She stated she did not recall anyone assisting her to sit outside. Resident #19 stated that would be nice sometimes not every day or every week but maybe once or twice a month when weather was cooler. She stated she did like to listen to devotionals. She stated it would be nice if someone read the bible to her or a devotional to her once a week. Resident #19 stated there is never anything to do and no one comes by and will sit and talk to me. She stated do you think you can talk to someone and ask them if they would visit with me sometimes and bring me something to do instead of watching television all the time. In an interview on 08/21/2024 at 8:15 AM, Activity Director M stated Resident #19 was not on the in-room activity program. She stated she did not realize Resident #19 was not getting out of bed very often. The Activity Director M stated she did not have any participation records for Resident #19 during months of July 2024 and August 2024. She stated she had not been reminiscing using photos of Resident #19's family and friends. Activity Director M stated if Resident #19 did not want to attend group activities she needed to be receiving in room activities. Activity Director M stated she did not realize it was on Resident #19's care plan she was to receive in room activities reminiscing about family or friends' photos. She stated Resident #19 had a potential of becoming bored and depressed if she was not doing the activities she preferred or not doing any type of activities in her room. Activity Director M stated she had not been offering her large print books to read, books on tape or a radios. She stated if music, religious activities and going outside was her favorite activities these type of activities was expected to be provide to Resident #19. She stated it was her responsibility to ensure all residents received activities according to their past and current interest. 3. Record review of Resident #25's Face Sheet, dated 06/17/2024, reflected a [AGE] year-old male admitted on [DATE] with a diagnoses of lack of coordination (a problem with movement that can manifest in a variety of ways, such as difficulty with fine motor skills), age-related physical debility ( frail patients often present with symptoms including weakness, fatigue, medical complexity, and reduced tolerance to medical and surgical interventions), muscle weakness (loss of muscle strength), muscle wasting and atrophy, not elsewhere classified, other site ( muscle atrophy - the wasting or thinning of muscle mass, muscle wasting- weakening, shrinking, and loss of muscle caused by disease or lack of use), and anxiety disorder due to known physiological condition ( when anxiety symptoms (startle easily and can't relax) are a direct result of a physical health problem). Record review of Resident #25's admission MDS Assessment, dated 06/21/2024, reflected Resident #25 had a BIMS score of 9 indicated Resident cognition was moderately impaired. Resident#25's activity preference was the following: have books, newspaper, and magazines to read, listen to music, watching news, go outside to get fresh air when the weather was good, and participating in religious services or practices. Record review of Resident #25's Comprehensive Care Plan, dated 07/12/2024, reflected Resident #25 had a mood problem anxiety related to disease process of CVA ( a medical conditions that occurs when blood flow to the brain is suddenly cut off - this diagnosis was not listed on the face sheet) Intervention: Monitor/record/ report to medical doctor as needed acute episode feelings or sadness; feelings of worthlessness or guilt or change in psychomotor (movement-oriented activities that require practice and involved characteristics such as coordination, strength, speed and flexibility). Resident # 25 had impaired cognitive function/dementia or impaired thought process (a condition in which a person loses the ability to think and solve problems). Intervention Reminisce with Resident #25 using photos of family and friends. Observation on 08/20/2024 at 11:30 AM, Resident #25 was lying in bed. The lights were off in his room and the door was slightly open leading into his room. He did not want to discuss anything about his nails. He made eye contact with Surveyor O when mentioned in room activities or in room visits. Resident #25 also clinched his mouth / jaw (sign of stress) when surveyor O mentioned if he received in room visits talking about pictures of his family and friends. Resident #25 did not have any stimulation in his room. Interview on 08/20/2024 at 11:34 AM, Resident #25 stated no when asked if he received activities or visits in his room showing him pictures of his family and friends. Resident #25 stated no when asked if he liked to do anything with a group of people. In an interview on 08/21/2024 at 8:15 AM, Activity Director M stated Resident #25 was on the in-room activity program due to Resident #25 did not attend group activities. She stated her schedule was to visit all in room residents Monday to Friday in the morning. Activity Director M stated according to Resident #25's participation records he only received two in room activities during the month of July 2024 and did not receive any in room activities during month of August 2024. She stated Resident #25 had a potential of becoming depressed, lonely and may have a decrease of quality of life. She stated she had not reminisced with Resident #25 with photos of his family and friends. She stated Resident #25 was expected to receive in room visits/ activities Monday thru Friday. Activity Director M stated she did not have any excuse why she did not visit Resident #25 to provide in room activities/ visits. She stated it was her responsibility to ensure all residents received activities according to their past and current interest. In an interview on 08/22/2024 at 2:05 PM, the Administrator stated all activities including in room visits was expected to be documented on the date the activity occurred with the residents. She stated if the Activity Director M did not document any activities, the activity did not occur with the resident or residents. The Administrator stated a resident may become depressed, lonely and have a diminish quality of life if they were not receiving activities of their preferences on a daily or weekly basis. She stated she had been in this facility approximately two weeks and would definitely be making observations of the activity programming. Record review of the Facility's Policy on Activity Programs, revised on 06/2018, reflected activity programs are designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Activities offered are based on the comprehensive resident -centered assessment and the preferences of each resident. All activities are documented in the resident's medical record.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with profession standards for food safety for 1 of 1 kitchen reviewed for food and safety and sanitation. 1. The facility failed to appropriately thaw frozen meant defrost on 08/20/2024. 2. The facility failed to store boxes of food off the floor, ensure the floor of the refrigerator was free of debris in the walk- in refrigerator on 08/20/2024. 3. The facility failed to ensure Dietary Aide P washed or sanitized her hands prior to placing new gloves on her hands when she was giving a resident some zip lock bags on 08/21/2024. These failures placed residents at risk for health complications and foodborne illness. Findings included: Observation on 08/20/2024 at 9:05 AM, there was approximately 10 pound of frozen hamburger meat in a clear plastic round tube shape located in a pot sitting in the kitchen sink. The hamburger meat was not thawed and more than half was frozen. There was not any running water over the frozen hamburger meat. There was approximately half of the frozen hamburger meat not submerge in the water. Only half of the hamburger meat was submerged in the water. In an interview on 08/20/2024 at 9:08 AM, Dietary Aide P stated all the hamburger meat was required to be in the water to be defrosted. She stated running water was also expected to be running over the hamburger meat while it was being defrosted. Dietary Aide P stated she forgot to run the water over the hamburger meat and place the hamburger meat in a larger pot. Dietary Aide P stated she was in a hurry and forgot. She stated if the hamburger meat was not defrosted properly there was a possibility the hamburger meat may be ruined from being defrosted at room temperature. She stated it was a possibility a resident may become ill with stomach issues if the resident ate ruined meat. 2. Observation on 08/20/2204 at 9:13 AM, there were four boxes of food stacked on top of one another located in the walk-in refrigerator floor. There were also some paper napkins on the floor and one was stuck to the surveyors shoe. In the corner of the walk-in refrigerator was some type of crumbled food. 3. Observation on 08/22/2024 at 11: 15 AM, Dietary Aide P removed gloves from her hand and placed them in garbage can. She did not wash or sanitize hands after removing the gloves. Dietary Aide P touched her clothes and picked up 2 new gloves from the glove container. She touched the outside of the gloves such as fourchettes (slender pieces of fabric or rubber that forms the sides of the finger). Dietary Aide P placed the gloves on her hands and picked up approximately 3 zip plastic bags and placed her fingers inside two of the plastic bags and gave it to a resident. Interview on 08/22/2024 at 11:20 AM, Dietary P stated she did touch her shirt after she removed her gloves. She stated she did not sanitize or wash her hands prior to placing new gloves on her hands. Dietary aide stated she did pick up the gloves where the fingers go inside the gloves. She stated she was expected to wash her hands prior to placing new gloves on her hands. Dietary Aide P stated she had been in-serviced on hand hygiene and wearing gloves when changing tasks or touching anything not sanitary. Interview on 08/22/2024 at 2:05 PM, the Administrator stated all boxes located in the walk-in refrigerator was expected to be on a crate or on the shelves. She stated no boxes was to be stored on the floor of the refrigerator. She stated the boxes may become damp and the food inside of the boxes had a potential of being wet or damp. She also stated it was a possibility of a safety hazard if the boxes were stacked on each other they could fall and injure a staff. The Administrator stated all frozen meat was required to be defrosted on a flat pan located in the refrigerator on the bottom shelf. She stated if the dietary staff was defrosting hamburger meat in the sink all of the hamburger meat was expected to be submerged in water with running water pouring over the frozen hamburger meat. She stated it was a possibility the meat may ruin if not defrosted correctly but there was a slight chance of this occurring when defrosting. The Administrator stated all staff was to wash and sanitize their hands when they removed gloves and prior to placing new gloves on their hands. She stated if the dietary aide P did not sanitize her hands and touched inside the zip plastic bags to give to a resident there was a possibility the bags could become cross contaminated. She stated there should not be any paper napkins on the floor in the walk-in refrigerator. The Administrator stated all areas of the kitchen including walk-in refrigerator was expected to be kept clean and organized. In an interview on 08/22/2024 at 3:45 PM, Dietary Manager L stated all meat was required to be defrosted either in the refrigerator on a flat pan located on the bottom shelf of the refrigerator or in the sink in a container with running water pouring over the meat. She stated the hamburger meat was to be submerged in the pot and be defrosted with running water over the entire hamburger meat. Dietary Manger L stated there was a possibility the portion of the hamburger meat not submerged in the water would not be defrosted correctly and may cause illness with a resident if the hamburger meat was ruined. She stated any time dietary staff removes their gloves they were expected to wash their hands immediately before doing any other type of task including placing new gloves on their hands. Dietary Manger L stated if Dietary Aide P touched the outside of the new gloves with her contaminated hands there was a possibility bacteria could cross contaminated inside of the plastic bags. She stated if the resident was placing food inside of those bags there was a potential where bacteria touch the food. Dietary Manger L stated if a resident ate contaminated food the resident may become sick with any type of stomach issues such as vomiting and diarrhea. She stated the boxes located in the walk-in refrigerator was not to be stored on the floor. She stated they were expected to be stored on pallets or on the shelves in the refrigerator. Dietary Manager L stated this had a potential of becoming a safety hazard due to the boxes was stacked on top of each other and if they feel a staff may become injured. She stated there should never been any type of napkins or paper on the floor in the walk-in refrigerator or anywhere in the kitchen. Dietary Manager L stated this was not sanitary. She stated there should never be any type of food on the refrigerator floor. She stated this was also not sanitary. Review of the facility policy on Food Preparation and Service, dated 10/2022, reflected Foods will not be thawed at room temperature. Thawing procedures include: a. Thawing in the refrigerator in a drip-proof container. b. Completely submerging the item in cold running water (70°F or below) that is running fast enough to agitate and remove loose ice particles. c. Thawing in a microwave oven and then cooking and serving immediately; or d. Thawing as part of a continuous cooking process Facility policy of Refrigerators and Freezers, dated 10/2022, reflected This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on scheduled basis and more often as necessary. Facility policy on Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices, reviewed 06/12/2024, reflected Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Employees must wash their hands during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or after engaging in other activities that contaminate the hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection and prevention control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 (Resident #1, Resident #11, Resident #28, Resident #4, and Resident #17) of 35 residents reviewed for infection control. 1. LVN B failed to clean the reusable blood pressure (BP) cuff between resident use. 2. LVN A failed to perform hand hygiene and clean the catheter tip before performing catheter irrigation for Resident #17's suprapubic catheter (a flexible tube that drains urine from the bladder through a small incision in the lower abdomen) 3. The facility failed to ensure LVN I sanitized or washed her hands after touching contaminated items when delivering meal trays to residents, when setting up Resident #1, Resident #11 and, Resident #28's meal trays and during feeding of Resident #11 on 08/20/2024. These failures could place residents at risk for cross contamination and infection. Findings include: 1. Review of Resident #4's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of hemiplegia (paralysis or severe weakness in one side of the body) and cerebral infarction (stroke). Review of Resident #4's Optional MDS, dated [DATE], reflected a BIMS score of 11 indicating moderate cognitive impairment. Review of Resident #4's Care Plan reflected resident requires staff assistance for meeting needs and has hypertension requiring BP monitoring and medication. Observation during med pass on 08/21/2024 at 08:30 AM, revealed LVN B checked the vital signs for Resident #6 and placed the BP cuff back on the medication cart without cleaning it. She then used the BP cuff to take vital signs for Resident #4 without cleaning the cuff first. In an interview on 08/21/2024 at 08:36 AM, LVN B stated she should have cleaned the BP machine in between resident use but didn't. She stated it is policy to clean it before and after use because of the germs and risk for infection. 2. Review of Resident #17's face sheet reflected an [AGE] year old male admitted to the facility on [DATE] and again on 09/02/2022 with diagnoses of incomplete quadriplegia ( paralysis that affects a person's limbs and body from the neck down), chronic obstructive pulmonary disease (a group of lung disease that blocks airflow and makes it difficult to breathe), and overactive bladder (a problem with bladder function that causes the sudden need to urinate). Review of Resident #17's care plan, dated 07/16/2024, reflected resident has a suprapubic catheter and foley care should be provided every shift and as needed. Review of Resident #17's orders, date 07/17/2024, reflected an order to flush the catheter with 120-180 milliliters of sterile water every other day. Observation on 08/21/2024 at 09:56 AM, during suprapubic catheter irrigation procedure for Resident #17 revealed LVN A sanitize her hands and don gloves and gown. She placed the irrigation tray and supplies on the bedside table, opened the kit and then disconnected the draining bag from Resident #17's catheter and handed it to the resident to hold. She then poured the sterile water into the container and drew up some in the syringe. She connected the syringe to the catheter without cleaning the catheter tip first. She then began attempting to flush the catheter. She was not able to flush the catheter and called for assistance. She then reconnected the old drainage bag to the catheter while waiting for assistance. In an interview on 08/21/2024 at 11:10 AM, LVN A stated she forgot to clean the catheter before and after she attempted irrigation and reconnected the old bag. She stated not cleaning her hands and the catheter before irrigation placed the resident at risk for bladder infection. In an interview on 08/22/2024 at 5:30 PM, the interim DON stated reusable medical equipment should be sanitized before every use to prevent the spread of infection. She stated she would expect staff to follow procedure for aseptic technique during catheter irrigation to prevent the spread of infection. In an interview on 08/22/2024 at 5:50 PM, the Administrator stated the BP cuff should be cleaned in between residents for infection control. She stated she is not a nurse but would expect staff to follow procedure for catheter flushing to prevent the resident from getting an infection. Review of facility policy for reusable medical equipment, dated 03/2023, reflected items that come in contact with intact skin but not mucous membranes, such as BP cuffs, should be cleaned and disinfected between residents. Review of facility policy for catheter care, dated March 2024, reflected staff should use aseptic technique when there is a break in the closed system and clean technique when handling the catheter, tubing, or drainage bag. The policy does not specifically address the procedure for catheter irrigation. 3. Observation on 09/20/2024 at 12:13 PM to 12:35 PM, reflected LVN I entered the dining room from the hall. She touched her clothes and moved her hair away from her face. LVN I began to speak to residents and touched the residents' clothes and wheelchair handles. She began to look at the meal trays on the meal tray cart. LVN I picked up one lid of a meal tray and touched the tines ( the pointed prongs that allow you to spear and pick up the food) of the fork of Resident #28's meal tray. LVN I delivered Resident #28's meal tray to him in the dining room and did not change his fork. LVN I returned to the meal tray cart and did not sanitize her hands. She had the meal tray and touched the dirty dishwasher doorknob to enter the dishwasher room and placed meal tray on top of dirty plates and the middle finger, forefinger and ring finger touched dirty dishes in the dishwasher room. She exited the dishwasher room and proceeded to the meal cart without sanitizing or washing her hands. She picked up a meal tray off the meal cart and delivered the meal tray to Resident #1. When LVN I sat the meal tray on the table in front of Resident #1 she opened the thickened liquid water and the top part of her middle finger and fore finger on her right hand touched inside the container and touched the thickened water. LVN J asked LVN I to go into the hall and sanitize her hands. LVN I did not go into the hall to sanitize her hands or attempt to wash her hands. LVN I continued to pass out meal trays. LVN I delivered Resident #11's meal tray to her. She touched resident's hand and her specialty chair. LVN I opened Resident #11's thickened liquid and her forefinger and middle finger touched the thickened liquid and when she removed the lid off of Resident #11's plate of food she touched the green beans. After setting up the meal tray LVN I sat in a chair to begin to feed Resident #11. LVN I was given hand sanitizer and did sanitize her hands prior to feeding Resident #11. During feeding Resident #11, LVN I touched with her fore finger, ring finger and middle finger on her right hand the following: the arms of the chair she was sitting in, touched her own clothes and touched Resident #11's Hoyer lift sling to reposition the sling in Resident #11's chair. She also touched Resident #11's right hand. LVN I did not re-sanitize or wash her hands. LVN I picked up Resident #11's napkin to wipe off Resident #11's mouth. When LVN I wiped Resident #11's mouth she touched the side of Resident #11's upper lip with her fore finger and middle finger on her right hand. LVN J was sanitizing her hands every time she touched the table, chair or any object may be considered contaminated. She was feeding Resident #3. In an interview on 08/20/2024 at 1:33 PM, LVN I stated she never sanitized her hands during the time she was passing out meal trays and setting up meal trays for the residents. LVN I stated she was expected to sanitize or wash her hands when passing out meal trays and when she was setting up meal trays for the residents. She stated she did not recall if she touched the tips of the fork, napkins, inside the thickened liquids container for Resident #1 and Resident #11. LVN I stated she did touch the door knob leading into the dishwashing room and she may have touched dirty dishes. She stated she did not recall touching her clothes, her hair, resident's wheelchair, or sling in Resident #11's specialty chair. She stated it was possible she did touch all of this but she was focused on delivering meal trays and feeding Resident #11 instead of what she was touching. LVN I stated it is impossible for staff to sanitize their hands if they touch anything may be contaminated. She stated the only time she sanitized her hands was when she sat on a chair to feed Resident #11. She stated she did touch arm of her chair; the sling Resident was sitting on in her specialty chair and possibly her own clothes. LVN I stated it is crazy to expect staff to sanitize their hands every time they touch an object that may be contaminated. She stated this was impossible. LVN I stated she did wipe Resident #11's mouth and she may have touched the side of her lip with her fingers. She stated if she had touched anything contaminated it was a possibility bacteria could cross contaminate onto the fluids, food, napkin, and Resident #11's mouth. LVN I stated she did not believe it was necessary to sanitize her hands every time she touched any type of object that may be contaminated. She stated staff would be sanitizing their hands every few seconds. LVN I stated she had been in-serviced on passing out meal trays and feeding the residents. She stated during in-service it was explained to wash or sanitize hands in between delivering meal trays to the residents and when feeding the residents. LVN I did not answer the question if a resident may become ill if they did ingest some type of bacteria that potentially transferred from her fingers or hands onto the resident's food or drink. In an interview on 08/20/2024 at 00:00, LVN J stated she did ask LVN I to sanitize her hands. She stated LVN I did not sanitize her hands when she was passing out meal trays and setting up meal trays for residents. LVN J stated all staff was expected to sanitize or wash hands during each meal tray delivered to a resident. LVN J stated all staff was to sanitize their hands when they touch their hair, clothes or any object that was considered contaminated. She stated they had been in-serviced on hand hygiene during dining room service. LVN J stated she did not recall the date of the in-service. She stated if a resident did swallow some type of bacteria the resident had a potential of becoming physically ill such as vomiting or diarrhea. In an interview on 08/22/2024 at 1:30 PM, ADON G stated all staff was expected to sanitize their hands prior to delivering meal trays and in between each meal tray delivered to a resident. She stated if staff touched any type of object such as doorknob, wheelchair, resident or staff clothes, hair, Hoyer sling, arms of a chair and/ or table, the staff was expected to sanitize or wash their hands after each contact with anything may be considered contaminated. ADON G stated if staff were not washing or sanitizing their hands during meal service and was touching residents' drinks, food or even plates it was a possibility bacteria may cross contaminate food, utensils such as fork and or the resident's plates. She stated if a resident ingested bacteria there was a possibility a resident may become sick with some type of food borne illness. She stated she had only been working at the facility about three weeks and she only knows about the in-services she had completed since she had been employed at this particular facility. In an interview with the Administrator on 8/22/2024 at 2:05 PM, she stated all staff was expected to wash or sanitize hands prior and in between each meal tray delivered to the residents. She stated the staff was expected to sanitize or wash hands whenever they became in contact with anything considered contaminated such as: hair, clothes, dirty dishes, wheelchair, arms of a chair, etc. The Administrator stated there was a potential a resident may develop a food borne illness if a resident's food or drink was cross contaminated by bacteria on a staff fingers or hands. She stated she began working at this facility approximately two weeks ago and she was trying to look at a lot of things and the in-services been given in the past she had not looked at the in-services at this time and could not answer if an in-service had been given on dining room hand hygiene. Review of facility policy for reusable medical equipment, dated 03/2023, reflected items that come in contact with intact skin but not mucous membranes, such as BP cuffs, should be cleaned and disinfected between residents. Review of facility policy for catheter care, dated March 2024, reflected staff should use aseptic technique when there is a break in the closed system and clean technique when handling the catheter, tubing, or drainage bag. The policy does not specifically address the procedure for catheter irrigation. Review of the Facility Policy of Hand Hygiene, revised on 10-2020 reflected This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall be trained on the importance of hand hygiene in preventing the transmission of healthcare- associated infections. Use and alcohol-based hand rub containing at least 62 % alcohol; or , alternatively, soap and water for the following situations: 1. Before and after direct contact with residents. 2. After direct contact with a resident's intact skin.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 5 residents (Resident #4, Resident #14, Resident #31, Resident # 9, and Resident #8) out of 10 resident rooms reviewed for environment. The facility failed to ensure walls and floors were clean and in good repair for Resident # 4, Resident #14, Resident #31, Resident #9, and Resident #8's room. This failure could affect all residents, staff, and the public by placing them at risk for diminished quality of life due to the lack of a well-kept environment. Findings include: Observation on 08/20/2024 at 03:10 PM in Resident # 4 and Resident # 14's room revealed large (approximately 2 ft) long holes in the wall behind Resident #14's bed. The bed was pushed up into the wall and there was a white powdery substance on the floor behind the bed. Observation in the room further revealed a cable outlet hanging from the wall next to the dresser. Behind Resident #4's bed there were holes in the wall, unable to see the size due to the bed. In an interview on 08/20/2024 at 03:10 PM, Resident # 4 stated he did not know about the holes behind the bed, but he knew about damaged wall where the cable outlet was. He stated it had been that way for a while. Resident #14 was not interview able. Observation on 08/20/2024 at 4:00 PM in Resident # 31's room revealed scratch marks and missing paint behind and next to the resident's bed. There was a brown substance on the floor and white debris on the floor. Observation on 08/20/2024 at 4:10 PM, in Resident # 8 and Resident #9's room revealed missing trim and paint under the windowsill with exposed drywall. Resident # 8's bed was up against the wall under the window with pillows and bedding by the damaged wall. Observation behind Resident #9's bed revealed the bed pushed up into the wall with damaged drywall and white debris/powder on the floor. In an interview on 08/20/2024 at 4:12 PM, Resident #9 stated she did not know about the holes behind her bed, but she knew they pushed the bed in the wall to get the door closed. In an interview on 08/22/2024 at 4:45 PM, Housekeeping supervisor D stated debris falls on the floor every time the bed hits the wall. She stated they do their best to keep the floors clean, but she needs assistance from the nursing staff to move the resident's bed out of the way because she cannot do it herself. She stated they clean the rooms and floors everyday and try to deep clean often. She stated they do not have a floor crew anymore and she does the best she can with the staff they do have. In an interview on 08/22/2024 at 5:00 PM, Maintenance supervisor E stated there have been damages to the walls since March of 2023. He stated he began working in the maintenance department in May of 2024 and started repairing the damaged walls using sheetrock that was previously ordered by someone else but realized it was the wrong material. He stated the administrator told him to hold off until they get the correct supplies. He stated the reason for the damaged walls was because there is no tolerance for door clearance if the bed is pulled away from the wall. He further stated the damaged walls were not homelike and could cause illness due to the drywall dust and could cause depression and make the residents feel unnoticed. He was not aware of the cable wire hanging from the wall and said he would take care of that immediately. In an interview on 08/22/2024 at 5:50 PM, the Administrator stated they were working on fixing the holes in the walls. She stated she contacted a maintenance person from another building to assist. She stated they plan to replace the drywall and place some type of bumper on the walls to prevent further damage. She stated she is unsure how long the holes have been there and did not realize how big they were. She stated maintenance was scheduled to come back this week but delayed due to the survey. She further stated the damaged walls could cause potential harm or risk to the resident from the drywall dust and possible pest problem from the holes. She stated the damages are not homelike. Regarding the dirty floors she stated she has spoken with housekeeping already and expects the floors to be cleaned every day. Review of facility Homelike Environment policy, dated February 2021, reflected residents are provided with a safe, clean, comfortable and homelike environment . the staff and management maximizes the characteristics of a homelike setting . including a clean, sanitary and orderly environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review the facility failed to ensure residents were free from physical and verbal abuse for one (Resident #1) of five residents reviewed for abuse. The facility failed to ensure Resident #1 was protected verbal abuse on 09/18/2023 when CNA H made a derogatory comment regarding Resident #1 within earshot of Resident #1 and failed to assess Resident #1's pain before adjusting her swollen leg. This failure could place residents at risk for injury, mental anguish, depression, intimidation, and a diminished quality of life. Findings included : Record review of Resident #1's face sheet, dated 09/22/2023, revealed Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses which included low back pain ( pain between the lower edge of the ribs), signs symptoms of musculoskeletal system ( mild to severe aches, low back pain, numbness, tingling, atrophy, and weakness), muscle weakness ( a lack of strength in the muscles), osteoporosis without current pathological fracture (generally caused by a fall from a standing height or lower and usually involves the spine, hip or wrist), lack of coordination (uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements) left foot drop ( caused by weakness of the muscles involved in lifting the front part of the foot) and, abnormalities of gait and mobility (when a person is unable to walk in the usually way). Record review of Resident #1's Annual MDS assessment, dated 07/28/2023, reflected Resident #1 had a BIMS score of fifteen, which indicated the residents' cognition was intact. Resident did not reject care. Resident #1 was assessed to require extensive assistance by two staff members for transfers. She required extensive assistance by one staff for bed mobility and toileting. Resident #1 was also assessed to require limited assistance by one staff for personal hygiene. She was assessed require staff to stabilize her when moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer. Resident #1 was on scheduled pain medication and PRN pain medication. She had frequent pain. Resident #1 did not exhibit any behaviors. Record review of Resident #1's Comprehensive Care Plan completed on 08/17/2023 reflected Resident #1 had an ADL self-care performance deficit. Interventions: resident required extensive assistance by two staff members. Resident #1 required extensive assistance by one staff members with bed mobility. Resident #1 was at risk for falls related to gait/balance problems. She had limited physical mobility. Resident had chronic pain related to osteoporosis (a condition when bone strength weakens) Interventions: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Identify and record previous pain history and management of that pain and impact of function. Identify previous response to analgesia including pain relief, side effects and impact on function. Monitor/ document for probable cause of each pian episode. Remove/limit causes where possible. Resident #1's further interventions were: Monitor/document for side effects of pain medication. Administer analgesia as per orders. Give ½ hour before treatments or care. Notify the physician if interventions are unsuccessful or if current complaint is a significant change from resident's experience of pain. Provide the resident and family with information about pain and options available for pain management. Discuss and record preferences. Record review of the Daily Nurses Schedule for 09/18/2023 for the 6:00 PM - 6:00 AM shift reflected LVN A was the only nurse in the facility. The staff did not have access to receive assistance for Resident #1 from another nurse. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 05:52 PM COTA/ Marketing Coordinator and PTA began to transfer Resident #1 from her wheelchair to her bed. Resident #1 was not yelling or complaining about pain. Resident #1 was transferred to her bed and as soon as she sat on the bed, she began to yell my knee is hurting my knee is broken. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 05:53 PM Resident #1 was yelling my knee is hurting and my leg broken. Resident #1 began to rub her left leg as she continued to yell. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 Resident #1 continued to yell when staff would touch her left leg or move her left leg. Resident would scream she was hurting. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 6:00 PM, Resident #1 stated you ( PTA) turned me around and Resident #1 was looking at PTA as she made this statement. The PTA stated, we did not mean to hurt you. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 7:58 PM, CNA H was in Resident #1's room. She lifted Resident #1's left leg up and Resident #1 began to scream. CNA H let Resident #1's the left leg fall onto the bed and began to exit Resident #1's room. CNA H was not providing care to Resident #1. Resident #1 was screaming the entire time CNA H lifted her leg and when Resident #1 lowered the left leg on the bed. Resident #1 was not yelling prior to CNA H picking up her leg. As she was walking out Resident #1's room she stated you are acting all crazy. In an interview on 09/20/2023 at 8:11 PM Resident #1's family stated he witnessed from the camera in Resident #1's room on 09/18/2023 at 5:51PM, staff breaking Resident #1's leg, Resident #1 complaining of pain and staff saying back to Resident #1 you know you are not hurt. You had complained about your back hurting before too and it was nothing. He stated staff did not call the family to notify them of the incident until 09/19/2023 and an ambulance was called to transfer Resident #1 to the hospital on [DATE]. He also stated a staff came into Resident #1's room on 09/18/2023 ( the staff was identified by the DON as CNA H) and staff picked up Resident #1's leg dropped it back on the bed and stated to Resident #1, she was not hurt. He stated in the video after staff (CNA H) began walking toward the door they stated to Resident #1 you are crazy . He also stated when the staff began to realize Resident #1 was in pain one of the staff turned the volume up on the television where it was difficult at times after these statements to hear what staff was saying. He also stated Resident #1 was in surgical unit at Hospital B and awaiting surgery. He stated Resident #1 was not available for interview. He did not want to show the video to administration except to identify the staff in the video. In an interview/observation on 09/21/2023 at 10:30 AM the Director of Nurses stated if Resident #1 were having severe pain in her left leg and CNA H picked up Resident #1's left leg and did not place the leg gently on the bed with Resident #1 yelling the entire time I would consider this physical abuse. She also stated if CNA H allegedly stated to Resident #1 you are crazy as CNA H was exiting the room this is verbal abuse. She stated staff had been in serviced on abuse and neglect numerous times. She stated this was abuse. The Director of Nurses was required to identify the staff in the video. Director of Nurses viewed the electronic monitoring video provided by the family on 09/21/2023 and observed CNA H pick up Resident #1's leg and lower it and heard CNA H state you are crazy as CNA H was exiting the room. The Director of Nurses stated this was verbal and physical abuse by CNA H. In an interview on 09/21/2023 at 11:00 AM, attempted to contact LVN A and was unable to leave message. LVN A was working the night of 09/18/2023. In an interview on 09/21/2023 at 11:05 AM, attempted to contact CNA H and left voice message of name, agency, and phone number. In an interview on 09/21/2023 at 11:10 AM, attempted to contact CNA I and left voice message of name, agency, and phone number . CNA I was in Resident #1's room when Resident #1 was complaining of pain. CNA I may have heard in the hall what CNA H stated to Resident #1. In an interview on 09/21/2023 at 2:45 PM the Administrator stated if Resident #1 was having severe pain in her left knee and left leg, and if CNA H was aware Resident #1 had pain and was not given care to Resident #1 and lifted her left leg up and resident yelling from pain and did not lay the left leg softly on the bed, she stated that would be considered abuse. She also stated if CNA H was exiting Resident #1's room and allegedly stated you are crazy, that was considered verbal abuse. The Administrator stated it was her, the DON, ADON and all staff's responsibility to monitor for any type of abuse and report it immediately to her, the DON, ADON or the staff's supervisor . In an interview on 09/20/2023 at 8:40 AM Med Aide E stated she had been in-serviced on abuse and neglect. She stated she did not recall the last time she was in-serviced. She also stated if a CNA picked up a resident's leg and was aware the resident had pain and swelling in the knee and pain in that leg and was not providing care, she stated if the resident were screaming when the CNA did that, she would consider that physical abuse. She stated if a CNA stated you are crazy as she was exiting a resident's room that would be verbal abuse. She stated the Administrator was abuse coordinator. In an interview on 09/22/2023 at 10:30 AM, the ADON stated if a CNA picked up Resident #1's leg and if they knew Resident #1 was in severe pain and her knee was swollen, that would be considered physical abuse. She also stated if a CNA was exiting Resident #1's room and allegedly made the statement you are crazy , that was verbal abuse. The ADON stated an abuse and neglect in-service was given recently, however, she did not recall the date. She stated the Administrator was the abuse coordinator. In an interview on 09/22/2023 at 1:36 PM, attempted to contact LVN A and was unable to leave message. LVN A was in the facility on the night of 09/18/2023 and needed to interview LVN A to determine if she heard what CNA H stated to Resident #1 or if she knew about CNA H picking up Resident #1's leg. In an interview on 09/22/2023 at 1:40 PM, attempted to contact CNA H and left voice message of name, agency, and phone number. In an interview on 09/22/2023 at 1:47 PM, attempted to contact CNA I and left voice message of name, agency, and phone number. CNA I was in the facility on 09/18/2023 and may have witnessed what CNA H stated from the hallway. Record review of the facility's policy for Prohibition of Abuse, Neglect and Misappropriation of Property dated 05/01/01 reflected each resident had the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion, and financial abuse. Abuse means: the willful infliction of injury, withholding or misappropriating property or money, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Verbal abuse is defined as the use of , oral, written or gestured language that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to implement their written policies and procedures that prohibit and prevent the abuse/neglect of residents for one Resident #1) of three residents reviewed for abuse and neglect. The facility failed to implement their abuse/neglect policy when LVN A was notified of Resident #1's pain and the administrator was notified of the incident by the COTAand the administrator failed to investigate the injury per policy. This failure could place residents at risk of abuse, neglect, physical harm, pain, mental anguish, emotional distress, and serious harm. Findings include: Record review of Facility Policy on Prohibition of Abuse, Neglect and Misappropriation of Property dated 05/01/01 reflected each resident had the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion, and financial abuse. The facility will investigate of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations. 1. Abuse means: the willful infliction of injury, withholding or misappropriating property or money, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. 2. Verbal abuse is defined as the use of , oral, written, or gestured language that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Staff responsibility to immediately report any violations or alleged violations. 3. Neglect: was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The facility will track all occurrences, trends or patterns that could potentially constitute abuse or neglect. All incidences of unknown origin will be investigated. Record review of Resident #1's face sheet, dated 09/22/2023, revealed Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses which included low back pain ( pain between the lower edge of the ribs), signs symptoms of musculoskeletal system ( mild to severe aches, low back pain, numbness, tingling, atrophy, and weakness), muscle weakness ( a lack of strength in the muscles), osteoporosis without current pathological fracture (generally caused by a fall from a standing height or lower and usually involves the spine, hip or wrist), lack of coordination (uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements) left foot drop ( caused by weakness of the muscles involved in lifting the front part of the foot) and, abnormalities of gait and mobility (when a person is unable to walk in the usually way). Record review of Resident #1's Annual MDS assessment, dated 07/28/2023, reflected Resident #1 had a BIMS score of fifteen, which indicated the residents' cognition was intact. Resident did not reject care. Resident #1 was assessed to require extensive assistance by two staff members for transfers. She required extensive assistance by one staff for bed mobility and toileting. Resident #1 was also assessed to require limited assistance by one staff for personal hygiene. She was assessed require staff to stabilize her when moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer. Resident #1 was on scheduled pain medication and PRN pain medication. She had frequent pain. Resident #1 did not exhibit any behaviors. Record review of Resident #1's Comprehensive Care Plan completed on 08/17/2023 reflected Resident #1 had an ADL self-care performance deficit. Interventions: resident required extensive assistance by two staff members. Resident #1 required extensive assistance by one staff members with bed mobility. Resident #1 was at risk for falls related to gait/balance problems. She had limited physical mobility. Resident had chronic pain related to osteoporosis (a condition when bone strength weakens) Interventions: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Identify and record previous pain history and management of that pain and impact of function. Identify previous response to analgesia including pain relief, side effects and impact on function. Monitor/ document for probable cause of each pian episode. Remove/limit causes where possible. Resident #1's further interventions were: Monitor/document for side effects of pain medication. Administer analgesia as per orders. Give ½ hour before treatments or care. Notify the physician if interventions are unsuccessful or if current complaint is a significant change from resident's experience of pain. Provide the resident and family with information about pain and options available for pain management. Discuss and record preferences. Record review of the Daily Nurses Schedule for 09/18/2023 for the 6:00 PM - 6:00 AM shift reflected LVN A was the only nurse in the facility. The staff did not have another nurse in the facility to report of Resident #1's pain. Record review of Resident #1's nurses notes dated 09/18/2023 at 6:50 PM, reflected pain medication was given by mouth every four hours for pain. Resident #1 complained of left knee pain and requested pain medication. Record review of Resident #1's nurses notes dated 09/18/2023 at 8:10 PM, reflected the MD was notified of resident's complaint of pain to the left knee and left knee was slightly swollen. Awaiting return call. Record review of Resident #1's nurses notes dates 09/18/2023 at 9:14 PM, reflected the MD returned call and ordered an x-ray to the left knee. Record review of Resident #1's nurses notes dated 09/18/2023 at 11:41 PM, reflected pain medication was given by mouth every four hours as needed for pain. Resident #1 reported pain to her knee. (Did not specify which knee). Record review of Resident #1's nurses note dated 09/19/2023 at 1:05 AM, reflected the pain medication was effective and follow-up pain scale was zero Record review of Resident #1's nurses note dated 09/19/2023 at 4:15 AM, reflected pain medication was given to the resident. Resident #1 was complaining of pain to her left knee and requested pain medication. Record review of Resident #1's nurses note dated 09/19/2023 at 8:09 AM, reflected report was received from LVN A concerning Resident #1 had an order for a left knee x-ray. LVN B notified the x-ray company and was informed the x-ray company would be at the facility as soon as possible. Resident aware. Signed by LVN B Record review of Resident #1's nurses note dated 09/19/2023 at 10:05 AM, reflected Was the resident in pain? 0-no pain, 1-3 - mild pain , 4-6- moderate pain , 7-10- severe pain. Every shift follows MD orders. Resident #1 complained of pain to left knee. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:06 AM, reflected pain medication was administered. Give one tablet by mouth every four hours as needed for pain. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:26 AM, reflected the x-Ray company was unable to do the x-ray at the facility for Resident #1's left knee. Resident #1 would be transferred via EMS to the hospital for an x-ray to her left knee. Resident #1 aware and the family was notified. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:44 AM, reflected EMS was at the facility to transport the resident to hospital. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:47 AM, reflected the pain medication was ineffective and follow-up pain was a five (moderately strong pain). Resident #1 was transferred to emergency room for evaluation and treatment. Record review of Resident #1's pain assessments reflected there was only one pain assessment completed from 07/21/2023 through 09/19/2023. Record review of Resident #1's pain assessment dated [DATE] reflected Resident #1 had been in pain for the past five days. She frequently had pain. Resident #1 was assessed she had difficulty completing her day-to-day activities as related to her pain. Her pain was moderate. Resident #1 was on scheduled pain medication. Signed by the MDS Coordinator. Record review of Resident #1's hospital records from the emergency room hospital A dated 09/19/2023 reflected Resident #1 was transferred by EMS with a complaint of knee pain. She was being transferred between the bed and wheelchair yesterday (09/18/2023) in the facility where she resided when her knee twisted and then became painful and swollen. EMS reported she was given 7.5 milligram of pain medication this AM (09/19/2023) for pain. The EMS did not know the time the pain medication was administered. admission: Urgent, admission Source: Nursing Home. Nursing Assessment: extremity lower. There was obvious swelling to the knee and there appeared to be slight angulation (two ends of the broken bone are at an angle to each other) of the leg. No bruising or open wounds noted to the knee. Record review of Resident #1's doctors notes from the emergency room Hospital A dated 09/19/2023 reflected Resident #1was transferred to the hospital on [DATE] from the nursing home where she resided. On 09/18/2023 Resident #1 was being rotated out of her wheelchair when the staff heard a popping noise from her left knee, and she had called out in pain. The staff noticed on 09/19/2023 the knee continued to be swollen and very painful for the patient when she was moving her knee. Resident #1 was transferred to emergency room for evaluation for possible knee dislocation or knee fracture or any injury. Resident #1was able to express that she felt a significant amount of pain when her left knee was mobilized. The x-ray result reflected Resident #1 had traumatic fracture of the distal femur (where the bone flares out like an upside-down funnel). Record review of Resident #1's emergency room clinical course and plan reflected, Resident #1 had a distal femur fracture. The fracture was acutely comminuted fracture (a type of fracture where broken bones fracture into more than three separate pieces). Resident #1's pain was under control if the leg was immobile. Two rigid boards were placed on the side of the knee and an ace bandage was used to wrap around the knee for compression and stability. Resident #1 would be transferred to a hospital with orthopedics. Resident #1 required a higher level of care. Record review of Resident #1's emergency room history and physical from a hospital B dated 09/20/2023 reflected chief complaint of Resident #1: Left knee pain after hearing a pop, being lifted from wheelchair to bed. Resident #1 was transferred from the nursing home following left knee pain during the time when the staff were trying to transition her from her wheelchair to her bed. There was a popping noise and Resident #1 had immediate pain. Resident #1 was seen today (09/20/2023) in the hospital bed with her left leg splinted. Imaging studies reflected: X-ray of the left knee, two views reflected impression, acute mildly comminuted fracture of the distal femur medtadiaphysis (a type of fracture where broken bones fracture more than three separated places - medtadiaphysis is a term used to describe the combined region of a long bone and the shaft of the bone. Lesions that span both regions). Plan: to admit to surgical unit. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 05:52 PM COTA/ Marketing Coordinator and PTA began to transfer Resident #1 from her wheelchair to her bed. Resident #1 was not yelling or complaining about pain. Resident #1 was transferred to her bed and as soon as she sat on the bed, she began to yell my knee is hurting my knee is broken. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 05:53 PM Resident #1 was yelling my knee is hurting and my leg broken. Resident #1 began to rub her left leg as she continued to yell. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 Resident #1 continued to yell when staff would touch her left leg or move her left leg. Resident would scream she was hurting. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 6:00 PM, Resident #1 stated you ( PTA) turned me around and Resident #1 was looking at PTA as she made this statement. The PTA stated, we did not mean to hurt you. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 7:58 PM, CNA H was in Resident #1 room she lifted Resident #1 left leg up and Resident # 1 began to scream, and CNA let the left leg fall onto the bed and began to exit Resident #1 room. CNA H was not providing care to Resident #1. Resident #1 was screaming the entire time she lifted her leg and when she lowered the left leg on the bed. Resident #1 was not yelling prior to CNA H picking up her leg. She stated as she was walking out Resident #1's room , you have that camera in your room, and you are acting all crazy. In an interview on 09/20/2023 at 8:11 PM Resident #1's family member stated he witnessed from the camera in Resident #1's room on 09/18/23 at 5:51 PM staff breaking Resident #1's leg, Resident #1 complaining of pain and staff saying back to Resident #1 you know you're not hurt. You've complained about your back hurting before too and it was nothing. He stated staff did not call the family to notify them of the incident until 9/19/2023 at 10:44 AM and an ambulance was called to take Resident #1 to the hospital on 9/19/2023 at 10:44 AM. He stated there was also video of a CNA checking Resident #1's leg, picking the broken leg up and dropping it back on the bed and telling Resident #1 she was not hurt. Resident #1's family member also stated in the video after CNA dropped Resident #1 leg and began toward the door the CNA stated to Resident #1 you are crazy. He also stated the facility did not do anything for Resident #1 except give her pain medication she was already receiving. He stated he did not believe this medication helped Resident #1 due to Resident #1 continued to be in pain. He also stated Resident #1 was neglected and she needed to be in the hospital for x-rays immediately when Resident #1 began to yell she was in pain and her leg was broken. He stated she would rub on her left leg and by her expression from the video footage he noticed she was in pain. He stated he did not view the videos until 09/19/2023 after family received a phone call Resident #1 was going to be transferred to the hospital. He stated if he had seen the videos from Resident #1's room on 09/18/2023 he would have drove two hours to ensure she was getting the treatment she needed and was sent to the hospital immediately. He stated that was a new pain for Resident #1 and she had not been complaining about her knee. He also stated it was a new symptom for her knee to swell. In an interview on 09/20/2023 at 2:41 PM the COTA/ Marketing Coordinator stated she reported to LVN A on 09/18/2023 from 6:00 PM, until approximately 09/18/2023 at 8:25 PM of Resident #1 complaining of pain in knee and left leg. She stated she also reported to LVN A that Resident #1 was making statements her knee was broken. She stated she explained to LVN A Resident #1 was in severe pain. She stated LVN A made the remark that that is normal for Resident #1, she was always complaining about being in pain and that was nothing new. The COTA/ Marketing Coordinator stated LVN A was informed of the information at approximately 6:10 PM and LVN A did not go to Resident #1's room until approximately 8:30 PM. She stated either she or the PTA was always in Resident #1's room from around 6:00 PM until 8:45 PM. She stated LVN A would not go to Resident #1's room to administer pain medication and the resident was in pain for at almost 2 hours. She stated she asked LVN A to give her the pain medication and she would administer it to Resident #1. She stated LVN A gave her the pain medication (narco) and she gave it to Resident #1. She stated she could not sit by and watch Resident #1 be in pain for an hour or more and the nurse refused to go to Resident #1's room due to believing Resident #1 was complaining for no reason. She stated it was difficult to even talk to LVN A due to her expressing no compassion towards Resident #1 and not wanting to assess her to determine if anything was wrong with Resident #1. She also stated she called the Administrator on 09/18/2023 ( did not recall the time). She stated she informed the Administrator of Resident #1's pain and swelling in the left knee. She stated the Administrator advised her to speak with the nurse and explain to the nurse to call the MD and have x-rays ordered. She stated she spoke with LVN A and explained the Administrator stated to call the MD and have x-rays ordered. She stated LVN A was organizing to pass out medications and began to pass medications and there was not an emergency occurring where she could not stop what she was doing to go to Resident #1's room. She stated she did not feel comfortable leaving Resident #1 on 09/18/2023 due to LVN A not going to Resident #1's room to complete an assessment or make any type of observation of why Resident #1 was in extreme pain. She stated Resident #1's left knee continued to become larger, and she was going to report Resident #1's condition approximately every 10 minutes and the nurse stated to the COTA/Marketing Coordinator that Resident #1 was ok, that is the way Resident #1 always was and there was not anything wrong with Resident #1. She stated around 8:30 PM LVN A entered Resident #1's room and stated Resident #1's left knee does not look any different than it has in the past. The COTA/Marketing Coordinator stated that LVN A informed her and PTA C to go home, she had this and promised to take care of Resident # 1. She stated LVN A did not assess Resident #1. The COTA/Marketing Coordinator stated when she came on duty on 09/19/2023 the ambulance was in front of the facility transferring Resident #1 to the hospital. She stated she was shocked and could not believe LVN A allowed Resident #1 to remain in the facility that night without getting an x-ray or doing anything to ensure Resident #1 did not have any broken bones. The COTA/Marketing Coordinator stated she did believe LVN A was neglecting Resident #1. She stated LVN A refused to go to Resident #1's room and complete an assessment approximately 2 hours after being informed of Resident #1's left knee/ leg pain and Resident #1 stating she thought her leg was broken. She stated she was upset, and the nurse ignored her whenever she reported anything about Resident #1. She stated LVN A neglected Resident #1 on 09/18/2023. In an interview on 09/20/2023 at 3:41 PM LVN D stated Resident #1 yelled out frequently. She stated when she was yelling, she was in pain. LVN D stated resident complains about her back hurting. She stated everyone knew Resident #1 yelled frequently when she was in pain. She stated there were times when she was speaking to Resident #1, and she was complaining/ yelling with pain, and she would administer her ordered pain medication without asking Resident #1 where she was hurting or her pain level. She stated she has not ever completed a pain assessment on Resident #1 but now she realized she was required to complete pain assessment and document in nurses notes about Resident #1's pain. She also stated the nurses was expected to ask where the pain was located and the pain level on a scale of zero-ten. She stated zero - no pain and ten- extreme pain. She stated due to Resident #1 complaining about pain all the time the nurses would give her the pain medication if it was scheduled and not ask her any questions. She stated if she had been working on the night of 09/18/2023 and Resident #1 was complaining about pain in her knee she would have given her pain medication and probably would not have asked any questions or completed any type of incident reports or pain assessments due to this was how Resident #1 she was always complained about pain. She stated this was her normal behavior. LVN D stated resident did not have any behavior problems. She stated she would yell but only when she was in pain. She stated Resident #1 was cooperative with staff and did not have any behavior issues. LVN D stated she has given care to Resident #1 numerous times. She stated it varied from week to week, but she was very familiar with Resident #1 physical condition, moods, and behaviors. She also stated when Resident #1 was in pain she did not assess the resident to determine if it was a new pain or pain from her back. She stated everyone in the facility was aware if Resident #1 was in pain she will yell, and we don't assess the pain very closely when giving pain medication. She stated we give her anti -anxiety medication to prevent her from yelling. She also stated she did not believe any assessment was required when she was yelling about pain in her knee. She stated she was not working on 09/18/2023 but she would not have completed a pain assessment on resident. She also stated if a nurse was informed by staff over an hour that Resident #1's knee had increased in size due to swelling, Resident #1 was yelling in pain and Resident #1 stated she thought she broke her leg/knee, a nurse was expected to go to that room immediately due to that was a new pain for Resident #1; and anytime a resident stated they thought their leg/knee was broken that was serious. She stated if a nurse did not visit Resident #1 immediately after allegedly being informed every 10 minutes of her change in physical condition, that would be considered neglect. She stated unless there was an emergency with another resident. She stated a nurse could not ignore when staff was concerned about a resident's physical condition, and they felt there was a major concern for resident's physical health. She stated if a nurse continued to refuse to go to Resident #1's room for almost 2 hours, they did neglect Resident #1. She stated if the staff did not know why Resident # 1's knee was swelling, very painful to touch and Resident #1 allegedly stating her leg was broken, that would be considered an injury of unknown origin and would need to be investigated. In an interview on 09/21/2023 at 11:00 AM, attempted to contact LVN A and was unable to leave message. LVN A was in the facility when Resident was in pain and complaining of her left knee hurting In an interview on 09/21/2023 at 12:00 PM, PTA C stated the COTA/ Marketing Coordinator asked her to help her to transfer Resident #1 from her recliner to the wheelchair and then to the bed. She stated this occurred approximately 6:00 PM. She stated Resident #1 was transferred from the recliner to the wheelchair and Resident #1 complained about her back hurting after the transfer. She stated Resident #1 was assisted by the bed in her wheelchair to prepare for the transfer from the wheelchair to the bed. She stated once Resident #1 was in her wheelchair by the bed she was calm and quit complaining about her back hurting. PTA C stated the COTA/ Marketing Coordinator was in front of resident and placed the gait belt around the resident waist. She stated they began to transfer Resident #1 to the bed and as soon as they pivoted Resident #1 onto the bed, she began to yell my knee hurts. PTA C stated she assumed it was similar of her complaining about her pain in her back. She stated Resident #1 at some point stated her left leg was broken. PTA C also stated she realized this was a different type of pain than what she has complained in the past. She stated COTA/ Marketing Coordinator left the room to report to LVN A. She stated they kept waiting on pain medication or the nurse to come assess Resident #1 due to her knee continued to swell and was becoming larger. She stated Resident #1 would yell in pain when her leg was barely touched or moved. Resident #1 would rub her knee and below the knee onto her left leg and stated it was broken. PTA C stated LVN A would not come to Resident #1 room to give her pain medication or assess her. She stated the nurse gave COTA/ Marketing Coordinator the pain medication and the COTA/ Marketing Coordinator gave Resident #1 pain medication. PTA C stated she did not recall the time, but she thought it was around 7:00 PM. She stated LVN A entered Resident #1's room approximately 8:30 PM. She stated she was in the room while LVN A talked to Resident #1. PTA C stated LVN A looked at Resident #1's knee approximately 5 seconds and stated her knee is fine. PTA C stated LVN A did not assess Resident #1 or ask her if she hurting in other areas. She stated LVN A did not ask Resident #1 what her pain level was or if the pain medication was effective. She also stated LVN A did not realize PTA C was in the room. PTA C stated when LVN A saw her in the room she stated oh are you a family member I didn't know anyone was in the room. PTA C stated no I am not a family member I am a Physical Therapist Assistant at this facility, and I helped assist Resident #1 to be when she began complaining about her knee. PTA C stated LVN A did not ask her any questions about the transfer or anything about Resident #1. PTA C stated she informed LVN A that she and COTA/ Marketing Coordinator had been in the room with Resident #1 since around 6:00 PM after she began complaining about pain in left knee and stating her left leg was broken. She stated LVN A walked out of the room and stated she is fine she always complains about pain. She also stated LVN A was preparing to pass out medications and began to pass out meds to residents and there was not an emergency. LVN A could have stopped what she was doing and came to Resident #1's room to complete an assessment. She stated if an assessment had been completed and LVN A would have went to Resident #1's room at approximately 6:10 PM she believed Resident #1 would have been sent to the hospital for evaluation that night. She stated she did believe LVN A was neglecting Resident #1. She stated the statements from LVN A was that Resident #1 was always like that and she was always complaining about something, and there was not anything wrong with her. She stated that was deliberate neglect from LVN A . In an interview on 09/21/2023 at 2:45 PM the Administrator stated the COTA/ Marketing Coordinator contacted her on 09/18/2023 in the evening. She stated she did not recall the exact time. She stated she was informed of Resident #1 had pain and some swelling in her left knee. She stated she asked COTA/Marketing Coordinator to inform the nurse to contact the physician and have an x-ray ordered. The Administrator stated anytime a Resident complains of pain whether it is an old or new pain she expected a pain assessment to be completed. She stated LVN A was expected to assess Resident #1 and ask the staff questions and contact the DON with the information. She stated LVN A did not follow protocol of assessing Resident #1,completing a pain assessment, and asked questions reason Resident #1 knee began to swell and why Resident # 1 believed her leg was broken. The Administrator stated Resident #1 needed an x-ray on 09/18/2023 and if the x-ray company could not come to the facility, the nurse was expected to call MD and request for Resident #1 to be sent to the emergency room that night. She stated if Resident #1 was in pain and complaining of her left knee being broken on 09/18/2023, 911 needed to be called and EMS transfer her to the Emergency Room. She stated anytime a Resident complains of pain the nurse was expected to ask the resident where the pain was located , the level of the pain, and to document all this information in the nurses notes and complete a pain assessment. She stated if Resident #1 had a new pain after a transfer, the nurse was expected to ask the staff questions about the transfer, immediately do an assessment, and begin an incident report if needed. She stated the nurse was expected to contact the DON with the information and after she contacted the physician and call 911 to transfer Resident #1 to emergency room. The Administrator stated it was not best practice to have a resident in the facility from the night of 09/18/2023 until the morning of 09/19/2023 in pain with a possible left leg or knee fracture. She stated based on the information she learned today (09/21/2023) of Resident #1's new physical concerns she endured on 09/18/2023 Resident #1 required to be assessed by a physician in the emergency room and have x-rays on her left leg and left knee as soon as possible on 09/18/2023. She stated the facility had protocols in place to ensure the residents was receiving the best care for their physical condition whether it was a new physical issue or an old physical issue. She stated the nursing staff on 09/18/2023 did not follow the facility's protocol and there was a system failure. She stated it was the DON's responsibility to monitor the nurses to ensure they were following protocol. She stated it was discussed in the morning meeting on 09/19/2023 about Resident #1's knee and leg. She stated it was discussed Resident #1 needed an X-Ray. She stated the staff was not interviewed and there was not any questioning of what happened to Resident #1's left knee or left leg. The Administrator stated after today ( 09/21/2023) she realized either she or the DON needed to complete an investigation of what happened with Resident #1. She stated if a nurse continued to refuse to assess a resident after being asked several times by the staff, she would consider that neglect. She also stated if a staff knew Resident #1 was in extreme pain in her left leg and they lifted the left leg in the air and did not gently place the left leg on the bed she would consider that abuse. She also stated if staff made a statement to Resident #1 as she was leaving the room that Resident #1 was crazy, she stated that was verbal abuse. She stated in the abuse and neglect policy and protocol it was clear what to do if anything was suspected and she stated they did not follow protocol to investigate what occurred with Resident #1 on 09/18/2023. The Administrator also stated if Resident #1 complained that her leg was broken, her knee continued to swell and she was in extreme pain within a few seconds after she was transferred from a wheelchair to the bed, there was a potential of an injury of unknown origin. She stated no one reported that to her. The Administrator did not see the electronic video given from family; however, she heard the video and the Administrator stated Resident #1 stated her leg was broken. In an interview on 09/22/2023 at 9:05 AM, LVN B stated Resident #1 did complain about pain frequently. LVN B stated if it was reported to the nurse of Resident #1 having pain and swelling in her left knee and Resident #1 believed her left knee or left leg was broken, LVN A did not follow proper protocol to ensure Resident #1 was receiving the medical care she needed the night of 09/18/2023. She stated Resident #1 needed to be transferred to the hospital on [DATE]. LVN B stated if staff continued to report to LVN A over an hour that Resident #1 was in pain, the swelling in left knee had increased in size and Resident #1 stated her leg/knee was broken, LVN A was expected to go to Resident #1's room immediately. She stated if LVN A continued to refuse to assess Resident #1 that would be considered neglect, unless there was an emergency with another resident. She stated if it was verified there was not an emergency every time staff was reporting the new physical condition Resident #1 was in , LVN A did neglect Resident #1. She also stated on Tuesday 09/19/2023 at approximately 9:00 AM in the staff meeting she reported Resident #1's knee was swollen, and she had been in pain. She stated she also informed the administrative staff in the morning meeting that the x-ray department may not be available to come to the facility until the afternoon. She stated the Administrator stated to call the physician and send Resident #1 to hospital[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice for one (Resident #1) of four residents reviewed for pain in that: The facility failed to properly assess or provide effective pain management to Resident #1 after a new onset of pain following the accidental fracture of her left tibia during a transfer from wheelchair to her bed. This failure could place residents at risk of not receiving the highest practicable care through resident assessments by recognizing and addressing the physical dysfunctions in an effective and timely manner to prevent residents from further harm, injury, or death Findings included: Record review of Resident #1's face sheet, dated 09/22/2023, revealed Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses which included low back pain (pain between the lower edge of the ribs), signs symptoms of musculoskeletal system ( mild to severe aches, low back pain, numbness, tingling, atrophy, and weakness), muscle weakness ( a lack of strength in the muscles), osteoporosis without current pathological fracture (generally caused by a fall from a standing height or lower and usually involves the spine, hip or wrist), lack of coordination (uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements), left foot drop ( caused by weakness of the muscles involved in lifting the front part of the foot) and, abnormalities of gait and mobility (when a person is unable to walk in the usually way). Record review of Resident #1's Annual MDS assessment, dated 07/28/2023, reflected Resident #1 had a BIMS score of fifteen, which indicated the resident's cognition was intact. Resident #1 did not reject care. Resident #1 was assessed to require extensive assistance by two staff members for transfers. She required extensive assistance by one staff for bed mobility and toileting. Resident #1 was also assessed to require limited assistance by one staff for personal hygiene. She was assessed to require staff to stabilize her when moving from a seated to standing position, moving on and off the toilet, and surface-to-surface transfers. Resident #1 was on scheduled pain medication and PRN pain medication. She had frequent pain. Resident #1 did not exhibit any behaviors. Record review of Resident #1's Comprehensive Care Plan completed on 08/17/2023 reflected Resident #1 had an ADL self-care performance deficit. Interventions included that the resident required extensive assistance by two staff members. Resident #1 required extensive assistance by one staff member with bed mobility. Resident #1 was at risk for falls related to gait/balance problems. She had limited physical mobility. Resident had chronic pain related to osteoporosis (a condition when bone strength weakens) Interventions included to anticipate the resident's need for pain relief and respond immediately to any complaint of pain; identify and record previous pain history and management of that pain and impact of function; identify previous response to analgesia (treatment that prevents you from feeling pain while you are awake) including pain relief, side effects and impact on function; monitor/document for probable cause of each pian episode; and remove/limit causes where possible. Resident #1's further interventions were: monitor/document for side effects of pain medication; administer analgesia as per orders; give ½ hour before treatments or care; notify the physician if interventions are unsuccessful or if current complaint is a significant change from resident's experience of pain; provide the resident and family with information about pain and options available for pain management; and discuss and residents' preferences . Record review of Resident #1's Physician Orders last reviewed on 07/31/2023 reflected Resident #1 had a physician order for Norco Oral Tablet 7.5-325 milligram give tablet by mouth every four hours as needed for pain. Record review of Resident #1's Physician Orders last reviewed on 07/31/2023 reflected Resident #1 had a physician order for Acetaminophen Extra Strength oral Tablet 500 mg by mouth every six hours as needed for pain. Record review of Resident #1's nurses notes dated 09/18/2023 at 6:50 PM, reflected pain medication was given by mouth every four hours for pain. Resident #1 complained of left knee pain and requested pain medication. Record review of Resident #1's nurses notes dated 09/18/2023 at 8:10 PM, reflected the MD was notified of resident's complaint of pain to the left knee and left knee was slightly swollen. Awaiting return call. Record review of Resident #1's nurses notes dates 09/18/2023 at 9:14 PM, reflected the MD returned call and ordered an x-ray to the left knee. Record review of Resident #1's nurses notes dated 09/18/2023 at 11:41 PM, reflected pain medication was given by mouth every four hours as needed for pain. Resident #1 reported pain to her knee. (Did not specify which knee). Record review of Resident #1's nurses note dated 09/19/2023 at 1:05 AM, reflected the pain medication was effective and follow-up pain scale was zero Record review of Resident #1's nurses note dated 09/19/2023 at 4:15 AM, reflected pain medication was given to the resident. Resident #1 was complaining of pain to her left knee and requested pain medication. Record review of Resident #1's nurses note dated 09/19/2023 at 8:09 AM, reflected report was received from LVN A concerning Resident #1 had an order for a left knee x-ray. LVN B notified the x-ray company and was informed the x-ray company would be at the facility as soon as possible. Resident aware. Signed by LVN B Record review of Resident #1's nurses note dated 09/19/2023 at 10:05 AM, reflected Was the resident in pain? 0-no pain, 1-3 - mild pain , 4-6- moderate pain , 7-10- severe pain. Every shift follows MD orders. Resident #1 complained of pain to left knee. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:06 AM, reflected pain medication was administered. Give one tablet by mouth every four hours as needed for pain. Record review of Resident #1's nurses notes dated 09/ 19/2023 at 10:26 AM, reflected the x-Ray company was unable to do the x-ray at the facility for Resident #1's left knee. Resident #1 would be transferred via EMS to the hospital for an x-ray to her left knee. Resident #1 aware and the family was notified. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:44 AM, reflected EMS was at the facility to transport the resident to hospital. Record review of Resident #1's nurses notes dated 09/19/2023 at 10:47 AM , reflected the pain medication was ineffective and follow-up pain was a five (moderately strong pain). Resident #1 was transferred to emergency room for evaluation and treatment. Record review of Resident #1's pain assessments reflected there was only one pain assessment completed from 07/21/2023 through 09/19/2023. Record review of Resident #1's pain assessment dated [DATE] reflected Resident #1 had been in pain for the past five days. She frequently had pain. Resident #1 was assessed she had difficulty completing her day-to-day activities as related to her pain. Her pain was moderate. Resident #1 was on scheduled pain medication. Signed by the MDS Coordinator. Record review of Resident #1's hospital records from the emergency room Hospital A dated 09/19/2023 reflected Resident #1 was transferred by EMS with a complaint of knee pain. She was being transferred between the bed and wheelchair yesterday (09/18/2023) in the facility where she resided when her knee twisted and then became painful and swollen. EMS reported she was given 7.5 milligram of pain medication this AM (09/19/2023) for pain. The EMS did not know the time the pain medication was administered. admission: Urgent, admission Source: Nursing Home. Nursing Assessment: extremity lower. There was obvious swelling to the knee and there appeared to be slight angulation (two ends of the broken bone are at an angle to each other) of the leg. No bruising or open wounds noted to the knee. Record review of Resident #1's doctors notes from the emergency room Hospital A dated 09/19/2023 reflected Resident #1was transferred to the hospital on [DATE] from the nursing home where she resided. On 09/18/2023 Resident #1 was being rotated out of her wheelchair when the staff heard a popping noise from her left knee, and she had called out in pain. The staff noticed on 09/19/2023 the knee continued to be swollen and very painful for the patient when she was moving her knee. Resident #1 was transferred to emergency room for evaluation for possible knee dislocation or knee fracture or any injury. Resident #1was able to express that she felt a significant amount of pain when her left knee was mobilized. The x-ray result reflected Resident #1 had traumatic fracture of the distal femur ( where the bone flares out like an upside-down funnel) Record review of Resident #1's emergency room clinical course and plan reflected, Resident #1 had a distal femur fracture. The fracture was acutely comminuted fracture (a type of fracture where broken bones fracture into more than three separate pieces). Resident #1's pain was under control if the leg was immobile. Two rigid boards were placed on the side of the knee and an ace bandage was used to wrap around the knee for compression and stability. Resident #1 would be transferred to a hospital with orthopedics. Resident #1 required a higher level of care. Record review of Resident #1's emergency room history and physical from a hospital B dated 09/20/2023 reflected chief complaint of Resident #1: Left knee pain after hearing a pop, being lifted from wheelchair to bed. Resident #1 was transferred from the nursing home following left knee pain during the time when the staff were trying to transition her from her wheelchair to her bed. There was a popping noise and Resident #1 had immediate pain. Resident #1 was seen today (09/20/2023) in the hospital bed with her left leg splinted. Imaging studies reflected: X-ray of the left knee, two views reflected impression, acute mildly comminuted fracture of the distal femur medtadiaphysis (a type of fracture where broken bones fracture more than three separated places - medtadiaphysis is a term used to describe the combined region of a long bone and the shaft of the bone. Lesions that span both regions). Plan: to admit to surgical unit. Record review of the Daily Nurses Schedule for 09/18/2023 for the 6:00 PM - 6:00 AM shift reflected LVN A was the only nurse in the facility. There was not another nurse the staff could report Resident #1 was in pain. LVN A was the only nurse on duty. Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by the family revealed on 09/18/2023 revealed the following: - At 05:44 PM, the COTA/Marketing Coordinator stated to Resident #1 she had not transferred Resident #1 before, and asked Resident #1 if she was able to help during transfers or did, she need a gait belt. The COTA/Marketing Coordinator stated she was going to find a gait belt. -At 05:49 PM, the COTA/ Marketing Coordinator and PTA began transferring Resident #1 from the recliner to the wheelchair ( on 09/18/2023 PM) Resident #1 complained about her back hurting but was not yelling. - At 05:52 PM, the COTA/Marketing Coordinator and PTA began to transfer Resident #1 ( by 2 person assist with gait belt) from her wheelchair to her bed in PM. Resident #1 was not yelling or complaining about pain. Resident #1 was transferred to her bed and as soon as she sat on the bed, she began to yell that her knee was hurting, and her knee was broken. - At 05:53 PM, Resident #1 began to rub her left leg as she continued to yell. Resident #1 continued to yell when staff would touch her left leg or move her left leg. Resident #1 would scream she was hurting. - At 6:00 PM. Resident #1 stated to PTA that they turned her around and Resident #1 was looking at PTA as she made the statement. The PTA stated to Resident #1 they did not mean to hurt her. In an interview on 09/20/2023 at 12:58 PM the Director of Nurses stated anytime a resident was requesting a pain medication or makes a statement they are in pain; prior to giving the pain medication the nurse was expected to ask the resident where the pain was located and to ask the resident on a scale of 0-10 with zero meaning no pain and ten being the highest pain level what was the resident's pain level was. She stated the nurse was expected to document that information in the nurses notes of where the pain was located and the pain scale. The Director of Nurses stated a pain assessment was required to be completed when a resident reported they were in pain. She also stated the nurse administering the pain medication was the nurse expected to complete the pain assessment. She stated there was only one pain assessment in Resident #1's electronic medical record. The Director of Nurses stated pain assessment was required whenever a resident complained about being in pain. She stated Resident #1 did yell al lot when she was in pain and was in pain al lot. She stated if Resident #1 complained about her left knee and leg hurting that was a new pain for Resident #1. She stated if Resident #1's left knee was swollen the nurse was expected to do a complete pain assessment and possibly incident report to determine if anything happened during the resident's transfer from the wheelchair to the bed. The Director of Nurses stated it was reported to her by the PT/ Marketing Coordinator on 09/19/2023 Resident #1 was yelling her left knee and left leg were hurting after she was transferred from the wheelchair to the bed. She stated the nurse was expected to gather information from the COTA/Marketing Coordinator and PTA who transferred Resident #1 and possibly needed an incident report completed and the nurse was required to completed a pain assessment or do some type of assessment of the resident. The Director of Nurses stated Resident #1 only yelled out when she was in pain. She stated she was not aware of any behavior problems Resident #1 had with staff or with anyone. She stated Resident #1 should have been transferred to the emergency room on [DATE] after the nurse received orders for the x-ray. She stated the x-ray company does not come to the facility if there is an x-ray needed any time after 5:00 PM and before 8:00 AM. She also stated the nurse was expected to complete a pain assessment or document in the nurses notes of Resident #1 complaining about her knee and the knee swelling. She stated the nurse on duty that night was responsible for documenting on Resident #1 on 09/18/2023. In an interview on 09/20/2023 at 2:41 PM the COTA/Marketing Coordinator stated she heard Resident #1 yelling for help around 6:00 PM on 09/18/2023. She stated when she entered Resident #1's room at approximately 6:05 PM Resident #1 was needing assistance to be transferred to her bed from her recliner. She stated she explained to the resident she needed to find a gait belt and get someone to help her with the transfer. The COTA / Marketing Coordinator stated she asked PTA C to assist her transferring Resident #1. She stated the PTA assisted her with Resident #1's transfer from the recliner to wheelchair. She stated Resident #1 complained about back pain. The COTA/Marketing Coordinator also stated Resident #1's wheelchair was positioned beside the bed to transfer onto her bed. She stated she was in front of the resident, and they placed the gait belt on the resident and assisted her from the wheelchair. They pivoted the resident for her to sit on the bed. She stated resident was not yelling during the transfer, however, within few seconds of the resident sitting on the bed the resident began to yell my knee hurts. She stated Resident #1 repeated stating her knee hurt. The COTA/ Marketing Coordinator stated she and PTA C assisted the resident to lie in bed in a supine position (resident is face up with their head resting on a pad positioner or pillow),and that was when she noticed Resident #1's knee began to swell. She stated Resident #1 complained of her pain being at 10 on a pain scale of zero being in no pain to ten being in extreme pain. She stated the PTA stayed in the room and she left the room to report that to the LVN A at approximately 6:30 PM. She stated LVN A did not go to Resident #1's room to assess the resident. She stated LVN A was at her nurses' cart preparing to administer medications. She stated she explained to LVN A Resident #1 was in extreme pain in her left knee and the knee was swelling. She stated she stayed at the facility until she knew Resident #1 was going to be seen by the nurse. She stated it was approximately 8:30 PM when the nurse entered Resident #1's room for the first time after she reported Resident #1's pain and swelling to LVN A. She stated she did become frustrated with LVN A ignoring Resident #1's pain and knee swelling that she told her just give Me the medicine and she will give it to her. She stated she could not stand to see Resident #1 in pain any longer and the nurse would not come to the Resident #1's room. The COTA/ Marketing Coordinator stated she got the pain medication from the nurse and took it to Resident #1 and gave the pain medication narco to Resident #1. She stated after numerous times of reporting to LVN A to go assess Resident #1, the LVN A stated the resident is always in pain that is not anything new. The COTA/ Marketing Coordinator stated she was so upset because she stated she kept reporting to LVN A about Resident #1's condition with her left knee and she continued to ignore her. She also stated she called the Administrator on 09/18/2023 ( did not recall the time). She stated she informed the Administrator Resident #1 had pain and swelling in the left knee. She stated the Administrator advised her to speak with the nurse and explain to the nurse to call the MD and have x-rays ordered. She stated she spoke with LVN A and explained the Administrator stated to call the MD and have x-rays ordered. She stated LVN A was organizing to pass out medications and began to pass medications and there was not an emergency occurring where she could not stop what she was doing and go to Resident #1's room. She stated she did not feel comfortable leaving Resident #1 on 09/18/2023 due to LVN A not going to Resident #1's room to complete an assessment on her or giving her pain medication when Resident #1 was in pain more than an hour before LVN A gave me the pain medication to give to Resident #1. She stated she had to do something because Resident #1's left knee swelling was increasing, and the pain was getting a lot worse. In an interview on 09/20/2023 at 3:41 PM LVN D stated Resident #1 yells out frequently. She stated when she is yelling, she is in pain. LVN D stated the resident complains about her back hurting. She stated everyone knew Resident #1 yelled frequently when she was in pain. She stated there were times when she was speaking to Resident #1, and she was complaining/ yelling with pain, and she would administer her ordered pain medication without asking Resident #1 where she was hurting or her pain level. She stated she has not ever completed a pain assessment on Resident #1 but now she realized she was required to complete a pain assessment and document in the nurses notes about Resident #1's pain. She also stated the nurses were expected to ask where the pain was located and the pain level on a scale of zero-ten. She stated zero was- no pain and ten was extreme pain. She stated due to Resident #1 complaining about pain all the time the nurses would give her the pain medication if it was scheduled and not ask her any questions. She stated if she had been working on the night of 09/18/2023 and Resident #1 was complaining about pain in her knee she would have given her pain medication and probably would not have asked any questions or completed any type of incident report or pain assessment due to Resident #1always complained about pain. She stated that was her normal behavior. LVN D stated the resident did not have any behavior problems. She stated she would yell but only when she was in pain. She stated Resident #1 was cooperative with staff and did not have any behavior issues. LVN D stated she has given care to Resident #1 numerous times. She stated it varied from week to week, but she was very familiar with Resident #1's physical condition, moods, and behaviors. LVN D stated Resident #1 will yell out when she is in pain. She stated she had severe back pain and had an MRI. She also stated when Resident #1 was in pain she did not assess the resident to determine if it was a new pain or pain from her back. She stated everyone knows if Resident #1 is in pain she will yell, and they do not assess the pain very closely when giving pain medication. She stated the nurses gives her anti -anxiety medication to prevent her from yelling. She also stated she did not believe any assessment was required when she was yelling about pain in her knee. She stated she was not working on 09/18/2023 but she would not have completed a pain assessment on resident. In an interview on 09/20/2023 at 8:11 PM Resident #1's family member stated he witnessed from the camera in Resident #1's room on 09/18/2023 at 5:51 PM, staff breaking Resident #1's leg, Resident #1 complaining of pain and staff saying back to Resident #1 you know you're not hurt. He stated the staff said to Resident #1 she complained about her back hurting before too and it was nothing. He stated staff did not call the family to notify them of the incident until 09/19/2023 and an ambulance was called to transfer Resident #1 to the hospital on [DATE]. He also stated when the staff began to realize Resident #1 was in pain one of the staff turned the volume up on the television where it was difficult at times after those statements to hear what staff was saying. On 09/21/2023 at 11:00 AM, attempted to contact LVN A and was unable to leave a message. On 09/21/2023 at 11:05 AM, attempted to contact CNA H and left a voice message . CNA H was in Resident #1's room for few minutes on 09/18/2023. In an interview on 09/21/2023 at 12:00 PM, PTA C stated the COTA/ Marketing Coordinator asked her to help her transfer Resident #1 from her recliner to the wheelchair and then to the bed. She stated that occurred 09/18/2023 approximately 6:00 PM. She stated Resident #1 was transferred from the recliner to the wheelchair and Resident #1 complained about her back hurting after the transfer. She stated Resident #1 was assisted by the bed in her wheelchair to prepare for the transfer from the wheelchair to the bed. She stated once Resident #1 was in her wheelchair by the bed she was calm and quit complaining about her back hurting. PTA C stated the COTA/ Marketing Coordinator was in front of the resident and placed the gait belt around the resident's waist. She stated they began to transfer Resident #1 to the bed and as soon as they pivoted Resident #1 onto the bed, she began to yell her knee hurt. PTA C stated she assumed it was similar of her complaining about her back pain. She stated at some point Resident #1 stated her left leg was broken. PTA C also stated she realized that was a different type of pain than what she has complained in the past. She stated the COTA/ Marketing Coordinator left the room to report to LVN A. She stated they kept waiting on pain medication or the nurse to assess Resident #1 due to her knee continuing to swell and becoming larger. She stated Resident #1 would yell in pain when her leg was barely touched or moved. Resident #1 would rub her knee and below the knee onto her left leg and stated it was broken. PTA C stated LVN A would not go to Resident #1's room to give her pain medication or assess her. She stated the nurse gave the PT/ Marketing Coordinator the pain medication and the COTA/ Marketing Coordinator gave Resident #1 the pain medication. PTA C stated she did not recall the time, but she thought it was around 7:00 PM. She stated LVN A entered Resident #1's room at approximately 8:30 PM. She stated she was in the room while LVN A talked to Resident #1. PTA C stated LVN A looked at Resident #1's knee for approximately 5 seconds and stated her knee is fine. PTA C stated LVN A did not assess Resident #1 or ask her if she was hurting in other areas. She stated LVN A did not ask Resident #1 what her pain level was or if the pain medication was effective. She also stated LVN A did not realize PTA C was in the room. PTA C stated when LVN A saw her in the room she stated oh are you a family member I did not know anyone was in the room. PTA C stated, no I am not a family member I am a Physical Therapist Assistant at this facility, and I helped assist Resident #1 to be when she began complaining about her knee. PTA C stated LVN A did not ask her any questions about the transfer or anything about Resident #1. PTA C stated she informed LVN A that she and the COTA/ Marketing Coordinator had been in the room with Resident #1 since around 6:00 PM after she began complaining about pain in her left knee and stating her left leg was broken. She stated LVN A walked out of the room and stated she is fine; she always complains about pain. She also stated LVN A was preparing to pass out medications and began to pass out meds to residents and there was not an emergency and LVN A could have stopped what she was doing and came to Resident #1's room. In an interview on 09/21/2023 at 2:45 PM the Administrator stated the COTA/ Marketing Coordinator contacted her on 09/18/2023 in the evening. She stated she did not recall the exact time. She stated she was informed Resident #1 had pain and some swelling in her left knee. She stated she asked the COTA/Marketing Coordinator to inform the nurse to contact the physician and request an x-ray to be ordered. The Administrator stated anytime a resident complained of pain whether it was an old or new pain she expected a pain assessment to be completed. She stated LVN A was expected to assess Resident #1 and ask the staff who was in Resident #1's room questions and contact the DON with the information. She stated LVN A did not follow protocol of assessing Resident #1, completing a pain assessment, and asked staff questions of how Resident #1 knee began to swell and why Resident # 1 believed her leg was broken. The Administrator stated Resident #1 needed an x-ray on 09/18/2023 and if the x-ray company could not come to the facility, the nurse was expected to call the MD and request for Resident #1 to be sent to the emergency room that night. She stated if Resident #1 was in pain and complaining of her left knee being broken on 09/18/2023, 911 needed to be called and EMS transfer her to the hospital. She stated anytime a resident complains of pain the nurse was expected to ask the resident where the pain was located , the level of the pain, and to document all that information in the nurses notes and complete a pain assessment. She stated if Resident #1 had new pain after a transfer, the nurse was expected to ask the staff questions about the transfer, immediately do an assessment, and begin an incident report (reviewed incident reports and did not observe any incident reports of this incident of Resident #1 on 09/18/2023) if needed. She stated the nurse was expected to contact the DON with the information and after she contacted the physician, then call 911 to transfer Resident #1 to emergency room. The Administrator stated it was not best practice to have a resident in the facility from the night of 09/18/2023 until the morning of 09/19/2023 in pain with a possible left leg or knee fracture. She stated it was the DON's responsibility to monitor the nurses to ensure they are following protocol. In an interview on 09/22/2023 at 8:40 AM Med Aide E stated she had given medications to Resident #1 except pain medications and her anxiety medications. She stated whenever Resident #1 has reported to her she was in pain she would inform the nurse. She stated Resident #1 did not exhibit any behavior problems; however, she would yell only when in pain. She stated other than yelling she was not aware of any behavior problems with Resident #1. She also stated if a resident had new pain and was complaining for hours of being in pain and had stated her leg or knee was broken, the resident needed to be transferred to emergency room immediately. Med Aide E stated Resident #1 was alert and oriented and was able to verbalize her pain, and the nurse needed to listen to Resident #1 and should know it could be serious and needed immediate medical attention in the hospital. She stated she would continue to ask the nurse to send a resident to hospital if the resident was complaining of knee pain, if the knee was swollen, and if resident stated her leg was broken. In an interview on 09/22/2023 at 9:05 AM, LVN B stated Resident #1 did complain about pain frequently. LVN B stated the resident did not have any behavior problems except for yelling when she was in pain. She stated whenever a resident complained about pain, the nurse was expected to ask where the pain was located and complete a pain scale assessment with zero indicated no pain and ten indicated extreme pain. She stated that was to be documented in the nurses notes at the time of administer the pain medication. LVN B also stated the nurse was expected to speak to the resident within 2 hours and determine if the pain medication was effective. She stated a pain assessment was required whenever a resident was in pain. She stated she had given medications to Resident #1 when she had been in pain. She also stated there should be more than one pain assessment completed on Resident #1 due to her having pain a lot. She stated a nurse giving the resident pain medication since she had been admitted should have completed a pain assessment on Resident #1. She stated the nurse would document the pain level on the MAR when they interact with a resident. LVN B stated, however, the resident may have pain during the shift and there was not a place on the MAR to document that pain. She stated when a resident had pain during the shift where the pain is located, and the pain level was required to be documented in the nurses notes prior to administering pain medication. She also stated if the pain was not a zero, a pain assessment was required to be completed. She stated she was surprised that only MDS Nurse completed a pain assessment. In an interview on 09/22/2023 at 9:55 AM, LVN F stated if any staff reported a resident was having a new pain and their knee was swelling, she would immediately go to that resident's room and assess the resident. She stated she would complete a pain assessment and if resident were in severe pain and has stated her leg was broken, she would contact the MD immediately and if the MD did not return call within 5 minutes, she would immediately call 911. She stated if a nurse did not complete an assessment on the resident or ask the other staff questions of what might have caused the knee to swell, she did not follow proper protocol. LVN F stated the nurse was expected to assess residents whenever there is a change of condition and a new pain in the knee with swelling and the resident yelling her leg was broken, that is a change of condition. She stated she did not give care very often to Resident #1, but she did know Resident #1 would yell when she was only in pain. She stated Resident #1 should not have stayed in the facility all night if she said her left leg was broken, if her left knee was swelling, and she was in extreme pain . She stated Resident #1 needed to be transferred to the emergency room the night of 09/18/2023. She stated anytime a resident voices pain to a nurse, or another staff reports a resident was in pain the nurse was to complete pain assessment. She stated the nurse was required to ask the resident where the pain is located and the pain level using the pain scale of zero which indicated no pain and a ten which indicated extreme pain. She s[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that licensed nurses had the specific competencies and skills sets necessary to care for residents' needs as identified through resident assessments and described in the plan of care for one of one resident (Resident #1) one of one nurses and one of one COTA reviewed for competent nursing staff. The facility failed to ensure nursing staff were properly trained and nursing staff failed to report to management when the nurse gave the COTA a pain pill to administer to Resident #1. This failure could place residents at risk for serious injury, serious harm, serious impairment, or death. The findings include: Record review of Resident #1's face sheet, dated 09/22/2023, revealed Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses which included low back pain ( pain between the lower edge of the ribs), signs symptoms of musculoskeletal system ( mild to severe aches, low back pain, numbness, tingling, atrophy, and weakness), muscle weakness ( a lack of strength in the muscles), osteoporosis without current pathological fracture (generally caused by a fall from a standing height or lower and usually involves the spine, hip or wrist), lack of coordination (uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements) left foot drop ( caused by weakness of the muscles involved in lifting the front part of the foot) and, abnormalities of gait and mobility (when a person is unable to walk in the usually way). Record review of Resident #1's Annual MDS assessment, dated 07/28/2023, reflected Resident #1 had a BIMS score of fifteen, which indicated the residents' cognition was intact. Resident did not reject care. Resident #1 was assessed to require extensive assistance by two staff members for transfers. She required extensive assistance by one staff for bed mobility and toileting. Resident #1 was also assessed to require limited assistance by one staff for personal hygiene. She was assessed require staff to stabilize her when moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer. Resident #1 was on scheduled pain medication and PRN pain medication. She had frequent pain. Resident #1 did not exhibit any behaviors. Record review of Resident #1's Comprehensive Care Plan completed on 08/17/2023 reflected Resident #1 had an ADL self-care performance deficit. Interventions: resident required extensive assistance by two staff members with transfers. Resident #1 required extensive assistance by one staff members with bed mobility. Resident #1 was at risk for falls related to gait/balance problems. She had limited physical mobility. Resident had chronic pain related to osteoporosis (a condition when bone strength weakens) Interventions: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Identify and record previous pain history and management of that pain and impact of function. Identify previous response to analgesia including pain relief, side effects and impact on function. Monitor/ document for probable cause of each pian episode. Remove/limit causes where possible. Resident #1's further interventions were: Monitor/document for side effects of pain medication. Administer analgesia as per orders. Give ½ hour before treatments or care. Notify the physician if interventions are unsuccessful or if current complaint is a significant change from resident's experience of pain. Provide the resident and family with information about pain and options available for pain management. Discuss and resident preferences . Record Review of the video provided by the family member on 9/18/2023 reflected COTA/ Marketing Coordinator and PTA was in Resident #1's room. The COTA/ Marketing Coordinator exited Resident #1 room at 6:09 PM. PTA stayed in Resident #1 room and was talking to Resident #1. Resident #1 stated several times I think it is broken as she was rubbing her left leg. COTA/ Marketing Coordinator entered Resident #1's room and at 6:12 PM she began to open the small clear plastic pouch with medication been crushed and poured it into a medication cup. COTA/ Marketing Coordinator opened a small container of apple sauce and put apple sauce in the medication cup with the medication. COTA / Marketing Coordinator began to stir the medication in the cup and at 6:13 PM the PTA poured some more crushed medication into the cup. COTA /Marketing Coordinator asked Resident #1 if she wanted her medicine. She also asked Resident #1 if she wanted to take one big bite and at 6:13 PM COTA/ Marketing Coordinator gave Resident #1 her medication. COTA/Marketing Coordinator asked Resident #1 how long it took for her medicine to help her. Record review of Resident #1's medication administration record for the month of 09/2023 reflected on 09/18/2023 there was not any medication signed out by anyone around the time of 6:09 PM. The PRN medication was signed out be LVN A at 6:50 PM and at 11:41 PM. In an interview on 09/20/2023 at 2:41 PM, the COTA /Marketing Coordinator stated she reported to LVN A on 09/18/2023 from 6:00 PM, until approximately 09/18/2023 at 8:25 PM of Resident #1 complaining of pain in knee and left leg. She stated she also reported to LVN A that Resident #1 was making statements her knee was broken. She stated she explained to LVN A Resident #1 was in severe pain. She stated LVN A made the remark that that is normal for Resident #1, she was always complaining about being in pain and that was nothing new. The COTA/Marketing Coordinator stated LVN A was informed of the information at approximately 6:10 PM and LVN A did not go to Resident #1's room until approximately 8:30 PM. She stated either she or the PTA was always in Resident #1's room from around 6:00 PM until 8:45 PM. She stated LVN A would not go to Resident #1's room to administer pain medication and the resident was in pain for at almost 2 hours. She stated she asked LVN A to give her the pain medication and she would administer it to Resident #1. She stated LVN A gave her the pain medication (Norco) and she gave it to Resident #1. She stated she could not sit by and watch Resident #1 be in pain for an hour or more and the nurse refused to go to Resident #1's room due to believing Resident #1 was complaining for no reason. She stated it was difficult to even talk to LVN A due to her expressing no compassion towards Resident #1 and not wanting to assess her to determine if anything was wrong with Resident #1. She also stated she called the Administrator on 09/18/2023 (did not recall the time). She stated she informed the Administrator of Resident #1's pain and swelling in the left knee. She stated the Administrator advised her to speak with the nurse and explain to the nurse to call the MD and have x-rays ordered. She stated she spoke with LVN A and explained the Administrator stated to call the MD and have x-rays ordered. She stated LVN A was organizing to pass out medications and began to pass medications and there was not an emergency occurring where she could not stop what she was doing to go to Resident #1's room. She stated she did not feel comfortable leaving Resident #1 on 09/18/2023 due to LVN A not going to Resident #1's room to complete an assessment or make any type of observation of why Resident #1 was in extreme pain. She stated Resident #1's left knee continued to become larger, and she was going to report Resident #1's condition approximately every 10 minutes and the nurse stated to the COTA/Marketing Coordinator that Resident #1 was ok, that is the way Resident #1 always was and there was not anything wrong with Resident #1. She stated around 8:30 PM LVN A entered Resident #1's room and stated Resident #1's left knee does not look any different than it has in the past. The COTA/Marketing Coordinator stated that LVN A informed her and PTA C to go home, she had this and promised to take care of Resident # 1. She stated LVN A did not assess Resident #1. The COTA/Marketing Coordinator stated when she came on duty on 09/19/2023 the ambulance was in front of the facility transferring Resident #1 to the hospital. She stated she was shocked and could not believe LVN A allowed Resident #1 to remain in the facility that night without getting an x-ray or doing anything to ensure Resident #1 did not have any broken bones. The COTA/Marketing Coordinator stated she did believe LVN A was neglecting Resident #1. She stated LVN A refused to go to Resident #1's room and complete an assessment approximately 2 hours after being informed of Resident #1's left knee/leg pain and Resident #1 stating she thought her leg was broken. She stated she was upset, and the nurse ignored her whenever she reported anything about Resident #1. She stated LVN A neglected Resident #1 on 09/18/2023. In an interview on 09/21/2023 at 12:00 PM, PTA C stated the COTA/ Marketing Coordinator asked her to help her transfer Resident #1 from her recliner to the wheelchair and then to the bed. She stated that occurred 09/18/2023 approximately 6:00 PM. She stated Resident #1 was transferred from the recliner to the wheelchair and Resident #1 complained about her back hurting after the transfer. She stated Resident #1 was assisted by the bed in her wheelchair to prepare for the transfer from the wheelchair to the bed. She stated once Resident #1 was in her wheelchair by the bed she was calm and quit complaining about her back hurting. PTA C stated the COTA/ Marketing Coordinator was in front of the resident and placed the gait belt around the resident's waist. She stated they began to transfer Resident #1 to the bed and as soon as they pivoted Resident #1 onto the bed, she began to yell her knee hurt. PTA C stated she assumed it was similar of her complaining about her back pain. She stated at some point Resident #1 stated her left leg was broken. PTA C also stated she realized that was a different type of pain than what she has complained in the past. She stated the COTA/ Marketing Coordinator left the room to report to LVN A. She stated they kept waiting on pain medication or the nurse to assess Resident #1 due to her knee continuing to swell and becoming larger. She stated Resident #1 would yell in pain when her leg was barely touched or moved. Resident #1 would rub her knee and below the knee onto her left leg and stated it was broken. PTA C stated LVN A would not go to Resident #1's room to give her pain medication or assess her. She stated the nurse gave the COTA/ Marketing Coordinator the pain medication and the COTA/ Marketing Coordinator gave Resident #1 the pain medication. PTA C stated she did not recall the time, but she thought it was around 7:00 PM. She stated LVN A entered Resident #1's room at approximately 8:30 PM. She stated she was in the room while LVN A talked to Resident #1. PTA C stated LVN A looked at Resident #1's knee for approximately 5 seconds and stated her knee is fine. PTA C stated LVN A did not assess Resident #1 or ask her if she was hurting in other areas. She stated LVN A did not ask Resident #1 what her pain level was or if the pain medication was effective. She also stated LVN A did not realize PTA C was in the room. PTA C stated when LVN A saw her in the room she stated, oh are you a family member I did not know anyone was in the room. PTA C stated, no I am not a family member I am a Physical Therapist Assistant at this facility, and I helped assist Resident #1 to be when she began complaining about her knee PTA C stated LVN A did not ask her any questions about the transfer or anything about Resident #1. PTA C stated she informed LVN A that she and the COTA/ Marketing Coordinator had been in the room with Resident #1 since around 6:00 PM after she began complaining about pain in her left knee and stating her left leg was broken. She stated LVN A walked out of the room and stated she is fine; she always complains about pain. She also stated LVN A was preparing to pass out medications and began to pass out meds to residents and there was not an emergency and LVN A could have stopped what she was doing and came to Resident #1's room. 1. In an interview on 10/18/2023 at 11:35 AM, the Director of Nurses stated only a licensed nurse or a medication aide was the only staff to administer any type of medication to a resident. She stated a non-nurse staff would not know if she was administering the correct medication. She stated it was not the facilities protocol for a non-nurse to administer any medication. She stated a resident could choke and there were protocols to follow when administering medications such as: ensuring it is the correct person by viewing the resident picture on the medication administration record, the nurse required to check to ensure it was the correct medication, ensure it was given at the right time and it was the right dose. She stated if a non-nurse was giving the medication how did that person know the nurse completed all of these precautions prior to placing medicine in the cup and give the medication to the non-nurse. She stated this is not the facility protocol. In an interview on 10/19/2023 at 10:40 AM, Med Aide E stated she had been a Med Aide approximately 10 or 15 years and she stated she was taught in med-aide class it was not protocol for a med-aide or a nurse to give medication to a non -nurse staff to administer to a resident. She stated if a nurse or med-aide signs the medication administration form that the nurse or med-aide gave the medication and then give the medication to a non-nurse, a nurse or med-aide could lose their license. She stated anything could go wrong with a non -nurse administering any type of medication. Med Aide E stated how does the nurse knows the non -nursing staff will give it to the resident. She also stated there were certain residents required their medication be administered a certain way such as in pudding or may need extra water to ensure the resident swallowed the pill. She stated this was against nursing protocol and she would never allow anyone give medication she had put her initial on the medication administration record. She stated whoever signs the record they are responsible for the medication. Med-Aide E also stated if a nurse gave medication to a non-nurse staff the nurse was 100 percent wrong. She stated a resident could choke on the medication, may pocket the medication, and not swallow the medicine. She stated there was a cluster of mistakes possibly could occur with the resident. She also stated when administering medications, the nurse or med-aide was expected to look at the picture on the MAR prior to administering the medication. She stated she had been in serviced on medications on 10/19/2023 from the ADON. She stated the ADON discussed all medications was only to be administered by nurses and med-aides and if you are not a licensed nurse or medication- aide do not take any medications from the nurse or medication aide and administer the medication to a resident. In an interview on 10/19/2023 at 10:50 AM CNA P stated she received an in-service on medications from the ADON on 10/19/2023. She stated anyone who was not a nurse or medication -aide was not to give medicines to a resident or take medications from the nurse or med-aide. In an interview on 10/19/2023 at 11:15 AM, LVN D stated the ADON gave an in-service on 10/19/2023 about not giving medications to a non-nurse staff for them to administer medication to a resident. She stated it could be dangerous for the resident if a non-nurse gave a resident medication. She stated a resident could choke and how did the nurse know the staff would not take the medication themselves and not give it to the resident. She stated when she gives medications, she views the medical medication record and compares it to the medicine located in the package. She stated when she determined it was the correct medication, she would place the pills in a medicine cup. She stated after she completed this process with all the medicines a resident takes, she would compare the resident to the picture on the mar and then administer the medication. She stated if a resident required medications to be crushed, she would crush the medicines. She stated a resident receiving medication from a non-nurse may choke or have difficulty with swallowing med or may prefer to take the medication a certain way such as place the pill in a certain area in the resident's mouth. In an interview on 10/19/2023 at 1:00 PM the Administrator stated she as in serviced on medications by the Corporate Nurse she stated a non-nurse was not qualified to administer medications. She stated only nurses and med-aides were qualified to administer medications. When asked her the potential of what may happen to a resident or with the medication if a non-nurse administer medication to a resident, the Administrator stated she was no clinical and was not answering any questions about medications or the potential result of non-nurse giving medications. That would be a nursing question not an Administrator question. She stated again she was not clinical and don't know what a nurse was supposed to do when administering medications. I will have to refer to the facility policy and protocol I am not familiar with it at this time. When the Administrator was asked if she was not in serviced by the corporate nurse today, she stated I will not answer any questions. The administrator left the conference room and did not return for further interview. 2. In an interview on 10/19/2023 at 1:20 PM the ADON stated she stated gave in-service on 10/19/2023 to all staff about medications. She stated she in serviced all staff related to only licensed nurses and medication-aides were the only staff to administer any type of medication to a resident. She stated there was a possibility a resident could choke when given a medication and if a non-nurse was giving the medication there were several negative possibilities could happen to the resident. The ADON stated she could keep naming them, but she believed point was made of negative outcome with possible choking. She stated there were 5 rights on giving medications. She stated all nurses and med-aides was expected to follow the 5 rights: Right Person, Right Medication, Right Route, Right Time, Right Dosage The ADON stated when a nurse was administering medication it was expected for the nurse to view the resident picture in the medication administration record and to ensure when administering the medication, it was to the right person and had the right dose and medication. She stated as a nurse she would not expect a non-nurse to administer medications. She stated she did not have any idea how the non -nurse would know if she was giving the right medication. The ADON also stated she did not know why the nurse gave the medication to the non-nurse. She stated she was not aware of the knowledge the non-nurse had about medications. Record Review of the in-service on Medication Administration given by the ADON ( the in-service was not dated but was verified by the Administrator this was the in-service given to all the staff by the ADON. The in-service consists of the following: 1. All medications should only be administered by a licensed nurse or medication aide. 2. If you are not a licensed nurse or medication aide. Do not take medication from a licensed nurse or medication aide and administer the medication to a resident. Record Review of in-service on Medication Administration given by the Administrator and Corporate Clinical Specialist on 10/19/2023. A video was shown to all staff on medication administration training from the corporate you tube video. The video explained how to administer medication correctly. There were not any details about the video shared prior to exit. Record Review of in-service on medications not dated, however, it came from a binder dated January 2023 to June 2023. The in-service was on medications need to be given in a timely manner. Medication times are part of the five medication rights such as: 1. Right person 2. Right medication 3. Right time 4. Right route 5. Right dosage LVN A attended this in-service. Record Review of the facility policy on Administering Medications dated 04/2019 reflected the following: 1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. 2. The individual administering medications verifies the resident's identity before giving the resident his/her medications. 3. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication. The individual administering the medication initials the resident's medication administration records in the resident's medical record: the date and time the medication was administered, the dosage, the route of the administration, any complaints or symptoms for which the drug was administered, any results achieved and when those results were observed and the signature and title of the person administering the drug.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to implement comprehensive care plans that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. for one (Resident #27) of three residents reviewed for care plans. The facility failed to implement a comprehensive care plan for Resident #27. This failure could place residents at risk of not meeting their immediate needs, long term and or short-term goals, and and interventions. Findings included: Record review of Resident #27's admission MDS dated [DATE] revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Hemiplegia (paralysis) affecting the left side, Diabetes Mellitus (high blood sugar), and Hyperlipidemia (high cholesterol). With a BIMs of 15 (cognitively intact). Resident #27 is visually impaired, with verbal behavioral symptoms towards others, she requires limited to extensive assistance with ADLs, she requires set up and supervision during meals, and has occasional incontinence. Record review of Resident #27's Care Plans revealed there was a total of three care plans initiated on 6/20/23. The care plans available were the use of antidepressant (Sertraline), the use of antipsychotic (Keppra), and the use of anti-anxiety (Hydroxyzine). Further investigation revealed there were no person-centered comprehensive care plans available. Record review of Resident #27's Fall Scale Evaluation dated 6/11/23 revealed she was a high fall risk. Record review of Residents #27's care plans dated 6/20/23 revealed there was no short-term or long-term fall care plan was available. Interview with LVN E on 07/13/23 at 11:46 AM revealed the MDS nurse was the one responsible for doing the person-centered comprehensive care plans. MDS nurse does care plans for new admissions and updates them for short-term and long-term issues. She stated the charge nurses do not do any care plans; they only do the baseline care plan assessment upon admission. She stated that the risk of not having up to date care plans could be that the nurses would not know the right interventions for the residents, and they would not get adequate care. Interview with MDS F on 07/13/23 at 12:52 PM revealed MDS was responsible for completing all care plans with the help of the DON. She stated the DON opened the care plans on admission, and she completed them within 7 days of completing the MDS assessment. She stated she was responsible for both short term and long-term care plans. She stated the short-term care plans were updated during morning meetings and long-term care plans were updated with MDS assessments. She cannot recall any breakdown or issues with care plans being missed. Interview and record review with MDS F on 07/13/23 at 2:09 PM revealed Resident #27 did not have comprehensive care plans and there were only three medication care plans available. She stated there should be more care plans to include other areas for the residents such as medical care, behavioral care, activities, dietary, fall prevention, and they should be person centered, she was not sure how they were missed. She stated the risk of not having up to date care plans could lead to complications and further decline of the resident. To avoid missing care plans she stated she will bring her laptop to their morning meetings to assess any short-term and long-term changes of the residents and discuss with IDT. Record review of Resident #27's Care Plan dated 06/20/2023, revealed person-centered comprehensive care plans were initiated and created on 07/13/23. Comprehensive care plans were provided at the conclusion of the survey. Interview with ADON/Staffing Coordinator on 07/13/23 at 2:13 PM revealed MDS F and DON were responsible for care plans, which also included the comprehensive person-centered care plans. MDS F also was responsible to complete the short-term and long-term care plans. She stated the CNAs could see the interventions for the residents based on the [NAME]. She stated her expectation was that the care plans would be completed according to the facility policy. She also stated the risk for the care plans not being up to date would be the CNAs and nurses would not know how to properly care for the resident. Interview with CNA G on 07/13/23 at 2:18 PM revealed she would be able to see how to care for the residents by looking in the [NAME]. This is where she would be able to see if the resident had specific interventions like if they are a fall risk. Interview with DON on 07/13/23 at 2:22 PM revealed MDS nurse was responsible to complete short-term and long-term person-centered comprehensive care plans. She stated that she opened them on admission and MDS F completed them within 7 days of completing the MDS assessment. She stated her expectation was that the care plans should be documented within the patient chart that includes goals and interventions. Her expectation was that MDS F would update care plans quarterly and as needed. Missing care plans for Resident #27 would be reviewed along with all residents moving forward to ensure completion. Risks to residents of gaps in care plans would be they would not be cared for properly. Record review of policy titled Care Plans, Comprehensive Person-Centered with a revision date of [DATE] revealed comprehensive, person-centered care plans will be developed within 7 days of the completion of the required comprehensive assessment (MDS). It also revealed that comprehensive, person-centered care plans that includes measurable objectives and timetables to meet the residents physical, psychosocial, and functional needs is developed and implemented for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week in the facility for 9 (RN coverage days) of 101 days reviewed for RN coverage. The ADON/Staffing Coordinator failed to have an effective documentation and tracking system and was unaware of which RN's worked when she reviewed the schedule sheets and based on the timesheets, there was not 8 hours of RN Coverage on: 05/13/23, 05/14/23, 05/29/23, 06/11/23, 06/22/23, 07/06/23, 07/07/23, 07/09/23 and 07/10/23. These failures could place all residents at risk of not having an adequate amount of higher level nursing services which could result in a decline in the residents mental, physical and psycho-social well-being. Findings included: Record review of the facility's staff roster, undated indicated the facility had two RN Nurse Supervisors and one DON. Record review of the facility's 672 CMS form (Resident Census and Conditions of Residents) dated 07/13/23 revealed a census of 29 residents. Record review of the Facility's May Staff Schedule Sheet from 05/01/23 to 05/31/23 revealed no RN Coverage for 24 days: 05/01/23, 05/02/23, 05/03/23, 05/04/23, 05/05/23, 05/07/23, 05/08/23, 05/09/23, 05/10/23, 05/11/23, 05/12/23, 05/15/23, 05/16/23, 05/17/23, 05/18/23, 05/19/23, 05/22/23, 05/23/23, 05/24/23, 05/25/23, 05/26/23, 05/29/23, 05/30/23 and 05/31/23. Record review of the Facility's June Staff Schedule Sheet from 06/01/23 to 06/30/23 revealed no RN Coverage for 19 days: 06/01/23, 06/02/23, 06/05/23, 06/06/23, 06/07/23, 06/08/23, 06/12/23, 06/13/23, 06/14/23, 06/15/23, 06/18/23, 06/20/23, 06/21/23, 06/22/23, 06/26/23, 06/27/23, 06/28/23, 06/29/23 and 06/30/23. Record review of the Facility's July Staff Schedule Sheet from 07/01/23 to 07/13/23 revealed no RN Coverage for 9 days: 07/03/23, 07/04/23, 07/05/23, 07/06/23, 07/07/23, 07/10/23, 07/11/23, 07/12/23 and 07/13/23. A) Record review of RN A's time sheets 05/01/23 to 07/04/23, provided by the ADON/Staffing/ Coordinator revealed she worked 8 hours or more per day on 05/06/23, 05/07/23, 05/20/23, 05/21/23, 05/27/23, 05/28/23, 06/03/23, 06/04/23, 06/09/23, 06/10/23, 06/19/23, 06/23/23, 07/01/23, 07/02/23 and 07/04/23. Record review of the Facility's Staff Schedule Sheets for May 2023, June 2023 and July 2023 revealed RN A worked 05/06/23, 05/13/23, 05/14/23, 05/20/23, 05/21/23, 05/27/23, 05/28/23. 06/03/23, 06/04/23, 06/10/23, 06/11/23, 06/17/23, 06/19/23, 07/01/23 and 07/02/23. B) Record review of RN B's time sheet dated 06/01/23 to 06/30/23, provided by ADON/Staffing Coordinator revealed she worked 8 hours or more on 06/17/23, 06/24/23 and 06/25/23. Record review of the Facility's Staff Schedule sheets for May 2023, June 2023 and July 2023 undated revealed RN B worked 05/06/23, 06/24/23 and 06/25/23. C) Record review of the DON's time sheets dated from 06/20/23 to 07/13/23, provided by the ADON/Staffing Coordinator revealed she worked 8 hours or more on 06/20/23, 06/21/23, 06/26/23, 06/27/23, 06/28/23, 06/29/23, 06/30/23, 07/03/23, 07/05/23, 07/11/23. Review of the Facility's Staff Schedule sheets for June 2023 and July 2023 undated revealed the DON did not work any days in June 2023 or July 2023. Record review of the facility's Direct Care Staff Daily Assignment Sheet/Sign in Sheets from 06/22/23 to 07/11/23, provided by ADON/Staffing Coordinator revealed the DON worked 06/22/23, 07/05/23, 07/06/23, 07/07/23, 07/10/23, 07/11/23. D)Record review of the facility's May 2023, June 2023 and July 2023 Schedule Sheets revealed the Clinical RN Clinical Specialist worked on 06/09/23, 06/16/23, and 06/23/23. E) Record review of the Staffing Agency time sheets dated 05/03/23, 05/04/23, 05/05/23, 06/18/23 and 07/08/23 revealed Shift details .RN nurse's name . shift resolution: Resolved .Provider Worked Shift. In the top right hand corner. F) Record review of the Staffing Agency time sheet dated 07/09/23 revealed, Shift opening, Shift details .Specialty: Registered Nurse did not have a RN nurse's name on it and no shift resolution and it did not indicate a provider worked shift, in the top right hand corner. Record review of the CMS PBJ Staffing Data Report ([DATE] - March 31 2023) run date 07/06/2023 revealed this facility triggered for A One star rating, No RN hours and failed to have licensing nursing coverage 24 hours/day revealed Infraction Dates: No RN hours 01/01 (SU); 01/03 (TU); 01/04 (WE); 01/05 (TH); 01/06 (FR); 01/09 (MO); 01/10 (TU); 01/11 (WE); 01/12; (TH); 01/13 (FR); 01/14 (SA); 01/15 (SU); 01/16 (MO); 01/17 (TU); 01/18 (WE); 01/19 (TH); 01/20 (FR); 01/21 (SA); 01/23 (MO); 01/24 (TU); 01/25 (WE); 01/26 (TH); 01/27 (FR); 01/30 (MO); 02/01 (WE); 02/07 (TU); 02/08 (WE); 02/09 (TH); 02/10 (FR); 02/13 (MO); 02/14 (TU); 02/15 (WE); 02/16; (TH); 02/17 (FR); 02/18 (SA); 02/19 (SU); 02/20 (MO); 02/21 (TU); 02/22 (WE); 02/23 (TH); 02/24 (FR); 02/25 (SA); 02/26 (SU); 03/01 (WE); 03/02 (TH); 03/03 (FR); 03/06 (MO); 03/07 (TU); 03/08 (WE); 03/09 (TH); 03/10 (FR); 03/11; (SA); 03/12 (SU); 03/14 (TU); 03/15 (WE); 03/16 (TH); 03/17 (FR); 03/20 (MO); 03/21 (TU); 03/22 (WE); 03/23 (TH); 03/24 (FR); 03/27 (MO); 03/28 (TU); 03/29 (WE); 03/30 (TH); 03/31 (FR) .Failed to have Licensed Nursing Coverage 24 Hours/Day 01/01 (SU); 01/03 (TU); 01/06 (FR); 01/07 (SA); 01/11 (WE); 01/14 (SA); 01/15 (SU); 01/20 (FR); 01/21; (SA); 01/25 (WE); 01/30 (MO); 02/09 (TH); 02/17 (FR); 02/18 (SA); 02/19 (SU); 02/22 (WE);03/18 (SA) . Record review of the PBJ Staffing Summary Report for 2023 2nd Quarter (01/01/23 - 03/31/23) run date 07/11/23 provided by the Administrator revealed staffing hours: One Registered Nurse Director of nursing - 45.00 hours, two Registered Nurses - 153.11 hours . Interview on 07/11/23 at 4:00 pm, the ADON/Staffing Coordinator stated they used Agency staffing for RN coverage at times and said since being at this facility for the past three months, they always had RN coverage. She stated they had a DON and two RN weekend supervisors. She stated she was responsible for ensuring they had enough RN's for the weekends and the DON worked Monday - Friday. She stated RN A worked every weekend and if she could not work she asked RN B about working and if she could not, she contacted the Staffing Agency for RN coverage. She stated the staff had to contact her four hours before their shift to call off. She stated they did not have enough staff and needed three LVN's and one PRN RN Supervisor to work the weekends. She stated she could only go back to 04/01/23 for the timesheets because they had a CHOW on 04/01/23. She stated RN coverage was needed because the LVN's practice only went so far like they could not pronounce a death, sign off on care plans, do picc line dressings and if staff ever had a question they had an RN to go to. She stated for 05/13/23 and 5/14/23 she was not sure if RN A worked those days and thought maybe a Corporate RN came in and RN A was sent home. She stated she was not told by the Administrator or anyone else if an RN agency nurse worked those days. Interview on 07/13/23 at 10:75 am, RN A stated she had retired and was an RN nurse who worked at this facility PRN and usually worked two weekends/four days out of the month and the other RN B covered working the other two weekends. She stated she did not work too often. She stated on 05/13/23 she worked for 4 hours and did not work 05/14/23 and thought RN filled in for her. She stated she was not sure if she worked 6/11/23 - 06/18/23 but she worked on 06/19/23, 06/23/23, 07/01/23, 07/02/23 and 07/04/23. She stated RN's were needed to make critical decisions and supervise the staff to ensure the residents had quality of care and was within the state regulations. Interview on 07/13/23 at 3:55 pm, RN B worked here at times as a PRN RN nurse and last worked here a few weekends back and passed out meds in June 2023 and was not sure if she worked 6/11/23 but did not work May 2023. She stated she had not worked July 2023 and added she was a PRN RN and RN A worked more than she did at this facility. Interview on 07/13/23 at 12:33 pm, the ADON/Staffing Coordinator stated RN A worked 06/11/23 and 06/12/23 and said she was not sure why RN A missed punch sheet was not filled out all the way showing she worked 06/11/23. She stated on 5/13/23 RN A worked four hours and was not sure why and would have to get on the phone and talked to her. She stated the Corporate RN's sat in her office but did keep up with when they worked and had no documentation to prove they worked. She stated on 07/09/23 she was not able to confirm an agency nurse worked because there was no RN listed on the time sheet form. She stated RN A covered pretty much every weekend. Interview on 07/13/23 at 2:29 pm, the DON stated she started work at this facility on 06/20/23 and had to call off work on 6/22/23 and 6/23/23 because she got sick and week after that on 07/06/23 and 07/07/23 she took off from work because she had a family emergency. She stated she was pretty sure the facility had RN coverage as far as she knew. She stated they had two RN Supervisors and herself working at this facility and the designated RN supervisor for the weekends was RN A and RN B was the other RN who worked the other weekends. She stated they also used agency nurses for RN coverage at times and stated she was not aware of any inconsistencies with the RN timesheets and schedule sheets. She stated the ADON/staffing coordinator was responsible for ensuring they had sufficient RN coverage. She stated the facility needed 8 hours of RN coverage for supervision of the clinical staff, the LVN's and CNA's and was a state regulation. She stated they did not have a nurse waiver in place and stated if there was no RN at the facility no one would be able to pronounce a death, pull picc line, have a delegation of duties and supervision of the staff. She stated her expectations for RN coverage was to meet the standard for RN coverage. Interview on 07/13/23 at 2:50 pm, the Clinical RN Specialist stated they did not have any nursing waivers and this facility had a CHOW on April 1, 2023, and added they had proof of RN coverage at all times and if the facility did not have RN coverage in the building she or other Corporate RN's worked. She stated her and the other corporate RN hours did not sign the sign in sheets. She stated she was not sure why the Agency RN's name was not on the timesheet for 07/09/23 and thought the RN who worked had not logged in her time yet. She stated the ADON/Staffing Coordinator was good about letting her know when they needed to get an Agency RN and believed RN A worked the weekends but was not sure if she worked every weekend. She stated RN B worked but was not sure how often she worked here and the last time she worked here was last month. She stated they were trying to hire more RN's by posting on the job board Indeed. She stated the facility needed 8 hours RN coverage daily for overseeing the LVN's and making sure they were not doing anything out of their scope, communication with the Doctors and family members and took the DON duties on the weekends and to ensure everyone was being taken care of. She stated the RN's assisted with the resident's plan of care, removing picc lines, pronouncing death, changing out central lines and hub needles. She stated ADON/Staffing Coordinator tried to get the nursing schedule created a week in advance and if someone called off and she could not find a replacement she would let her know. She stated they had a policy that the staff must call the ADON/Staffing coordinator no later than two hours prior to starting their shift. She stated she was not aware of any inconsistencies between the time sheets and assignment sheets and added they had a good system with tracking the RN coverage hours. She stated the training was pending with new DON who just started working here 06/20/23 to assist with tracking the RN hours. She stated the DON called off one day Friday 6/23/23 she worked in the DON's place and thought that RN A worked 6/22/23 but was not sure, then the DON was off for a family emergency in July 2023 and think agency RN's worked in her place but was not sure. She stated the DON was responsible for ensuring they had RN coverage in the building and the administrator should follow-up to ensure it. She stated on 5/13/23 and 5/14/23 she was on vacation she did not work. She stated she had not done the orientation with the new DON so that they would have a better way of tracking and documenting to ensure they had RN coverages and was not sure why RN A timesheet on 06/11/23 was different from what was on the schedule sheet, then stated RN A had a mis-punch on 06/11/23 but was not able to provide a completed form with signatures from RN A and supervisor to confirm it. She stated when the RN's worked they needed to sign the schedule sheets also which was making it hard for them to determine who worked when. She stated RN A and DON had some issues with missed punches and could not provide proof they worked on certain days. She stated everyone had staffing challenges, but they figured it out and said she was getting ready to do an orientation training next week with the new DON who was going to do great here. Interview on 07/13/23 at 4:09 pm, the [NAME] President of Clinical Services stated she and the Corporate Representative reviewed the daily RN coverages to ensure there was 8 hours of RN coverage or more daily then submitted them with the other staffing data to CMS quarterly and said she was not aware of any RN coverage issues at this facility. Interview on 07/13/23 at 5:33 pm, the Administrator stated working at this facility since 12/01/22 and the facility did not have a nurse waiver. He stated he was not aware CMS had the facility listed with a one star rating because of not having enough RN hours since 10/01/22. He stated they had DON H in December 2022 until March 2023 and from March 2023 to April 2023 the facility had Acting DON D . He stated they did not have a fulltime DON from May 2023 to June 20, 2023, but the Clinical RN Specialist worked here at various times but was not sure of the actual days she worked and no documentation to confirm. He stated the facility was currently looking for a designated RN weekend supervisor to work the weekends because RN A and RN B work PRN weekends. He stated not being aware of any issues with the ADON/Staffing Coordinator not updating the schedule sheets if they changed and was not aware of any issues with her being able to keep track of the RN hours. He stated after review of RN A's timesheet dated 06/11/23 and schedule sheet 06/11/23 and was not really sure why there was inconsistencies with RN A's timesheets and schedule sheets. He stated the DON was responsible for ensuring the facility had RN coverage, the Administrator said they needed to find a better way to document on the assignment sheets for RN coverage. He stated the facility was not using RN Agency in December 2022 because the facility had RN coverage daily since he worked here and with the help of the Corporate RN's and agency staffing. He stated he had no proof the Corporate RN's worked at the facility because they were salaried and would talk to Corporate about getting the Corporate RN to sign their names on the assignment sheets. He stated the facility needed to create a better schedule sheet for better record keeping. He stated the staff were supposed to notify the ADON/Staffing Coordinator if they called off 4 hours prior to starting their shift so the ADON/Staffing Coordinator had to find the nursing coverage by first contacting the PRN RN's and if they could not work then get an agency staff and if that failed to find coverage she was supposed to call him so he could help. Interview on 07/13/23 at 6:11 pm, the Business Office Manager stated she worked here 12 years and said they have had a few DON's within the past year. She stated she was not really sure, but DON D was the acting DON from April 2023, and she stopped working here May 2023. She stated they had two RN Supervisors RN A and RN B and was not aware of any RN coverage issues and RN A worked as far as she knew was the main RN supervisor on the weekends. She stated RN B did not work too much and that they were currently looking for more RN's using the job posting board Indeed and used agency nursing staff. She stated she was not aware of any RN coverages issues from October 2022 to current. Record review of the facility's RN Position Description updated 04_2017 revealed, Job Summary: Registered nurses oversee the activities of the nursing staff. The RN is responsible for overseeing each patient's overall health and medical histories .RN's are also responsible for advanced activities such as starting intravenous infusions, administering oxygen, monitoring blood sugar levels and consulting with the supervising physicians . Record review of the facility's Staffing, Sufficient and competent Nursing policy revised 03-2023 revealed, Policy statement: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with the resident care plan and the facility assessment .Sufficient Staff .A registered nurse provides services as least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the residents .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to use the results of an assessment to develop, review and revise a comprehensive care plan of each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for one of thirteen residents reviewed for care plans. (Resident #24) The facility failed to ensure Resident #24 comprehensive care plan was updated and reflected a revision of his plan of care after a significant change MDS assessment was completed on 05/04/2022 which indicated Resident #24 was placed on Hospice services. This deficient practice placed residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury, a decline in physical well-being. Findings included: Review of Resident #24's face sheet dated 05/24/2022 reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses Vascular dementia, Fracture of right ilium and anxiety disorder. Further review of Resident #24's face sheet reflected her payer source was hospice. Review of Resident #24's Consolidated Physician order report dated 04/23/2022 through 05/25/2022 reflected Resident #24 had an order dated 04/27/2022 admit to hospice. Review of Resident #24's Significant Change in Status MDS dated [DATE] reflected Resident #24 did not have a BIMS score conducted and was assessed to have severe cognitive impaired. Resident #24 was assessed to require dependent assist with ADLs. Further review of Resident #24's MDS reflected Resident #24 was assessed to have hospice care while a resident. Review of Resident #24's Comprehensive Care Plan reflected no plan of care for Resident #24's hospice status. Observation and interview on 05/23/2022 at 1:50 PM revealed Resident #24 in room in bed with family at bedside. Resident #24's FM stated Resident #24 had a fall at the facility and broke her pelvis. The FM stated she had no concerns about the fall but Resident #24 was not able to have surgery and Resident #24 was placed on hospice services for pain control. In an interview on 05/25/22 at 9:50 AM LVN G the MDS nurse stated she was in charge of developing comprehensive care plans after MDS assessments were completed. LVN G stated Resident #24 was on hospice. LVN G stated she did not care plan hospice for Resident #24 after doing her significant change MDS on 05/24/2022. LVN G further stated she just missed it. A policy for developing comprehensive care plans was not provided to Surveyor prior to exit on 05/25/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for one (Resident #5) of thirteen residents reviewed for grooming. The facility failed to provide trimming and nail care of Resident #5's fingernails which were long with a dark substance noted under her fingernails. This deficient practice placed residents who require staff assistance at risk of poor personal hygiene, a decline in their sense of well-being, level of satisfaction with life, and feeling of self-worth. Findings include: Review of Resident #5's face sheet dated 05/24/2022 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses metabolic encephalopathy (is a broad category that describes abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function.), anxiety, nutritional anemia and severe protein-calorie malnutrition. Review of Resident #5's Quarterly MDS assessment dated [DATE] reflected Resident #5 was assessed to have a BIMS score of one indicating severe cognitive impairment. Resident was assessed to require extensive assist with ADLs and supervision with eating. Review of Resident #5's Comprehensive Care Plan reflected a problem dated 03/22/2022 ADL Functional/ Rehabilitation. Approaches included: clean and trim finger and toenails on bath/shower days. Observation on 05/24/22 at 9:45 AM Resident #5 in bed. MA K handed Resident #5 her medication which was added to her supplement (med pass 2.0 a protein supplement). Observation revealed Resident #5's fingernails were long and had a dark substance under her nails. MA K was asked who was responsible for Resident #5's nail care and she stated the CNA's. MA K agreed Resident #5's nails were long and dirty. MA K further stated Resident #5's nails should be short because she will scratch herself. In an interview on 05/25/2022 at 09:30 AM the ADON stated Resident #5's baths are done per hospice and nails should be done during bathing, but the floor CNAs are also responsible for nail care. In an interview on 05/25/22 at 09:35 AM CNA E stated Resident #5 is not combative during care and can drink water on own. CNA E stated the CNAs assigned to the hall should take care of Resident #5's fingernails and they should not be long and dirty. CNA E stated she did not know why Resident #5's nails were long and dirty, but she would take care of them. A policy on ADL assist and nail care was not provided to Surveyor prior to exit on 05/25/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 1 (Resident #23) out of 13 residents reviewed for activities. The facility failed to provide activities for Resident #23 for the past four months. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. Findings included: Review of Resident #23 face sheet dated 05/24/2022 revealed Resident #23 to be a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow) blindness in both eyes, high blood pressure and osteoporosis (condition in which bones become weak and brittle). Review of Resident #23 quarterly MDS assessment dated [DATE] revealed Resident #23 had a BIMS score of 15 which indicated intact cognition. Resident #23 required supervision and limited one person assistance for activities of daily living. Resident #23 required total assistance in mobility about the facility due to blindness. Review of Resident #23 Care Plan dated 05/23/2022 revealed Resident #23 did not have a care plan for activities. Resident #23 noted to have impaired vision related to blindness in bilateral eyes with a long-term goal of remaining physically safe and participating in social and self-care activities. Interventions included: -Assure the floor is free of glare, liquids and foreign objects -Keep call light in reach at times. -Orient Resident #23 when there had been new furniture placement or other changes in environment. -Provide Resident #23 an environment free of clutter. In an observation and interview on 05/24/2022 at 4:00 PM Resident #23 stated she has lived here since January and has been blind for almost 3 years. Resident #23 was observed sitting on the side of her bed and faced the door to her room with her tray table placed in front of her. Observation of a sign on the door to her room and above her bed read visually impaired resident - please knock and announce presence when entering the room. She stated she was still getting used to be being blind. She said she liked to eat in her room because she went one time to the dining room and had a pleasant time and then the man, she was eating with found out she was blind and would not eat with her again. When asked about leaving her room for social interaction and activity, she said she went to physical therapy Mondays, Wednesdays and Fridays and went to listen to music on Tuesday and Thursdays. She said she went to church service on Sunday at the facility. She said there were no other activities offered that she could do due to her blindness. She said she could not participate in bingo or other games. She said sometimes someone will walk her outside and sit with her, but you must have a staff member to sit with you to go outside. She said she would like to go outside more, and her family will take her outside when they visit. She stated otherwise she stayed in her room by herself and the activity director did visit her a couple times per month. In an interview on 05/24/2022 at 2:18 PM REG RN stated after reviewing the care plan there was no care plannedactivities on Resident #23's care plan. She said activities should have been on the care plan. She stated every resident should have activities on their care plan. She stated the activity director kept written log of who attended which activities and what their preferences were for activities. In an interview on 05/24/2022 at 2:25 PM, DON s tated there were multiple activities for Resident #23 but did not know which activities she attended. She stated Resident #23 did stay in her room mainly and required assistance to navigate the facility. When asked which activities were offered for visually impaired residents, she said there were multiple activities they could participate in like music and exercise. She did not know whether Resident #23 attended these activities. She said the ACT DIR was responsible for the completion of activity assessment and updating the nurse in charge of completion of MDS assessments and care plans. She said she did not know why activities was not on Resident #23's care plan. In an interview on 05/24/2022 at 3:00 PM, ACT DIR stated she did not keep a written log of activities but took attendance at each activity and then documented in the resident's electronic medical record they attended the activity. She stated the records for Resident #23's activity attendance would be in her electronic medical record. She stated Resident #23 liked to go listen to music and church on Sunday. She stated she also did room visits with Resident #23. She said she completed activity assessments and the nurse in charge of MDS assessments and care plans updated the resident care plans. She said she frequently checks in with residents regarding their activity choices and if they requested a different or better activity for them, she would try to make the suggestion happen within reasonable limits. In an interview on 05/25/2022 at 9:45 AM ADMIN said activities at the facility included bingo, dominoes, games. When asked about activities for blind residents, she stated Resident #23 attended music and church. She stated the activity director and she spend time talking to her and completed in-room activities. She said Resident #23 liked to stay in her room and said they did try to take her outside when able to do so. She said they had offered to take her to other activities, and she refused. When asked if the activities she refused to attend were for visually impaired residents, she said no. When asked if someone would help her play bingo, she said no the facility had not attempted to assist residents during activities that required being able to see. In a follow-up interview on 05/25/2022 at 2:30 PM, ACT DIR stated she found her attendance logs. When asked about documentation for Resident #23's activities she said there was not any in her electronic medical record because it was not in the assigned tasks for documentation because it was not on her care plan for activities . She stated when activity was added to the care plan it generated the task in the EMR for documentation. She said she did not have Resident #23 on the attendance logs either. She stated she would need to find additional activities for Resident #23 that would allow for more social interaction and activities. She stated activities was added to Resident #23's care plan yesterday. She said she did not have the documentation of room visits with Resident #23 and said she visited her weekly in her room. There were no observations of Resident #23 outside of her room or that she was engaged in activities between the dates of 05/23/2022 - 05/25/2022. Review of Activities Calendar dated May 2022 revealed the following activities: 05/23/2022 - 9:00 AM Room visits 10:00 AM Chair Zumba 11:00 AM Yahtzee 05/24/2022 - 9:00 AM Room visits 10:00 AM Resident Council Meeting with state 11:00 AM Work with Our [NAME] Lutheran 05/25/2022- 9:00 AM Room visits 10:00 AM Bingo 11:00 AM Uno Review of Resident #23 Electronic Medical Record dated 01/13/2022 - 05/24/2022 did not reveal documentation related to activities. Review of Group Programs and Activities Calendar Policy dated April 2009 revealed group activities are available in this facility and an activities calendar is completed to inform residents, families and staff of the activity opportunities available. Residents are encouraged to participate in all group activities, especially those that are best suited for their interests and physical, mental, and emotional needs. Review of Individual Activities and Room Visit Program dated August 2006 revealed individual activities will be provided for those residents whose situation or condition prevents participation in other types of activities, and for those residents who do not wish to attend group activities. The policy further revealed the activities offered are reflective of the resident's individual activity interests, as identified in the Activity Assessment, progress notes and the residents comprehensive care plan. It is recommended that residents on a full room visit program receive at a minimum three room visits per week with an average of 10-15 minutes in length. Review of Activities Attendance Policy dated November 2021 revealed the activity department records activities attendance and participation of all residents. Attendance and participation was recorded for every resident in group and individual activities on a daily basis. Review of Activities Documentation Policy dated January 2020 revealed the activity director/coordinator was responsible for maintaining appropriate departmental documentation to include for each resident activity evaluation, attendance records, activities calendar, activity progress notes and individualized activities care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide or obtain timely laboratory services to meet the needs of 1 (Resident #10) of 3 residents reviewed for ordered laboratory services in that: The facility failed to ensure Resident #10's complete metabolic panel laboratory order was completed per physician order in a timely manner. This deficient practice could place residents at risk for a delay in identifying or diagnosing a problem, adjusting medications, and ensuring treatment needs were identified and addressed. Findings included: Review of Resident #10 face sheet dated 05/25/2022 revealed Resident #10 to be a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of history of stroke with speech and language deficits, dysphagia (difficulty swallowing), aphasia (inability to comprehend or formulate language), and apraxia (motor disorder caused by damage to the brain which causes difficulty with motor planning to perform tasks or movements). Review of Resident #10 Annual MDS assessment dated [DATE] revealed Resident #10 to have unclear speech and was sometimes understood and usually understood others. Resident #10 was unable to complete the BIMS evaluation and the Staff Assessment for Mental Status revealed Resident #10 had a memory problem, but could remember her room location, staff names and faces and that she was in a nursing home. Resident #10 required total assistance with two people for activities of daily living. Review of Resident #10 Care Plan dated 03/22/2022 Resident #10 had a potential for complications related to diuretic medication usage with a goal of not exhibiting signs of side effects of complications secondary to diuretic use through next review date. Interventions included: -Administer diuretic Laxis 80 mg twice daily. -Monitor blood pressure every shift. -Monitor cardiovascular system and fluid status to determine effectiveness of diuretic therapy. -Monitor labs as ordered. -Obtain weight monthly and as needed. -Report signs and symptoms of low potassium levels. -Report signs of dehydration. Review of Resident #10 Pharmaceutical Review dated 03/24/22 revealed Resident #10 to have the following recommendation This resident is receiving Lasix without current lab work on the chart. Please consider ordering a BMP on the next lab day and repeat every 6-12 months to monitor therapy. Review of Resident #10 Physician orders dated 04/05/2022 revealed Resident #10 to have an order for a basic metabolic panel of labs. Review of Resident #10 Pharmaceutical Review dated 04/22/2022 Resident #10 recommended This resident is receiving Lasix without current lab work on the chart. Please consider ordering a BMP on the next lab day and repeat every 6-12 months to monitor therapy. Review of Resident #10 Lab Report dated 05/20/2022 revealed Resident #10 to have a complete metabolic lab panel resulted from lab draw completed on 05/20/2022. In an interview on 05/25/2022 at 1:45 PM the DON said labs for Resident #10 should have been completed within the week the physician ordered it and not a month and a half later. She said it was deficient practice to not immediately follow-up on the recommendation from the pharmacist review, obtain a physician order and complete the recommended lab draw. She said the pharmaceutical review should be sent within two days of receiving the report to the physician and then the changes or orders complete when received from the physician. She stated she was in charge of completing the pharmaceutical review follow-up and would ensure timely review and completion of recommendations. She said she started at the facility in April 2022 and the staff had not been monitoring the pharmacist review closely and she only recently realized the deficient practice. Review of Pharmacy Services - Role of the Consultant Pharmacist Policy dated April 2007 revealed the Consultant Pharmacist shall provide consultation on all aspects of pharmacy services in the facility to include helping to identify and evaluate medication-related issues. Review of Laboratory Guidelines Policy (undated) revealed lab work is ordered by physician for all medications that justify lab work for dosage scrutiny. Labs will be drawn per physician orders and routine labs will be drawn on routine lab visits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident received and the facility provided drinks, including water and other liquids consistent with resident needs and preferences for one of thirteen residents reviewed for hydration. (Resident #5). The facility failed to ensure Resident #5 had fresh ice water available and in reach. This failure could lead to dehydration, urinary tract infections, and falls. Findings included: Review of Resident #5's face sheet dated 05/24/2022 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses metabolic encephalopathy (is a broad category that describes abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function.), anxiety, nutritional anemia and severe protein-calorie malnutrition. Review of Resident #5's Quarterly MDS assessment dated [DATE] reflected Resident #5 was assessed to have a BIMS score of one indicating severe cognitive impairment. Resident was assessed to require extensive assist with ADLs and supervision with eating. Resident #5 was assessed to not have a swallowing disorder. Review of Resident #5's Consolidated Physician orders dated 04/25/2022 through 05/25/2022 reflected the following dietary orders give ice cream with lunch and supper dated 06/01/2020, Regular mechanical soft diet with thin liquids add fortified foods to all meals dated 06/01/2020, double deserts with meals dated 03/19/2021, Give 180mgl of 2.0 house supplement three times daily dated 03/19/202. Further review of Resident #5's physician orders reflected an order for hospice services dated 03/23/2022. Review of Resident #5's Comprehensive Care Plan reflected a problem dated 03/22/2022 Dehydration/ Fluid Maintenance, Resident #5 is at risk for dehydration related to recent decline and malnutrition, approaches included assist with fluids as needed, encourage fluids to 1500 cc/day offer a variety of fluids .Keep fluids accessible . Observation and interview on 05/23/2022 at 1:00 PM revealed Resident #5 in her room in bed. Resident #5 was in a low bed with a matt on the floor. Further observation revealed no water pitcher or fluids in room. Resident #5 skin and lips were dry. Resident #5 was asked if she was thirsty, she stated yes, she wanted some water. Observation on 05/23/2022 at 3:51 PM revealed Resident #5 in her room in bed and there was no water pitcher or fluids in the room. Observation on 05/24/2022 at 08:35 AM Resident #5 in room in bed. NA D was removing Resident #5's breakfast tray. Observation revealed the only food items on the tray was a bowl of cereal, no other food items, fluids, or supplements. In an interview on 05/24/2022 at 8:37 AM Resident #5 was asked if she was still hungry Resident #5 did not answer. No water was noted at bedside. NA D was asked why Resident #5 did not had any water in her room today or yesterday and NA D stated she gave her water yesterday and she gave Resident #5 milk this morning with breakfast. When asked if the milk was for the cereal she stated yes. NA D was asked if there was a reason Resident #5 could not have a pitcher of water in her room NA D stated Resident #5 spills it. Observation on 05/24/22 at 9:45 AM Resident #5 in bed. MA K handed Resident #5 her medication which was added to her supplement (med pass 2.0 a protein supplement). Resident #5 drank all her supplement, stating repeatedly that is good. Observation on 05/24/22 at 12:05 PM Resident #5 in room eating in bed only food on tray was a bowl of cereal. Resident #5 was feeding herself, using the bowl to bring to lips to eat the cereal. The only fluid on the meal tray was the milk for her cereal. In an interview on 05/25/2022 at 09:35 AM CNA E stated Resident #5 is not combative during care and can drink water on own. CNA E stated Resident #5's water should be close to her encase she wants to drink. In an interview on 05/25/2022 at 10:10 AM the DON stated all residents should always have fresh water available to them if allowed by physician orders. Observation on 05/25/2022 at 11:48 AM Resident #5 in room eating lunch stated it was good and drank all her ice cream milk shake. In an interview on 05/25/22 at 10:54 AM the RNC stated all residents should always have fluids within reach. Review of the facility's policy Hydration-Clinical Protocol dated 09/2017 reflected The physician and staff will help define the individual's current hydration status .will identify and repot signs and symptoms that might reflect existing fluid and electrolyte imbalance . The facility policy did not address providing fluids to residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews the facility failed to ensure the hospice services met the professional standards and principles that apply to individuals providing timely services in the facility for 1 of 3 residents (Resident #5) reviewed for hospice services in that: The facility failed to ensure Resident #5 was seen weekly by a hospice RN per Resident #5's hospice plan of care. The facility failed to ensure that Resident #5 was seen three times per week by a hospice Aide per Resident #5's hospice plan of care. These failures could place residents receiving hospice services at risk of not having their health needs met causing a decline in health. Findings Included: Review of Resident #5's face sheet dated 05/24/2022 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (is a broad category that describes abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function.), anxiety, nutritional anemia and severe protein-calorie malnutrition. Review of Resident #5's Quarterly MDS assessment dated [DATE] reflected Resident #5 was had a BIMS score of one indicating severe cognitive impairment. The resident required extensive assist with ADLs and supervision with eating. Resident #5 was assessed to have weight loss of 5% or more in the last month. Review of Resident #5's Comprehensive Care Plan reflected a problem with the start date of 04/14/2022 Resident #5 is on Terminal care with hospice. Review of Resident #5's Hospice Care Plan dated 12/31/2021 revealed skilled nursing visits, Nurse Practitioner visits two times per week for 12 weeks and Nurse Aide visits three times per week for 13 weeks (03/27/2022 to 06/21/2022). Review of facility's hospice binder for Resident #5 revealed Resident #5 received Registered Nurse visits on 04/04/2022, 04/11/2022, 04/19/2022, 04/27/2022 and 05/01/2022. Resident #5 received Nurse Aide visits on 03/27/2022 and 05/21/2022. Interview with hospice Nurse Aide on 06/08/2022 at 1:30 PM revealed she assisted Resident #5 once per week. She stated she was at the facility on 06/04/22 and 05/27/22. She stated lived extremely far from the facility and she was not able to see the resident more than one time per week, despite Resident's current hospice orders. She stated when she came to the facility she signed in the hospice binder. She was not aware of the consequences to Resident if she did not come to the facility to see the resident more than once per week. She stated that facility staff would take care of the resident's needs if hospice Aide was not available. Interview with hospice Registered Nurse on 06/08/2022 at 2:00 PM revealed she did not see Resident #5 any longer. She stated RN was listed as the resident's nurse with last documentation of visit on 05/02/2022. She stated the resident was supposed to be seen by an RN once per week according to her current hospice order. She stated the facility nurses should have noticed the RN was not coming to see Resident #5 and notified the DON. She stated it was absolutely unacceptable that the facility did not notice the resident was not being seen to by hospice. She stated the minimum that a hospice nurse comes to a facility to see Residents in Hospice care was every two weeks. She stated that the residents not being seen by Hospice nurses as ordered could lead to a decline or change of condition. Interview with LVN C on 06/08/2022 at 4:00 PM revealed she did not know how often hospice nurses needed to come and see residents on hospice for care. She was not familiar with Resident #5's hospice plan and was did not mention the hospice logbook located at the nursing station. Interview with Registered Licensed Nurse on 06/08/2022 at 4:15 PM revealed RN visits for residents are based on the residents care plan and had no further information regarding how often residents on hospice should be seen by Hospice Nurses or the responsibilities of facility to ensure residents were seen by hospice nurses. Interview with CNA K on 06/08/2022 at 4:30 PM revealed the hospice RN's should visit residents once per week and aides 5 times per week. She stated this was logged in the resident's hospice book kept at the nursing station which was supposed to be checked by the DON. She said she wasn't sure if the DON was checking this documentation. She stated that lack of sufficient visits to the resident from Hospice Nurses and Aides could result in Resident not receiving needed services for necessary care. Interview with ADMIN on 06/09/2022 at 12:00 PM revealed she was not aware of Resident #5's Hospice care plan dated 12/31/2021. She said she was not aware Resident #5 was to receive weekly visits from an RN and tri weekly visits from the Aides. She stated she was going to contact the Hospice contracting company to determine why this was not happening. She stated the DON was responsible for ensuring that weekly visits were being tracked to ensure the resident was getting needed services. She stated she thought the DON was ensuring Resident #5 received all visits in resident's hospice care plan. Interview with DON on 06/09/2022 at 1:35 PM revealed when a resident was on hospice care, an RN should visit weekly and the hospice aides five times per week. She stated there was a binder for each Resident and the hospice Resident, and she has told the nursing staff on duty as well as the hospice agency partners that nursing staff should ensure hospice signs logbook when entering the facility and hospice must document in the binder Resident notes. When asked how she ensured that hospice RNs are coming to see Resident weekly, she stated its hospice's responsibility to ensure weekly RN visits. She stated she has not checked to ensure that the hospice RN and aides were coming to see Residents for care and was not aware Hospice was not coming per their care plan. She was not aware of what might happen if Resident was not getting care from hospice as ordered. She stated the facility would provide necessary care if hospice did not come. Review of facility's Hospice and Nursing Facility Services Agreement (no date) revealed the Nursing Facility shall provide hospice patients served in the community all necessary respite services, as outlined in the hospice plan of care specifically to maintain the hospice plan of care while the patient's caregiver is provided relief. Nursing facility shall ensure that such respite services are provided in accordance with the hospice POC, are ordered and prescribed by the applicable attending physician, and are rendered as specifically authorized by hospice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their written policies and procedures that prohibit and prevent abuse and neglect of residents for four of thirteen residents (Resident #25, Resident #14, Resident #16, and Resident #18) reviewed for abuse and neglect. A) The facility failed to implement a policy and process for immediately investigating and reporting allegations of abuse and neglect to HHSC for allegations of alleged physical abuse for Resident #25. B) The facility failed to implement their policy and process for immediately investigating and reporting allegations of abuse and neglect to HHSC for allegations of witnessed Resident to Resident physical abuse between Resident's #14 & #16 on 05/17/2022. C) The facility failed to implement their policy and process for immediately investigating and reporting allegations of abuse and neglect to HHSC when an injury of unknown origin was identified to Resident #18's left eye on 04/26/2022. This deficient practice could place residents at risk for abuse. Findings included: Review of the facility's Abuse Prevention Program dated June 2021 revealed the administrator is responsible for the overall coordination and implementation of our Center's abuse prevention program policies and procedures. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor and to the Abuse Prevention Coordinator immediately. All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by Center management. Findings of abuse investigations will also be reported. A) In an interview on 05/23/22 at 12:40 PM COOK A stated on 04/22/2022 she saw CNA J pulling Resident #25 by his shirt in the dining and she ran over to tell her you're choking him. She said Resident #25 had broccoli in his mouth and was swatting at CNA J to let go of his shirt while his face turned red, and it seemed like he could not breathe. She said CNA J said she was trying to keep Resident #25 from falling. She said to CNA J you were choking him and CNA J said she was not. She said CNA J should have had Resident #25 wheelchair leaned further back and he would not have been able to lean forward and almost fall out of his chair. She said they went on working and then CNA J came back to her later in that day and said, just to let you know I wasn't choking him. She said she reported the incident to the charge nurse and had not heard anything more about it. She said she wrote up a statement the next day and gave it to DM. She said CNA J continued to work at the facility until she resigned about two weeks ago. She said on 05/17/2022 the regional nurse consultant was at the facility and she asked her about whether anyone looked into the incident. She said REG RN said she had not heard anything about the incident. She said she was asked to write another statement and she did. She said she left the facility for the day at the end of her shift on 05/17/2022. She said DM called her at home and said she was not allowed to return to the building and that she had a choice to either resign or transfer to another building for making false allegations. She said ADMIN said she was making false allegations. She said this was her first day back at work because someone at the corporate office called her and after she explained what happened she was asked to return to work at the facility. She said she and the food service workers were employed by two separate companies. She said the facility contracts for food service with her company. She said for abuse/neglect reporting she was instructed to report to ADMIN. She said for human resource issues her boss was REG DIR. She said she did not understand why she was suspended and not allowed to return to work for reporting abuse. She said she did what was required and felt retaliated on by ADMIN. She said the dietary aide DA K witnessed the incident too and no one has ever spoken to her. She said she did not think Resident #25 had any injuries from the choking incident but was not sure if any investigation was completed by the facility. She said she did not think an investigation was done at all. She said she received training on abuse and neglect training on reporting abuse and neglect to the administrator and what counts as abuse and neglect. In an interview on 05/23/22 at 12:55 PM DM said COOK A was a cook and her mom. She said COOK A told her on 04/23/2022 what happened between Resident #25 and CNA J. She said COOK A wrote a statement and gave it to her. She said she was not aware of any investigation into the incident. She said they were to report any concerns of abuse/neglect to ADMIN. She said her mom told her she told the charge nurse about the incident the night before because ADMIN was not in the building the evening of 04/22/2022. She said on 05/17/2022 her mom had left at the end of her shift and her boss REG DIR told her to call COOK A and tell her she was not allowed to return to the building. She said REG DIR told her to tell her mom she could transfer to another building or resign for making false allegations. She said she quit and did not return the next day to work because of how unfair management was being towards them. She said she felt like they were retaliating on COOK A for making a report of abuse. She said she received training on identifying abuse and neglect and that she must report any concerns of abuse or neglect to the administrator. In an interview 05/23/22 at 1:03 PM DA K said she and COOK A were walking back to the dining room after walking residents to the front room for TV on 04/22/2022. She said CNA J was wheeling Resident #25 in his wheelchair and he leaned forward, and CNA J grabbed him by the back collar of his t-shirt and was choking him with his t-shirt. CNA J said she was keeping him from falling. She said CNA J should have leaned Resident #25's chair back to keep him from falling, not choked him with his t-shirt. She said she was not contacted to give her statement or asked what happened back in April 2022 or in the last week. She said Resident #25 told CMA M about it the next day. She said normally Resident #25 was belted in his wheelchair but wasn't that day maybe? She was not sure. She said if CNA J had leaned him back in wheelchair, he would not have been falling and she would not have had to choke him with his t-shirt. She said she received training on abuse reporting and prevention and to report any concerns to ADMIN. In an interview on 05/23/2022 at 1:13 PM CMA M said she arrived to work on 04/23/2022 and was told by COOK A that CNA J had choked Resident #25. She said COOK A told her to go ask Resident #25 about it. She said she asked Resident #25 about it and he replied to her she grabbed my shirt and then went to a party. She said Resident #25 was not very with it and did not say anyone choked him. She said she observed no injuries on him. She said she was not sure if the facility completed an investigation. She said if she thought a resident was being abused, she would report it to the charge nurse, and to the administrator the abuse coordinator. She said she questioned COOK A's allegations because she did not immediately report the incident from what she heard from other staff. She said she was not working the day of the incident. She said she did not know if COOK A reported it to the charge nurse the same day and the charge nurse was no longer working at the facility. In an interview on 05/23/22 at 1:23 PM, DON stated she started at this facility on 04/11/2022. She said she called up to the facility to check on something else on 04/23/2022 and the staff member that answered the telephone, she could not remember their name, told her have you heard kitchen staff said CNA J was choking a resident. She said she immediately ended the call and called ADMIN at home. She said it was the weekend and neither of them were working. She said she told ADMIN they needed to investigate it. She said ADMIN said she would call the facility. She said ADMIN called her back and said she spoke with the staff at the facility, COOK A and CNA J. She said ADMIN said she confronted COOK A and told DON the incident didn't happen. She said ADMIN told her the COOK A supposedly reported it to the charge nurse on 04/22/2022 and ADMIN questioned her (the charge nurse) and the charge nurse said it didn't happen. She said the next week after 04/23/22, she asked ADMIN about it again and ADMIN told her she fully investigated it and it didn't happen. DON said she completed an abuse/neglect inservice with the staff. She said COOK A gave her a note with the allegation at some point during the week and she asked ADMIN about the allegations again and again. ADMIN said it didn't happen and it had been fully investigated. She said ADMIN kept insisting that COOK A was lying. She said she checked on Resident #25 and he was okay and had no physical injuries. She said there was family drama between COOK A, ADMIN and DM. She said she had not seen or read any documentation or witness statements that documented the investigation by ADMIN. She said it was not reported to HHSC until last week. She said ADMIN told her again it was fully investigated and unconfirmed. She said CNA J the aide quit and was not terminated. She said she was not aware of any performance issues by CNA J before she quit. She said last week when the RNC was visiting, she went to check on something and returned to find DM and COOK A speaking with the RNC in her office. She said COOK A and DM were complaining of personal issues with ADMIN and reported the choking to RNC. She said the RNC called ADMIN and said you have to report this to HHSC. She said she overheard as they were feeding residents at dinner on 05/17/2022 that the kitchen staff were told they had to transfer or resign for making the allegations. She said she was not part of those conversations or decisions. She said ADMIN did confirm with CNA J at some point that the incident happened, and it was as a result of CNA J not tilting the wheelchair back as she reversed the wheelchair and Resident #25 was able to lean forward and almost fall out of his chair. She said CNA J stated she did grab Resident #25 by the back of the shirt collar to keep him from falling. She said CNA J said she was not choking him. DON said Resident #25 did not have a wheelchair seat belt . She said at some point before CNA J quit, they did do training with CNA J to teach her how to reverse the wheelchair so Resident #25 could not lean forward. She said there was no documentation in progress notes or otherwise of the incident until 05/17/22. She said she had not heard of DA witnessing the incident or spoken to DA K about it. In an observation and interview on 05/23/2022, Resident #25 was clean, well-groomed, and appropriately dressed while sitting in his bed. He did not have any marks or bruises to indicate abuse. When asked about his care and treatment at the facility, he did not respond. When asked about whether he felt safe, he said yes. In an interview on 05/23/22 at 2:07 PM, the RNC stated she was visiting the facility to assist DON with training when DM and COOK A started to complain to her about ADMIN. She stated they told her about the choking incident with Resident #25. She said this was the first time she heard about it. She said ADMIN was not at work that day on 05/17/2022. She said she called her at home and told her she needed to report it to HHSC. She said ADMIN said it was not reported as abuse but as a near fall, so she did not report it. She said ADMIN said she investigated it and found it not to be abuse. She said she told ADMIN that if someone has the perception of abuse and reports an abuse allegation, ADMIN had to report it. She said she did not see any documentation for an investigation, but ADMIN's office was locked, and she was not at work that day. She said did not think ADMIN was ignoring abuse because she said she thought it was not willful abuse, but an accident because the aide grabbed his shirt to keep him from falling. She said she did not know anything about COOK A being accused of making false allegations and being suspended. She said they would not allow retaliation for allegations of abuse. In an interview on 05/23/2022 at 2:43 PM ADMIN said she first heard about the choking incident from CNA K on 04/24/22. She said she called COOK A immediately and told her she should have reported it immediately. She CMA M told her CNA J choked Resident #25. ADMIN said she tried to call CNA J that day too but was unable to reach her. She said she spoke with COOK A who reported the whole story. She said they did an Inservice with all staff on 04/27/2022 on abuse and neglect. She said after speaking with all of the witnesses and CNA J she could confirm there was not abuse. ADMIN said she did not have documentation of the interviews or other documentation of the investigation as required by their facility policy. She did not report to HHSC because it was not confirmed abuse. ADMIN said when CMA M told her the ADMIN she said, I knew it was a lie. She said back when the foodservice company wanted to hire COOK A and DM to work at the facility, she did not want them hired because they are family members. She stated COOK A and DM like to start drama and cause problems. She said her aides have to walk on eggshells around them because they are afraid of being accused of abuse. She said she did not interview DA K because she was not aware that she was a witness. ADMIN said they just did an inservice and took no other steps in the investigation. ADMIN said CNA J did tell her that she (CNA J) did pull Resident #25's t-shirt to keep him from falling as COOK A said. It was not done with willful intent to abuse. She said then last week the RNC called her at home because her baby was sick and told her she needed to report it immediately because it alleged abuse. She said last Tuesday 05/17/2022 she called DM and COOK A's boss on 05/17/2022 and said she wanted them out of her building. ADMIN said her boss and DM's boss spoke and she was not sure what DM's boss relayed to them. She said she wanted them suspended for violating HIPAA because they told family members who did not work at the facility about the incident. She said she did not suspend DM or COOK last Tuesday 05/17/2022. She said CNA J quit on 05/11/2022 due to hostile work environment and being harassed by DM and COOK A over the situation. She said DM and COOK A were asked to return to the facility today by their bosses. She said the REG DIR was coming tomorrow to sign an agreement with them about their unprofessional behavior. She said she had not spoken with the charge nurse that COOK A reported the initial incident to because she was a travel nurse for their corporation and had not returned to work at the facility. She said did not know if COOK A reported the incident to the charge nurse that day on 05/22/2022. She said she did not know why COOK A would have wanted to get CNA J in trouble. She said she felt like DM and COOK A were out to get her because DM was written up after ADMIN reported to DM's boss that she was seen cursing in front of residents a couple of months ago. In an interview on 05/23/2022 at 3:12 PM, REG DIR for [Contract Food Service Company] stated she was contacted by ADMIN on 05/17/2022 regarding the allegations. She said she spoke with COOK A who reported she turned in a statement on 04/23/2022 to the DM regarding the incident. She said ADMIN said she spoke with people and got statements. She said ADMIN's boss and her boss spoke later in the day on 05/17/2022 and ADMIN's boss told her boss they would like COOK A removed from the building due to COOK A making false allegations. She said she informed DM of the need for COOK A to be moved to a different building or resign and DM resigned. She said she felt like ADMIN retaliated on COOK A and DM because she did not do her job when the original allegation was reported back in April 2022 and now ADMIN was in trouble for not investigating the allegation. She said ADMIN told her during the phone on 05/17/2022 that the incident did not occur and there was no abuse. She said it was later confirmed the incident did occur and CNA J did grab Resident #25's shirt to keep him from falling. She said the dietary staff were required to report concerns of abuse to the abuse coordinator at the building, not her. She said she did not speak with DA K regarding the incident. She stated after completing their investigation on their side for their company, they asked DM and COOK A to return to work because there was no false allegation. She said she would be coming to the building tomorrow to speak with DM and COOK A. In an interview on 05/24/2022 at 8:25 AM DM stated she and COOK A were upset because their boss REG DIR was on her way to write them up. She stated she did not understand why they were being punished for reporting the allegations of abuse. She stated she felt like they were being retaliated against for reporting and then when nothing was done, reporting higher up the chain of command. In an interview on 05/24/2022 at 9:05 AM the REG RN stated when asked why would an Inservice done by DON on 04/27/2022 be completed with all staff regarding the incident with Resident #25 if it was not an abuse allegation, she stated the ADMIN knew it was an abuse allegation regarding the incident on 04/22/2022. She stated that was not the impression she was given and apologized for the misunderstanding. She said she was under the impression the incident of the resident being choked with t-shirt by CNA J was an accident to keep him from falling and no abuse was alleged. She stated ADMIN should have completed a full investigation per their policy and had the required documentation as well as reporting the allegation to HHSC. She stated she was not aware the food service REG DIR was on her way to write up the kitchen staff for the false allegations. She stated she understood that could have the appearance of retaliation from the facility for the reporting and would ensure there was no disciplinary action for the kitchen staff. In an interview on 05/25/2022 at 4:10 PM REG DIR stated there was no disciplinary action for COOK A and DM. She stated she did complete an inservice regarding professional behavior but did not write them up. When asked if there would be any changes for dietary staff to report abuse or neglect,she said they did not have any changes for them to report future concerns of abuse/neglect. She said they could grab a witness or something if reporting an allegation to ADMIN. She said they would still report concerns to ADMIN, the abuse coordinator. In an interview on 05/25/2022 at 8:10 AM the REG RN said they established an alternate abuse coordinator for the facility and it's the DON. Kitchen staff stated they feel comfortable reporting to her (DON) in the future. She stated her contact information, and the regional vice president's contact information of the nursing facility will also be on all abuse/neglect reporting signs if a person had a concern that they felt was not being handled appropriately. Review of CNA J Written Statement dated 05/20/2022 revealed CNA J emailed her written statement to ADMIN and it read After dinner on April 22nd I was pushing [Resident #25] in his wheelchair from the dining room. As I was approaching the nurse's station, he dropped his feet causing him to go forward towards the floor. I grabbed his shirt to keep him from falling out of the chair. I told the nurse about this and she showed me his chair would lean back to prevent him doing that in the future. Review of Abuse, Neglect and Exploitation Inservice documentation dated 04/27/2022 revealed all staff were educated on the facility abuse and neglect policy. B) Review of Resident #14's face sheet dated 05/25/2022 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses COVID-19 acute respiratory disease, epileptic seizures, history of traumatic brain injury, anxiety and depressive episodes. Review of Resident #14's Quarterly MDS assessment dated [DATE] reflected Resident #14 was assessed to have a BIMS score of 10 indicating moderate cognitive impairment. Resident #14 was assessed to have mood indicators or feeling down, depressed, or hopeless two to six days a week and having trouble concentrating on things two to six days a week. Resident #14 was further assessed to not have behavior problems during the assessment period. Resident #14 was assessed to require extensive assistance with ADLs. Review of Resident #14's Comprehensive Care Plan reflected a problem with the start date of 05/18/2022 Psychotropic drug use: Resident receives antianxiety medication related to episodes of anxiety, doctor with senior psych increased buspirone 20 mg to BID (twice daily) on 05/17/2022. Approaches included Assess Resident #14 if behavioral/ mood symptoms present a danger to the resident and/or others. Intervene as needed. Further review of Resident #14's care plan reflected a problem with the start date of 03/11/2022 Behavioral Symptoms: Resident #14 sometimes is inappropriate verbally and has touched other residents in non-sexual way without resident's permission. Approaches included Remind Resident #14 of the consequences of inappropriate verbal and physical interactions and redirect Resident #14 when he is inappropriate. Observation and interview on 05/23/2022 at 12:20 PM revealed Resident #14 ambulating in hall in wheelchair. Resident #14 was pleasant and voiced no concerns. Review of Resident #14's nursing progress notes dated 05/17/2022 reflected an entry aggressive /combative behavior, Senior Psych services notified, Doctor is in center now visiting with resident. Review of Resident #14's Event Report dated 05/17/2022 reflected Argument between Resident #14 and Resident #16 in the lobby. Resident #14 was yelling at Resident #16. Was told to be quiet. Resident #16 got out of his chair that was across the lobby and walked up to Resident #14. Resident #14 bowed up and continued to talk to Resident #16. Resident #16 then threw a punch at Resident #14; This nurse did not see contact. Resident #14 then throw a punch at Resident #16. Did not make contact. Resident #16 was moved away from Resident #14. Resident #14 continued to yell at Resident #16. Review of Resident #14's Physician progress note dated 05/18/2022 reflected According to the nurses' he had an altercation yesterday with one of the other residents. When I questioned the patient Resident #14 says that he got punched because he provoked the other man repeatedly. He admits it was his fault. He tells me he is not hurt and that he did not try to hurt the other resident in return . Review of Resident #16's face sheet dated 05/25/2022 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses dementia with behavioral disturbances, cognitive communication deficit and muscle weakness. Review of Resident #16's Quarterly MDS assessment dated [DATE] reflected Resident #16 was assessed to have a BIMS score of 2 indicating severe cognitive impairment. Resident #16 was assessed to not have behaviors during the assessment period and was assessed to require limited assist with ADLs. Review of Resident #16's Comprehensive Care Plan identified a problem with the start date of 07/21/2021 Behavioral symptoms, Resident #16 hit another resident in the face after that resident provoked him on 05/17/2022. Approaches included always ask for help if resident becomes abusive/resistive, redirect resident as needed and remove from public area when behavior is unacceptable. In an interview during a group meeting on 05/24/2022 at 10:00 AM, Resident #14 stated another resident hit him and Resident #14 wanted to hit him back. Resident #14 said if it happens again, Resident #14 will hit him again in the chest. Resident #14 could not identify when it happened or which resident hit him. Observation and interview on 05/23/2022 at 1:00 PM revealed Resident #16 ambulating in hallway with guidance from staff. Resident #16 did not verbally respond to questions. Review of Resident #16's Nursing Progress Note dated 05/17/2022 reflected aggressive/ combative behavior; Psych services notified today of resident behavior, doctor with geri-psych is in the center now visiting with resident. Review of Resident #16's Event Report dated 05/17/2022 at 9:19 AM reflected Argument between Resident #14 and Resident #16 in the lobby. Resident #14 was yelling at Resident #16. Was told to be quiet. Resident #16 got out of his chair that was across the lobby and walked up to Resident #14. Resident #14 bowed up and continued to talk to Resident #16. Resident #16 then threw a punch at Resident #14; This nurse did not see contact. Resident #14 then throw a punch at Resident #16. Did not make contact. Resident #16 was moved away from Resident #14. Resident #14 continued to yell at Resident #16. Review of Resident #16's Physician progress note dated 05/18/2022 reflected There was an altercation according to staff that the patient had punched another resident after being provoked. The patient does not appear to have any injuries. Does not seem to remember the altercation . Review of the state reporting system TULIP reflected the resident-to-resident altercation between Resident #14 and Resident #16 was not reported to HHSC. An observation on 05/25/2022 at 9:30 AM reflected Resident #16 walked over to Resident #14 in his wheelchair and put his hands around Resident #14's neck and squeezed. Resident #14 began to yell and swing at Resident #16 and said, I am going to kill you. LVN C separated the two men and then another staff member moved Resident #14 away. LVN C walked Resident #16 back towards his room. An observation on 05/25/2022 at 9:50 AM reflected Resident #16 walked around the nurse's station to Resident #14 while Resident #14 made hand gestures at Resident #16. LVN C's back was turned, and surveyor alerted her to the two residents' close proximity. An observation on 05/25/2022 at 10:15 AM reflected Resident #16 standing in between Resident #14's legs while Resident #14 was seated in his wheelchair. Resident #16 was leaning over Resident #14 and Resident #14 had his arm raised in the air. Surveyor alerted nearby staff and they separated the two men. Review of Resident #14's nursing progress notes dated 05/25/2022 reflected Resident sitting in wheelchair and another resident walked over and put both hands around his neck. Resident then pulled his fist back and stated, I'm going to f**ing kill you. Resident then stood up out of wheelchair with fist back. Staff was able to get resident to sit back down in wheelchair. Resident was wheeled outside to calm down. Charge nurse, DON, administrator, PCP, and RP notified . Review of Resident #16's Nursing Progress Note dated 05/25/2022 reflected This nurse was at nurses' station and observed resident walk over to another male resident who was sitting in wheelchair, and place hands around his neck. The nurse was able to get the resident to remove his hands and walk him into the lobby, and resident stated, I am going to kill that son of a b**ch. Resident is now sitting in the recliner drinking water. Charge nurse, DON, administrator, PCP, and RP notified . In an interview on 05/25/2022 at 12:15 PM with the RNC and DON regarding the 05/17/2022 incident between Resident #14 and Resident #16 the DON stated she was told there was no physical contact between the residents. When the DON was asked why his care plan stated Resident #16 hit Resident #14, she stated the care plan was wrong. When asked why the physician progress note also stated that Resident #14 stated he was hit by Resident #16 she stated she did not see the progress note and if that is the case then the incident should have been further investigated and reported. The RNC stated that in light of the physician progress note the incident was an allegation of abuse since Resident #14 stated he was hit by Resident #16 and based on the facilities policy the incident should have been thoroughly investigated and reported to the state. C) Review of Resident #18's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses Parkinson's disease (A chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement.) Bipolar disorder (A serious mental illness characterized by extreme mood swings. They can include extreme excitement episodes or extreme depressive feelings.) and Dementia. Review of Resident #18's Quarterly MDS assessment dated [DATE] reflected Resident #18 was assessed to have a BIMS score of 3 indicating severe cognitive impairment. Resident #18 was assessed to not have behaviors. Resident #18 was assessed to require extensive to dependent assist with all ADLs. Review of Resident #18's Comprehensive Care Plan reflected a problem with the start date 05/16/2022 reflected Category: ADL Functional/ Rehabilitation Potential Resident #18 is unable to use ROM in BUE (bilateral upper extremities). Further review reflected a problem dated 04/27/2022 Impaired skin integrity as evidence by reddened area to left eye. Further review reflected a problem with the edited dated 04/29/2022 Resident #18 has episodes of resisting care .she will curse and call staff other names when they enter her room. Observation and interview on 05/23/2022 at 12:10 PM revealed Resident #18 in bed. Resident #18 did not respond to questions. Review of Resident #18's Consolidated Physician orders dated 04/25/2022 through 05/25/2022 reflected an order dated 04/26/2022 Left eye bruise apply cold compress on and off as tolerated x 24 hours, then hot alternating with cold next 48-72 hours as tolerated. Review of Resident #18's Nursing progress notes reflected an entry dated 04/26/2022 Called to residents' room by CNA making routine ADL care. CNA observed residents (L) eye and informed this nurse. Resident with new bruise (L) eye outer 3cm x 2cm purple red with skin intact to area. Resident able to look around without difficulty. Resident denies pain or discomfort. This nurse asked resident if she scratched her eye with her finger resident stated yes. Notified D.O.N., notified Dr. notified RP. Further review reflected an entry dated 04/28/2022 .bruise to left eye with no Swelling or complications noted, hot and cold compresses alternating, and resident takes off, total care, all needs met and anticipated by staff, monitor frequently as unable to use call light . 05/02/2022 .bruise to left eye healing . 05/05/2022 Resident sitting in up in bed. area of bruise to left eye . Review of Resident #18's Event Report dated 04/27/2022 reflected reddened area noted to residents left eye, upon assessment, resident participates in her own facial grooming, ADLs, she was noted rubbing/ scratching eyes with facial towel .No evidence to support abuse or neglect . In an interview and observation on 05/24/2022 at 10:30 AM Resident #18 was asked if she had ever had a black eye (eye no longer bruised, no bruising noted to resident) she stated yes, when asked if she scratched her eye she stated yes, when asked if someone hit her, she stated yes and when asked if she hit her face on something she stated yes. Observation on 05/2