**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to treat each resident with respect and dignity that promoted maintenance or enhancement of quality of life for 1 of 14 residents reviewed for resident rights. (Resident #12) 1. The facility failed to treat Resident #12 with dignity and respect witnessed by Resident #43 when CNA D told Resident #12 Oh no ma'am, we are not fixing to do this because I am not going to be the one on 03/25/24 with an attitude and rude tone . These failures could place residents at risk for decreased quality of life, decreased self-esteem and increase anxiety. Findings included: 1. Record review of a face sheet dated on 09/17/2024 reflected Resident #12 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of slurred speech (weakness in the muscles used for speech, which often causes slowed or slurred speech), anxiety disorder unspecified (a diagnosis given when someone experiences clinically significant anxiety but doesn't meet the criteria for a specific anxiety disorder), muscle weakness (lack of muscle strength), and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (a common after-effect of stroke that causes weakness on one side of the body). Record review of the quarterly MDS assessment dated [DATE] reflected Resident #12 had a BIMS score of 10, which indicated mild cognitive deficit. Resident #12 required maximal assistance for ADLs such as bed mobility, transfer, and toileting. Record review of a care plan dated 02/15/2024 titled ADL assistance reflected Resident #12 had an ADL self-care performance deficit and is at risk for not having their needs met in a timely manner. The intervention for Resident #12 revealed the staff was to provide shower, shave, oral care, hair care, and nail care (prefers longer nails) per schedule and when needed with ADL's. Prefers nails long. Won't use hand splint/roll or let you paint fingernails right hand. During an interview on 09/16/204 at 10:47 a.m., Resident #43 said CNA D was rude to Resident #12. Resident #43 said Resident #12 tried to tell CNA D she was hurting her and grabbed her hand. CNA D grabbed Resident #12 hand an told her, Oh no ma'am you are not going to put your hands on me. Resident #43 said after that happened, she reported the incident to ADM and DON, and they took care of the situation. Resident #43 said the ADM and DON informed Resident #12 that she did not have to worry about anyone being mean to her here. Resident #43 said she thought CNA D does not work here anymore and she had not been back in their room since that incident. During an interview on 09/16/2024 at 3:17 p.m., Resident #12's family member stated there was an incident and she received information from the facility that a staff member had a bad attitude was rude to my mother. Resident #12 family member said she did not remember the details. During a phone interview on 09/17/24 1:32 p.m., CNA D said yes, I remember the incident with Resident #12. I weigh about 115 pounds. I wear a gait belt and it fits really loose, because I am so small. Resident #12 was very irritated that day I came in to work for someone else. I guess when I bent over to reposition her the metal part of the gait belt hit her and it made her upset. I apologized to her. Her oxygen nasal cannula was off and I was trying to put her stuffed animals back close to her and put her oxygen nasal cannula back on her face. She jerked the oxygen nasal cannula out of my hand and scratched me and I told her no ma'am; we are not going to do that, I am not going to be the one you put hands on today. CNA D said that was her first encounter with Resident #12. CNA D said she notified her charge nurse of the incident. CNA D said the nurse gave Resident #12 medication to relax her and after that she never went back into her room. CNA D said the facility fired her, so why are you calling me about the incident. CNA D said she was upset that day when she came in, because she was not informed by the facility staff that 5 residents on the hall, she was supposed to worked had Covid. During an interview on 09/18/2024 at 8:59 a.m., Resident #12 laid in bed awake. Resident #12 said she remembered CNA D. Resident #12 said CNA D hurt her feelings by the way she talked to her. Resident #12 said CNA D did not hit her. Resident #12 said she does feel safe at the facility. During an interview on 09/18/2024 at 9:10 a.m., LVN C said she knew CNA D. LVN C said when she worked with her, CNA D was a good aide. LVN C she had never heard CNA D be rude to staff or residents. LVN C said CNA D talked loud, but she was a good worker. LVN C said she was not there the day the incident occurred with CNA D and Resident #12. During an interview on 09/18/2024 at 9:32 a.m., CNA F said she remembered working with CNA D. CNA F said she had not witnessed CNA D be mean to the residents. CNA F said she had heard a couple of the residents said that CNA D had been rude to them. CNA F said Resident #43 told her that CNA D was rude, but she could not remember who the other resident was. CNA F said she had not seen CNA D be aggressive or mean toward the residents. During an interview on 09/18/2024 at 9:49 a.m., DON said CNA D does not work here anymore. DON said the facility had an investigation about the incident with CNA D and Resident #12 witnessed by Resident #43. DON said Resident #12 and Resident #43 agreed the incident was not abuse. DON said after spoke to the nurses at the facility; they agreed that CNA D had a bad attitude. DON said CNA D worked at the facility as a shower aide before she started to work as needed. DON said since CNA D came back to work for facility; she complained about where she worked. DON said she tried to keep the same staff with the same residents, because everyone was like family there. DON said she got rid of CNA D, because of her constant bad attitude; not from the incident with Resident #12 particularly. DON said she does not need a bad attitude in her building. DON said she believed CNA D was rude to Resident #12 and Resident #43 and both residents said she was rude that day. During an interview on 09/18/2024 at 2:30 p.m., DON said she thought an attitude with a resident was not acceptable. DON said she believed bedside manners was better than medication given to a resident. DON said we should watch what we say and how we treat people. DON said the incident could probably affected Resident #12's dignity. DON said Resident #12 had trouble with communication, so she does not know the extent the incident effected Resident #12. During an interview on 09/18/2024 at 2:39 p.m., ADM said, the facility let CNA D go, because if she was going to have a bad attitude and the resident felt that she was expressing that negative attitude to them, then she was not a good fit for this facility. ADM said she was sure the incident with CNA D made Resident #12 feel sad and she thought the incident shocked Resident #12. ADM said they had never had an incident like that happened at the facility. ADM said the incident could had infringed on Resident #12's dignity, but more than that she thought her feelings were hurt. ADM said the negative effect that incident could had on Resident #12 was it could had made her sad or upset. Review of a Resident Rights facility policy dated 02/20/2021 reflected, .All residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex sexual orientation, or gender identity or expression.The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents. These rights include the resident's right to .a dignified existence self-determination, and communication with and access to persons and services inside and outside the facility . Review of a Promoting/Maintaining Resident Dignity policy 02/16/2020 indicated, .It is the practice of the facility to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect.All staff members are involved in providing care to residents to promote and maintain resident dignity .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 6 residents (Resident #24) reviewed for PASRR Level I screenings. 1. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #24. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (PTSD with an onset date of 04/16/21) was present upon Resident #24's re-admission date on 05/17/2024. 2. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #24. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, after a new diagnosis of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), with an onset date of 08/28/24. The facility did not complete a 1012 form to update the PASRR Level 1 with the new diagnosis until surveyor intervention on 09/17/2024. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs. Findings included: Record review of Resident #24's face sheet, dated 09/17/24, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. He was most recently readmitted to the facility on [DATE]. His diagnoses included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), with an onset date of 08/28/24, and post-traumatic stress disorder (a mental health condition that was caused by an extremely stressful or terrifying event), with an onset date of 04/16/21. Record review of Resident #24's quarterly MDS assessment, dated 08/06/24, indicated he had a BIMS score of 15, which indicated intact cognition. He also took an antidepressant medication during the assessment window. Record review of Resident #24's PASRR Level 1 Screening, printed on 07/07/23, indicated that in Section C Mental Illness was marked as no, which indicated Resident #24 did not have a mental illness. During an interview on 09/17/24 at 02:25 PM, Social Worker A said that Resident #24 was marked as negative for mental illness on his PASRR Level 1 screening. She said he had recently received a major depressive disorder diagnosis on 08/27/24. She said she did not know that PTSD could be a PASRR positive diagnosis. She said she was going to fill out a 1012 form to notify the local health authority of the resident's diagnosis change. During an interview on 09/18/24 at 02:14 PM, the Administrator said the PASRR Level 1 screening should have been marked yes for mental illness so the local health authority could evaluate him. She said it was possible he could have received PASRR services since August 28, 2024. Record review of the facility's policy, Preadmission and Screening Resident Review (PASRR) Rules, last revised July 2023, stated: .It is the intent of Advanced Health Care Solutions to meet and abide by all state and federal regulations that pertain to resident preadmission and screening resident review (PASRR) rules . .Referring Entity completes a PL1 . .if negative: .If the resident has a qualifying MI (mental illness) diagnosis and the NF feels the resident should be positive they should talk to the referring entity and ask them to correct the PL1 or complete the 1012 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 6 residents reviewed for care plans. (Resident #28) The facility failed to implement Resident #28's signed physician order dated 03/31/2024 for occupational therapy to evaluate Resident #28 for a coffee lid. This failure could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services. Findings included: 1. Record review of a face sheet dated on 09/17/2024 indicated Resident #28 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of exudative age-related macular degeneration, left eye, stage, (a severe form of the disease that occurs when abnormal blood vessels grow under the retina and leak fluid and blood), muscle weakness (generalized) (lack of muscle strength), unsteadiness on feet (might occur due to vestibular problems, nerve damage to the legs, and neurological conditions, such as spondylosis), unspecified lack of coordination (can be a symptom of ataxia, a neurological condition that causes problems with muscle control) and cognitive communication deficit (a difficulty with communication that's caused by a disruption in cognition). Record review of the quarterly MDS assessment dated [DATE] reflected Resident #28 had a BIMS score of 9, which indicated mild cognitive deficit. Resident #28 was independent for ADLs such as eating and toileting but required setup with transfers. Record review of a care plan dated 10/03/2023 titled Visual function (impaired) indicatedreflected, Resident #28 has impaired visual function and was at risk for falls, injury, and a decline in functional ability. The intervention for Resident #28 monitor/document/report to the physician the following signs and symptoms of acute eye problems: change in ability to perform ADLs, decline in mobility, sudden visual loss, pupils dilated, gray or milky pupils, complaints of halos around lights, double vision, tunnel vision, blurred vision, or hazy vision. Care plan date 09/19/2023 titled Falls indicated Resident #28 has the potential for falls related to severely impaired eyesight, generalized weakness, impaired coordination, anxiety, and history of falls while at home. Record review of Resident #28's nurses notes dated 03/30/2034 indicated Resident #28 had reported to the nurse, she had spilled a cup of coffee and received a small blister on her finger that did not require treatment. Resident #28 was educated on letting staff get her coffee. There were no witnesses to the incident. Record review of Resident #28's signed physician order dated on 03/31/2024 indicated Resident #28 was referred to occupational therapy for an evaluation for a lid to be place on coffee cup. Record review on Resident #28's Interdisciplinary Patient Screen dated 09/17/2024 indicated Resident #28, Patient was referred for screening in March 2024 and therapy was notified nursing recommended a screening for a cup lid, because of spill incident. Patient was screened by occupational therapy and based of observation and lack of any significant incident since no adaptive lid at this time. During observations on 09/16/2024 at 12:10 p.m., Resident #28 was eating lunch in dining area independently. Staff setup Resident #28's tray and told her where everything was on the tray before resident started to eat her meal. During an interview and observation on 09/17/2024 at 8:41 a.m., Resident #28 was observed transferred self from her wheelchair to her bed independently. Resident #28 said she did not remember telling anyone about incident where she spilled coffee on herself. Resident #28 said Honey, I'm blind and always spilling stuff on myself. Resident #28 said if there were staff in the dining room, she would let them get coffee for her. She said if there were no staff in the dining room and she wanted coffee then she would get it herself. She said there was 2 types of coffee containers, one had a pump on top and she had to wait on staff because she could not use it, but the other one had a lever, and she could use that fine. She said if she wanted coffee then she would go to get it, but she would let staff get it if they were there. She said she did not have a lid for her coffee but would not use one if she did. During an interview on 09/17/2024 at 9:10 a.m., COTA G was asked about Resident #28 orders for Refer to occupational Therapy to assess for a lid for a coffee cup. COTA G said Resident #28 had therapy before, but therapy had not received an order for a lid for a coffee cup evaluation, so there was no assessment performed. During an interview on 09/17/2024 at 9:20 a.m., The DON said if therapy does not have the assessment performed for an evaluation for the lid on the coffee cup, then the facility does not have one. DON said she did not know about the evaluation order and Resident #28 has not had any issues since the day she said she spilled the coffee. During a phone interview on 09/17/2024 at 10:06 a.m., MD said he expected the facility to follow his orders. MD said if the resident did not like the coffee cup lid he ordered, the facility could cancel the order for the coffee cup lid, but he wanted the orders followed. During an interview on 09/17/2024 at 10:54 a.m., LVN E said Resident #28 told her she spilled coffee on her finger earlier that day and had not told reported it to staff. LVN E said she asked Resident #28 why she did not report the incident to staff about she had spilled coffee on her finger. LVN E said Resident #28 told her she felt like it was not a big deal, and she felt like it was not important, but she told her friends about the (coffee spill) incident and they told Resident #28 she should have told the nurse, so she told LVN. E LVN E said she educated Resident #28 on when things happened in the future let staff know, so they can take care of it. LVN E said her intervention was to educate Resident #28 and to notify occupational therapy to maybe get a coffee cup with a lid. LVN C said all nurses were responsible to make sure doctor orders were followed. LVN E said she did not write an order for occupational therapy to evaluate Resident #28 for a cup with a lid; that was an intervention. LVN E said if she wrote an order, it was a mistake; it was supposed to be an intervention. During an interview on 09/18/2024 at 9:10 a.m., LVN C said when a nurse received an order from the doctor the nurse was responsible for following through with the order. LVN C said when doctor orders are put into point click care therapy were able to access the orders the nurse applied to the computer system. LVN C said the nursing staff usually informed therapy about the new doctor's orders verbally. LVN C said when a nurse wrote an order for an evaluation for therapy, it would be therapy responsibility to follow and initiate the order. LVN C said a signed doctor order should be followed. During a phone interview on 09/18/2024 at 9:49 a.m., the DON said the MD did not write the order for occupational therapy evaluation. LVN E called another MD for the order, but it was not an order. The DON said LVN E wrote an intervention. The DON agreed MD signed the order. The DON said the facility intervention was for Resident #28 coffee spill was to educate the resident on getting assistance with the coffee. The DON said when the nurses put in doctor orders, she expected the nurses to follow the orders. DON said she does believe when a true doctor order was wrote, the orders should be followed, but that was not a doctor order; it was an intervention. During an interview on 09/18/2024 at 2:30 p.m., the DON said she expected the nurses to follow doctor's orders. The DON said not, following doctor orders could affect the residents in several different ways. DON said all signed doctor orders should be followed. During an interview on 09/18/2024 at 2:39 p.m., ADM said she expected the nurses to follow doctor's orders. ADM said not following doctor's orders could potentially cause issues for the resident, if the facility does not follow the doctor orders. ADM said when an order was signed by the doctor, she expected the staff to follow signed doctor's orders. Record review of a facility's Comprehensive Care Plans policy dated 02/10/2021, indicated .to meet the resident's physical, psychosocial and functional needs is developed and implemented for each residents .the care planning process will .include an assessment of the resident's strengths and needs .incorporate the resident's personal and cultural preferences .the services that are to be refurnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being . Record review of a facility's Following Physician Orders policy dated 02/10/2021 indicated . for consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: follow facility procedures for verbal or via telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administrator record .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 2 residents (Resident #147) reviewed for respiratory care and services. The facility failed to change the filter on an oxygen concentrator machine that were in use for Resident #147 on 09/16/24. This failure could place residents at risk for developing respiratory complications. Findings included: Record review of Resident #147's face sheet, dated 09/17/24, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included heart failure (a chronic condition in which the heart is unable to pump blood effectively), and shortness of breath. Review of Resident #147 MDS reflected they did not have an OBRA MDS assessment completed at the time of this visit. It was not yet due to be completed. During an observation and interview on 09/16/24 at 9:53AM, Resident #147 was lying in bed in his room. He had oxygen in place via a nasal cannula. The oxygen concentrator filter was dirty with a thick layer of white/gray material on the surface. Resident #147 said he usually wore oxygen. During an observation on 09/16/24 at 12:18 PM, Resident #147 was lying in bed in his room. He had oxygen in place via a nasal cannula. The oxygen concentrator filter was still dirty with a thick layer of gray/white material. During an observation on 09/16/24 at 03:06 PM, Resident #147 was lying in bed in his room. He had oxygen in place via a nasal cannula. The oxygen concentrator filter was dirty with a thick layer of gray/white material. During an interview on 09/18/24 at 11:24 AM, LVN B said she had taken care of Resident #147 on 09/16/24. She said she did not check the concentrator filter on the machine during her shift. She said the filters were normally checked weekly. She said she had worked full-time at this facility for only the past few weeks. She said the risk to Resident #147 was that he could get sick or suffer respiratory distress. She said he had been admitted over the past weekend. During an interview on 09/18/24 at 11:26 AM, LVN C, Hall Manager, said she had worked on 09/16/24 and went into Resident #147's room a few times. She said the nurses were supposed to check the concentrator filters once a week on night shift on Wednesdays. She said that Resident #147 had been recently admitted over the weekend, and it was possible that the filter had not been changed from the last time the concentrator was used. She said some of the concentrators did not take filters, so the nurses sometimes forgot to check the filter. She said she did not think the resident could get sick from the dirty filter because the machine would shut off before the resident would get sick. She said even though the machine was working on 09/16/24 with the dirty filter, she did not think the resident would get sick. She said if the machine shut off, then she would be worried about respiratory distress. During an interview on 09/18/24 at 01:44 PM, the ADON said the nurses were supposed to check the filters every week when the tubing was changed. She said she expected the nurse that had pulled the concentrator out of storage to look at it and check the filter. She said the risk to the resident could be that he could get sick from the dirty filter. During an interview on 09/18/24 at 01:53 PM, the DON said the nurses checked and changed filters every Wednesday. She said she did not catch it on Monday before this surveyor checked it. She said the risk to the resident could be sickness. During an interview on 09/18/24 at 02:14 PM, the Administrator said she expected the staff to keep the filter clean and change it per policy. She said the risk to the resident could be sickness. Record review of the facility's policy, Oxygen Administration, last reviewed 01/05/20, stated: .Concentrator 1. Clean filter weekly 2. Remove filter from back of concentrator 3. Rinse filter with water 4. Shake off excess water. Replace filter .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a comprehensive resident-centered assessment of each resident's cognitive, medical, and functional capacity in a timely manner for 1 of 13 residents (Resident #14) reviewed for accuracy of assessments. The facility failed to complete Resident #14's admission MDS assessment within 14 days of admission. This failure could place residents at risk of not having their needs met. Findings included: Record review of a face sheet dated 08/14/2023 indicated Resident #14 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), Type 2 diabetes mellitus with diabetic neuropathy (chronic condition that affects the way the body processes blood sugar with nerve damage caused by high blood sugars), and bipolar disorder, current episode depressed, severe, without psychotic features (a disorder associated with episodes of mood swings ranging from depression lows to manic highs). Record review of Resident #14's comprehensive MDS assessment with an ARD (assessment reference date) of 07/25/2023 indicated in Section A0310 it was an admission assessment (required by day 14). The MDS assessment for Resident #14 indicated in Section A1600 an entry date of 07/18/2023. The MDS assessment in Section Z0500B was signed completed on 08/04/2023, which indicated the MDS assessment for Resident #14 was completed 4 days late. During an interview on 08/16/2023 at 10:51 AM, the MDS Coordinator said she was responsible for the MDS assessments, and the ADON or the DON signed the MDS assessments. The MDS Coordinator said the admission MDS assessment should be completed within 7-14 days of admission. The MDS Coordinator said the corporate person overlooked the completion of the MDS assessments by performing audits, but she was not sure how often the audits were done. The MDS Coordinator said Resident #14's admission MDS assessment was not completed on time, and she was not sure why it was not completed on time. The MDS Coordinator said she had been at the facility for almost a year, and she was still learning. The MDS Coordinator said it was important for the MDS assessments to be completed on time to be compliant with state requirements. The MDS Coordinator said if the MDS assessments were completed late the needs of the residents would not be accurately reflected. During an attempted phone interview on 08/16/2023 at 11:19 AM, the Corporate MDS Nurse did not answer the phone. During an interview on 08/16/2023 at 1:19 PM, the ADON said both the MDS Coordinator and herself were responsible for completing the MDS assessments. The ADON said the admission MDS assessment should be completed within 7 days from admission. The ADON said she would not know if an MDS assessment was completed late. The ADON said she had taken an online course on MDS assessments, and she was still learning about the MDS assessments. The ADON said it was important to complete the MDS assessments on time so they could catch any issues the residents were having, and their care plans would be accurate to provide the best care to the residents. During an interview on 08/16/2023 at 1:26 PM, the Administrator said the MDS Coordinator was responsible for completing the MDS assessments. The Administrator said completion of the MDS assessments was overseen by the corporate support group, but she did not know how often they reviewed the MDS assessments. The Administrator said she expected the MDS assessments to be completed on time. The Administrator said it was important for the MDS assessments to be completed on time to maintain compliance and to ensure the residents were taken care of. During an interview on 08/16/2023 at 1:44 PM, the DON said the MDS Coordinator was responsible for completing the MDS assessments. The DON said occasionally she signed the MDS assessments if the ADON was not available. The DON said she did not know timeframes for completion of the MDS assessments. The DON said the Corporate MDS nurse monitored the completion of the MDS assessments. The DON said it was important to complete the MDS assessments on time because it completed the care plan, but she did not feel like it hindered the residents' care. Record review of the facility's policy titled, MDS Accuracy Guidelines, last revised 10/24/2022, indicated, The purpose of the MDS guideline is to ensure each resident receives an accurate assessment by qualified staff that are familiar with his/her physical, mental, and psychosocial well-being in order to identify the specific needs of the resident in accordance with the RAI Manual . Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 updated October 2023 indicated, For the admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 1 of 6 residents (Resident #14) reviewed for PASRR. The facility failed to ensure Resident #14's PASRR Level 1 Screening indicated a diagnosis of mental illness. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs. Findings included: Record review of a face sheet dated 08/14/2023 indicated Resident #14 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), Type 2 diabetes mellitus with diabetic neuropathy (chronic condition that affects the way the body processes blood sugar with nerve damage caused by high blood sugars), and bipolar disorder, current episode depressed, severe, without psychotic features (a disorder associated with episodes of mood swings ranging from depression lows to manic highs). Record review of the Comprehensive MDS assessment dated [DATE] indicated, Resident #14 was understood and understood others. The MDS assessment indicated Resident #14 had a BIMS score of 15, which indicated her cognition was intact. The MDS section, Preadmission Screening and Resident Review indicated Resident #14 did not have a serious mental illness. The MDS section, Level II Preadmission Screening and Resident Review Conditions did not reflect a mental illness. The MDS section of Psychiatric/mood disorder indicated diagnoses of anxiety and bipolar disorder. Record review of the care plan with a date initiated of 07/27/2023 indicated, Resident #14 used psychotropic medications (medications prescribed to treat conditions that affect the mind, emotions, and behavior) related to bipolar disorder. The care plan indicated Resident #14 had depression related to bipolar disorder, and interventions included to administer medications as ordered and to arrange for a psych consult. Record review of Resident 14's PASRR Level 1 Screening completed on 07/27/2023 indicated in section C0100 no evidence of this individual having mental illness. During an interview on 08/16/2023 at 9:39 AM, the Social Worker said she was responsible for PASRR. The Social Worker said she realized yesterday when the surveyor asked her for Resident #14's PASRR Level 1 Screening that it was not correct. The Social Worker said Resident #14 had Bipolar disease, which indicated she had mental illness. The Social Worker said she had missed that on admission because when a resident admitted she just reviewed the PASRR Level 1 Screening, but she did not look at the diagnoses to ensure accuracy of the PASRR Level 1 Screening. The Social Worker said it was important for the PASRR Level 1 Screening to be accurate because the facility needed to make sure the residents were getting the correct resources. During an interview on 08/16/2023 at 1:27 PM, the Administrator said the Social Worker was responsible for PASRR. The Administrator said to her knowledge nobody overlooked the PASRR services, but corporate could assist if the Social Worker needed assistance. The Administrator said she expected the PASRR Level 1 Screenings to be completed accurately. The Administrator said it was important the PASRR Level 1 Screenings were completed accurately to ensure that the needs of the residents were met.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to develop or implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 13 residents reviewed for care plans. (Resident #6) The facility did not develop or implement a comprehensive care plan to address Resident #6's diagnosis of PTSD (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations) and history of trauma. This failure could place residents at risk for inaccurate care plans and decreased quality of care. The findings included: Record review of the face sheet, dated 08/16/23, revealed Resident #6 was a [AGE] year-old male who admitted to the facility initially on 12/24/20 with diagnoses of PTSD (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations), unspecified dementia without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life), and Parkinson's disease (chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement). Record review of the MDS assessment, dated 05/16/23, revealed Resident #6 had clear speech and was understood by facility staff. The MDS revealed Resident #6 was able to understand others. The MDS revealed Resident #6 had a BIMS score of 15, which indicated no cognitive impairment. The MDS revealed Resident #6 had no behaviors or refusal of care. The MDS revealed Resident #6 had an active diagnosis of PTSD during the 7-day look back period. Record review of Resident #6's comprehensive care plan, initiated 01/06/21, did not address his diagnosis of PTSD or history of trauma. Record review of the progress note, dated 08/11/23, revealed Resident #6 was seen at the clinic for the treatment of the diagnosis of PTSD . During an observation and interview on 08/14/23 at 3:32 PM, Resident #6 was sitting up in a wheelchair in his room. Resident #6 was well-groomed with clothing in good repair without stains and hair combed neatly. Resident #6 was pleasant and calm during the interview. Resident #6 stated he had a history of trauma and a diagnosis of PTSD from being in Vietnam. During an interview on 08/16/23 at 1:46 PM, CNA A stated she normally worked the hall Resident #6 lived on. CNA A stated she had access to look at the care plan from the electronic charting system but relied on the nurses to inform her if a resident had any history of trauma or trauma triggers. CNA A stated she was aware Resident #6 had a diagnosis of PTSD but was unable to identify the trauma triggers or interventions that were put in place to prevent re-traumatization. CNA A stated if Resident #6 became triggered she would have discussed it with the Social Worker. CNA A stated it was important to ensure Resident #6's was accurately assessed for trauma and trauma triggers to make sure facility staff was avoiding the triggers to prevent emotional distress. During an interview on 08/16/23 at 1:55 PM, LVN C stated a history of trauma, or a diagnosis of PTSD was identified on admission to the facility via physician orders or a history and physical completed by the physician. LVN C stated she normally worked with Resident #6. LVN C was unaware Resident #6 had a diagnosis of PTSD or a history of trauma. LVN C stated the Social Worker was responsible for completing the trauma screening on admission to the facility. LVN C stated the Social Worker notified the nurses verbally if a resident had a history of trauma or a diagnosis of PTSD. LVN C stated the management staff was responsible for ensuring a diagnosis of PTSD or history of trauma was included on the plan of care. LVN C stated it was important to accurately identify a history of trauma and identify the trauma triggers to ensure staff avoided the triggers to prevent emotional distress. During an interview on 08/16/2023 at 2:05 PM, the ADON stated care planning was an IDT effort. The ADON stated the MDS Coordinator was ultimately responsible for ensuring diagnosis were included on the comprehensive care plan. The ADON stated a diagnosis of PTSD, and a history of trauma should have been included on the care plan. The ADON stated it was important to ensure a diagnosis of PTSD, or a history of trauma was included on the plan of care to avoid trauma triggers and provide staff with information on what type of behaviors or trauma they were dealing with. The ADON stated it was important to ensure staff were aware of the trauma triggers to prevent re-trauma to the residents. During an interview on 08/16/23 at 2:16 PM, the Social Worker stated she was responsible for ensuring the trauma screening was completed accurately. The Social Worker stated she completed a trauma screen within 14 days of admission to the facility. The Social Worker stated the residents that had a new diagnosis of PTSD or history of trauma, would have been referred to psych services or counseling but no new trauma screening would have been completed. The Social Worker stated the MDS Coordinator was responsible for ensuring Resident #6's diagnosis of PTSD or history of trauma was included on the care plan. The Social Worker stated it was important to accurately screen the residents for trauma and identify trauma triggers to ensure the proper steps were taken to prevent the triggers and avoid further emotional distress to the residents. During an interview on 08/16/23 at 2:22 PM, the MDS Coordinator stated she and the Social Worker were responsible for ensuring a diagnosis of PTSD and history of trauma was included on the care plan. The MDS Coordinator stated it could have been missed on Resident #6 because it was overlooked. The MDS Coordinator stated it was important to ensure a diagnosis of PTSD and history of trauma, and the trauma triggers were care planned to make sure the care plan was individualized, and the staff were meeting all his needs mentally. During an interview on 08/16/23 at 4:12 PM, the DON stated a diagnosis of PTSD, or a history of trauma should have been identified on a trauma screen upon admission to the facility by the Social Worker. The DON stated trauma triggers should have also been identified and included on a care plan to ensure the facility staff was aware how to care for the residents. During an interview on 08/16/23 at 4:32 PM, the Administrator stated she needed to check the policy and procedure for trauma informed care, but she expected staff to ensure the trauma screening was completed accurately and was reflected on the plan of care. The Administrator stated she expected the trauma screening to be completed according to policy and procedure. The Administrator stated it was important to ensure trauma screening was completed accurately and trauma triggers were identified to ensure quality of life for residents and needs were being met. Record review of the Trauma Informed Care policy, dated 10/24/22, revealed 4. The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions. The policy further revealed Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan. Record review of the Comprehensive Care Plans policy, dated 02/10/21, revealed Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma informed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure necessary services to maintain personal hygiene were provided for 1 of 47 residents reviewed for ADLs. (Resident #11). The facility did not ensure Resident #11 received fingernail care. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem. The findings included: Record review of the face sheet, dated on 8/16/23, indicated that Resident #11 was a [AGE] year-old female who admitted to the facility on initial admission dated 1/18/23, with a diagnosis of Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements), Type 2 Diabetes mellitus (chronic condition that affects the way the body processes blood sugar), Lack of coordination (disorder that affects body movements),and Polyarthritis (disorder that causes pain, stiffness or swelling in the joints). Record Review of Resident #11 MDS assessment, dated 6/20/23 indicated that Resident #11 had clear speech and was understood by staff. The MDS revealed Resident #8 was able to understand others. The MDS revealed Resident #11 had a BIMS score of 11, which indicated moderately impaired cognition. The MDS revealed Resident #11 had no behaviors or refusal of ADL care. The MDS revealed Resident #11 required a limited, one-person physical assistance with personal hygiene. Record Review of the comprehensive care plan, revised on 7/12/23, indicated that Resident #11 had a Resident #11 was at risk for further decline in ADL's related to Parkinson's Progression. The interventions included: ADL's may fluctuate based on resident's daily needs. During an observation on 8/14/2023 at 2:44 p.m., Resident #11 had long, uneven fingernails on her left and right hand. During an Observation and Interview on 8/15/23 at 8:45 p.m., Resident #11 had long, uneven fingernails on her left and right hand. Resident #11 stated she wanted her fingernails trimmed, but the treatment nurse who normally does her fingernails had been busy. Resident #11 indicated that she verbally expressed her fingernail trimming needs to the Treatment nurse. Resident #11 stated she could not recall the day and time she told the treatment nurse she needed fingernail trimming on the prior week. Resident #11 stated she had Parkinson's disease and the disease had caused her to accidently scratch herself in the past. Resident #11 stated she feared accidently scratching herself again. During an interview on 08/14/2023 at 1:48 p.m., the CNA stated if the resident was not diabetic then the CNA's would perform fingernail care. The CNA stated if a resident was diabetic, then the treatment nurse or charge nurse were responsible for ensuring fingernails were trimmed. The CNA was unsure if Resident #11 was a diabetic. The CNA was unsure why Resident #11 was not provided fingernail care. The CNA stated she had not been monitoring fingernail care for Resident #11 and could not recall when Resident #11 fingernails were last trimmed. The CNA stated fingernail care should have been performed on shower days and if it was needed. The CNA could not recall if Resident #11 had ever refused fingernail care. The CNA stated she did not complete in-services on ADL's. The CNA stated fingernail care was important to ensure health and dignity of the resident. During an interview on 8/14/2023 at 1:56 p.m., the Charge nurse stated Resident #11 was a diabetic. The Charge nurse stated the CNAs were not supposed to trim or cut diabetic resident's fingernails. The Charge nurse stated the treatment nurse was responsible for monitoring the diabetic residents who needs fingernail care. The Charge nurse stated the Treatment nurse was in charge of fingernail care for Resident #11. The Charge nurse stated fingernail care should have been performed during showers. The Charge nurse could not recall if Resident #11 had ever refused fingernail care. The charge nurse stated she had completed in-services on ADLs but could not recall when ADL in-services were completed. The Charge nurse stated fingernail care was important to prevent the spread of infection and to prevent self-harm. During an interview on 8/14/2023 at 2:58 p.m., the treatment nurse stated she was responsible for fingernail care on Resident #11. The treatment nurse stated she was responsible for monitoring fingernail on Resident #11. The treatment nurse stated fingernail care was monitored on Wednesday shower days for Resident #11. The Treatment nurse stated Resident #11 refused fingernail care on 8/9/23 and was unsure of the time for refusal. The Treatment nurse stated she did not document refusal of fingernail care treatment. The treatment nurse stated if a resident refused care then it was not documented at the facility. The treatment nurse stated she could not recall when she completed in-services on ADL's. The treatment nurse stated fingernail care was important to avoid skin tear, fingernail fungus and nail breaking. During an interview on 8/14/2023 at 2:49 p.m., the DON stated the treatment nurse was responsible for fingernail on Resident #11. The DON stated the CNAs were not responsible for performing fingernail care on diabetic residents. The DON stated fingernail care was monitored weekly by the Treatment nurse on Resident #11. The DON stated that she could not recall the last time Resident #11 fingernails were trimmed. The DON stated that Resident #11 had never refused fingernail care until recently on 8/14/23. The DON was unsure of the time on 8/14/23 that Resident #11 declined fingernail trimming. The DON stated that refusal of fingernail care did not get documented in Resident #11 care plan as the facility does not document when a resident refuses care. The DON would not answer why fingernail care was important to Resident#11 health and safety. During an interview on 8/14/2023 at 3:08 p.m., The Administrator stated that she was unaware that Resident #11's fingernails had not been trimmed. The Administrator stated that she was not sure if staff had completed in-service training on ADL's but would get with the DON to provide documentation on the completion of staff ADL in-services training prior to exit. The Administrator stated that Resident #11 had never refused fingernail care until recently on 8/14/23. The Administrator stated that she was verbally informed by the DON that Resident #11 refused fingernail trimming on 8/14/23. The Administrator stated that she was unsure of the time on 8/14/23 that Resident #11 refused fingernail trimming. The Administrator stated she did not have any documentation to provide that would indicate that Resident #11 refused fingernail care. The Administrator stated that fingernail care was important to ensure quality of life. Record Review of in-services revealed that the CNA and Charge nurse did not complete ADL training. Record Review of the facility Activities of Daily Living Care Guidelines, policy, origination date of 1/23/16, indicated that, Residents will receive essential services for activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene. Conditions which may demonstrate unavoidable decline in ADLs include a) natural progression of the resident's disease state b) deterioration of the resident's physical condition associated with the onset of a physical or mental disability c) refusal of care and treatment by the resident or his/her surrogate to maintain functional abilities. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 2 residents' (Resident #6) reviewed for trauma-informed care. The facility did not ensure Resident #6 had an accurate trauma screen that identified possible triggers when Resident #6 had a diagnosis of PTSD (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations). This failure could put residents at an increased risk for psychological distress due to re-traumatization. The findings included: Record review of the face sheet, dated 08/16/23, revealed Resident #6 was a [AGE] year-old male who admitted to the facility initially on 12/24/20 with diagnoses of PTSD (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations), unspecified dementia without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life), and Parkinson's disease (chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement). Record review of the MDS assessment, dated 05/16/23, revealed Resident #6 had clear speech and was understood by facility staff. The MDS revealed Resident #6 was able to understand others. The MDS revealed Resident #6 had a BIMS score of 15, which indicated no cognitive impairment. The MDS revealed Resident #6 had no behaviors or refusal of care. The MDS revealed Resident #6 had an active diagnosis of PTSD during the 7-day look back period. Record review of Resident #6's comprehensive care plan, initiated 01/06/21, did not address his diagnosis of PTSD or history of trauma. Record review of the comprehensive trauma screening, dated 12/28/20, did not indicate Resident #6 had a history of trauma or a diagnosis of PTSD. Record review of the progress note, dated 08/11/23, revealed Resident #6 was seen at the clinic for the treatment of the diagnosis of PTSD . During an observation and interview on 08/14/23 at 3:32 PM, Resident #6 was sitting up in a wheelchair in his room. Resident #6 was well-groomed with clothing in good repair without stains and hair combed neatly. Resident #6 was pleasant and calm during the interview. Resident #6 stated he had a history of trauma and a diagnosis of PTSD from being in Vietnam. During an interview on 08/16/23 at 1:46 PM, CNA A stated she normally worked the hall Resident #6 lived on. CNA A stated she had access to look at the care plan from the electronic charting system but relied on the nurses to inform her if a resident had any history of trauma or trauma triggers. CNA A stated she was aware Resident #6 had a diagnosis of PTSD but was unable to identify the trauma triggers or interventions that were put in place to prevent re-traumatization. CNA A stated if Resident #6 became triggered she would have discussed it with the Social Worker. CNA A stated it was important to ensure Resident #6 was accurately assessed for trauma and trauma triggers to make sure facility staff was avoiding the triggers to prevent emotional distress. During an interview on 08/16/23 at 1:55 PM, LVN C stated a history of trauma, or a diagnosis of PTSD was identified on admission to the facility via physician orders or a history and physical completed by the physician. LVN C stated she normally worked with Resident #6. LVN C was unaware Resident #6 had a diagnosis of PTSD or a history of trauma. LVN C stated the Social Worker was responsible for completing the trauma screening on admission to the facility. LVN C stated the Social Worker notified the nurses verbally if a resident had a history of trauma or a diagnosis of PTSD. LVN C stated it was important to accurately identify a history of trauma and identify the trauma triggers to ensure staff avoided the triggers to prevent emotional distress. During an interview on 08/16/2023 at 2:05 PM, the ADON stated the Social Worker was responsible for ensuring the trauma screen was completed on new residents who admitted to the facility. The ADON was unsure how quickly the comprehensive trauma screen should have been completed. The ADON stated the nurses had access to the comprehensive trauma screen under the assessment part in the electronic charting system. The ADON stated a diagnosis of PTSD, or a history of trauma was communicated verbally at times, but the trauma screen was accessible as well. The ADON stated it was important to ensure a diagnosis of PTSD, or a history of trauma was accurately identified to avoid trauma triggers and provide staff with information on what type of behaviors or trauma they were dealing with. The ADON stated it was important to ensure staff were aware of the trauma triggers to prevent re-trauma to the residents. During an interview on 08/16/23 at 2:16 PM, the Social Worker stated she was responsible for ensuring the trauma screening was completed accurately. The Social Worker stated she completed a trauma screen within 14 days of admission to the facility. The Social Worker stated the residents that had a new diagnosis of PTSD or history of trauma, would have been referred to psych services or counseling but no new trauma screening would have been completed. The Social Worker stated it was important to accurately screen the residents for trauma and identify trauma triggers to ensure the proper steps were taken to prevent the triggers and avoid further emotional distress to the residents. During an interview on 08/16/23 at 4:12 PM, the DON stated a diagnosis of PTSD, or a history of trauma should have been identified on a trauma screen upon admission to the facility by the Social Worker. The DON stated trauma triggers should have also been identified and included on a care plan to ensure the facility staff was aware how to care for the residents. During an interview on 08/16/23 at 4:32 PM, the Administrator stated she needed to check the policy and procedure for trauma informed care, but she expected staff to ensure the trauma screening was completed accurately and was reflected on the plan of care. The Administrator stated she expected the trauma screening to be completed according to policy and procedure. The Administrator stated it was important to ensure trauma screening was completed accurately and trauma triggers were identified to ensure quality of life for residents and needs were being met. Record review of the Trauma Informed Care policy, dated 10/24/2022, revealed 2. The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asked the resident about triggers that may be stressors or may prompt recall of a previous traumatic even, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), admission Assessment, the history and physical, the social history/assessment, and others. The policy further revealed 6. The facility will identify triggers which may re-traumatize residents with a history of trauma.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 2 of 6 residents (Resident #43, #45) reviewed for medication administration. 1. The facility did not ensure Resident #43 rinsed and spit after administration of an inhalation medication (Breo Elipta) for a diagnosis of COPD. 2. Resident #43 was not given a multivitamin tablet as prescribed by the physician. 3. Resident #45 was not given senna 8.6mg (laxative) as prescribed by the physician. This failure could place residents at an increased risk for inaccurate drug administration and not receiving the care and services to meet their individual needs. The findings included: 1. Record review of the face sheet, dated 08/16/23, revealed Resident #43 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis COPD - chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the order summary report, dated 08/16/23, revealed Resident #43 had an order, which started on 08/02/23, for Breo Ellipta inhalation aerosol powder 100-25 mcg/act, 1 puff via inhalation orally in the morning for diagnosis of COPD with special instruction to rinse mouth and spit after each use. The order summary report further revealed an order, which started on 09/21/22, for a multivitamin tablet - give one gummy by mouth in the morning. Record review of the EMAR, dated August 2023, revealed Resident #43 received Breo Ellipta and a multivitamin daily. Record review of the MDS assessment, dated 07/21/23, revealed Resident #43 had clear speech and was understood by staff. The MDS revealed Resident #43 was able to understand others. The MDS revealed Resident #43 had a BIMS of 8, which indicated moderately impaired cognition. The MDS revealed Resident #43 had no behaviors or rejection of care. Record review of the comprehensive care plan, initiated on 12/20/22, revealed Resident #43 had a diagnosis of COPD and took medication. The interventions included: administer medication per orders. During an observation on 8/15/23 at 8:45 AM, LVN E was preparing Resident #43's medication for administration. LVN E obtained a bottle of multivitamin with minerals and placed one, round, pale pink tablet in the cup. LVN E finished preparing the remainder of Resident #43's morning medication, which included the Breo Ellipta aerosol inhaler. LVN E obtained a plastic glass of water and went into Resident #43's room. LVN E gave Resident #43 her medication cup, which included the multivitamin with minerals, and Resident #43 swallowed the medication. LVN E then administered Resident #43's Breo Ellipta aerosol inhaler orally via inhalation. LVN E gave Resident #43 a glass of water after administration of the medication but did not instruct Resident #43 to rinse and spit after the use of her aerosol inhaler. 2. Record review of the face sheet, dated 08/23/23, revealed Resident #45 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis of hemiplegia and hemiparesis following a stroke (weakness or paralysis to one side of the body), squamous blepharitis to right upper eyelid (inflammation of the eyelids), and conjunctival hyperemia, right eye (redness of the eye). Record review of the order summary report, dated 08/23/23, revealed Resident #45 had an order, which started on 05/21/23, for senna 8.6mg - give one tablet by mouth two times a day. Record review of the EMAR, dated August 2023, revealed Resident #45 received senna 8.6 mg daily. Record review of the MDS assessment, dated 07/28/23, revealed Resident #45 had clear speech and was understood by others. The MDS revealed Resident #45 was able to understand others. The MDS revealed Resident #45 had a BIMS of 12, which indicated moderately impaired cognition. The MDS revealed Resident #45 had no behaviors or refusal of care. Record review of the comprehensive care plan, dated 02/21/23, revealed Resident #45 had a history of constipation. During an observation on 08/15/23 at 8:30 AM, LVN E was preparing Resident #45's medication for administration. LVN E obtained a bottle of senna plus tablets and placed one, round, orange tablet in the cup. LVN E finished preparing the remainder of Resident #45's morning medication, obtained a plastic glass of water, and went into Resident #45's room. LVN E gave Resident #45 her medication cup, which included the senna plus, and Resident #45 swallowed the medications. During an interview on 08/16/23 at 4:06 PM, LVN E stated medication should have been administered per the physician orders. LVN E stated special instructions should have been followed during medication administration. LVN E stated she should have instructed Resident #43 to rinse and spit after administration of her aerosol inhaler, but she did not think to look at the label on the box. LVN E stated she should have verified the order and the medication bottle prior to administering the medication to Resident #43 and Resident #45. LVN E stated she was provided an in-service on correctly administering an aerosol inhaler via inhalation to include instructing the resident to rinse and spit after use. LVN E stated it was important to ensure medication were administered per the physician orders to prevent adverse effects. During an interview on 08/16/23 at 4:12 PM, the DON stated she expected medications to be given as ordered by the physician. The DON stated LVN E should have instructed Resident #43 to rinse and spit after administration of her aerosol inhaler. The DON stated the EMAR, and the medication label should be verified at least 3 times prior to medication administration. The DON stated it was important to ensure special instructions were followed and the correct medications were administered to prevent adverse reactions to the resident. During an interview on 08/16/23 at 4:32 PM, the Administrator stated she expected medication to be administered per the physician order. The Administrator stated nursing management was responsible for monitoring to ensure medications were administered correctly. The Administrator stated it was important to administer medications according to the physician order to ensure the safety and well-being of the residents. Record review of the Medication - Treatment Administration and Documentation Guidelines policy, reviewed on 02/10/20, revealed 3. Verify and provide medication or treatment focused assessment as indicated by manufactures guidelines or physician orders.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 3 errors out of 25 opportunities, resulting in a 12 percent medication error rate for 2 of 6 residents reviewed for medication error. (Resident #43, Resident #45) The facility failed to ensure the following: 1. Resident #43 rinsed and spit after administration of an inhalation medication (Breo Elipta). 2. Resident #43 was given a multivitamin tablet as prescribed by the physician. 3. Resident #45 was given senna 8.6mg (laxative) as prescribed by the physician. These failures could place residents at risk for inaccurate drug administration. The findings included: 1. During an observation on 8/15/23 at 8:45 AM, LVN E was preparing Resident #43's medication for administration. LVN E obtained a bottle of multivitamin with minerals and placed one, round, pale pink tablet in the cup. LVN E finished preparing the remainder of Resident #43's morning medication, which included the Breo Ellipta aerosol inhaler. LVN E obtained a plastic glass of water and went into Resident #43's room. LVN E gave Resident #43 her medication cup, which included the multivitamin with minerals, and Resident #43 swallowed the medication. LVN E then administered Resident #43's Breo Ellipta aerosol inhaler orally via inhalation. LVN E gave Resident #43 a glass of water after administration of the medication but did not instruct Resident #43 to rinse and spit after the use of her aerosol inhaler. Record review of the order summary report, dated 08/16/23, revealed Resident #43 had an order, which started on 08/02/23, for Breo Ellipta inhalation aerosol powder 100-25 mcg/act, 1 puff via inhalation orally in the morning for diagnosis of COPD with special instruction to rinse mouth and spit after each use. The order summary report further revealed an order, which started on 09/21/22, for a multivitamin tablet - give one gummy by mouth in the morning. Record review of the EMAR, dated August 2023, revealed Resident #43 received Breo Ellipta and a multivitamin daily. 2. During an observation on 08/15/23 at 8:30 AM, LVN E was preparing Resident #45's medication for administration. LVN E obtained a bottle of senna plus tablets and placed one, round, orange tablet in the cup. LVN E finished preparing the remainder of Resident #45's morning medication, obtained a plastic glass of water, and went into Resident #45's room. LVN E gave Resident #45 her medication cup, which included the senna plus, and Resident #45 swallowed the medications. Record review of the order summary report, dated 08/23/23, revealed Resident #45 had an order, which started on 05/21/23, for senna 8.6mg - give one tablet by mouth two times a day. Record review of the EMAR, dated August 2023, revealed Resident #45 received senna 8.6 mg daily. During an interview on 08/16/23 at 4:06 PM, LVN E stated medication should have been administered per the physician orders. LVN E stated special instructions should have been followed during medication administration. LVN E stated she should have instructed Resident #43 to rinse and spit after administration of her aerosol inhaler, but she did not think to look at the label on the box. LVN E stated she should have verified the order and the medication bottle prior to administering the medication to Resident #43 and Resident #45. LVN E stated she was provided an in-service on correctly administering an aerosol inhaler via inhalation to include instructing the resident to rinse and spit after use. LVN E stated it was important to ensure medication were administered per the physician orders to prevent adverse effects. During an interview on 08/16/23 at 4:12 PM, the DON stated she expected medications to be given as ordered by the physician. The DON stated LVN E should have instructed Resident #43 to rinse and spit after administration of her aerosol inhaler. The DON stated the EMAR, and the medication label should be verified at least 3 times prior to medication administration. The DON stated it was important to ensure special instructions were followed and the correct medications were administered to prevent adverse reactions to the resident. During an interview on 08/16/23 at 4:32 PM, the Administrator stated she expected medication to be administered per the physician order. The Administrator stated nursing management was responsible for monitoring to ensure medications were administered correctly. The Administrator stated it was important to administer medications according to the physician order to ensure the safety and well-being of the residents. Record review of the Medication - Treatment Administration and Documentation Guidelines policy, reviewed on 02/10/20, revealed 3. Verify and provide medication or treatment focused assessment as indicated by manufactures guidelines or physician orders.

**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, and comfortable homelike environment for 2 of 13 resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) and 1 of 1 dining room reviewed for physical environment. 1. The facility did not ensure room [ROOM NUMBER] had clean floors and walls. 2. The facility did not ensure the bathroom in room [ROOM NUMBER] had no holes and the sheetrock was in good repair. 3. The facility failed to repair scratches in the paint on the wall behind the head of the bed and on the wall next to the bed in room [ROOM NUMBER]A. 4. The facility failed to ensure the wallpaper in the dining room was in good repair. This failure could place the residents at risk for decreased quality of life and infection due to unsanitary conditions. The findings included: 1. During an observation on 08/14/2023 at 10:24 AM, the dining room had crinkled, floral, boarder wallpaper that had fallen off the wall and was held together by clear tape. During an observation on 08/15/2023 at 11:16 AM, the dining room had crinkled, floral, boarder wallpaper that had fallen off the wall and was held together by clear tape. During an observation on 08/16/2023 at 1:08 AM, the dining room had crinkled, floral, boarder wallpaper that had fallen off the wall and was held together by clear tape. During an interview on 08/16/2023 at 3:32 PM, the Maintenance Director stated he was responsible for ensuring the wallpaper was in good repair. The Maintenance Director stated he was unaware the wallpaper in the dining room was taped and crinkled. The Maintenance Director stated he was unsure who could have taped the wallpaper. The Maintenance Director stated it was important to ensure the wallpaper was in good repair because it was the resident's home, and they would want it to look nice. 2. During an observation on 08/14/2023 between10:31 AM - 10:36 AM, room [ROOM NUMBER] had the following issues: 1. The bathroom had a hole in the sheetrock under the sink that was approximately 12 inches in diameter. 2. The sheetrock located under the sink was warped and uneven. 3. The floors had blackish-brown dirt-like spots and streaks under the closet and near the door to the bathroom. 4. The walls in the corner of room near the bathroom were dirty with brownish liquid stains and a piece of white trash stuck on the wall behind the trashcan. During an observation on 08/15/2023 at 11:22 AM, room [ROOM NUMBER] had the following issues: 1. The bathroom had a hole in the sheetrock under the sink that was approximately 12 inches in diameter. 2. The sheetrock located under the sink was warped and uneven. 3. The floors had blackish-brown dirt-like spots and streaks under the closet and near the door to the bathroom. 4. The walls in the corner of room near the bathroom were dirty with brownish liquid stains and a piece of white trash stuck on the wall behind the trashcan. During an observation on 08/16/2023 at 1:12 PM, room [ROOM NUMBER] had the following issues: 1. The bathroom had a hole in the sheetrock under the sink that was approximately 12 inches in diameter. 2. The sheetrock located under the sink was warped and uneven. 3. The floors had blackish-brown dirt-like spots and streaks under the closet and near the door to the bathroom. 4. The walls in the corner of room near the bathroom were dirty with brownish liquid stains and a piece of white trash stuck on the wall behind the trashcan. During an interview on 08/16/2023 at 3:36 PM, Housekeeper D stated she was responsible for cleaning room [ROOM NUMBER] during the survey. Housekeeper D stated she cleaned the room and the bathroom. Housekeeper D stated she wiped the walls and high touch areas, swept, and mopped daily. Housekeeper D stated resident rooms were deep cleaned once a month and were on a schedule. Housekeeper D stated she was unsure what day room [ROOM NUMBER] should have been deep cleaned but she believed it had already been completed for the month. Housekeeper D stated the damage to the walls in the bathroom was reported to the Maintenance Director. Housekeeper D stated the facility recently switched mops and it was harder to clean the black stuff off the floor. Housekeeper D stated it was important to ensure the room was cleaned daily to prevent infection and ensure the building remained clean and looked how she would have wanted it to look if she was living at the facility. During an interview on 08/16/2023 at 3:44 PM, the Environmental Services Supervisor stated the housekeepers were responsible for cleaning the resident's rooms and she was responsible for inspecting it. The Environmental Services Supervisor stated room [ROOM NUMBER] should have been deep cleaned at the beginning of the month. The Environmental Services Supervisor stated the walls and flooring should have been cleaned daily. The Environmental Services Supervisor stated she expected staff to ensure the rooms were cleaned daily. The Environmental Services Supervisor stated the buffer machine has been down for approximately the last 3 weeks. The Environmental Services Supervisor stated the brownish-black areas on the floor were from stripping and waxing. The Environmental Services Supervisor stated she noticed the flooring in room [ROOM NUMBER] was not looking good and had made plans to clean it within the week. The Environmental Services Supervisor stated it was important to ensure the rooms were cleaned daily for the health of the residents and she would not have wanted the residents to live in anything she would not have lived in herself. During an interview on 08/16/2023 at 3:52 PM, the Maintenance Director stated he was aware the bathroom in room [ROOM NUMBER] needed to have been fixed. The Maintenance Director stated he worked on a lot of things at the facility and had not gotten to it yet. The Maintenance Director stated several bathrooms in the facility needed a complete remodel because it was an old building. The Maintenance Director stated he did not have adequate time to complete the issues that needed to be addressed. The Maintenance Director stated it was important to ensure the bathrooms were in good repair and the walls did not have holes because it was the resident's home, and it should have looked nice. During an interview on 08/16/2023 at 4:32 PM, the Administrator stated environmental services was responsible for ensuring resident rooms were kept clean and the Maintenance Director was responsible for ensuring the facility was in good repair. The Administrator stated she expected housekeeping staff to ensure cleanliness and report any issues that needed repaired to the Maintenance Director so he could have followed up. The Administrator stated it was important to ensure the facility was cleaned and in good repair to ensure a clean and sanitary environment for the residents. 3. During an observation on 08/14/2023 at 10:53 AM, there were scratches in the paint behind the head of the bed and on wall next to the bed by the head of the bed in room [ROOM NUMBER]A. The paint was peeled down and the areas were rough when touched. During an observation on 08/15/2023 at 3:39 PM, there were scratches in the paint behind the head of the bed and on wall next to the bed by the head of the bed in room [ROOM NUMBER]A. The paint was peeled down and the areas were rough when touched. During an observation on 08/16/2023 at 10:00 AM, there were scratches in the paint behind the head of the bed and on wall next to the bed by the head of the bed in room [ROOM NUMBER]A. The paint was peeled down and the areas were rough when touched. During an interview on 08/16/2023 at 10:03 AM, CNA A said if a room needed to be repaired, she would report it to the charge nurse, and the charge nurse would fill out a maintenance form. CNA A said she was aware room [ROOM NUMBER]A had scratched off paint on the wall behind the head of the bed and on the side wall. CNA A said she had reported to the charge nurse that room [ROOM NUMBER]A had scratched off paint on the walls. CNA A said it was important for the residents' rooms to not have scratched off paint because she did not want for chipped paint to go in the residents' beds, and because it was the residents' home. During an interview on 08/16/2023 at 10:05 AM, Housekeeper B said she had noticed the scratched off paint on the walls in room [ROOM NUMBER]A, and she had reported it to her supervisor (the Environmental Services Supervisor). Housekeeper B said the Environmental Services Supervisor told her she was going to notify the Maintenance Director. Housekeeper B said it was important for the residents' rooms to not have scratches on the walls because the facility was the residents' home, where they lived. During an observation and interview on 08/16/2023 at 11:05 AM, the Maintenance Director said he repainted the rooms quarterly, unless he was told a room needed to be repainted. The Maintenance Director said if something needed to be repaired, he was told verbally, or the staff could log it in the Maintenance Book. The Maintenance Director said nobody had told him room [ROOM NUMBER]A had scratched off paint on the walls. The Maintenance Director said it was important for the residents' rooms to be in good repairs to show that he cared about them and because the facility was their home. During an interview on 08/16/2023 at 1:29 PM, the Administrator said the Maintenance Director was responsible for ensuring the building was in good repairs. The Administrator said if the walls had scratched off paint the staff should report it to the Maintenance Director for it to be repaired. The Administrator said she expected the Maintenance Director to repair things when they were reported to him. The Administrator said it was important for the residents' rooms and the building to be in good repair for the well-being of the residents. During an interview on 08/16/2023 at 1:46 PM, the DON said the Maintenance Director was responsible for fixing the residents' rooms. The DON said she was not aware that room [ROOM NUMBER]A had scratches to the paint on the walls. The DON said if a CNA noticed the walls were scratched, they should notify the DON or the Administrator, or log it in the Maintenance Book. The DON said it was important for the residents' rooms to be repaired because the facility was their home. During an interview on 08/16/2023 at 1:57 PM, the Environmental Services Supervisor said Housekeeper had notified her Resident #17's walls needed to be repaired, and she had told the Maintenance Director. The Environmental Services Supervisor said she did not remember exactly when she had reported it to the Maintenance Director. The Environmental Services Supervisor said it was important for the residents' rooms to be repaired because the facility was their home. Record review of the facility's 2 Maintenance Books with maintenance request forms dated between 4/5/22-07/19/23, did not reveal a maintenance request form for room [ROOM NUMBER]A or room [ROOM NUMBER]. Record review of the facility's policy titled, Resident Rights, date reviewed 02/20/2021, indicated, . The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely .

Based on observation, interviews, and record review, the facility failed to ensure the meals served to residents met the nutritional needs of residents for 1 of 1 meal (the lunch meal), as evidenced by: The facility failed to ensure [NAME] F followed the menu for the lunch meal on 08/14/23. The facility failed to ensure [NAME] F followed the recipe for pureeing the hamburger beef patty for the lunch meal. These failures could place residents at risk for weight loss, not having their nutritional needs met, and a decreased quality of life. Findings included: During a record review of the facility menu (lunch meal) for Monday 08/14/23 indicated: chicken fajitas, chopped cilantro, Spanish rice, shredded lettuce, diced tomatoes and an oatmeal raisin cookie was served for lunch. (Cycle: Southwest 2 - 1st week dated 07/20/23 - Primary) During an observation on 08/14/23 at 12:40 PM of the lunch, chicken fajitas, Spanish rice, mashed potatoes, green beans, and an oatmeal raisin cookie were served to the residents. During record review of a facility pureed menu (lunch meal) dated 08/14/23 indicated: beer battered cod, French fries, buttered green peas, and dinner roll served with margarine, tartar sauce and ketchup. (Cycle: Southwest 2 - 1st week dated 07/20/23 - Secondary) During an observation of the lunch meal on 08/14/23, the residents who received pureed food were served a hamburger patty, mashed potatoes, and green beans. During an observation and interview on 08/14/23 at 11:25 a.m., [NAME] F prepared the pureed meal for the residents. [NAME] F said he normally followed a recipe when he pureed food, but he did not have one that day. [NAME] F had 4 beef hamburger patties in the blender. [NAME] F said he had 4 residents who received pureed meals. [NAME] F placed the hamburger patties into the blender and proceeded to puree. [NAME] F said if the food in the blender became runny, he added a small amount of thickener. [NAME] F took the blender and emptied the mixture into a metal pan on the steam table. [NAME] F said he was aware the recipe had instructions on preparing pureed meals, but he could not locate the recipe. [NAME] F said he asked the Dietary Manager for the recipe and she did not provide it. [NAME] F said he watched the consistency of the food until it looked to be the consistency of baby food. [NAME] F boiled an unmeasured amount of water, then added potato flakes directly from the box and stirred. [NAME] F then placed the mixture in a pan on the serving line. [NAME] F said following the menu and recipe for meals was important to maintain the nutrient value of the food and to maintain resident weights. During an interview on 8/16/2023 at 10:34 a.m., the Dietary Manager said she normally printed off the menu and pureed recipes for the cooks to use. The Dietary Manager said she had not printed them off for the lunch menu because she had not had time. The Dietary Manager said [NAME] F knew the recipe because he had used it before. The Dietary Manager did not provide [NAME] F with a copy of the recipe with the instructions to prepare the pureed meal. The Dietary Manager said she was not aware the kitchen did not serve the food items listed on the 8/14/2023 menu. The Dietary Manager stated she was unaware of the policy or procedure for making a substitution to the menu. The Dietary Manager stated it was important to follow the menus and recipes, so residents received the correct amount of food, and the nutrient value of the food did not decrease. During an interview on 08/16/2023 at 2:36 PM, the ADM stated she expected dietary staff to follow the menu and the recipes for pureed food. The ADM stated she expected the Dietary Manager to ensure recipes were printed for each meal. The ADM stated the importance of following the recipe was to ensure residents had the appropriate nutrients. Record review of the Recipe for Pureed Meat last revised on 05/2012 indicated, after meat has been cooked, weight or measure meat and place in food processor, process until fine in consistency. Measure hot Broth and Thickener, whisk thickener into broth to make slurry. All the liquid may not be needed therefore it is important to add liquid gradually while processing until smooth consistency is achieved. Scrape down sides of processor with a rubber spatula and process for 30 seconds. Record review of the Menus and Nutritional Adequacy policy, last revised on 02/2018 indicated, .Fundamental Information: A preplanned menu is provided to the facility, which has been planned or reviewed by a Registered Dietitian and includes meals that are adequate to meet the average resident's nutritional needs. Menu changes will be made at least one week in advance and will be made on the week at a glance and extended for all diets on the menu spread sheet. The policy did not address following pureed recipes or preparing pureed meals.

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 10 residents (Resident's #10, Resident # 21, and Resident # 46) reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #10, Resident #21, and Resident #46 who complained the food was served cold and did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. The findings included: During an interview on 08/14/23 at 10:28 AM, Resident #10 stated the food was bland and cold. During an interview on 08/14/23 at 11:01 AM, Resident #21 stated the food was awful: Resident #21 stated the food was overcooked, cold, tasted bad and the meat was crunchy. During an interview on 08/14/23 at 11:17 AM, Resident #46 stated the food tasted bad. Resident #46 stated it just did not taste good and was cold when it gets here. During an observation and interview on 08/15/23 at 12:54 PM, the DM sampled a lunch tray. The sample tray consisted of King Ranch Casserole, Mashed Potatoes, Zesty Mexican Corn, Corn Bread, Chocolate Brownie. The DM stated the King Ranch Casserole was bland and needed more flavor. The DM stated the Mashed Potatoes were bland. The DM said the Zesty Mexican Corn was bland but buttery. The DM stated the cornbread was cold. During an interview on 08/15/23, [NAME] Q stated today was her first day back at work after being off for over a month. She was unaware the resident's had any food complaints. [NAME] Q stated food should have tasted good and looked appetizing or appealing. [NAME] Q stated it was important to ensure the food tasted good and looked good because it could have caused weight loss for the residents. During an interview on 08/16/23 at 10:30 AM, the DM stated she had not received any complaints regarding the temperature of the food. The DM stated she was responsible for ensuring the food looked appetizing and was palatable. The DM stated it was important to ensure the food looked appetizing because the resident's nutrition. During an interview on 08/16/23 at 2:46 PM, the Administrator stated the food should have tasted good and looked appealing or appetizing. The Administrator stated it was important to ensure the food looked and tasted good so they residents would eat it. Record review of the Grievance/Complaint Report, dated 03/07/23, indicated Resident #27, complained the food was cold. Record review of the Grievance/Complaint Report, dated 06/12/23, indicated Resident #18, complained the food was cold and no vegetables for burgers, and fries were barely cooked. Record review of the Food and Nutrition Services policy, revised November 2017, indicated 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident and the food appears palatable and attractive, and it is served at a safe and appetizing temperature.

Based on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 7 of 8 meetings (January 2023, February 2023, March 2023, April 2023, May 2023, June 2023, July 2023, and August 2023) reviewed for QAPI. The facility did not ensure the DON attended their QAPI meeting in August 2023. The facility did not ensure the Infection Preventionist attended their QAPI meetings in March 2023 and April 2023. The facility did not ensure the Medical Director attended their QAPI meetings in January 2023, February 2023, April 2023, June 2023, and July 2023. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings include: 1.Record review of the facility's QAPI Committee sign-in-sheets indicated the following: 2.The DON did not sign in for their meetings in August 2023. 3.The sign-in-sheets did not indicate the Infection Preventionist did not sign in for their meetings in March 2023 and April 2023. 4.The sign-in-sheets did not indicate the Medical Director did not sign in for their meetings in January 2023, February 2023, April 2023, June 2023, and July 2023. During an interview on 8/16/23 at 9:33 AM, the Medical Director stated he was out of the country for the month of June and July. The Medical Director stated he reviewed the QAPI meetings after he returned from vacation and would sign the sign-in-sheets if the facility would deliver them. The Medical Director would not indicate the importance of attending the QAPI meetings. During an interview on 8/16/23 at 11:20 AM, the Infection Preventionist stated there were times she was not available for the QAPI meetings because she was taking call or worked the night shift. The Infection Preventionist stated she reviewed the QAPI plan, even if she did not attend the QAPI meetings. The Infection Preventionist stated she did not know if she was responsible for signing the sign-in sheets after she reviewed the QAPI plan. The Infection Preventionist stated the Importance of attending the QAPI meetings was to keep up with everything going on in the facility, with the residents, and the PIP plans. The Infection Preventionist stated the QAPI plan determined if there was anything in the facility they needed to do better or improve. During an interview on 8/16/23 at 10:41 AM, the DON stated she was on vacation during the August QAPI meeting. The DON stated she always reviewed the QAPI plan after she returned and would go back and sign the QAPI sign-in-sheet. The DON stated she had not signed the August sign-in-sheet because, She had not had a chance to yet and she was still getting caught up. The DON stated the Medical Director was responsible for attending QAPI meetings and had been out of the country recently. The DON stated the Medical Director received a copy of the QAPI to review and a facility staff member would deliver the sign-in sheet to his office for him to sign. The DON stated there was no process in place to make sure the Medical Director signed the QAPI sign-in-sheets. The DON stated the importance of attending QAPI was to know what the problems were at the facility and what the facility needed to work on to improve. During an interview on 8/16/23 at 3:01 PM, the Administrator stated the facility provided staff with a copy of the QAPI when they were not present for the monthly meetings. The Administrator stated the sign-in-sheet for QAPI was only for staff members that attended the meeting to sign. The Administrator stated that a staff member would take the QAPI sign-in form to the Medical Directors office for him to review and sign if he was not able to attend the meeting. The Administrator stated the importance of QAPI meetings was to meet the needs of the residents and if staff members failed to attend QAPI meetings or review it, then it could have been a missed opportunity for the residents. Record review of the facility's policy titled QAPI Change Process, dated on 10/24/2022 indicated, The facility has in operation a Quality Assessment and Assurance Committee that is responsible for coordinating and evaluating activities under the facility's QAPI program.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free from pests in 1 of 1 dining room, 1 of 1 kitchen for pest control. The facility did not maintain an effective pest control program to ensure the facility was free of flies. This failure could place residents at risk for an unsanitary environment and a decreased quality of life. Findings included: During an observation on 08/14/23 starting at 09:35 a.m., multiple flies were observed in the kitchen area. During an observation on 08/14/23 at 11:30 AM, the Dietary Manager was swatting away multiple flies in the kitchen while doing food temperatures. During an observation of the lunch meal on 08/14/23 at 11:50 AM, multiple flies observed in the dining area while the residents were eating their meals. During an observation of the lunch meal on 08/15/23 at 12:15 PM, several residents and staff swatting away multiple flies with their hands in the dining room area. During an interview on 08/16/23 at 11:10 AM, the Maintenance Director said he had notified the exterminator to see if he could do something about the excess flies that he had noticed in the facility. The Maintenance Director said all the staff were responsible for making sure there was a clean, safe environment for everyone. The Maintenance Director said it was important to keep the environment free of pests, including flies, because it was their home and it needed to be clean and for a safe environment. During an interview on 08/16/23 at 2:20 PM, the DON said the Maintenance Director was responsible for notifying the pest control company. The DON said it was important to prevent the residents from unsanitary conditions and infections could be spread from the flies. The DON said the flies could aggravate the residents. During an interview on 08/16/23 at 2:24 PM, the Administrator said the Maintenance Director was responsible for the facility being free of pests. The Administrator said it was important to have an environment free of pests because they could get on the food and result in infections. The Administrator said the pests could affect the residents' dignity. Record review of the pest control service reports indicated visits on: o 07/26/2023- Fly Program insect light trap maintenance o 07/05/2023- Fly Program insect light trap maintenance (noted by pest control trash at backdoor drawing in flies) Facility had requested extra service o 06/23/2023- Fly Program insect light trap maintenance o 06/09/2023- Fly Program insect light trap maintenance o 06/02/2023- Fly Program insect light trap maintenance o 05/24/2023- Fly Program insect light trap maintenance. o 04/26/2023- Fly Program insect light trap maintenance Record review of the facility's policy dated 01/2020 titled, Pest Control Program, indicated .Effective pest control program is defined as a measure to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitos, flies, mice and rats). The policy further states, Policy Explanation and Compliance Guidelines: 4. Facility will utilize a variety of methods in controlling certain seasonal pests, i.e. flies .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen and the facility's only dining room. The facility failed to ensure that a canister of oatmeal was closed properly in an airtight container after opening. The facility failed to ensure that dirty rags were stored in proper containers prior to being taken to the laundry. The facility failed to ensure that the walls and floors inside the kitchen were properly cleaned. The facility failed to ensure the toaster was cleaned after each use per facility protocol. The facility failed to ensure that trash was properly disposed of. The facility failed to ensure that the kitchens fryer was properly cleaned and the oil changed. The facility did not ensure the ice scoop was not left in the ice bucket during the lunch meal service. These failures could place residents at risk of cross-contamination and foodborne illness. Findings included: 1. During an observation on 08/14/2023 starting at 09:35 a.m.: o approximately three dirty towels/rags with a hardened dried brown/orange color/ substance on them were piled on top of the stainless shelf near the dishwasher, o the kitchen stainless steel shelves and cabinets had food splatters, o the toaster had a build-up of crumbs, o there was an empty, open sugar canister with a thick brown substance built up on the bottom inside corners, o the walls of the mixer had food splattered on them o the fryer had crumbs floating in the grease and piled around the sides, o there were food crumbs, thick dust, and dirt on the floors near the baseboards in the kitchen area and across the lids of the canister storage units, o the oatmeal canister had approximately an inch of the plastic covering missing exposing it to the air, o there was water leakage under the 3 compartment washing sinks, o the wall air conditioning unit had thick dust and dirt and it was blowing towards the food preparation area, o the trashcan lid located near the hand washing sink was broken, o the liner inside the trash can was not properly placed and had trash spilling out of the bag inside the can and the trash overflowed onto the floor, o the steam table had brown murky water in the bottom with two cups of coffee covered in saran wrap sitting directly in the discolored water, o the steam table had a large pile of dusty chalk like ashy substance built up touching the bottoms of the pans, o the walk-in cooler located in the kitchen area contained expired chocolate pudding dated 08/13/23, expired unlabeled canister of stewed tomatoes dated 08/12/23 and a carton of Vanilla Shake expired on 06/2023 o the Freezer contained an undated opened box of uncovered egg pasta sheets o the two large trash cans on rollers stationed in the hall area of the kitchen had trash overflowing onto the floor with flies crawling on top of the trash and lids During an observation on 08/14/23 at 11:40 a.m., the Dietary Manager returned to the kitchen and did not wash her hands before filling a large pan with water for cooking. During an interview on 08/14/23 at 10:00 a.m., the Dietary Manager said the grease was changed twice weekly on Thursday and Sunday. The Dietary Manager said the grease was not changed yesterday because the cook did not come to work. During an interview on 08/16/2023 at 10:30 a.m., the Dietary Manager said that she went behind the staff to ensure that the kitchen was being cleaned and that everyone was doing the tasks as assigned. The Dietary Manager said that she expected a deep cleaning of the kitchen to be done weekly except for sweeping the floors and wiping down the walls which should be done at the end of each shift/mealtime. The Dietary Manager said that the dirty towels should be taken to the laundry to be washed but laundry services had refused to wash the kitchen towels, and someone had to take them home to be washed. The Dietary Manager expected all open containers to be securely closed with a lid. The Dietary Manager said the toaster should be cleaned after each use. The Dietary Manager said she expected the trash liners to be placed properly inside of the trash can and that all trash be placed inside of the trash can with an appropriately fitted lid. During an interview on 08/16/2023 at 2:24 p.m., Administrator said that there was a kitchen cleaning schedule and that she expected the Dietary Manager to check behind the staff to ensure that these tasks were completed. The Administrator said that she expected the kitchen to be swept and walls wiped down daily. The Administrator said the kitchen staff emptied the grease from the fryer twice weekly on Thursday and Sunday. The Administrator said that she expected for anything in the pantry to be securely covered with a proper lid, trash cans to have liners properly placed to catch the trash and for dirty towels to be in a separate bin and then taken to housekeeping for washing. Record review of the Food Safety and Sanitation Plan policy, revised November 2017, indicated . Fundamental Information All bulk food items that are removed from original containers into food grade containers must have tight fitting lids, and must be properly labeled. The policy further states 13. Personal Hygiene Practices E. after eating, drinking, or smoking . 2. During a dining observation on 08/14/23 between 11:43 AM - 12:26 PM the dietary staff provided the staff in the dining room with a bucket and an ice scoop. The CNA, in the dining room, filled the bucket with ice without removing the ice scoop. The Social Worker removed the ice scoop, that was buried under the ice, without wearing gloves. The Social Worker and CNA took turns using the ice scoop to fill up drinking glasses, leaving the ice scoop in the ice bucket in between uses. Several nurses and the ADON were assisting during the lunch observation and filled up several cups of ice, leaving the ice scoop inside the ice bucket. During a dining observation on 08/15/23 between 12:16 PM - 12:32 PM the staff in the dining room took turns filling cups with ice and leaving the ice scoop in the ice bucket. The DON observed the staff passing out ice and instructed the staff to place the ice scoop into a cup. D During an interview on 08/16/23 at 1:46 PM, CNA A stated the ice scoop should not have been left in the ice bucket while passing ice during the lunch meal. CNA A stated she normally placed the ice scoop in a glass. CNA A stated during the lunch meal on 08/15/23 she noticed the ice scoop was in the ice bucket and placed it in a cup. CNA A stated it was important to ensure the ice scoop was not left in the ice bucket, so germs did not get on the ice. During an interview on 08/16/23 at 1:55 PM, LVN C stated the ice scoop should not have been left in the ice bucket. LVN C stated the ice scoop should have been placed in a cup. LVN C stated it was important to ensure the ice scoop was not left in the ice bucket because it could have contaminated the ice. During an interview on 08/16/23 at 2:05 PM, the ADON stated she was also the infection control preventionist. The ADON stated the ice scoop should not have been left in the ice bucket. The ADON stated the ice scoop was normally placed in a cup. The ADON stated the staff was nervous, so it was probably missed. The ADON stated it was important to ensure the ice scoop was not left in the ice bucket for infection control. During an interview on 08/16/23 at 2:16 PM, the Social Worker stated she believed it was okay to leave the ice scoop inside the ice bucket. The Social Worker stated the ice scoop was normally left in the ice bucket during meals. During an interview on 08/16/23 at 4:12 PM, the DON stated the ice scoop should not have been left in the ice bucket while passing ice during meals. The DON stated she expected the staff to ensure the ice scoop was placed in a bag or a cup. The DON stated it was important to ensure the ice scoop was not left in the ice bucket because it was infection control. During an interview on 08/16/23 at 4:32 PM, the Administrator stated the ice scoop should not have been left in the ice bucket. The Administrator stated education was provided the staff. The Administrator stated it was important to ensure the ice scoop was not left in the ice bucket for infection control. Record review of the Safe Ice Handling policy, revised March 2012, revealed Scoops must be stored outside of the ice in a manner which protects them from contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement written policies that prohibit and prevent abuse, neglect, and exploitation for 2 of 4 (Resident #1 and Resident #2) residents reviewed for abuse and neglect. The facility failed to implement the abuse and neglect policy and procedure regarding reporting resident-to-resident altercation. This failure could place the residents at increased risk for abuse and neglect. The findings included: Record Review of the Policy and Procedures for Abuse, Neglect and Exploitation dated 2/01/2021 indicated that (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any responsible suspicion of a crime against an individual who is a resident of or is receiving care from the facility (B) Each covered, individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. Record Review of the Provider Investigation Report dated on 4/06/23 indicated a resident-to-resident incident between Resident #1 and Resident #2 occurred on 04/1/2023 at 6:00 p.m. The report indicated the hospitality aide and charge nurse found Resident #1 and Resident #2 holding each other by the arms and yelling at each other, both residents appeared to have had blood on their clothing. The report indicated Resident #1 was assessed by the charge nurse and found to have had a skin tear on her right arm and a bruise on her right hand. Resident #2 was assessed by the charge nurse found an old skin tear with dried edges, no signs of drainage and no bruises following this incident. The incident was reported to the state agency on 04/3/2023 at 5:32 p.m. Record Review of Resident #1 face sheet, dated on 8/14/23, indicated that Resident #1 was a [AGE] year-old female, admitted to the facility on the original administration date of 9/09/22 with a primary diagnosis of dementia which included (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), hypotension (low blood pressure) and Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements). Record Review of Resident #1 quarterly MDS assessment, dated on 6/21/23, indicated that Resident # 1 was usually understood others and made herself understood. The MDS assessment indicated that resident #1 was unable to complete the interview. The MDS assessment was not coded with a BIMS summary score. The MDS assessment indicated that Resident #1 was not coded for any behaviors. Record Review of Resident #1 care plan, revision date of 6/09/23, indicated that Resident #1 was resistance to care related to pinching, scratching, hitting, periods of disorientations and spitting at staff when approaching during care. The care plan interventions included administer medications as ordered, monitor and document for effectiveness and potential adverse side effects, monitor behavior episodes and attempt to determine underlying cause and document behaviors and interventions in behavior log. Record Review of Resident #2 face sheet, dated on 8/14/23, indicated that Resident #2 was a [AGE] year-old female, admitted to the facility on the original administration date of 11/17/22 with a primary diagnose of dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), essential hypertension (high blood pressure), Alzheimer's Disease with early onset (progressive disease that destroys memory and other important mental functions). Record Review of Resident #2 discharge MDS assessment dated on 6/26/23 indicated that Resident #2 was not coded for any behaviors. The assessment indicated Resident #2 was moderately cognitively impaired with a BIMS score of 9. Record Review of Resident #2 care plan, revision date of 7/03/23, indicated that resident #2 had a behavior problem as related to been bossy to other residents, staff and guest; wants to touch others while she was talking to them, cursing, attention seeking, condescending tone of voice, and packing room belongings. The care plan interventions included administer medications as ordered, monitor and document for effectiveness and potential adverse side effects, monitor behavior episodes and attempt to determine underlying cause, consider location, time of day, persons involved and situations and document behavior and interventions in behavior log. Record Review of the progress note, dated on 6/26/23, indicated that Resident #2 was transferred to a different facility on 6/26/23. Record Review indicated that in services were completed for all staff on abuse on 4/2/2023. Record Review of a written statement dated 4/2/23 signed by the Administrator, indicated that the Administrator interviewed LVN B regarding the resident-to-resident incident that occurred on 4/1/23. The administrator stated, in a signed written statement, that she were informed by LVN B of the skin tear injury and bruise on resident #1. The Administrator stated in the written statement that she questioned LVN B if other marks were found on resident #1 and LVN B stated that she did not find no other marks or injuries. During phone interview on 8/08/23 at 11:03 a.m., the family member of Resident #2 stated that the facility informed him about the resident-to-resident alteration that occurred on 4/1/23. The family member of Resident #2 stated that since Resident #2 was diagnosed with dementia, that her activities with dealing with physical aggression had increased. The family member of Resident #2 stated that the facility would normally move her to a room by herself as an intervention. During a phone interview on 8/08/2023 at 02:25 p.m., the Hospitality aide stated that as she were picking up meal trays on the hall on 4/1/23, that she overheard Resident #1 and Resident #2 hollering. The Hospitality aide stated Resident #1 and Resident #2 were roommates. Hospitality aide stated that when she entered the room she saw both residents, Resident #1 and Resident #2 holding each other by the arms and yelling at each other. The Hospitality aide stated that she yelled down the hall for help and LVN B ran down the hall to assist her. The Hospitality aide stated that she noticed immediately that both residents had bright red blood on their clothing. The Hospitality aide stated that she transferred resident #2 to her wheelchair. The Hospitality aide stated that she noticed a skin tear on Resident #1 right arm. The hospitality aide stated that Resident #2 was immediately moved to a different room. The Hospitality aide stated that she does not know why this happened. The hospitality aide stated that to her knowledge, this was the first incident between Resident #1 and Resident #2. The Hospitality aide stated that this incident was report to the DON and the Administrator on the same day. During a phone interview on 8/08/2023 at 2:33 p.m., LVN B stated that she ran down the hall to assist the Hospitality Aide who was yelling for help. LVN B stated that upon entering Resident #1 and Resident #2 room that she saw both residents, Resident #1 and Resident #2 holding each other by the arms, yelling out loud. LVN B stated that she immediately separated Resident #1 and Resident #2. LVN B stated that she assisted resident #2 to her wheelchair then moved Resident #2 to a different room across the hall. LVN B stated that upon assessing Resident #1, she immediately noticed that Resident #1 had a significant skin tear on her right arm that was bleeding and bruising on right hand that appeared purple in color. LVN B stated that upon assessing Resident #2 that she noticed that Resident #2 had a skin tear underneath her arm that appeared to be an old skin tear with dried edges and had no new injuries. LVN B stated there were not any aggressions in the past between Resident #1 and Resident #2. LVN B stated she does not know why this happened. LVN B stated that this incident was reported to the DON and Administrator on the same day of the incident. During a phone interview on 8/09/2023 at 11:55 p.m., the DON stated the different types of abuse were physical, verbal, emotional and sexual. The DON stated that the Administrator was the abuse coordinator. The DON stated that resident to resident altercations was considered abuse. The DON stated that abuse should be reported immediately within 2 hours. The DON stated that she was not fully informed of the full details of this incident, which was why she did not report it timely. The DON stated that the staff were aware that they should report directly to the Administrator and then report to her as secondary. The DON stated that she were made aware of this incident on 4/1/23 while at home recovering from COVID. The DON stated that she did not follow up with the Administrator regarding this incident. The DON stated that reporting was important to ensure that the resident was safe. An attempted interview on 8/9/23 at 12:32 p.m. and on 8/9/23 at 1:02 p.m., the Administrator was not reachable by telephone for interviewing purposes after 2 unsuccessful calls with call back requested.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 of 4 (Resident #1 and Resident #2) residents reviewed for abuse and neglect. The facility failed to report to the state agency within 24 hours of being notified of resident to resident altercation for Resident #1 and resident #2. This failure to report could place the residents at risk for abuse. Findings included: Record Review of the Policy and Procedures for Abuse, Neglect and Exploitation dated 2/01/2021 indicated that (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any responsible suspicion of a crime against an individual who is a resident of or is receiving care from the facility (B) Each covered, individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. Record Review of the Provider Investigation Report dated on 4/06/23 indicated a resident-to-resident incident between Resident #1 and Resident #2 occurred on 04/1/2023 at 6:00 p.m. The report indicated the hospitality aide and charge nurse found Resident #1 and Resident #2 holding each other by the arms and yelling at each other, both residents appeared to have had blood on their clothing. The report indicated Resident #1 was assessed by the charge nurse and found to have had a skin tear on her right arm and a bruise on her right hand. Resident #2 was assessed by the charge nurse found an old skin tear with dried edges, no signs of drainage and no bruises following this incident. The incident was reported to the state agency on 04/3/2023 at 5:32 p.m. Record Review of Resident #1 face sheet, dated on 8/14/23, indicated that Resident #1 was a [AGE] year-old female, admitted to the facility on the original administration date of 9/09/22 with a primary diagnosis of dementia which included (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), hypotension (low blood pressure) and Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements). Record Review of Resident #1 quarterly MDS assessment, dated on 6/21/23, indicated that Resident # 1 was usually understood others and made herself understood. The MDS assessment indicated that resident #1 was unable to complete the interview. The MDS assessment was not coded with a BIMS summary score. The MDS assessment indicated that Resident #1 was not coded for any behaviors. Record Review of Resident #1 care plan, revision date of 6/09/23, indicated that Resident #1 was resistance to care related to pinching, scratching, hitting, periods of disorientations and spitting at staff when approaching during care. The care plan interventions included administer medications as ordered, monitor and document for effectiveness and potential adverse side effects, monitor behavior episodes and attempt to determine underlying cause and document behaviors and interventions in behavior log. Record Review of Resident #2 face sheet, dated on 8/14/23, indicated that Resident #2 was a [AGE] year-old female, admitted to the facility on the original administration date of 11/17/22 with a primary diagnose of dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), essential hypertension (high blood pressure), Alzheimer's Disease with early onset (progressive disease that destroys memory and other important mental functions). Record Review of Resident #2 discharge MDS assessment dated on 6/26/23 indicated that Resident #2 was not coded for any behaviors. The assessment indicated Resident #2 was moderately cognitively impaired with a BIMS score of 9. Record Review of Resident #2 care plan, revision date of 7/03/23, indicated that resident #2 had a behavior problem as related to been bossy to other residents, staff and guest; wants to touch others while she was talking to them, cursing, attention seeking, condescending tone of voice, and packing room belongings. The care plan interventions included administer medications as ordered, monitor and document for effectiveness and potential adverse side effects, monitor behavior episodes and attempt to determine underlying cause, consider location, time of day, persons involved and situations and document behavior and interventions in behavior log. Record Review of the progress note, dated on 6/26/23, indicated that Resident #2 was transferred to a different facility on 6/26/23. Record Review indicated that in services were completed for all staff on abuse on 4/2/2023. Record Review of a written statement dated 4/2/23 signed by the Administrator, indicated that the Administrator interviewed LVN B regarding the resident-to-resident incident that occurred on 4/1/23. The administrator stated, in a signed written statement, that she were informed by LVN B of the skin tear injury and bruise on resident #1. The Administrator stated in the written statement that she questioned LVN B if other marks were found on resident #1 and LVN B stated that she did not find no other marks or injuries. During phone interview on 8/08/23 at 11:03 a.m., The family member of Resident #2 stated that the facility informed him about the resident-to-resident alteration that occurred on 4/1/23. The family member of Resident #2 stated that since Resident #2 was diagnosed with dementia, that her activities with dealing with physical aggression had increased. The family member of Resident #2 stated that the facility would normally move her to a room by herself as an intervention. During a phone interview on 8/08/2023 at 02:25 p.m., the Hospitality aide stated that as she were picking up meal trays on the hall on 4/1/23, that she overheard Resident #1 and Resident #2 hollering. The Hospitality aide stated Resident #1 and Resident #2 were roommates. Hospitality aide stated that when she entered the room she saw both residents, Resident #1 and Resident #2 holding each other by the arms and yelling at each other. The Hospitality aide stated that she yelled down the hall for help and LVN B ran down the hall to assist her. The Hospitality aide stated that she noticed immediately that both residents had bright red blood on their clothing. The Hospitality aide stated that she transferred resident #2 to her wheelchair. The Hospitality aide stated that she noticed a skin tear on Resident #1 right arm. The hospitality aide stated that Resident #2 was immediately moved to a different room. The Hospitality aide stated that she does not know why this happened. The hospitality aide stated that to her knowledge, this was the first incident between Resident #1 and Resident #2. The Hospitality aide stated that this incident was report to the DON and the Administrator on the same day. During a phone interview on 8/08/2023 at 2:33 p.m., LVN B stated that she ran down the hall to assist the Hospitality Aide who was yelling for help. LVN B stated that upon entering Resident #1 and Resident #2 room that she saw both residents, Resident #1 and Resident #2 holding each other by the arms, yelling out loud. LVN B stated that she immediately separated Resident #1 and Resident #2. LVN B stated that she assisted resident #2 to her wheelchair then moved Resident #2 to a different room across the hall. LVN B stated that upon assessing Resident #1, she immediately noticed that Resident #1 had a significant skin tear on her right arm that was bleeding and bruising on right hand that appeared purple in color. LVN B stated that upon assessing Resident #2 that she noticed that Resident #2 had a skin tear underneath her arm that appeared to be an old skin tear with dried edges and had no new injuries. LVN B stated there were not any aggressions in the past between Resident #1 and Resident #2. LVN B stated she does not know why this happened. LVN B stated that this incident was reported to the DON and Administrator on the same day of the incident. During a phone interview on 8/09/2023 at 11:55 p.m., the DON stated the different types of abuse were physical, verbal, emotional and sexual. The DON stated that the Administrator was the abuse coordinator. The DON stated that resident to resident altercations was considered abuse. The DON stated that abuse should be reported immediately within 2 hours. The DON stated that she was not fully informed of the full details of this incident, which was why she did not report it timely. The DON stated that the staff were aware that they should report directly to the Administrator and then report to her as secondary. The DON stated that she were made aware of this incident on 4/1/23 while at home recovering from COVID. The DON stated that she did not follow up with the Administrator regarding this incident. The DON stated that reporting was important to ensure that the resident was safe. An attempted interview on 8/9/23 at 12:32 p.m. and on 8/9/23 at 1:02 p.m., the Administrator was not reachable by telephone for interviewing purposes after 2 unsuccessful calls with call back requested.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure all drugs were stored in a locked compartment and only accessible by authorized personnel for 1 of 1 (Resident #3) residents reviewed for medication storage. 1. The facility failed to keep medication being administered under the direct observation of the person administering medications. Resident #3 had a medication cup with 4 tablets and 1 capsule sitting on top of her dresser. This failure could place residents at risk for health complications and not receiving the intended therapeutic benefit of their medication. Findings included: During an observation on 8/8/2023 at 10:20 AM revealed Resident #3 had a clear plastic medication cup with 4 tablets and 1 capsule sitting by a clear plastic cup of water on top of her dresser. Resident #3 stated the medication belonged to her roommate however, records indicated resident # 3 didn't have a roommate. Record review of face sheet, dated 10/12/2022, revealed Resident #3 was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included unspecified dementia (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems.), Alzheimer's disease with late onset (Alzheimer's disease was a progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain. Alzheimer's disease that develops when someone was 65 or older was late onset, generalized anxiety disorder (a mental condition characterized by excessive or unrealistic anxiety about two or more aspects of life), and essential (primary) hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition). Record review of Resident # 3's care plan, dated 1/13/2022, did not address medications left at bedside. Record review of the MDS assessment, dated 6/10/2023, revealed Resident #3 had a BIMS score of 9 (moderately impaired cognition). The assessment indicated Resident #3 did not reject care necessary to achieve the resident's goals for health or well-being. Record review of the MAR, dated 8/1/2023, indicated Resident #3 was ordered to receive Amlodipine 5mg 1 tablet in the morning with instructions to hold medication if systolic blood pressure was less than 100 mmhg and diastolic was below 60 mmhg. Losartan 10mg 1 tablet in the morning with instructions to hold medication if systolic blood pressure was less than 100 mmhg and diastolic was below 60 mmhg. Gabapentin 300mg 1 tablet by mouth two times a day. Namenda 10 mg 1 tablet by mouth two times a day. During an interview on 8/9/2023 at 10:47 a.m., LVN A stated there were no residents on hall 300 with the ability to self-administer medications. LVN A stated the requirement for a resident to be able to self-administer medications was that they must know what medications they take, the strength of the medication, what the medication was for, and how to take the medication. LVN A stated people who were unable to self-administer medications should not have them at bedside. LVN A stated after 14 years she has never left medications at bedside. LVN A stated she had observed Resident #3 put the cup with the medication to her mouth and had the cup of water in the other hand. LVN A stated she observed the pills going into Resident #3's mouth, and LVN A stated she was called out into the hall. LVN A stated she left the room as the pills were going into Resident #3's mouth. LVN A stated if she had seen medications left at the bedside she would collect the medication, assess the resident, notified charge nurse, notify the doctor, monitor the resident, get labs if ordered by the doctor, and notify the family. LVN A stated it was important to not keep medication at the bedside in case of overdose. LVN A stated if another resident was to take the medication or if a child comes into the facility and take the medication. LVN A stated it was for community safety. During an interview on 8/9/2023 at 11:30 a.m., the DON stated to ensure medications were not left at bedside different department heads would make rounds. The DON stated the department heads made rounds at 9:00 a.m., yesterday. The DON stated after the medication was found at bedside, she did a Qapi and in-service. The DON stated she expects staff to ensure medications aren't left at bedside. The DON stated department heads would monitor that medications were not left sitting at bedside by making rounds in the morning. The DON stated each department head will take a hall after every med pass to ensure no medication was left. Record review of the 'Medication - treatment Administration and Documentation Guidelines policy, revised date 2/2/2014, revealed verify and provide medication or treatment focused assessment i.e. BP. P wound measurement as indicate by manufactures guidelines or physician orders. Administer the medication according to the physician order. Document initials and/or signature for medication administration on the MAR or TAR immediately following administration.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food items in the kitchen refrigerators and freezers were dated, labeled, and sealed appropriately. The facility failed to ensure food items in the kitchen refrigerators were used by the best by date. These failures could place the residents at risk for food-borne illness, and food contamination. Findings include: During an observation of freezer #1 on 06/13/22 at 9:37 a.m. the following items were found with undated, unlabeled, and were unsealed. *crinkle cut French fries located on the second shelf. * Frozen Peanut Butter cookies located on the second shelf * Frozen Oatmeal Raisin Cookies located in freezer #1 stacked on boxes in the middle section * Frozen Hamburger Patties located in freezer #1 stacked on boxes in the middle section During an interview and observation on 06/13/22 at 9:37 a.m., the FSS was shown the opened, undated French fries. The FSS took the opened bag of French fries and threw them away. The FSS said the French fries were freezer burnt. The FSS said she believed the French fries were last used on 6/12/22. During an observation of dry storage on 6/13/22 at 9:40 a.m. the following items were past the use by date; * Nectar Thickened Cranberry Cocktail 48-ounce box with the use by date of 1/18/22. * Nectar thickened Cranberry Cocktail 48 ounce, three 48-ounce boxes with the use by date of 3/28/22. * A case of honey thickened Sweet Tea (48-ounce boxes) with the use by date of 4/26/22. * Nectar thickened Water without Flavor, four 48-ounce boxes with the use by date of 3/29/22. During an interview on 6/13/22 at 9:45 a.m. the FSS said the Real Lemon Juice concentrate was not used and had been in the facility since before she started as FSS. The FSS said she had worked in the kitchen at the facility since approximately 2013 and had been the Dietary Manger since January 2022. The FSS said that groceries were rotated weekly. The FSS said the facility did not have any residents receiving honey thickened-consistency liquids. During an observation of refrigerator #1 on 6/13/22 at 10:00 a.m. the following items were found with unsealed, undated, and unlabeled; * Western style beef patties on a middle shelf. * Bag of Hushpuppies located on top of a box inside the refrigerator door. During an interview on 6/14/22 at 10:59 a.m. the FSS said the facility had been using honey thickened for a resident until 6/3/22 when his order changed to nectar thick liquid following a swallow study. The FSS said when a product was opened it should be sealed and labeled with the opened date. The FSS said if a product was not sealed and dated it should be thrown out. The FSS said the kitchen staff would not be able to verify when the products would no longer be safe to serve if products were not dated after opening. The FSS said the risk for not dating or sealing products after opening was the residents contracting a food borne illness and possible death. The FSS said the kitchen staff checked for expired, not dated, and opened and not sealed food item weekly. The FSS said it was the responsibility of all the kitchen staff to ensure these weekly checks were being performed. The FSS said she ensured the weekly checks are being performed by daily monitoring. The FSS said she could not answer how the expired, opened, and undated food items were overlooked. The FSS said the thickened liquids had been in the facility since she took over as Dietary Manager in January 2022. She said she had disposed of all undated and expired food items observed on 6/13/22. During an interview on 6/15/22 at 10:25 a.m. the DON said she expected food to be covered and dated when opened. The DON said the kitchen should not have expired food items. The DON said having food items not properly dated or expired in the kitchen could cause residents to suffer from food borne illness. During an interview on 6/15/22 at 10:30 a.m. the Administrator said she expects dietary staff to follow policy and procedure for sealing and dating food items. The Administrator said inventory should be checked for expired food items continuously and the dietary staff should be following policy and procedure. The Administrator said serving food past its shelf life could cause food borne illness to the residents. Record review of the facility's Storage of Frozen and Refrigerated Foods policy dated 10/2017 indicated, .Refrigerated products that are opened must be labeled with an opened on date. The use by date is 7 days from when the product was opened, unless there is a manufacture's use by, expiration, or sell by date .Packaged frozen items that are opened and not used in their entirety must be properly sealed, labeled, and dated for continued storage . Record review of the facility's Director of Food and Nutrition services Job Description dated 9/18/07 indicated, .The Director of Food and Nutrition Services was responsible for ensuring proper storage of food and supplies . Record review of the facility's undated Dietary Services Manager Task Planner indicted, .The Dietary Services Manager must perform weekly inventory .