**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible 1 of 14 resident (Resident #36) reviewed for quality of care. The facility failed to maintain resident use hot water at safe and comfortable temperature between 100 to 110 on Hall/Room where the hot water temperatures was 122 F on 10/09/2024. This failure could place residents at risk for sustaining scalding injuries when using resident accessible hot water. The findings include: Record review of the face sheet, dated 10/09/2024, revealed Resident # 36 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the blood that affects the brain), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), venous insufficiency (a condition that occurs when the veins in the legs have difficulty returning blood to the heart). Record review of the MDS assessment, dated 08/06/2024, revealed Resident # 36 had a BIMS score of 7, which indicated severe cognitive impairment. The MDS revealed Resident #36 needed partial assistance from another person to complete bathing, dressing, toileting, or eating. Record review of the comprehensive care plan, revised on 05/14/2024, revealed Resident #36 required one person assist with dressing and grooming. During an observation on 10/09/2024 at 09:00 a.m., the surveyor observed water temperature at 125 F with a digital thermometer in Resident #36's bathroom sink. During an interview and observation 10/09/2024 at 09:25 a.m., the Maintenance Supervisor checked the hot water with a digital thermometer in Resident #36's bathroom and the temperature was 122 F. The Maintenance Supervisor stated it was his responsibility to maintain the correct water temperature. The Maintenance Supervisor stated the water temperature should be between 100 and 110 F. The Maintenance Supervisor stated the risk to the resident with a water temperature of 122F was someone could get scolded. During an interview on 10/09/2024 at 1:46p.m., the DON stated it was the Maintenance Supervisor's responsibility to make sure the water temperature was correct. The DON stated it was important for the water temperature was correct so no one would get scolded. The DON stated the harm would be if someone was to get burned. During an interview on 10/09/2024 at 2:05 p.m., the Administrator stated maintenance was responsible for maintaining the correct water temperature. The Administrator stated it was important to keep the water temperature at 110 to prevent scolding. The Administrator stated the water temperature would be monitored daily by maintenance. Record review of facilities undated policy Maintenance Policies & Procedures revealed .Regulations require that hot water temperature be maintained at not less than100 degrees F (38 degrees C) and not more than 110 degrees F (43 degrees C) for all hot water used by residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 14 residents (Resident #30) reviewed for pharmacy services. The facility failed to ensure MA A secured Resident #30's medications when she left Resident #30's medications on the top of the medication cart unattended. This failure could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion. Findings included: Record review of a face sheet dated 10/08/2024 indicated Resident #30 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of chest pain, eye pain, and lower abdominal pain. Record review of a Quarterly MDS assessment dated [DATE] indicated Resident #30 was understood and understood others. The MDS indicated Resident #30 was cognitively intact with a BIMS score of 13. Section J-Health Conditions of the MDS indicated Resident #30 received scheduled pain medications. Record review of the comprehensive care plan dated 6/19/2024 indicated Resident #30 had pain and the goal of the care plan was Resident #30 would be as comfortable as possible. The interventions for the care plan were administer pain medications as needed, monitor pain, and use non-drug interventions. Record review of the consolidated physician's orders dated 10/07/2024 - 10/08/2024 indicated Resident #30 on 9/13/2024 was ordered aspirin 81 milligrams one time daily, and on 6/21/2024, she was ordered acetaminophen-codeine-Schedule lll tablet 300-60 milligrams one tablet every 6 hours as needed for pain. During an observation and interview on 10/08/2024 at 8:21 a.m., on the top of the Hall 300 medication cart, there was a paper medication cup with two medication tablets inside the cup. The medication cart was unattended. At 8:26 a.m., MA A walked up to the medication cart. MA A said she had a personal emergency and thought she had locked the medications belonging to Resident #30 inside the cart. MA A said the medications in the cup was an acetaminophen with codeine 300-60 milligram and an aspirin 81 milligrams. MA A said another resident could have taken this medication and the medication could have been harmful to them. During an interview on 10/09/2024 at 1:50 p.m., the ADON said the instance where MA A left medications unattended should have never happened. The ADON said she monitored forthat type of error with rounds, random checks, and competencies. The ADON said the facility had residents who wandered and there was a risk for another resident taking Resident #30's medications. During an interview on 10/09/2024 at 2:28 p.m., the DON said she expected MA A to administer the medications right away when she prepared them. The DON said MA A should have given the medications to her nurse when the personal emergency occurred. The DON said she monitored each shift, different times and different days, to ensure compliance with medication management. The DON said they had residents who wandered but not on Hall 300 in particular. The DON said there was a risk another resident could have taken Resident #30's medication. During an interview on 10/09/2024 at 3:03 p.m., the Administrator said she expected the medications to be administered; not left sitting around where someone else could have gotten them. The Administrator said monitoring included rounds by the nurse managers. The Administrator said the nursing mangers were responsible for monitoring. Record review of the Medication Storage in the Facility policy dated 6/01/2022 indicated: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. Procedures A. The director of nursing, in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances. Only authorized licensed nursing and pharmacy personnel have access to controlled substances.

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 reviewed for food and nutrition services. 1. The facility failed to ensure the can opener blade was free a black substance and a rusty-like material. 2. The facility failed to ensure 2 skillets, 5 large sheet pans, 3 small sheet pans, and 6 muffin pans were free from carbon build up on the cooking surface of the pan. 3.The facility failed to ensure the microwave was free from a thick, hard yellow substance, and a brownish substance resembling rust material on the inside top surface. These failures could place residents at risk of foodborne illness and food contamination. Findings included: During initial tour on 10/07/2024 at 11:02 a.m. - 11:55 a.m., the following was observed: 2 large skillets with black carbon build up on the inside cooking surfaces. 5 large sheet pans with black carbon build up on the outside pan surfaces, and on the sides of the inside pan surfaces. 3 small sheet pans with black carbon build up on the outside pan surfaces, and on the sides of the inside pan surfaces. 6 muffin pans with black carbon build up on the entire top surface. The microwave had a thick yellow hard substance and a brownish substance resembling rust material on the inside top surface. Record review of a Quality Assurance Monitor 1 Kitchen/Food Service Observation with attachment dated 5/13/2024 indicated the Dietician found there were no cleaning schedules posted and followed to indicate routine cleaning of equipment, and the equipment, drawers, shelves, worksurfaces, cutting boards, utensils, pots, pans, can opener, microwave, toaster, robot coupe mixer, over, plate warmer, fryer, juice gun, steam table and other equipment was not clean. Record review of a Quality Assurance Monitor 1 Kitchen/Food Service Observation with an attachment dated 6/17/2024 indicated the Dietician found there were no cleaning schedules posted and followed to indicate routine cleaning of equipment, and the equipment, drawers, shelves, worksurfaces, cutting boards, utensils, pots, pans, can opener, microwave, toaster, robot coupe mixer, over, plate warmer, fryer, juice gun, steam table and other equipment was not clean. The attachment indicated the pans had carbon buildup. Record review of a Quality Assurance Monitor 1 Kitchen/Food Service Observation with an attachment dated 9/16/2024 indicated the Dietician found the equipment, drawers, shelves, worksurfaces, cutting boards, utensils, pots, pans, can opener, microwave, toaster, robot coupe mixer, over, plate warmer, fryer, juice gun, steam table and other equipment was not clean. During an interview on 10/09/2024 at 9:53 a.m., the Dietary Manager said she was aware of the pans and had tried to clean them with a chemical for removing carbon but was unsuccessful. The Dietary Manager said they would have to purchase new pans. The Dietary Manager said the microwave should be cleaned after each use and was unsure what the material was inside on the top surface. The Dietary Manager said the can opener should be clean and free of rust. The Dietary Manager said the can opener having the material on the blade could fall in the food items when opening. The Dietary Manager said kitchen sanitation was important, so residents did not get sick. The Dietary Manager said kitchen sanitation monitoring was her responsibility. During an interview on 10/09/2024 at 2:33 p.m., the DON said she expected the kitchen equipment and dishware to be clean to prevent food borne illness from cross contamination. The DON said the Dietary Manager was responsible for the dietary department. During an interview on 10/09/2024 at 3:05 p.m., the Administrator said the staff had tried using the carbon removing product but was unsuccessful. The Administrator said the Dietary Manager was responsible for ensuring the equipment and dishware was clean to prevent food borne illness. Record review of an undated Kitchen Sanitation and Cleaning Schedule policy indicated all surfaces, including floors, walls, storage shelves, prep tables, trash cans, and all food contact surfaces must be routinely cleaned and sanitized. Ceilings, vents, light fixtures, pipes, and any other potentially contaminated surfaces will be cleaned as needed. All equipment must be thoroughly washed and sanitized between uses, in different food preparation tasks and anytime contamination occurs or is suspected . https://www.fda.gov/media/164194/download?attachment FDA Food Code 2022 on 10/09/2024 indicated: Chapter 4. Equipment, Utensils, and Linens Multiuse 4-101.11 Characteristics. Multiuse equipment is subject to deterioration because of its nature, i.e., intended use over an extended period of time. Certain materials allow harmful chemicals to be transferred to the food being prepared which could lead to foodborne illness. In addition, some materials can affect the taste of the food being prepared. Surfaces that are unable to be routinely cleaned and sanitized because of the materials used could harbor foodborne pathogens. Deterioration of the surfaces of equipment such as pitting may inhibit adequate cleaning of the surfaces of equipment, so that food prepared on or in the equipment becomes contaminated. Inability to effectively wash, rinse and sanitize the surfaces of food equipment may lead to the buildup of pathogenic organisms transmissible through food. Studies regarding the rigor required to remove biofilms from smooth surfaces highlight the need for materials of optimal quality in multiuse equipment. Cleanability 4-202.11 Food-Contact Surfaces. The purpose of the requirements for multiuse food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and accessible for cleaning. Food contact surfaces that do not meet these requirements provide a potential harbor for foodborne pathogenic organisms. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. Once established, these biofilms can release pathogens to food. Biofilms are highly resistant to cleaning and sanitizing efforts. The requirement for easy disassembly recognizes the reluctance of food employees to disassemble and clean equipment if the task is difficult or requires the use of special, complicated tools. 4-202.15 Can Openers. Once can openers become pitted or the surface in any way becomes uncleanable, they must be replaced because they can no longer be adequately cleaned and sanitized. Can openers must be designed to facilitate replacement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 14 residents (Resident #24 and Resident #36) and 1 laundry room reviewed for infection control practices and transmission-based precautions. 1) The facility failed to ensure LVN C provided proper hand hygiene during wound care to Resident #24's sacrum/coccyx area of the buttocks. 2) The facility failed to ensure the laundry staff were using a barrier when sorting contaminated linens. 3)The facility failed to ensure enhanced barrier precautions were initiated for Resident #36. These failures could place residents at increased risk for serious complications from a communicable disease that could diminish the resident's quality of life. Findings included: 1)Record review of Resident #24's face sheet dated 10/09/24 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses dementia (loss of cognitive functioning), diabetes (a chronic condition that affects the way the body processes blood sugar), high blood pressure, major depressive disorder (mental illness that negatively affects how you feel, the way you think and how you act), and a stage 4 pressure ulcer to sacrum. Record review of Resident #24's significant change MDS assessment dated [DATE] indicated she understood others and usually made herself understood. The MDS indicated she had a BIMS score of 2 which means she was severely cognitively impaired. The MDS also indicated she required total assistance from staff for transfers, bed mobility, toileting, eating, and bathing. Record review of Resident #24's care plan dated 4/18/24 indicated she had a stage 4 pressure ulcer to her coccyx with a goal for the wound to not increase in size and to not exhibit signs of infection. The interventions for the wound included providing wound treatments as ordered. During an observation on 10/08/24 at 03:32 PM, LVN C provided wound care to Resident #24's sacrum/coccyx area of the buttocks. LVN C cleaned the dirty wound and then failed to use hand hygiene and change gloves prior to applying the gentamycin ointment, calcium alginate with silver, and the clean dressing to Resident #24's wound. During an interview on 10/08/24 at 04:09 PM, LVN C said after she cleaned Resident #24's wound to her sacrum, her hands were considered dirty, and she should have changed her gloves and used hand sanitizer in between. She said she was nervous. LVN C said the failure placed Resident #24 at risk for infection. During an interview on 10/09/24 at 02:59 PM, the ADON said she expected the wound care to be performed properly when providing wound care. She said the DON was the infection preventionist and she completed the proficiency checks offs for nurses upon hire and quarterly to ensure the nurses were competent. The ADON said the failure placed a risk of infection being passed to Resident #24 and the risk for the wound not healing properly. During an interview on 10/09/24 at 03:04 PM, the DON said her expectation was to correctly provide wound care. She said LVN C was very anxious and nervous. The DON said LVN C's gloves should have been changed by her after the cleaning of the wound, hand sanitizer should have been used, and new gloves put on. She said she was responsible for ensuring the nursing staff could properly perform treatments, and she said she checked the nurses off for wound care proficiency twice yearly. The DON said the failure placed a risk for cross contamination and infection for Resident #24. During an interview on 10/09/24 at 03:23 PM, the Administrator said her expectation was for the nurses to follow the proper protocol for wound care. She said nursing administration (which was the DON and ADON) were responsible for ensuring the nurses properly provided wound care. The Administrator said the failure placed Resident #24 at risk for potential infection. 2)Record review of a face sheet dated 10/08/2024 indicated Resident #36 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnosis of urinary tract infection. Record review of the Quarterly MDS dated [DATE] indicated Resident #36 understood and was understood by other. The MDS indicated Resident #36's BIMS score was 7 indicating Resident #36 had severe cognitive impairment. The MDS indicated Resident #36 was dependent for toileting and showering/bathing, required partial/moderate assistance with upper body dressing, substantial/maximal assistance with lower body dressing, and touching assistance with personal hygiene. The MDS indicated Resident #36 was always incontinent of bowel and bladder. Record review of the comprehensive care plan dated 10/01/2024 and edited on 10/07/2024 indicated Resident #36 received IV medications. The goal of the care plan indicated Resident #36 would not exhibit signs of complications from the IV (localized infection, systemic infection, .) The care plan interventions indicated initiated enhanced barrier precautions related to midline placement dated 10/07/2024. The care plan interventions dated 10/01/2024 included assess for complications from the IV, follow regimen when caring for the IV site, and the midline placement by an outside vendor. Record review of the Consolidated Physician's Orders dated October 2024 indicated on 10/01/2024 Resident #36 was ordered Mid-line (a long-erm central venous catheter inserted in the upper limb for medium-term treatments) for IV (intravenous) for intravenous therapy and to change the Mid-line IV dressing and clean insertion site every 7 days. During an observation and interview on 10/07/2024 at 12:55 p.m., Resident #36 was lying in her bed. Resident #36 said she had a device in her right upper arm. Resident #36 held up her arm revealing a mid-line catheter. Resident #36 said she had a urinary tract infection and was receiving antibiotics. Resident #36's door or outside wall had no signage indicating enhanced barrier precautions or any other precautions. CNA B said she was unaware if Resident #36 had an infection and was unaware of a need for the use of PPE or any special precautions related to Resident #36's care. During an interview and observation on 10/07/2024 at 3:36 p.m., CNA B came to ask the surveyor to go to Resident #36's room where CNA B revealed signage had been placed on Resident #36's door indicating she was on enhanced barrier precautions. CNA B said because of the IV line and Resident #36's urinary tract infection, staff could spread germs. 3)During an observation and interview on 10/07/2024 at 3:15 p.m., Laundry Aide and the Housekeeping Supervisor provided the tour to the laundry room. The Laundry Aide and Housekeeping Supervisor said they wore gloves when sorting the dirty clothes/linen but there were no aprons or any goggle/shields available nor had they used them when sorting the contaminated laundry. The Housekeeping Supervisor said there were residents on transmission-based precautions. The Housekeeping Supervisor said they could spread germs if the dirty clothes/linens touched their personal clothing. During an interview on 10/09/2024 at 1:53 p.m., the ADON said she was one of the infections preventionists of the facility. The ADON said when sorting clothes, the staff should prevent their personal clothing from coming in contact with contaminated linen. The ADON said the facility currently had residents on transmission-based precautions and there was a risk to spread infection. The ADON said Enhanced Barrier Precaution signage should be placed when a resident initiated the use of a device or has an infection. The ADON said she was unsure how Resident #36's enhanced barrier precautions sign was missed. The ADON said when proper precautions were not taken germs could spread. During an interview on 10/09/2024 at 2:39 p.m., the DON said she had not placed Resident #36 on enhanced barrier precautions because she believed the mid-line was not a central line and therefore was not required to have the precautions. The DON said when referring to the facility's policy concerning the use of enhanced barrier precautions with devices such as central lines e.g. she indicated she believed it was based on an individual's interpretation. The DON said she believed contamination of the laundry personnels personal clothing when not using a form of PPE would be dependent upon the technique of the person handling the laundry. During an interview on 10/09/2024 at 3:07 p.m., the Administrator said she would have to research the use of PPE when sorting laundry, and the use of enhanced barrier precautions with a mid-line. Record review of the Infection Prevention and Control Program dated July 2024 indicated an infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections 2. The program is based on accepted national infection prevention and control standards. Record review of an Enhanced Barrier Precautions policy dated 4/01/2024 indicated it was the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistance organisms. Definition: Enhanced barrier precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employes targeted gown and gloves use during high contact resident care activities. 2. Initiation of Enhanced Barrier Precautions: .b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO (multi-drug resistant organism) 4. High-contact resident care activities include: .g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes. 9. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Record review of a Laundry and Bedding, Soiled policy dated April 2020 indicated soiled laundry/bedding shall be handled, transported, and processed according to best practices for infection prevention and control. Handling: 1. All used laundry is handled as potentially contaminated until it is properly bagged and labeled for appropriate processing. A. Soiled laundry and bedding contaminated with blood or other potentially infectious material is handled as little as possible and with minimum of agitation .Personal Clothing 1. Personal clothing that becomes soiled with blood or body fluids is covered (e.g., with a gown) or removed and immediate laundered before leaving the work area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 2 of 15 residents reviewed for resident rights. (Residents #18 and #7) 1. The facility failed to treat Resident #18 with respect and dignity when she received her lunch tray 25 minutes after the other resident at her table had already been served their meal and was eating in front of her. 2. The facility failed to ensure Resident #7's wanderguard was discontinued, after the elopement assessment indicated she was at no risk for elopement. These failures could place residents at risk for decreased quality of life, decreased self-esteem and increased anxiety. Findings included: 1. Record review of the consolidated physicians' orders date 09/12/2023, indicated Resident #18 was a [AGE] year-old female, re-admitted to the facility on [DATE] with diagnoseis including cerebral infarction (stroke), constipation, limitation of activities due to disability, depression, anxiety, dysphagia (difficulty swallowing), and emotional lability. Record review of the comprehensive MDS dated [DATE], indicated Resident #18 made herself understood and understood others. The MDS indicated Resident #18 had a Brief Interview for Mental Status (BIMS) of 00. This score indicated Resident #15 was unable to complete the interview. The MDS indicated Resident #18 required extensive assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS indicated Resident #18 required supervision for eating. Record review of the care plan dated 06/14/2023, indicated Resident #18 had a communication deficit with a goal to have needs met at all times. The care plan indicated Resident #18 required the assistance of one person for eating. During an observation on 9/10/2023 at 12:30 PM., rResident #18 watched intently as other residents around the dining room were served trays after her table mate received and had eaten his lunch. Resident #18 rested her chin in her hand while her eyes darted around watching all the resident's served dessert. Resident #18 leaned over the table and muttered out loudly on several occasions as she waited for her food to be served. Resident #18 cried and was not able to interview at this time. During an interview on 09/12/2023 at 09:40 AM, the Dietary Manager said Resident #18 did not get served because her tray was on the hall cart, but she did get served. The Dietary Manager said Resident #18 could be impacted by dignity by not being served with the other residents in the dining hall. During an interview on 09/12/2023 at 09:52 AM, the DON said Resident #18 did get served after they realized her tray was on the hall cart. The DON said it was not a home like environment and could cause a decrease of quality of life and dignity by not being served at the same time as fellow residents. 2.Record review of Resident #7's face sheet, dated 09/12/2023, indicated Resident #7 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included acute respiratory failure (difficulty breathing), and essential hypertension (high blood pressure). Record review of the physician order report dated 08/12/2023-09/12/2023 indicated Resident #7 had an order for a wander guard. The order indicated to check placement every shift with a start date 03/30/2023. Record review of the significant change in status MDS assessment, dated 05/02/2023, indicated Resident #7 made herself understood and understood others. The assessment did not address Resident #7's BIMS score. The assessment indicated no behaviors or refusal of care. Record review of the comprehensive care plan, dated 07/31/2023, indicated Resident #7 experienced wandering. The care plan interventions included equipped resident with a device that alarms when resident wanders to close to exits, check for proper functioning of device every HS. The care plan was resolved after surveyor intervention on 09/11/2023. Record review of an elopement evaluation dated 04/19/2023 completed by LVN B indicated no elopement risk factors identified or verbalized for Resident #7. Record review of an elopement evaluation dated 07/27/2023 completed by LVN D indicated no elopement risk factors identified or verbalized for Resident #7. During an observation on 09/10/2023 at 2:30 p.m., Resident #7 was sitting on the edge of her bed watching tv. Resident #7 had a wander guard to her left wrist. During a telephone interview on 09/11/2023 at 4:25 p.m., Resident #7's family member stated there was times when Resident #7 told her she felt like a prisoner. Resident #7's family member stated she would ask her why she had to wear this when she no longer tried to leave the facility. Resident #7 stated she had spoken to the ADON back in August about removing the wanderguard but she stated it could not be removed because it was for her own safety. During an interview on 09/11/2023 at 4:40 p.m., Resident #7 stated she felt confined with the wanderguard. Resident #7 stated she could go outside with supervision but felt like a prisoner because the facility had so many rules. Resident # 7 stated they were afraid I was going to run away. During a telephone interview on 09/12/2023 at 3:25 p.m., LVN B stated she should have reported to the administration which included the DON, ADON and Administrator when the assessment revealed Resident #7 was no longer a risk for elopement. LVN B stated to her knowledge she had told the ADON that Resident #7 was no longer a risk for elopement. LVN B was unable to provide the surveyor with the date she told the ADON. LVN B stated this could potentially violate Resident #7's rights. During a telephone interview on 09/12/2023 at 3:59 p.m., LVN D stated she should have notified the DON, ADON or Administrator that Resident #7 no longer needed the wanderguard after the elopement assessment indicated she was at no risk for elopement. LVN D stated she was under the impression the administration would have been notified by reviewing the charts during morning meetings. LVN D stated this failure could make Resident #7 feel like her rights were violated. During an interview on 09/12/2023 at 4:32 p.m., the ADON stated she was unaware Resident #7's assessment revealed she was no longer an elopement risk until surveyor intervention. The ADON stated the nurses should have notified administration that Resident #7 was no longer an elopement risk. The ADON stated if the administration was notified in April and July, the wander guard would have been removed at that time. The ADON stated the system of the nurse expecting to notify the administration was ineffective. The ADON stated this potential failure inhibits the resident rights. During an interview on 09/12/2023 at 4:52 p.m., the DON stated she expected the nurses to document on the 24 hr report when Resident #7's assessment revealed she was no longer an elopement risk. The DON stated she did not know what the company expected at that time prior to her assuming the DON position on 8/10/2023. The DON stated this potential failure could result in infringement of her right. During an interview on 09/12/2023 at 00:00, the Administrator stated her or the nursing management should have been notified that Resident #7 was no longer an elopement risk. The Administrator stated if they were notified when her assessment revealed Resident #7 was no longer an elopement risk the wander guard would have been removed at that time. The Administrator stated this potential failure could result in violation of her right. Record Rreview of a policy revised February 2021 titled Dignity indicated, .1. Residents are treated with dignity and respect at all times. E. provided with a dignified dining experience. Record review of the facility's policy titled Resident Rights last revised 02/2021, indicated, Employees shall treat all residents with kindness, respect, and dignity Record review of the facility's policy titled Wandering and Elopement last revised 09/01/2023, indicated, 1. Monitoring and Managing Residents at risk for elopement or unsafe wandering f. the effectiveness of interventions will be evaluated, and changes will be made as needed quarterly and, if indicted with change of condition. Any changes or new interventions will be communicated to relevant staff

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 2 of 3 residents (Residents #18 and #150) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #18 and #150 was given a SNF ABN when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services. Findings include: 1. Record review of Resident #18's face sheet, dated 09/13/2023, indicated Resident #18 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke), and essential hypertension (high blood pressure). Record review of the quarterly MDS assessment, dated 07/03/2023, indicated Resident #18 made herself understood and understood others. The assessment indicated Resident #18's BIMS was 0, which indicated severe cognitive impairment. Record review of the SNF Beneficiary Protection Notification Review indicated Resident #18 was receiving Medicare Part A services starting on 02/20/2023 and the last covered day of Part A services was 03/14/2023, however it was revealed that a SNF ABN was not completed which would have informed Resident #18 of the option to continue services at the risk of out-of-pocket. 2. Record review of Resident #150's face sheet , dated 09/13/2023, indicated Resident #150 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included acute osteomyelitis (inflammation of the bone cause by an infection) and type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar). Record review of the discharge MDS assessment, dated 07/25/2023, did not address Resident #150's speech. The MDS assessment indicated Resident #150's BIMS was 9, which indicated his cognition was moderately impaired. Record review of the SNF Beneficiary Protection Notification Review indicated Resident #150 was receiving Medicare Part A services starting on 05/23/2023 and the last covered day of Part A services was 07/10/2023, however it was revealed that a SNF ABN was not completed which would have informed Resident #150 of the option to continue services at the risk of out-of-pocket. During an interview on 09/12/2023 at 2:05 p.m., the MDS Coordinator stated the previous MDS Coordinator was responsible for ensuring Resident #18 and #150 were issued a SNF ABN. The MDS Coordinator stated the form should have been issued if the resident had skilled benefit days remaining and was being discharged from Part A services and will continue living in the facility. The MDS Coordinator stated it was important for the residents to receive the form so that if they wanted to continue with those skilled services, they would know their financial responsibility. The MDS Coordinator stated there was no negative outcome for not receiving a SNF ABN form prior to covered days being exhausted. During an interview on 09/12/2023 at 2:35 p.m., the Regional Reimbursement Manager stated the previous MDS Coordinator was responsible for ensuring Resident #18 and #150 were issued a SNF ABN. The Regional Reimbursement Manager stated she was responsible for monitoring by completing random audits. The Regional Reimbursement Manager stated she had noticed prior to 8/1/23 SNF/ABNs was not being issued with the NONMC. The Regional Reimbursement Manager stated when those issues arise education was provided immediately. The Regional Reimbursement Manager stated her last audit was done on 09/05/2023. The Regional Reimbursement Manager stated Residents #18 and #150 were not part of the sample batch that was being audited. The Regional Reimbursement Manager stated it was important for the residents to receive the form so that if they wanted to continue with those skilled services, they would know their financial responsibility. During an interview on 09/12/2023 at 5:42 p.m., the Administrator stated the MDS Coordinator was responsible for ensuring the SNF ABN was completed. The Administrator stated the form should have been issued if the resident had skilled benefit days remaining and was being discharged from Part A services and will continue living in the facility. The Administrator stated there was no negative outcome for not receiving a SNF ABN form prior to covered days being exhausted. During an interview on 09/12/2023 at 4:26 p.m., the Clinical Resource Nurse stated there was not a policy and procedure regarding SNF/ABN's.

**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 1 of 15 resident rooms (room [ROOM NUMBER]), 1 of 15 residents (Resident #46), 3 male shower rooms #1, #2 and #3 and 1 of 1 female bathrooms reviewed for physical environment. The facility failed to repair the trim in room [ROOM NUMBER]. The facility failed to replace the missing shower tile in male bathroom [ROOM NUMBER]. The facility failed to unclog the shower drain in the male bathroom [ROOM NUMBER]. The facility failed to ensure that the toothbrush in Resident #46 bathroom was labeled with Resident # 46 name and room number. The facility failed to ensure that the used single-use razors in the facility's male shower room [ROOM NUMBER] were discarded after use. The facility failed to ensure unused single-use razors in the facility male shower room # 3 cabinet were labeled with residents' names and room numbers. The facility failed to ensure that the hairbrush in the facility male shower room [ROOM NUMBER] was labeled with the resident's name and room number. The facility failed to ensure the female shower room and the facility male shower room [ROOM NUMBER], #2, #3 were clean and sanitized after use of each resident. These failures could place the resident at risk for decreased quality of life and infection due to unsanitary conditions. The findings included: 1.During an observation on 09/10/23 at 2:22 PM, the trim was hanging off the bottom of the wall in room [ROOM NUMBER]. During an interview on 09/12/23 at 10:13 AM, Maintenance stated he checked every resident's room daily and asked each resident if they needed anything. Maintenance stated he was not aware of the wall in room [ROOM NUMBER]. Maintenance stated the importance of making sure the wall trim was repaired was to prevent falls or an accident. Maintenance stated it could have result in hurting a resident if not fixed. Record review of the facility's, To do list, no date, did not reveal a maintenance request form for room [ROOM NUMBER]. During an interview on 09/12/23 at 2:40 PM, the DON stated she expected the trim in room [ROOM NUMBER] to be fixed. The DON stated the wall trim was an environmental issue of care and she expected it to be fixed to prevent falls. The DON stated the process was for staff to notify Maintenance and he would go fix it. The DON stated nursing staff just told maintenance when things needed to be repaired and he did not write them down in a logbook that she was aware of. During an interview on 09/12/24 at 5:27 PM, the Administrator stated she expected the trim to be fixed in room [ROOM NUMBER]. The Administrator stated the importance of making sure the trim was fixed, was so there were not any hazards that could cause harm. The Administrator stated if the trim was not fixed, then residents could have tripped or fell. 2. During an observation on 9/11/23 at 9:03 a.m., the facility male shower room [ROOM NUMBER] shower tile missing exposing the wet drywall. During an observation on 9/12/23 at 8:00 a.m., the facility male shower room [ROOM NUMBER] shower tile missing exposing the wet drywall. During an observation on 9/11/23 at 9:16 a.m., the facility male shower room [ROOM NUMBER] shower drain was clogged with strands of black hair. During an observation on 9/12/23 at 8:15 a.m., the facility male shower room [ROOM NUMBER] shower drain was clogged with hair and clear band aide tape. During an interview on 9/12/23 at 8:12 a.m., LVN D stated that the missing tile in the Male shower room [ROOM NUMBER] needed to be replaced. LVN D stated that she did not know why the tile had not been replaced. LVN D stated she did not know how long the tile had been missing. LVN D stated that she did not know if maintenance was working on replacing the shower tile in the male shower room [ROOM NUMBER]. LVN D stated maintenance was responsible for replacing the tile in the male shower room. LVN D stated it was important for the resident to have a clean and safe place to shower to prevent accidents. During an interview on 9/12/23 at 10:30 a.m., the Maintenance Director stated he was aware in a meeting last month that shower tile in the male shower room [ROOM NUMBER] needed to be replaced. The Maintenance Director stated he did shop at the local stores to try matching the tile but none of the local stores had the correct shower tile. The Maintenance Director stated contractors were responsible for replacing the tile. The Maintenance Director stated the Administrator had bids in place but was not sure if any bids were approved to complete the work. The Maintenance Director stated once maintenance jobs are completed that his work does not get checked. The Maintenance Director stated it was important to have repairs completed for the safety of the residents. During an interview on 9/12/23 at 4:30 p.m., the DON stated she assumed this position on 8/10/23. The DON did not know what the company expected of her prior to assuming this position at 8/10/23. The DON stated that she was not aware of the shower tile missing in the male shower room [ROOM NUMBER]. The DON stated maintenance was responsible for replacing the tile in the male shower room [ROOM NUMBER]. The DON stated the male shower room [ROOM NUMBER] had a shower drainage issue. The DON stated she was not aware of the CNA's using the male shower room [ROOM NUMBER]. The DON stated she does expect maintenance to complete repairs in the facility. The DON stated facility repairs was important for the resident's safety. During an interview on 9/12/23 at 5:00 p.m., the Administrator stated the Administrator stated that she was not aware of the missing shower tile in the male shower room [ROOM NUMBER]. The Administrator stated that she was not aware of the clogged plumbing issue in the male shower room [ROOM NUMBER]. The Administrator stated she was not aware that the shower chairs were not stabled in the female shower room and the male shower room [ROOM NUMBER], #2 and #3 for residents when taking a shower. The Administrator stated there was no process in place to monitor shower room repairs. The Administrator stated that she would create a logbook for maintenance requests. The Administrator stated that the maintenance requests and completed repairs would be presented to QAPI every month. The Administrator stated the showers should be safe for residents for safety. 3. Record Review of Resident #46 face sheet, dated on 9/12/23, indicated Resident #46 was a [AGE] year-old male, admitted to the facility on the administration date of 8/30/23 with a diagnosis of acute kidney failure, chronic kidney disease, severe sepsis with septic shock, hypothyroidism, type 2 diabetes mellitus and Chronic obstructive pulmonary disease. Record review of the MDS dated [DATE] indicated Resident #46 makes self-understood and understood others. The MDS indicated Resident #46 had moderate cognitive impairment. The MDS indicated Resident #46 required two-person extensive assistance with personal hygiene. The MDS indicated Resident #46 required supervision with one-person assistance for bed mobility, transfer and eating. The MDS indicated Resident #46 required limited assistance with one-person physical assist for dressing and toileting. Record review of the care plan updated on 8/31/23 indicated Resident #46 had a problem with ADL care and required hygiene one-person assistance. During an observation on 9/10/23 at 2:12 p.m., Resident #46 had a toothbrush in his bathroom that was not labeled with Resident #46 name or room number. During an observation on 9/11/23 at 8:31 a.m., Resident #46 had a toothbrush in his bathroom that was not labeled with Resident #46 name or room number. During an observation on 9/11/23 at 8:30 a.m., the facility male bathroom [ROOM NUMBER],#2, #3 and female shower room had balls black hairs in the drains. During an observation on 9/12/23 at 8:00 a.m., the facility male bathroom [ROOM NUMBER],#2, #3 and female shower room had balls black hairs in the drains. During an interview on 9/12/23 at 8:12 a.m., the LVN D stated that she did not know when the shower for the female shower and male shower room [ROOM NUMBER], #2, #3 were last cleaned. The LVN D stated the shower chairs for the male and female room were not stable for residents even with the chair locks on the bottom of each leg of the shower chair. The LVN D stated the CNA's are supposed to clean the shower rooms after each use. The LVN D stated that the shower room for the female shower room and male shower room [ROOM NUMBER], #2, #3 did not appeared to be cleaned after used. The LVN D stated she did not know why the shower rooms for the female and male shower room [ROOM NUMBER], #2, #3 were not cleaned. The LVN D stated she did not know which CNA's last used the shower room. The LVN D stated that the facility did not have a log in place to determine who last assisted a resident in the shower rooms. The LVN D stated it was important for the resident to have a clean and safe place to shower to prevent accidents. During an interview on 9/12/23 at 1:58 p.m., housekeeping aid N stated she was responsible cleaning the shower. Housekeeping stated that showers were to be cleaned daily. Housekeeping aid N stated the CNA's were to clean the shower and clean the drains after each use. The Housekeeping aid N stated she did not know why the CNA's were not cleaning the showers and shower drains. The Housekeeping aid N stated the housekeeping policy did not specify if or when CNA's were to clean the showers. The Housekeeping aid N stated she was responsible for taking out the trash, napkin holder, toilet and shower walls and railings, shower sink, and mopping the shower floor. The Housekeeping aid N stated shower rooms were to be cleaned daily. The Housekeeping aid N stated the Maintenance director supervises her work. The Housekeeping aid N stated cleaning and sanitation was important to prevent cross contamination. During an interview on 9/12/23 at 10:30 a.m., the Maintenance Director he was not aware of the clogged shower in the male shower room [ROOM NUMBER]. The Maintenance director stated the facility did not a have a monitoring system in place. The Maintenance Director stated it was important to have repairs completed for the safety of the residents. During an interview on 9/12/23 at 4:30 p.m., the DON stated she was not aware of the CNA's not cleaning the shower rooms after each use. The DON stated that maintenance was notified last week on 9/6/23 to fix the shower drainage issue in the male shower room [ROOM NUMBER]. The DON stated that she did not follow up on the maintenance request on 9/6/23 for drainage issue in the male shower room [ROOM NUMBER]. The DON stated that the CNA's were to clean the showers and shower drains and any bodily fluids after use of each resident shower. The DON stated she does expect CNA's to clean showers after each use and for housekeeping to clean showers daily. The DON stated there is no process for monitoring that showers are cleaned and sanitized. The DON stated housekeeping is responsible to sanitizing the showers daily. The DON stated the lack of being held accountable for cleaning and sanitation was why the CNA's have not cleaned the shower rooms after each use. The DON stated cleanliness and sanitation was important for residents safety and infection control. During an interview on 9/12/23 at 5:00 p.m., the Administrator stated that the CNA's were responsible for cleaning out bodily waste in the shower rooms. The Administrator stated the CNA's were responsible for cleaning the showers after each resident had used the shower room for showers. The Administrator stated housekeeping was responsible for cleaning the shower room floors, sinks, toilets and walls. The Administrator stated CNA's were responsible for ensuring all personal items are labeled with each residents name and room number. The Administrator stated that disposable items like razors should have been discarded after used. The Administrator stated she was not aware of the single use used razors in the male shower room [ROOM NUMBER] were not discarded. The Administrator stated she was not aware of the unused single use razors not labeled or numbered with residents name and room number in the male shower room [ROOM NUMBER]. The Administrator stated that she was not aware of the unlabeled used hairbrush with white hairs in the brush was not labeled with the resident name or room number. The Administrator was not aware of a white plastic hanger securing the cabinet lock with residents personal unused razors not labeled in the male shower room [ROOM NUMBER]. The Administrator stated that she was not aware of resident #46 toothbrush in resident #46 bathroom was not labeled with resident #46 name and room number. The Administrator stated that she expected staff to clean the shower rooms daily and after each use by housekeeping and CNA's. The Administrator stated there was no process in place to monitor shower room cleanliness. The Administrator stated she would create a deep cleaning logbook for the CNAs and housekeeping. The Administrator stated that she would create a logbook for maintenance requests. The Administrator stated deep cleaning logbook would be presented to Qappi every month. The Administrator stated that after viewing the pictures of the facility male and female clogged shower drains with dirt and black hairs, brown stains on toilets, and missing shower tile, that she agreed the showers had not been cleaned and shower tile in the male shower room # 1 needed to be repaired. The Administrator stated the showers should be clean and safe for residents to prevent infection. Record review of the facility's policy on Homelike Environment policy, revised February 2021, revealed The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean, sanitary, and orderly environment. Record review of the facility Cleaning and Disinfecting Non-Critical Resident-Care items, with a revision date of April 2020, revealed (2) single use items are for single resident use only. [NAME] with the resident's name and/or room number and discard upon transfer or discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free from abuse for 2 of 15 residents (Resident #20 and Resident #14) reviewed for resident abuse. The facility did not ensure Resident #20 was free from abuse, as a result Resident #20 was physically assaulted by Resident #14 with no injuries. This failure could place residents at risk of physical harm, mental anguish, or emotional distress. The findings included: 1.Record review of Resident #20's face sheet, 09/11/23, indicated Resident #20 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included bipolar (episodes of mood swings), dementia (memory loss and poor judgment), and HTN (force of blood against the artery walls is too high). Record review of Resident #20's quarterly MDS dated [DATE] indicated he made himself understood and was able to understand others. There was no BIMS score indicated. Section E of the MDS did not indicate any behavior issues. Record review of Resident #20's care plan, revised on 08/24/23, indicated he had abusive behavioral symptoms, and another resident was yelled at and an attempt to hit another resident was made. The approach included to obtain a psych consult and to offer verbal directions for tasks. 2. Record review of Resident #14's face sheet, 09/12/23, indicated Resident #14 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included bipolar (episodes of mood swings), HTN (force of blood against the artery walls is too high) and impulse disorder (inability to maintain self-control). Record review of Resident #14's quarterly MDS dated [DATE] indicated he was sometimes understood and had to ability to understand others. There was no BIMS score indicated. Section E of the MDS did not indicate any behavior issues. Record review of Resident #14's care plan, revised on 09/11/23, did not indicate any issues regarding resident-to-resident altercation or mood. Record review of the physical altercation incident report dated 07/07/23 indicated Resident #20 went into Resident #14's room and requested for the TV to be turned down. Resident #14 turned the TV down and when Resident #20 turned around to head back to his room, Resident #14 turned the TV back up. Resident #20 went back to Resident #14's room to tell him to turn down the TV again and Resident #14 took both hands and hit Resident #20 on each shoulder and hit his face. Record review of the Every 15 Minute Check Sheet dated 7/7/23 indicated Resident #20 was checked from 8:15 PM on 7/7/23 until 12:15 AM on 7/8/23 for behavior. Record review of the Every 15 Minute Check Sheet dated 7/8/23 indicated Resident #20 was checked from 6:15 AM on 7/8/23 until 6:00 PM for behavior. Record review of the Safe Surveys dated 7/7/23 completed on multiple residents. Record review of the In-Service Education Form dated 07/07/23 on Abuse, Neglect, and Misappropriation were a crime. Record review of the External Investigation Summary indicated the incident occurred on 7/7/23 at 7:59 PM. The residents were separated successfully with no further altercation. No injuries or bruising were sustained to either resident. During an interview on 9/10/23 at 10:51 AM, Resident #20 stated he went to Resident #14's room to tell him to turn down the TV and Resident #14 did not like it. Resident #20 stated when he left the room, Resident #14 turned the TV back up and he went back into the room to tell him again to turn the TV down again. Resident #20 stated that Resident #14 then hit him on his shoulders. Resident #20 stated it did not hurt him and he did not receive any injuries. Resident #20 stated him, and Resident #14 were friends now and denied any issues since the incident. Resident #20 stated he had informed staff of the incident and they spoke to both residents after the incident occurred. During an interview on 9/10/23 at 11:02 AM, Resident #14 stated he did not remember the incident that occurred with Resident #20. During an interview on 09/12/23 at 9:00 AM, CNA H stated she was not aware of the resident-to-resident incident. CNA H stated the types of abuse were verbal, mental, and physical. CNA H stated the abuse coordinator was the Administrator. CNA H stated if a resident refused a bath, she would ask 3 more times throughout the day and then notify the charge nurse so she could talk to the resident. CNA H stated if 2 residents were fighting, she would notify the charge nurse and the Administrator and if she overheard someone being mean to a resident, she would notify the Administrator. During an interview on 09/12/23 at 11:13 AM, CNA L stated the different types of abuse were physical, emotional, and mental abuse. CNA L stated abuse was reported the Administrator. CNA L stated if a resident refused a bath, she would ask again later and would have reported it to the charge nurse. CNA L stated if 2 residents were fighting, she would have separated them and made sure they were safe, deescalate the situation, then report it immediately to the Administrator. CNA L stated if someone was speaking in a mean tone to a resident, she would have reported it to the Administrator immediately. During an interview on 09/12/23 at 2:40 PM, the DON stated she was not working at the facility in July when the resident-to-resident altercation occurred. During an interview on 09/12/24 at 5:27 PM, the Administrator stated Resident #20 and Resident #14 were separated and staff moved them apart from each. The Administrator stated there have been no issues since with the residents. Record review of the facility's policy on Resident-to-Resident Altercations policy, revised December 2016, revealed If two residents are involved in an altercation, staff will: Separate the residents, and institute measures to calm the situation and review the events with the Nursing Supervisor and Director of Nursing, and possible measures to try to prevent additional incidents. Record review of the facility's policy on Abuse Prevention Program, revised 01/09/23, revealed Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 2 of 15 residents (Resident's #44 and #33) reviewed for abuse. 1. The facility failed to implement the abuse and neglect policy and procedure regarding reporting fall incident. 2.The facility did not implement policy on reporting neglect for bruise of unknown origin for Resident #33 to the abuse coordinator (Administrator). These failures could place the residents at increased risk for abuse and neglect. Findings included: Record review of the facility policy for Abuse Prevention Program dated 01/09/23, indicated, Policy Statement:1. The Administrator is responsible for the overall coordination and implementation of our Center's abuse prevention program policies and procedures in accordance with the Elder Justice Act. 2. Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but was not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Reporting 2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury. 1.Record review of the Provider Investigation Report dated on 8/12/23 indicated an allegation of fall with left hip fracture incident on Resident #44 occurred on 8/11/23 at 3:45 p.m. The report indicated no staff witnessed the fall incident. The report indicated LVN B completed a neuro assessment on Resident #44 on 8/11/23. The report indicated resident reported mild hip pain on 8/11/23 at 3:25 p.m. The report indicated the DON requested hip x-ray post fall to rule out injury/fracture on 8/11/23 at 3:25 p.m. The report indicated Resident #44 was assessed by the facility contracted x-ray company and found to have a fracture on his left hip. The incident was reported to the state agency on 8/12/23 at 8:11 a.m. Record review of Resident # 44 face sheet, dated on 9/12/23, indicated Resident #44 was a [AGE] year-old male, admitted to the facility on the original administration date of 8/8/23 with a diagnosis of bipolar which included (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), hypothyroidism (thyroid gland does not produce enough thyroid hormone) panic disorder (anxiety disorder where you regularly have sudden attacks of panic or fear) and cognitive communication deficit (the inability to think of the correct word). Record review of Resident #44 quarterly MDS assessment, dated on 8/25/23, indicated Resident #44 was understood others and made himself understood. The MDS assessment indicated Resident #44 was moderately cognitively impaired with a BIMS score of 8. The MDS assessment indicated Resident #44 was coded for verbal behavior symptoms directed toward others occurring one to three days and for rejection of care behaviors occurring one to three days. Record review of Resident #44 care plan, dated on 8/30/23, indicated Resident #44 had has history of falling and is at risk for falls r/t cognitive deficit, need of assistance with ADLs, fractured hip; left, weakness. The care plan interventions included frequent checks on resident, keep call light in reach at all times, give resident verbal reminders not to ambulate/transfer without assistance, keep bed in lowest position with brakes locked, and keep personal items and frequently used items within reach. Record review of the facility incident report, dated on 9/11/23 at 7:53 am, indicated Resident #44 fell on [DATE]. The facility incident report on Resident #44 fall on 8/11/23, indicated Resident #44 was noted on floor in room by staff; unwitnessed fall; sent to emergency room for fractured hip. The facility incident report noted Resident #44 family member was notified on 8/11/23 at 3:45 p.m. Record review of Resident #44 Physical Therapy treatment encounter noted on 8/11/23 at 1:55 p.m., indicated Resident #44 actively participated with skilled interventions and Resident #44 was compliant with adaptations. Record review of Resident #44 Occupational Therapy treatment encounter noted on 8/11/23 at 5:02 p.m., indicated Resident #44 displayed noncooperation and noncompliance in occupational therapy session. Record review of Resident #44 Speech Therapy treatment encounter noted on 8/13/23 at 7:52 p.m., indicated Resident #44 was compliant with skilled interventions. Record review of Resident #44 Neurological evaluation flowsheet dated on 8/11/23 at 3:45 p.m., indicated neuro checks were completed every 15 minutes times 2 hours. Record review indicated in-services were completed for all staff on abuse on 8/14/23. During an interview on 9/9/23 at 2:57 p.m., a family member of Resident #44 stated that the facility informed her about the fall alteration that occurred on 8/11/23. The family member stated the resident had been admitted to the facility for a few weeks prior his fall incident on 8/11/23. The family member stated the facility staff would check on Resident #44 more frequently, and a fall mat had been placed at Resident #44's beside as an intervention. The family member of Resident #44 did not have any additional concerns that needed to be addressed. During an interview on 9/12/23 at 2:47 p.m., CNA M stated she was not at work when Resident #44 fell on 8/11/23. CNA M stated she did not witness the fall incident on 8/11/23. CNA M stated Resident #44 had reported no pain when he returned from the hospital. CNA M stated she could not recall which day Resident #44 returned from the hospital. CNA M stated Resident #44 had multiple falls incidents in the facility prior to his fall incident on 8/11/23. CNA M reported Resident #44 used his call light and occasionally scream for help when he needed assistance. CNA M could not recall how often Resident #44 screamed for help. CNA M stated she had completed in-service training on falls. CNA M could not recall the timeframe of when she completed her in-service on falls. CNA M stated incidents were to be reported immediately to the charge nurse on duty and the charge nurse on duty should complete an assessment on that resident. CNA M stated incident were to be reported to the charge nurse on duty. CNA M stated reporting timely was important to ensure the safety of the residents and staff. During a phone interview on 9/12/23 at 2:07 P.M, LVN B stated she found Resident #44 on the floor on 8/11/23 at 3:25 p.m. LVN B stated she did not witness the fall. LVN B stated she did not know how long Resident #44 was on the floor. LVN B could not recall what Resident #44 was attempting to do prior to his fall incident. LVN B stated she LVN B stated Resident #44 had several reports of being on found crawling on the floor prior to this incident that occurred on 8/11/23. LVN B stated the facility was becoming more aggressive with physical therapy and encouraging Resident #44 to participate in physical therapy. LVN B stated fall mats are in place as an intervention for Resident #44. LVN B stated staff was informed to check on Resident #44 every 15 minutes. LVN B stated Resident #44 verbally expressed having mild pain on left hip following the fall incident. LVN B stated Resident #44 call light was not on prior to the fall incident. LVN B stated she verbally expressed to Resident #44 to use the call light when needing help. LVN B stated she completed the neuro assessment on Resident #44 on 8/11/23. LVN B stated Resident #44 family member was notified on 8/11/23. LVN B could not recall the exact time the family member was notified. LVN B stated Resident #44 wife wished to have the resident #44 x-rayed immediately at the facility. LVN B stated the facility x-ray contracted company performed an x-ray on the resident at the facility on 8/11/23. LVN B stated the x-ray results are received on the same usually within a few hours. LVN B could not recall the time of x-ray Resident #44 was x-rayed. LVN B stated the x-rays results received on 8/11/23 from the facility contracted x-ray company indicated Resident #44's left hip was fractured. LVN B stated Resident #44 was transferred to the hospital on 8/12/23. LVN B stated she had completed in-service training on falls. LVN B stated she reported this incident to the DON. LVN B stated reporting timely was important to keep residents safe. During an interview on 9/12/23 at 4:14 p.m., the DON stated she did not witness the fall incident on Resident #44 on 8/11/23. The DON stated that she was aware of Resident #44 fall incident on 8/11/23. The DON described serious harm as Resident suffering a fracture after falling. The DON stated Resident #44 believed he could stand up on his own and walk. The DON stated Resident #44 verbally complained of mild pain following the fall incident on 8/11/23. The DON stated as a precaution she recommended that the facility to perform an x-ray on Resident #44 on 8/11/23. The DON stated she believed the fall incident was reported late to State because the x-ray results were e-faxed late by the facility contracted x-ray technician. The DON stated x-ray results are usually received within 2 to 4 hours after the x-ray is performed. The DON stated Resident #44 x-ray result were not e-faxed to the facility timely on 8/11/23. The DON did not know why the results were received e-faxed late by the contracted x-ray company on 8/11/23. The DON could not recall the time the e-faxed results were received but did indicate that it was very late at night on 8/11/23. The DON stated that when the facility learned of Resident #44 hip fracture, Resident #44's fall incident should have been reported to State within two hours. The DON stated Resident#44 family was notified on 8/11/23. The DON stated the Administrator was aware of Resident #44 fall incident on 8/11/23. The DON stated reporting timely was important to ensure the residents safety. During an interview on 9/12/23 at 3:53 p.m., the Administrator stated she learned of Resident #44's fall incident on 8/11/23 as she passed through Resident #44 hall. The Administrator stated LVN B responded to the fall on Resident #44. The Administrator did not know if other staff responded to Resident #44 fall on 8/11/23. The Administrator stated that a resident who fractures his or her bone would be considered a serious injury. The Administrator stated that she reported Resident #44 fall incident to State on 8/12/23. The Administrator stated Resident #44 fall incident should have been reported to State within 2 hours. The Administrator stated she did not report to State within two hours because she did not know Resident #44 had a fracture within two hours after the fall occurred. The Administrator stated that the care for Resident #44 was not delayed. The Administrator stated reporting timely was important to ensure the residents are safe. 2. Record review of Resident #33's face sheet, dated 09/12/2023, indicated Resident #33 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood) and essential hypertension (high blood pressure). Record review of Resident #33's significant change in status MDS assessment, dated 07/31/2023, indicated Resident #33 was usually understood and usually understood others. Resident #33's BIMS score was 10, which indicated she was cognitively moderately impaired. The assessment did not indicate any physical, verbal, or other behavior symptoms towards self or others. Record review of the comprehensive care plan dated 07/31/2023 did not address the bruise to Resident #33 left arm. Record review of the admission observation dated 07/17/2023 indicated there was no bruising to her left arm. Record review of Resident #33's progress note dated 07/20/2023 at 11:08 a.m., charted by LVN E indicated, Resident #33 had a bruise to her left arm. The note stated it was not present yesterday and she had complained of pain. The note indicated the nurse practitioner ordered a 2-view x ray of left upper arm and shoulder. During an interview on 09/11/2023 at 3:00 p.m., Resident #33 was non-interview able as evidenced by confused conversation and inappropriate answers to questions asked by the surveyor. During an interview on 09/11/2023 at 4:45 p.m., Resident #33's family member stated the facility informed her about the bruise on 07/21/2023. Resident #33's family member stated resident had been leaning on the arm of the chair prior to obtaining the bruise. Resident #33's family member stated Resident #33 requested to go the hospital on [DATE] because she was unsatisfied with the action of the facility. Resident #33's family member stated she was pleased with the care provided at the facility and did not suspect abuse. During an attempted phone interview on 09/12/2023 at 11:09 a.m., message left for LVN E. During an interview on 09/12/2023 at 9:45 a.m., the DON stated she was not working at the facility on the date of the incident. During an interview on 09/12/2023 at 5:42 p.m., the Administrator stated the nurse should have reported the bruise of unknown origin to the abuse coordinator on 07/20/23. The Administrator stated she should have reported the bruise of an unknown origin within 2 hours. The Administrator stated on the day of the noted bruising, she was attending a New Leadership Conference which began on the 19th and ended on the evening of the 20th. The Administrator stated she was in the facility on the 21st but they were dealing with an incident that was a priority and she was focused on the event happening and the clinical meeting was not held completely. The Administrator stated on the 24th the resident was making an allegation that the previous facility wrapped a cord around her arm. The Administrator stated she saw the arm in the afternoon and made the report to state. The Administrator stated the failure could potentially put residents at risk for delay in care. The Administrator stated she monitored during daily IDT meetings progress reports and any new observations were reviewed to ensure changes of condition was addressed and reported to appropriate entities in a timely manner. Record review of provider investigation report, dated 11/10/2022, revealed an injury of unknown origin. The provider investigation report indicated the incident occurred on 07/20/2023 and was reported to the state agency on 07/24/2023 at 4:44 p.m. The provider investigation report stated the facility was unable to confirm abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 2 of 15 residents (Residents #44 and 33) reviewed for abuse and neglect. 1. The facility failed to report to the state agency within 2 hours of being notified of fall incident for Resident #44. 2. The facility failed to report Resident #33's bruised left arm, an injury of unknown origin, timely to HHS. These failures to report could place the residents at risk for abuse. Findings included: 1. Record review of the Provider Investigation Report dated on 8/12/23 indicated an allegation of fall with left hip fracture incident on Resident #44 occurred on 8/11/23 at 3:45 p.m. The report indicated no staff witnessed the fall incident. The report indicated LVN B completed a neuro assessment on Resident #44 on 8/11/23. The report indicated resident reported mild hip pain on 8/11/23 at 3:25 p.m. The report indicated the DON requested hip x-ray post fall to rule out injury/fracture on 8/11/23 at 3:25 p.m. The report indicated Resident #44 was assessed by the facility contracted x-ray company and found to have a fracture on his left hip. The incident was reported to the state agency on 8/12/23 at 8:11 a.m. Record review of Resident # 44's face sheet, dated on 9/12/23, indicated Resident #44 was a [AGE] year-old male, admitted to the facility on the original administration date of 8/8/23 with a diagnoses of bipolar which included (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), hypothyroidism (thyroid gland does not produce enough thyroid hormone) panic disorder (anxiety disorder where you regularly have sudden attacks of panic or fear) and cognitive communication deficit (the inability to think of the correct word). Record review of Resident #44's quarterly MDS assessment, dated on 8/25/23, indicated Resident #44 was understood others and made himself understood. The MDS assessment indicated Resident #44 was moderately cognitively impaired with a BIMS score of 8. The MDS assessment indicated Resident #44 was coded for verbal behavior symptoms directed toward others occurring one to three days and for rejection of care behaviors occurring one to three days. Record review of Resident #44's care plan, dated on 8/30/23, indicated Resident #44 had history of falling and is at risk for falls r/t cognitive deficit, need of assistance with ADLs, fractured hip; left, weakness. The care plan interventions included frequent checks on resident, keep call light in reach at all times, give resident verbal reminders not to ambulate/transfer without assistance, keep bed in lowest position with brakes locked, and keep personal items and frequently used items within reach. Record review of the facility incident report, dated on 9/11/23 at 7:53 am, indicated Resident #44 fell on [DATE]. The facility incident report on Resident #44 fall on 8/11/23, indicated Resident #44 was noted on floor in room by staff; unwitnessed fall; sent to emergency room for fractured hip. The facility incident report noted Resident #44 family member was notified on 8/11/23 at 3:45 p.m. Record review of Resident #44's Physical Therapy treatment encounter noted on 8/11/23 at 1:55 p.m., indicated Resident #44 actively participated with skilled interventions and Resident #44 was compliant with adaptations. Record review of Resident #44's Occupational Therapy treatment encounter noted on 8/11/23 at 5:02 p.m., indicated Resident #44 displayed noncooperation and noncompliance in occupational therapy session. Record review of Resident #44's Speech Therapy treatment encounter noted on 8/13/23 at 7:52 p.m., indicated Resident #44 was compliant with skilled interventions. Record review of Resident #44's Neurological evaluation flowsheet dated on 8/11/23 at 3:45 p.m., indicated neuro checks were completed every 15 minutes times 2 hours. Record review indicated in-services were completed for all staff on abuse on 8/14/23. During an interview on 9/9/23 at 2:57 p.m., the family member of Resident #44 stated that the facility informed her about the fall alteration that occurred on 8/11/23. The family member of Resident #44 stated the resident had been admitted to the facility for a few weeks prior his fall incident on 8/11/23. The family member stated the facility staff would check on Resident #44 more frequently, and a fall mat had been placed at Resident #44's beside as an intervention. The family member of Resident #44 did not have any additional concerns that needed to be addressed. During an interview on 9/12/23 at 2:47 p.m., CNA M stated she was not at work when Resident #44 fell on 8/11/23. CNA M stated she did not witness the fall incident on 8/11/23. CNA M stated Resident #44 had reported no pain when he returned from the hospital. CNA M stated she could not recall which day Resident #44 returned from the hospital. CNA M stated Resident #44 had multiple falls incidents in the facility prior to his fall incident on 8/11/23. CNA M indicated Resident #44 used his call light and occasionally scream for help when he needed assistance. CNA M could not recall how often Resident #44 screamed for help. CNA M stated she had completed in-service training on falls. CNA M could not recall the timeframe of when she completed her in-service on falls. CNA M stated incidents were to be reported immediately to the charge nurse on duty and the charge nurse on duty should complete an assessment on that resident. CNA M stated incident were to be reported to the charge nurse on duty. CNA M stated reporting timely was important to ensure the safety of the residents and staff. During a phone interview on 9/12/23 at 2:07 P.M, LVN B stated she found Resident #44 on the floor on 8/11/23 at 3:25 p.m. LVN B stated she did not witness the fall. LVN B stated she did not know how long Resident #44 was on the floor. LVN B could not recall what Resident #44 was attempting to do prior to his fall incident. LVN B stated she LVN B stated Resident #44 had several reports of being on found crawling on the floor prior to this incident that occurred on 8/11/23. LVN B stated the facility was becoming more aggressive with physical therapy and encouraging Resident #44 to participate in physical therapy. LVN B stated fall mats are in place as an intervention for Resident #44. LVN B stated staff was informed to check on Resident #44 every 15 minutes. LVN B stated Resident #44 verbally expressed having mild pain on left hip following the fall incident. LVN B stated Resident #44 call light was not on prior to the fall incident. LVN B stated she verbally expressed to Resident #44 to use the call light when needing help. LVN B stated she completed the neuro assessment on Resident #44 on 8/11/23. LVN B stated Resident #44 family member was notified on 8/11/23. LVN B could not recall the exact time the family member was notified. LVN B stated Resident #44 wife wished to have the resident #44 x-rayed immediately at the facility. LVN B stated the facility x-ray contracted company performed an x-ray on the resident at the facility on 8/11/23. LVN B stated the x-ray results are received on the same usually within a few hours. LVN B could not recall the time of x-ray Resident #44 was x-rayed. LVN B stated the x-rays results received on 8/11/23 from the facility contracted x-ray company indicated Resident #44's left hip was fractured. LVN B stated Resident #44 was transferred to the hospital on 8/12/23. LVN B stated she had completed in-service training on falls. LVN B stated she reported this incident to the DON. LVN B stated reporting timely was important to keep residents safe. During an interview on 9/12/23 at 4:14 p.m., the DON stated she did not witness the fall incident on Resident #44 on 8/11/23. The DON stated that she was aware of Resident #44 fall incident on 8/11/23. The DON described serious harm as Resident suffering a fracture after falling. The DON stated Resident #44 believed he could stand up on his own and walk. The DON stated Resident #44 verbally complained of mild pain following the fall incident on 8/11/23. The DON stated as a precaution she recommended that the facility to perform an x-ray on Resident #44 on 8/11/23. The DON stated she believed the fall incident was reported late to State because the x-ray results were e-faxed late by the facility contracted x-ray technician. The DON stated x-ray results are usually received within 2 to 4 hours after the x-ray is performed. The DON stated Resident #44 x-ray result were not e-faxed to the facility timely on 8/11/23. The DON did not know why the results were received e-faxed late by the contracted x-ray company on 8/11/23. The DON could not recall the time the e-faxed results were received but did indicate that it was very late at night on 8/11/23. The DON stated that when the facility learned of Resident #44 hip fracture, Resident #44's fall incident should have been reported to State within two hours. The DON stated Resident#44 family was notified on 8/11/23. The DON stated the Administrator was aware of Resident #44 fall incident on 8/11/23. The DON stated reporting timely was important to ensure the residents safety. During an interview on 9/12/23 at 3:53 p.m., the Administrator stated she learned of Resident #44's fall incident on 8/11/23 as she passed through Resident #44 hall. The Administrator stated LVN B responded to the fall on Resident #44. The Administrator did not know if other staff responded to Resident #44 fall on 8/11/23. The Administrator stated that a resident who fractures his or her bone would be considered a serious injury. The Administrator stated that she reported Resident #44 fall incident to State on 8/12/23. The Administrator stated Resident #44 fall incident should have been reported to State within 2 hours. The Administrator stated she did not report to State within two hours because she did not know Resident #44 had a fracture within two hours after the fall occurred. The Administrator stated that the care for Resident #44 was not delayed. The Administrator stated reporting timely was important to ensure the residents are safe. 2. Record review of Resident #33's face sheet, dated 09/12/2023, indicated Resident #33 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood) and essential hypertension (high blood pressure). Record review of Resident #33's significant change in status MDS assessment, dated 07/31/2023, indicated Resident #33 was usually understood and usually understood others. Resident #33's BIMS score was 10, which indicated she was cognitively moderately impaired. The assessment did not indicate any physical, verbal, or other behavior symptoms towards self or others. Record review of the comprehensive care plan dated 07/31/2023 did not address the bruise to Resident #33 left arm. Record review of the admission observation dated 07/17/2023 indicated there was no bruising to her left arm. Record review of Resident #33's progress note dated 07/20/2023 at 11:08 a.m., charted by LVN E indicated, Resident #33 had a bruise to her left arm. The note stated it was not present yesterday and she had complained of pain. The note indicated the nurse practitioner ordered a 2-view x ray of left upper arm and shoulder. During an interview on 09/11/2023 at 3:00 p.m., Resident #33 was non-interview able as evidenced by confused conversation and inappropriate answers to questions asked by the surveyor. During an interview on 09/11/2023 at 4:45 p.m., Resident #33's family member stated the facility informed her about the bruise on 07/21/2023. Resident #33's family member stated resident had been leaning on the arm of the chair prior to obtaining the bruise. Resident #33's family member stated Resident #33 requested to go the hospital on [DATE] because she was unsatisfied with the action of the facility. Resident #33's family member stated she was pleased with the care provided at the facility and did not suspect abuse. During an attempted phone interview on 09/12/2023 at 11:09 a.m., message left for LVN E. During an interview on 09/12/2023 at 9:45 a.m., the DON stated she was not working at the facility on the date of the incident. During an interview on 09/12/2023 at 5:42 p.m., the Administrator stated the nurse should have reported the bruise of unknown origin to the abuse coordinator on 07/20/23. The Administrator stated she should have reported the bruise of an unknown origin within 2 hours. The Administrator stated on the day of the noted bruising, she was attending a New Leadership Conference which began on the 19th and ended on the evening of the 20th. The Administrator stated she was in the facility on the 21st but they were dealing with an incident that was a priority and she was focused on the event happening and the clinical meeting was not held completely. The Administrator stated on the 24th the resident was making an allegation that the previous facility wrapped a cord around her arm. The Administrator stated she saw the arm in the afternoon and made the report to state. The Administrator stated the failure could potentially put residents at risk for delay in care. The Administrator stated she monitored during daily IDT meetings progress reports and any new observations were reviewed to ensure changes of condition was addressed and reported to appropriate entities in a timely manner. Record review of provider investigation report, dated 11/10/2022, revealed an injury of unknown origin. The provider investigation report indicated the incident occurred on 07/20/2023 and was reported to the state agency on 07/24/2023 at 4:44 p.m. The provider investigation report stated the facility was unable to confirm abuse. Record review of the facility policy for Abuse Prevention Program dated 01/09/23, indicated, Policy Statement:1. The Administrator is responsible for the overall coordination and implementation of our Center's abuse prevention program policies and procedures in accordance with the Elder Justice Act. 2. Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but was not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Reporting 2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 5 residents (Resident #7) reviewed for MDS assessment accuracy. The facility did not ensure Resident #7's MDS assessment was accurately coded to reflect her level II PASRR status for mental illness. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #7's face sheet, dated 09/12/2023, indicated Resident #7 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included schizoaffective disorder (a condition that can make you feel detached from reality and can affect our mood), bipolar (serious mental illness characterized by extreme mood swings) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of the significant change in status MDS assessment, dated 05/02/2023, indicated Resident #7 was not considered by the state level II PASRR process to have serious mental illness. Record review of the comprehensive care plan did not address Resident #7 was identified as having mental illness PASRR positive. Record review of Resident #7's PASRR Level 1 Screening, completed on 01/18/2023, indicated, in section C0100, this individual having mental illness. During an interview on 09/12/2023 at 2:05 p.m., the MDS Coordinator stated the previous MDS coordinator was responsible for coding Resident #7's MDS accurately. The MDS Coordinator stated she was hired for this position effective 08/01/2023. The MDS Coordinator stated the MDS Section A1500 should have been coded yes. The MDS Coordinator stated it was important to complete the MDS assessment accurately to ensure the resident received the appropriate care. The MDS Coordinator stated this failure could potentially cause Resident #7 not to receive the services she would be rendered. During an interview on 09/12/2023 at 2:35 p.m., the Regional Reimbursement Manager stated the MDS Coordinator was responsible for coding Resident #7's MDS accurately. The Regional Reimbursement Manager stated she was responsible for monitoring by completing random audits. The Regional Reimbursement Manager stated she had noticed prior to 08/01/23 residents MDS was not coded accurately. The Regional Reimbursement Manager stated when those issues arise education was provided immediately. The Regional Reimbursement Manager stated her last audit was done on 09/07/2023. The Regional Reimbursement Manager stated Resident #7 was not part of the sample batch that was being audited. The Regional Reimbursement Manager stated it was important to complete the MDS assessment accurately to ensure the resident received the appropriate care. Record review of the Electronic Transmission of the MDS, revised 11/2019 did not address MDS accuracy. Record review of the Resident Assessment Instrument 3.0 User's Manual, last revised October 2019, indicated Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASRR) to the maximum extent practicable to avoid duplicative testing and effort for 1 of 5 (Resident #15) residents reviewed for PASRR. The facility failed to refer Resident #15 for PASRR Level ll assessment when a diagnosis of Major Depressive Disorder was diagnosed after admission on [DATE]. This failure could affect residents with mental illnesses and place them at risk of not being assessed to receive needed services. Findings include: Record review of a face sheet dated 09/12/23 indicated Resident #15 was [AGE] years old female admitted on [DATE] with diagnoses including vascular dementia (deterioration of memory, language, and other thinking abilities with behaviors), Epileptic seizures (disorders of the brain characterized by repeated seizures) related to external causes, not intractable, without status epilepticus, major depressive disorder, recurrent, moderate (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), generalized anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, Schizoaffective disorder, unspecified (a combination of symptoms of schizophrenia and mood disorder symptoms, such as depression or mania). Record review of the most recent MDS assessment, dated 08/03/23, indicated Resident #15 was understood and understood others. The MDS indicated Resident #15 had a Brief Interview for Mental Status (BIMS) of 12. This score indicated cognitively intact for Resident #15. The MDS section, Preadmission Screening and Resident Review indicated Resident #15 did not have a serious mental illness. The section named 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 disorder, depression, and Schizophrenia. Record review of Resident #15's PASRR Level 1 Screening completed on 10/20/2022 indicated in section C0100 no evidence of this individual having mental illness. Record review of the care plan last revised 07/14/2023 indicated Resident #15 required psychotropic medication and was at risk for adverse consequences related to receiving antidepressant medication for treatment of depression. Record review of the electronic health record indicated the facility had not completed a Form 1012 for Resident #15. During an interview on 09/12/2023 at 03:48 PM, the [NAME] Reimbursement Manager indicated the MDS Coordinator was responsible for all the PASRR Level 1 Screenings and for coordinating the appropriate PASRR services. The [NAME] Reimbursement Manager said she did not know why Resident #15's PASRR was not updated after the new diagnosis of Major Depressive Disorder was made. The Regional Reimbursement Manager reported the MDS coordinator was responsible for PASRR. The Regional Reimbursement Manager said there was a process of quarterly audits for PASRR, but not enough help and time available and they had identified a stack of 1012 to be completed. The Regional Reimbursement Manager said residents not receiving the adequate PASRR services could negatively affect their mental status, ADL function, and quality of life. During an interview on 09/12/2023 at 4:21 PM, the Administrator said that she required more education on the timelines and guidelines involved with the PASRR process. The Administrator said not completing the PASRR accurately could result in residents not having the services they require to help with their mental illness. Record review of the facility's revised policy dated February 2023 titled, PASRR, indicated, . 4. The facility must use the Mental Illness/Dementia Resident Review form (Form 1012) for assistance in determining whether a resident needs further evaluation if a resident currently has a negative PL 1 and is suspected to have or is diagnosed with a mental illness. A. The CCM must ensure that the 1012 form is completed and uploaded into the resident's electronic medical record. B. The CCM must submit a positive PL1 if indicated from the Form 1012 through the Simple LTC software. C. Complete steps under number 2 of this policy for a positive PASRR resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's needs for 1 of 15 residents (Resident #7) reviewed for care plans. The facility failed to ensure Resident #7 care plan indicated she was PASRR positive. This failure could place residents at risk for unmet care needs and decreased quality of care. Findings included: Record review of Resident #7's face sheet, dated 09/12/2023, indicated Resident #7 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included schizoaffective disorder (a condition that can make you feel detached from reality and can affect our mood), bipolar (serious mental illness characterized by extreme mood swings) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of the significant change in status MDS assessment, dated 05/02/2023, indicated Resident #7 was not considered by the state level II PASRR process to have serious mental illness. Record review of the comprehensive care plan did not address Resident #7 was identified as having mental illness PASRR positive. Record review of Resident #7's PASRR Level 1 Screening, completed on 01/18/2023, indicated, in section C0100, this individual having mental illness. During an interview on 09/12/2023 at 2:05 p.m., the MDS Coordinator stated the previous MDS coordinator was responsible for ensuring Resident #7 care plan reflected that she was PASARR positive. The MDS Coordinator stated she was hired for this position effective 08/01/2023. The MDS Coordinator stated it was important to ensure the care plan reflected that she was PASARR positive in order for her to receive services. During an on 09/12/2023 at 2:35 p.m., the Regional Reimbursement Manager stated the MDS Coordinator was responsible for ensuring Resident #7 care plan reflected that she was PASARR positive. The Regional Reimbursement Manager stated she was responsible for monitoring by completing random audits. The Regional Reimbursement Manager stated she had noticed prior to 8/1/2023 that the comprehensive care plans were not being thoroughly initiated. The Regional Reimbursement Manager stated when these issues arise education was provided immediately. The Regional Reimbursement Manager stated her last audit was done in March. The Regional Reimbursement Manager stated it was important to ensure the care plan reflected that she was PASARR positive in order for her to receive services. Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered last revised 02/01/2023, indicated, a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet he resident's physical, psychosocial and functional needs is developed and implemented for each resident. The services provided or arranged by the facility, as outlined by the comprehensive care plan, are provided by qualified persons, are culturally competent and trauma informed. 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive, person-centered care plan will: g. Incorporate identified problem areas, h. Incorporate risk factors associated with identified problems

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to 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 15 residents (Resident #20) reviewed for care plans. The facility failed to ensure Resident #20's care plan was updated to not indicate a stage 3 pressure ulcer to his coccyx. This failure could place the resident at increased risk of not having their individual needs met and a decreased quality of life. Findings included: Record review of Resident #20's face sheet, 09/11/23, indicated Resident #20 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included bipolar (episodes of mood swings), dementia (memory loss and poor judgment), and HTN (force of blood against the artery walls is too high). Record review of Resident #20's order summary report, no date, did not indicate any treatments to his coccyx. Record review of Resident #20's quarterly MDS dated [DATE] indicated he made himself understood and was able to understand others. There was no BIMS score indicated. Section M of Resident #20's care plan indicated no unhealed pressure ulcers or injuries. Record review of Resident #20's care plan, revised on 08/24/23, indicated he had a stage three pressure ulcer on his coccyx. The approach indicated to treat as ordered by the physician and report any negative outcomes. During an interview on 09/12/23 at 2:40 PM, the DON stated she was still learning how to use matrix and did not see the stage 3 pressure ulcer on Resident #20's care plan to remove it. The DON stated the IDT team reviewed care plans in the clinical meetings and updated them at that time. The DON stated she was not trained to run the repots correctly until corporate educated her on 9/7/23 and she was responsible for updating resident care plans. The DON stated Resident #20 did not have a pressure ulcer on his coccyx and the importance of making sure the care plans were correct was for continuity of care and patient centered care. During an interview on 09/12/24 at 5:27 PM, the Administrator stated that she expected care plans to be correct. The Administrator stated care plans were important for knowing what needed to be treated on individual resident's and they should have been checked quarterly and reviewed in the morning meeting if they were resolved. Record review of the facilities policy on, Care plans, Comprehensive Person-Centered, revised December 2020, indicated The care planning process will: reflect currently recognized standards of practice for problem areas and conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on 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 2 of 15 residents' (Resident #'s 7 and 31) reviewed for trauma-informed care. 1. The facility did not ensure Resident #7 had a trauma screening that identified possible triggers when Resident #7 had a history of trauma. 2. The facility did not ensure trauma screenings were completed upon admission to the facility. These failures could put residents at an increased risk for severe psychological distress due to re-traumatization. The findings included: 1. Record review of Resident #7's face sheet, dated 09/12/2023, indicated Resident #7 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included schizoaffective disorder (a condition that can make you feel detached from reality and can affect our mood), bipolar (serious mental illness characterized by extreme mood swings) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of the significant change in status MDS assessment, dated 05/02/2023, indicated Resident #7 made herself understood and understood others. The assessment did not address Resident #7 BIMS score. The assessment indicated no behaviors or refusal of care. Record review of the comprehensive care plan did not Resident #7 having a history of trauma. 2. Record review of Resident #31's face sheet, dated 09/12/2023, indicated Resident #31 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included atherosclerosis heart disease (buildup of fats and other substances in and on the artery walls). Record review of the significant change in status MDS assessment, dated 07/18/2023, indicated Resident #31 sometime understood others, and rarely/never made herself understood. The assessment did not address the BIMS score. The assessment indicated no behaviors or refusal of care. Record review of the comprehensive care plan did not Resident #7 having a history of trauma. During an interview on 09/12/2023 at 11:40 a.m., the Social Services Designee stated she was informed on 09/11/2023 that she was responsible for completing the trauma informed care assessment. The Social Services Designee stated she was told the assessment should be completed upon admission, annual, quarterly, and significant change. The Social Services Designee stated it was important to ensure trauma screening was completed to identify past trauma and avoid resident triggers to prevent re-traumatization. The Social Services Designee stated after surveyor intervention a trauma screening was completed on Resident #7 and #31. The Social Services Designee stated Resident #7 assessment triggered for trauma related to suicidal ideation. During a telephone interview on 09/12/2023 at 1:32 p.m., the Corporate Resource Social Worker stated the process for trauma informed care assessment was to be completed within 72 hours upon admission to the facility. The Corporate Resource Social Worker stated the nurses were completing the assessments not knowing this was not part of their responsibility. The Corporate Resource Social Worker stated she had sent out an email to all facilities stating the Social Worker should be completing the assessments. The Corporate Resource Social Worker stated this issue had been an ongoing problem due to change of staff not knowing the Social Worker was responsible for completing the assessments. The Corporate Resources Social Worker stated she was responsible for monitoring to ensure trauma assessments were completed upon admission. The Corporate Resource Social Worker stated she did random audits once a month. The Corporate Resource Social Worker stated her last audit was done in August. The Corporate Resource Social Worker stated it was important to ensure trauma screening was completed to identify past trauma and avoid resident triggers to prevent re-traumatization. Record review of the facility's policy titled Trauma Informed Care last revised 12/2019, indicated, 3. Include trauma-informed care as part of the QAPI plan, so that needs, and problem areas are identified and addressed. The policy further revealed 6. Implement universal screening of residents for trauma. The policy revealed 1. As part of the comprehensive assessment, identify history of trauma or interpersonal violence when possible. Identifying past trauma or adverse experiences may involve record review or the use of screening tools .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 4 medication carts (Front Hall Cart) reviewed for storage of medications. The facility failed to ensure the Front Hall medication cart was locked when unattended. This deficient practice could place residents at risk of medication misuse and diversion. Findings include: During an observation on 9/11/23 at 8:18 AM, the medication cart on the front hall was unlocked while CMA F was giving resident medications. During an observation and interview on 09/11/23 at 8:58 AM, CMA F did not lock the med cart prior to going into room [ROOM NUMBER] and administers medications. CMA F stated she pushed the lock in, but it sometimes does not go in all the way. CMA F stated the importance of locking the medication cart was to prevent other residents from coming up and helping themselves to the cart and so that medications did not get taken from the cart. CMA F stated there could be endless problems if another resident got into the unlocked medication cart and bad things could have happen if they took the wrong medication out of the cart. During an interview on 09/12/23 at 2:40 PM, the DON stated she expected the medication cart to be locked because of resident safety. The DON stated if the medication cart was not locked, then a resident could get into the cart and take something. During an interview on 09/12/24 at 5:27 PM, the Administrators stated she expected the medication cart to be locked. The Administrator stated if the medication cart was not locked, then a resident could have gotten in it and taken the drugs resulting in resident harm. Record review of the facility's policy on Storage of Medications, last revised November 2020, revealed . After the medication administration process is completed, the medication cart must be completely locked, or otherwise secured . Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 4 of 19 residents (Resident's #28, Resident #5, Resident # 46, and Resident #22) reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident's #28, Resident #5, Resident # 46, and Resident #22 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 09/10/2023 at 11:05 AM, Resident # 28 said the food does not taste good and it was cold when he received the tray on the hall. During an interview on 09/10/2023 at 11:09 AM, Resident #5 said the food is always cold when he received his tray in his room. During an interview on 09/10/2023 at 02:12 PM, Resident #46 said he ate his own food and eats very little kitchen food as the food is too salty. During an interview on 09/10/2023 at 03:30 PM, Resident #22 said the food was cold and tasted plain. During an observation and interview on 09/11/2023 12:15 PM, the DM and five surveyors sampled a lunch tray. The sample tray consisted of Salisbury steak, green beans, rice pilaf, a roll, and peach crisp. The Salisbury steak was cold, the green beans lacked flavor and the peach crisp was bland. During an interview on 09/12/2023 at 09:40 AM, the DM stated she had not received any complaints regarding the temperature of the food. The DM stated the food is hot when it leaves the kitchen. 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 09/12/2023 04:02 PM, [NAME] K stated She was a new employee and unaware the resident's had any food complaints. [NAME] K stated food should have tasted good and looked appetizing or appealing. [NAME] K 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 09/12/2023 at 04:21 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 Food and Nutrition Services policy, revised November 2022, 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 15 residents (Resident #35) reviewed for resident records. The facility failed to ensure LVN G accurately completed the elopement evaluation on Resident #35. Findings included: Record review of a face sheet dated 09/11/2023 indicated Resident #35 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses which included Schizoaffective disorder (combination of mood disorder and depression), COPD (chronic obstructive pulmonary disease is a lung disease that block the airflow and cause it difficult to breathe) and psychosis (mental disorder). Record review of the Quarterly MDS assessment, dated 09/07/2023, indicated Resident #35 was usually understood and usually understood others. The MDS assessment indicated Resident #35's BIMS score was 6, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #35 did not exhibit wandering. Record review of Resident #35's care plan last reviewed 06/14/2023 indicated he required a wander guard. The approach included to check for placement and nursing to monitor the wander guard to make sure it worked properly. Record review of Resident #35's Physician Order Report dated 08/11/2023-09/11/2023 indicated Resident #35 had a wander guard and to apply to resident for safety related to wandering and/or elopement seeking (left ankle). Record review of the elopement evaluation completed on 7/07/23 by LVN G indicated Resident #35 was clinically not at risk for elopement. During an observation made on 09/11/23 at 2:40 PM, Resident #35 was wearing a wander guard located on his left wrist. During an interview on 09/12/23 at 8:49 AM, LVN G stated she was aware that Resident #35 wore a wander guard. LVN G stated she does not remember filling out the elopement form for Resident #35 and would have to look at it in person to see how she filled it out. LVN G stated the importance of filling out the elopement form correctly was to determine the residents that would go around the building trying to open the doors. LVN G stated staff needed to be aware of residents that wandered to make sure the patient was safe and ensure the safety of the patient. LVN G stated that nursing was not required to document where they monitor Resident #35's wander guard anywhere. During an interview on 09/11/23 at 3:04 PM, the DON stated the night nurse was responsible for completing the last elopement assessment on Resident #35. The DON stated there was no process in place for making sure the forms were filled out correctly, but she completed the elopement assessment correctly today to reflect the need for Resident #35's wander guard after surveyor intervention. The importance was to identify the resident the right way. The DON stated not filling out the elopement form correctly could lead to the resident getting out of the facility and become missing. During an interview on 09/12/24 at 5:27 PM, the Administrator stated she expected the elopement forms to be completed correctly. The Administrator stated the importance of filling out the form correctly was for dignity, resident rights, and so staff knew what course of action they needed to take for the Resident #35. Record review of the facility's policy titled, Wandering and Elopements, revised 9-1-2023, indicated residents will be assessed by the IDT for risk of elopement or unsafe wandering on admission, readmission and quarterly, and/or with a change of condition (e.g., increased agitation, changes in mobility, wandering).

Based on observation, interview and record review, the facility failed to maintain an effective pest control program so the facility was free from pests and rodents for 1 of 1 kitchen reviewed for pest control. The facility failed to maintain an effective pest control program to ensure the facility kitchen was free from gnats. This failure could place residents at risk of unsanitary environment and decreased quality of life. Findings included: During an observation on 09/10/2023 at 10:29 AM, gnats swarmed over a bowl of dingy brown water with the juicer spout lying in it. During an observation on 09/10/2023 at 11:45 AM, gnats swarmed over a bowl of dingy brown water with the juicer spout lying in it. During an observation on 09/11/2023 at 12:15 AM, gnats flew over the area where the juice boxes were stored. Record review of a statement dated 08/30/2023 indicated the facility was treated for pest management and insect light trap monitoring. Record review of a document dated 9/5/2023 titled Service Inspection Report indicated rooms 1-5, 8, 10, 12,13, 14 and the kitchen were treated to prevent ants. Record review of a document dated 9/9/2023 titled Service inspection report indicated room nine and the exterior of the building around window and grass area was treated for ants. During an interview on 09/10/2023 at 11:45 AM, the Dietary Manager said she does not know what to do about the gnats. The Dietary Manager said she had added vinegar to the water bowl to help decrease the gnats around juicer spout. She said she had voiced the gnat concern to maintenance. During an interview on 09/12/2023 at 10:13 AM, the maintenance supervisor said the pest control company sprayed the facility once monthly. The maintenance supervisor said the pest control company sprayed for roaches, wood ants and termites last month. The maintenance supervisor said he was notified of gnats near a flowerpot. He said the flowerpot was removed and there had been no further reports of gnats. The maintenance supervisor said he was responsible for the pest control at the facility. During an interview on 09/12/2023 at 04:21 PM, the Administrator said the complaint of gnats should have been logged in the written binder by the Dietary Manager. The Administrator said the maintenance supervisor should have requested an extra visit be made by the pest control company immediately. The Administrator said she expected the facility to be always free of all pest and rodents. Record review of a policy revised May 2008 titled Pest Control indicated, . the facility shall maintain an effective pest control program. The policy indicated the facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. The maintenance services assist, when appropriate and necessary, in providing pest control .

Based on observations, interviews and record reviews, the facility failed to follow their own established smoking policy for one visitor (Resident #31's family member) reviewed for smoking. The facility failed to ensure Resident #31's family member was smoking in the designated smoking area. The facility failed to ensure smoked cigarettes were extinguished in a fire-retardant receptacle. Findings included: During an observation on 9/11/23 at 12:00 PM, Resident #31's family member was smoking in the front of the building under a gazebo with a no smoking sign posted. During an observation and interview on 09/12/23 at 9:00 AM, CNA H was sitting outside in the smoking area with residents. Observation made of cigarette butts on the ground outside of the laundry room and next to the oxygen tank storage. CNA H stated she did not think that anyone in the laundry department smoked, and residents only smoked in the designated areas. During an interview on 9/12/23 at 11:00 AM, Resident #31's family member stated he never thought to look at the no smoking signs posted under the gazebo because he was outdoors. Resident #31's family member stated he had not smoked in that area in the past, but he had smoked by his car in the parking lot. Resident #31's family member stated he did not remember any staff members telling him there was a designated smoking area, but the DON informed him yesterday and now he knew where the designated smoking area was to smoke at from now on. During an interview on 09/12/23 at 10:13 AM, Maintenance stated that the laundry department was responsible for cleaning the cigarette butts outside of the laundry room. Maintenance stated the importance of picking up the cigarette butts was because it was a dangerous area, and it could have caused a protentional hazard. Maintenance stated that no one was responsible for checking the area next the oxygen tanks that he knew of. During an interview on 09/12/23 at 2:40 PM, the DON stated she was not aware of anyone smoking in the front of the building prior to Resident #31's family member. The DON stated facility staff does not educate visitors on where to smoke in the facility routinely. The DON stated the importance of smoking in the designated area was so that proper receptacles were available, because not having the proper receptacles could result in a fire. The DON stated the cigarette butts next to the laundry room and oxygen storage looked older and she had never noticed them before in the past. The DON stated Maintenance was responsible for checking that specific area every day and making sure it was free from cigarette butts. During an interview on 09/12/24 at 5:27 PM, the Administrator stated visitors, residents and staff were education on where the smoking area was located. The Administrator stated the cigarette butts were a fire hazard and they did not look or smell good. The Administrators stated the oxygen storage tanks could have potentially blow up if anyone was smoking next to them. Record Review of the facility's policy on, Smoking, no date, indicated Residents and visitors shall not be permitted to smoke in any area that is not designated as a smoking area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided with professional standards of practice for 3 of 3 residents (Residents #7, #31, and #8) reviewed for respiratory care and services. 1. The facility failed to administer oxygen at 1L via nasal cannula as prescribed by the physician for Resident #7. 2. The facility failed to ensure Resident #31 and Resident #8's oxygen concentrator filters were cleaned. These failures could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory distress. Findings included: 1. Record review of Resident #7's face sheet, dated 09/12/2023, indicated Resident #7 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included acute respiratory failure (difficulty breathing), and essential hypertension (high blood pressure) and COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the physician order report dated 08/12/2023-09/12/2023 indicated Resident #7 had an order for oxygen at 1 liter per minute as needed with a start date 07/24/2023. Record review of the significant change in status MDS assessment, dated 05/02/2023, indicated Resident #7 made herself understood and understood others. The assessment did not address Resident #7 BIMS score. The assessment indicated Resident #7 was receiving oxygen therapy. Record review of the comprehensive care plan, edited on 08/30/2023, indicated Resident #7 was at risk for respiratory distress related to COPD. The care plan interventions included administer oxygen as needed and monitor oxygen saturation (amount of oxygen circulating in blood) via pulse oximetry as ordered. During an observation and interview on 09/10/2023 at 2:43 p.m., Resident #7 was sitting on the side of her bed wearing oxygen via nasal cannula. Resident # 7's five-liter oxygen concentrator was set on 3 liters per minute. Resident #7 stated she wore her oxygen as needed for SOB. Resident #7 stated she did not know what rate the oxygen should be on. During an observation on 09/11/2023 at 11:46 p.m., LVN B came in Resident #7's room to check her oxygen saturation blood sugar and blood pressure. Resident #7 became SOB and asked for her oxygen. LVN B placed the oxygen on Resident #7 and turned the oxygen concentrator on and stated, it's on 3 liter per minute. During an interview on 09/12/2023 at 3:25 p.m., LVN B stated she was not aware that Resident #7 supposed to be on 1 liter per minute. LVN B stated the charge nurses were responsible for ensuring she was on the correct liter. LVN B stated if the oxygen setting was wrong, Resident #7 would not have received the correct dose ordered from the physician. LVN B stated it was important to ensure the oxygen setting set on the correct liter to prevent oxygen toxicity. 2. Record review of Resident #31's face sheet, dated 09/12/2023, indicated Resident #31 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included acute respiratory failure (difficulty breathing), and shortness of breath. Record review of the physician order report dated 08/12/2023-09/12/2023 indicated Resident 31 had an order, which started on 07/17/2023, that stated O2 at 2-4 LPM as needed The order summary report did not address how often to clean the oxygen concentrator filters. Record review of the significant change in status MDS assessment, dated 07/18/2023, indicated Resident #31 rarely/never made herself understood and sometimes understood others. The assessment did not address Resident #31 BIMS score. The assessment indicated Resident #31 was receiving oxygen therapy. Record review of the comprehensive care plan, created on 07/24/2023, indicated Resident #31 required oxygen therapy. The care plan interventions included administer oxygen as needed and monitor and report signs and symptoms of hypoxia (absence of enough oxygen in the tissues to sustain bodily functions). During an observation and interview on 09/10/2023 at 2:23 p.m., Resident #31 was lying in bed. Resident #31 was wearing oxygen via nasal cannula at 3 liters per minute. Resident #31's oxygen concentrator filter had a thick, grey, fuzzy material. Resident #31 was non-interviewable as evidenced by confused conversation. During an observation on 09/11/2023 at 9:05 a.m., Resident #31 was lying in bed. Resident #31 was wearing oxygen via nasal cannula at 3 liters per minute. Resident #31's oxygen concentrator filter had a thick, grey, fuzzy material. During an observation on 09/12/2023 at 8:03 a.m., Resident #31 was lying in bed. Resident #31 was wearing oxygen via nasal cannula at 3 liters per minute. Resident #31's oxygen concentrator filter had a thick, grey, fuzzy material. During an interview on 09/12/2023 at 4:15 p.m., LVN C stated she was responsible for changing the oxygen concentrator filters. LVN C stated she was not aware that she was supposed to change the filter on 09/10/23. LVN C stated this failure could place residents at risk for respiratory infection. During an interview on 09/12/2023 at 4:52 p.m., the DON stated she expected Resident #7 oxygen to be set at 1 liter per minute per the physician's orders but to use nursing judgment if needs to be increased and then notify the physician of the changes. The DON stated she expected Resident #31 oxygen filter to be changed on Sunday's nights. The DON stated the floor nurse that was assigned to her was responsible. The DON stated random rounds are done daily to ensure the oxygen settings were correct. The DON stated she had not seen any issues during her rounds. The DON stated her last round was done on 9/10/23. The DON stated there was not a process to monitor o2 filters. The DON stated the risk associated with not setting the oxygen at the prescribed rate could potentially affect residents hyperoxygenation. The DON stated the risk associated with not changing the filters or not having an order for oxygen therapy could place resident's respiratory health at risk. 3. Record review of Resident #8's face sheet, dated on 9/12/23, indicated Resident #8 was a [AGE] year-old female, admitted to the facility on the administration date of 7/26/23 with a diagnosis of acute and chronic respiratory failure with hypoxia, acute on chronic diastolic (congestive) heart failure (admission), chronic obstructive pulmonary disease, pneumonia, and hypertension. Record review of the most recent MDS dated [DATE] indicated Resident #8 made herself understood, understood others, and was cognitively intact. The MDS indicated Resident #8 required extensive assistance with bed mobility, extensive assistance with toileting and dressing. The MDS indicated Resident #8 received oxygen therapy. Record review of the care plan updated dated on 8/03/23 indicated Resident #8 received oxygen therapy for chronic obstructive pulmonary disease. The care plan did not address the oxygen concentrator filter. During an interview and observation on 9/7/21 at 11:47 a.m., Resident #8 was sitting in his wheelchair and oxygen was being used by the resident via nasal cannula. The oxygen concentrator had no filter in place. Resident #19 said she used her oxygen all the time due to shortness of breath. During an observation on 9/10/23 at 2:12 p.m., Resident #8 was laying in her bed watching television and oxygen was being used by the resident via nasal cannula. The oxygen concentrator had a white fuzzy matter covering the oxygen filter. During an observation on 9/11/23 at 8:31 a.m., Resident #8 was laying in her bed watching television and oxygen was being used by the resident via nasal cannula. The oxygen concentrator had a white fuzzy matter covering the oxygen filter. During an interview on 09/12/2023 at 5:42 p.m., the Administrator stated she expected oxygen filters to be changed weekly. The Administrator stated she expected physician's orders to be followed. The Administrator stated these failures put residents at risk for respiratory infection/hyperoxygenation. Record review of the facility's policy titled Oxygen Administration last revised 10/2010, indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Record review of the Invacare [NAME] Oxygen Concentrator user manual, dated 2016, revealed on page 24, 1. Remove the filter and clean as needed. Environmental conditions that may require more frequent inspection and cleaning of the filter include, but are not limited to high dust, air pollutants, etc.

Based on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage. The facility failed to provide RN coverage for 8 consecutive hours daily on 1/19/2023, 1/20/2023, 1/29/2023, 2/18/2023, 2/19/2023, 2/25/2023, 2/26/2023, 3/11/2023, 3/15/2023, 3/16/2023, 3/17/2023, 3/20/2023, 3/24/2023, 3/25/2023, 3/29/2023, 3/30/2023, and 3/31/2023. This failure had the potential to affect residents in the facility by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters. Findings included: During an interview on 09/12/2023 at 4:52 p.m., the DON stated she was hired for this position effective 8/10/2023. During an interview on 09/12/2023 at 5:42 p.m., the Administrator stated she had no documentation that a RN was in the facility on 1/19/2023, 1/20/2023, 1/29/2023, 2/18/2023, 2/19/2023, 2/25/2023, 2/26/2023, 3/11/2023, 3/15/2023, 3/16/2023, 3/17/2023, 3/20/2023, 3/24/2023, 3/25/2023, 3/29/2023, 3/30/2023, and 3/31/2023. The Administrator stated she was aware that there was a regulation to have 8 hours of RN coverage a day. The Administrator stated she was not employed during the dates in question regarding RN coverage. The Administrator stated she did not feel comfortable commenting on past RN coverage. During an interview on 09/12/2023 at 4:26 p.m., the Clinical Resource Nurse stated there was not a policy and procedure regarding RN staffing.

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 in the facilities only kitchen. The facility failed to ensure proper storage and labeling of food in airtight container after opening. The facility failed to ensure that trash was properly disposed of. The facility failed to ensure that kitchen staff appropriately restrained hair with the hairnet. The facility failed to ensure cans were free from damage. These failures could place residents at risk of cross contamination and foodborne illness. Findings included: During an observation on 9/10/12 starting at 10:00 AM.: ? one tray with one cup of cranberry juice and twelve cups of orange juice with a use by date of 9/7/23. There was no open date,. ? a ½ full one gallon pitcher of orange juice had no use by date, ? a pitcher of cranberry juice was ¾ full dated 09/04/23, a pitcher of apple juice was ¼ full and dated 09/03 and a full pitcher of water dated 09/05., ? a ½ gallon of lemonade had a used by date of 09/10/23 with no open date,. ? one gallon of BBQ sauce had an open date of 08/30, no use by date observed,. ? a cherry jar with an open date of 06/21/23 did not have a use by date and the jar was sticky and dripping from the lid not being put back on properly,. ? 8 cups of milk were observed in the refrigerator with a use by date of 09/07/23,. ? six ¼ quarts of tea had a use by date of 09/07/23, ? one gallon jar of mustard had a thick black substance around the lid with an open date of 3/19,. ? a bag of Mozzarella Cheese had an open date of 8/31/23 but no use by date,. ? Six unlabeled cheesecake pans were dated 09/09/23 but did not have a use by date,. ? a half-gallon of pudding covered with saran wrap dated 09/09/23 with no use by date,. ? 4-gallon container labeled mac casserole was dated 09/09/23, no use by date,. ? 2-quart container of beef tips and gravy dated 09/09/23, no use by date, ? 1-quart container of ketchup dated 08/31, no use by date, ? 2 cups of nectar with a use by date of 09/06, ? 3 boiled eggs in an open unsealed and no open date or used by date on the bag,. ? premade omelets in a zip lock bag labeled 09/07 without a use by date,. ? one gallon of olives with a use by date of 08/31/23, no open date,. ? 4 bowls of rice crispies, 4 bowls of cheerios, and 3 bowls of fruit loop cereal had a used by date of 09/04/23,. ? a box of potatoes sitting on the bottom shelf in front of a sink had several rotten potatoes with an odor,. ? a scoop for the food/liquid thickener was observed inside an open zip lock bag inside the potato box,. ? two dented cans of green beans and two dented cans of pork and beans were observed in the kitchen pantry,. ? Chicken patties had a use by date of 09/23, did not have an open date,. ? the trash can in the cooking area did not have a lid,. ? the cook was not wearing the hairnet appropriately to restrain hair,. ? the dishwasher was not wearing the hairnet appropriately to restrain hair, and. ? the Dietary [NAME] was not wearing the hairnet appropriately to restrain hair. During an observation on 09/11/2023 at 11:30 AM., the dishwasher was in the kitchen without a hairnet on. During an interview on 09/12/2023 at 03:38 PM., the Dietary Manager expected all open containers to be securely closed and properly labeled with dates. The Dietary Manager said the damaged food cans should be separated from cans of food to be served. The Dietary Manager said she expected the kitchen trash cans to remain covered with lids. The Dietary Manager said all staff should wear hairnets that covered hair appropriately while in the kitchen. The Dietary Manager said these items or important to keep the residents healthy and prevent cross contamination and food borne illness. During an interview on 09/12/2023 at 4:02 PM., Administrator said that she expected the Dietary Manager to check behind the staff to ensure that the tasks to prevent infection and cross contamination and food borne illness were completed. The Administrator said that she expected the food to be palatable to prevent resident weight loss. Record review of a policy titled Food Storage dated 2018 indicated . was to ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to state, federal and US food codes. Dry storage rooms: d. to ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and date. E. Provide scoops for items stored in bins, such as sugar, flour, rice and other items. Store scoops covered in a protected area near the food containers. Was and sanitize the scoops weekly or as needed. Refrigerators: d. date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. Record review of an undated policy titled Preventing foodborne illness-Food Handling indicated . food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 1 resident (Resident #31) reviewed for hospice services. The facility did not ensure Resident #31's hospice records were a part of their records in the facility. This failure could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings included: Record review of Resident #31's face sheet, dated 09/12/2023, indicated Resident #31 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included atherosclerosis heart disease (buildup of fats and other substances in and on the artery walls). Record review of the physician order report dated 08/12/2023-09/12/2023 indicated Resident #31 had an order to admit to hospice with a start date of 07/16/2023. Record review of the significant change in status MDS assessment, dated 07/18/2023, indicated Resident #31 sometime understood others, and rarely/never made herself understood. The assessment did not address the BIMS score. The assessment indicated Resident #31 had a life expectancy of less than 6 months and received hospice services. Record review of the comprehensive care plan, edited on 07/24/2023, indicated Resident #31 had a terminal diagnosis and was on hospice. The care plan interventions included comfort measures to be provided as ordered and pain management. Record review of Resident #31's hospice binder, accessed on 09/12/2023 at 8:45 a.m., revealed no updated hospice nurses and aides notes since resident was admitted on [DATE]. During an interview on 09/12/2023 at 9:45 a.m., the DON stated there were no notes in the facility after July 2023 from the hospice company. The DON stated she was hired for this position effective 8/10/2023. During an interview on 09/12/2023 at 9:51 a.m., the Executive Director for the hospice company stated the last nurse visit for Resident #31 was on 09/11/2023. The Executive Director stated the nurses were required to see her two times per week and the aides were required to see her three times per week. The Executive Director stated it was the facility responsibility to request notes after each visit. The Executive Director stated the plan of care and hospice certification were the only notes that were brought to the facility when the IDG meetings were conducted, every 2 weeks. The Executive Director stated the process for collaborating with the facility was completed verbally with the nurses, ADON, and DON. During an interview on 09/12/2023 at 5:42 p.m., the Administrator stated there was no process in place for monitoring the hospice binders and documentation to ensure the most up to date information was in the facility. The Administrator stated the hospice nurse had been communicating with the facility staff verbally. The Administrator stated it was important to ensure recent hospice documentation was in the facility for continuity of care. Record review of the Nursing Facility Services Agreement, dated 01/09/2019, indicated, 2.6 Manner of Communication: All communications between the Hospice and Nursing Facility pertaining to the care and services provided to the resident shall be documented in the resident clinical record . Record review of the facility's policy titled Hospice Program last revised on 07/2017, indicated, 10. In general, it is the responsibility of the facility to meet the residents personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs. These include: (d.) Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day 12 (e.) Ensuring that our facility staff provides orientation on the policies and procedures of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services, based on the comprehensive assessment, to prevent infections to the extent possible for 1 resident reviewed for urinary catheters (Resident #30). The facility did not secure Resident #30's catheter to prevent it from pulling at the insertion site. Resident #30 complained of discomfort from the catheter tubing pulling. This failure could place 1 resident with an indwelling catheter at risk for urethral tears, infections, and discomfort. Findings included: Physician orders dated 06/01/2022 to 07/06/2022 indicated Resident #30 was [AGE] years old and admitted on [DATE] with diagnoses that included central cord syndrome of the spinal cord (disorder of the spinal cord), hypertension, pain, anxiety, polyneuropathy (nerve disorder), muscle wasting, depression, and neuromuscular dysfunction of the bladder. Resident #30 was ordered a urinary catheter on 06/10/2022 with catheter care to be performed every shift which included catheter secured to leg to promote comfort, minimize catheter tension/tissue trauma. A care plan dated 06/13/2022 indicated Resident #30 had an indwelling catheter and approaches included to provide catheter care per policy. A Minimum Data Set, dated [DATE] indicated Resident #30 made himself understood, understood others, and was cognitively intact. He required extensive assistance with bed mobility, dressing, toilet use, personal hygiene, and bathing. He was frequently incontinent of bowel and had an indwelling urinary catheter. A medication administration record dated 07/01/2022 to 07/06/2022 indicated the staff documented the catheter was secured to Resident #30's leg to promote comfort, minimize catheter tension/tissue trauma on shift one and shift two daily. During an observation and interview on 07/05/2022 at 9:55 a.m., Resident #30 was lying in his bed, responded appropriately and voiced his needs and his urinary indwelling catheter was draining at his bedside with clear yellow urine. He had a brief on, and his urinary indwelling catheter tubing was not secured and was freely hanging with tension on his urethra. Resident #30 said the urinary indwelling catheter pulled on his penis and was very uncomfortable every time the staff came in to give him care. Resident #30 said he requested the staff to secure his urinary indwelling catheter tubing multiple times, but they never did. Resident #30 said he used to have a strap to keep it from pulling on his penis, but it came off days ago and was not replaced even though he requested it to be replaced. Resident #30 said he felt like his prostate was being pulled out through his penis. During an interview on 07/05/2022 at 10:20 a.m., CNA A said she did not know Resident #30 had discomfort regarding his urinary indwelling catheter tubing pulling but would notify his charge nurse, LVN C. During an observation on 07/05/2022 at 12:30 p.m., Resident #30's urinary indwelling catheter was unsecured. During an observation and interview on 07/05/2022 at 4:10 p.m., CNA B provided incontinent care to Resident #30 and said she did not recall if Resident #30's urinary indwelling catheter was ever secured, and he had not complained of discomfort before. CNA B said she would notify LVN C Resident #30 complained of discomfort from his urinary indwelling catheter tubing pulling on his penis. Resident #30 said his penis hurt every time staff gave care and repositioned him due the urinary indwelling catheter tubing pulling on him. During an observation and interview on 07/06/2022 at 8:06 a.m., Resident #30 was resting in his bed and his urinary indwelling catheter tubing was not secured, and he said was causing him discomfort and hurt my prostate. During an interview on 07/06/2022 at 8:10 a.m., LVN C said she told the night shift nurse to make sure Resident #30's urinary indwelling catheter tubing was secured but was not aware it had not been secured. LVN C said Resident #30's urinary indwelling catheter tubing was supposed to be secured to his thigh and this was monitored and documented every shift on his treatment administration record. During an interview on 07/06/2022 at 8:30 a.m., the DON and corporate nurse said the facility protocol did not include securing urinary indwelling catheter tubing but Resident #'30s urinary indwelling catheter tubing was supposed to be monitored to ensure it was properly positioned over his leg unobstructed. The DON said he would check Resident #30's urinary indwelling catheter for placement. During an observation and interview on 07/06/2022 at 1:30 p.m., Resident #30 was lying in his bed, his urinary indwelling catheter tubing was secured to his right thigh and he said it felt much better. The Catheter Care, Urinary policy revised September 2014 indicated the purpose of this procedure was to prevent catheter-associated urinary tract infections. The changing catheters procedure indicated to ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site (Note: catheter tubing should be strapped to the residents' inner thigh.) The website, http://www.cdc.gov/hicpac/cauti/002_cauti_sumORecom.html, accessed 07/08/2022 indicated the following: .Properly secure indwelling catheters after insertion to prevent movement and urethral traction

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 8%, based on two errors out of 25 opportunities, which involved 1 of 4 residents (Resident #5); and 1 staff (Medication Aide D) reviewed for medication errors. Medication Aide D crushed levetiracetam (Keppra) and Cymbalta Delayed Release medications and administered it to Resident #5. This deficient practice placed residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. Findings Included: Record review of Resident #5's face sheet dated 07/06/2022 revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #5's diagnosis included hypertension, muscle wasting, mood disorder, epilepsy, heart disease, and dysphagia (difficulty in swallowing). Review of Resident #5's physician orders dated 03/25/2022 and medication administration record reflected order to administer Cymbalta (duloxetine), a fibromyalgia agent, 20mg capsule, delayed release (DR/EC) once a day and specified Crushed: No. Review of Resident #5's physician orders dated 04/06/2022 and medication administration record dated 07/01/2022 to 07/06/2022 reflected order to administer Keppra (levetiracetam), an anticonvulsant, 500 mg one tab oral twice a day and specified Crushed: No. Observation on 07/06/22 at 07:15 a.m. revealed Medication Aide D administer the following medications to Resident #5; vitamin c 500mg tablet-1 by mouth administered crushed in applesauce, aspirin 81mg tablet-1 by mouth administered crushed in applesauce, duloxetine delayed release 20mg capsule-1 by mouth administered crushed in applesauce, and levetiracetam 500mg tablet-1 by mouth administered crushed in applesauce. Medication D crushed the medications and mixed with apple sauce and then administered to Resident #5. During an interview with Medication D on 07/06/2022 at 07:30 a.m. after the medication administration regarding duloxetine delayed release 20mg capsule-1 by mouth administered crushed in applesauce, and levetiracetam 500mg tablet-1 by mouth administered crushed in applesauce, Medication Aide D stated she always crushed Resident #5's medications and cocktailed them all together in applesauce. Medication Aide D said the pharmacy would not dispense Resident #5's delayed release medications in any other form so the charge nurses told her just to open the capsules. During an interview on 07/06/2022 at 8:15 a.m. with Medication Aide D regarding medication administration, Medication Aide D stated she was supposed to administer medications per the physician orders and follow the five rights of medication administration. Medication Aide D said she did not know she was not supposed to crush Resident #5's delayed release or anticonvulsant medications. During an interview on 07/06/2022 at 08:30 a.m. with the DON, he said he administered Resident #5's medications on Sunday in whole pill form and did not think he required crushed medications. The DON said Medication Aide D was not supposed to crush DR and ER medications because it will not be effective if it was crushed, he also stated Medication Aide D should know better not to crush any medication that was enteric coated or extended release. During an interview on 07/06/2022 at 3:00 p.m., the regional nurse consultant said Resident #5's delayed release and convulsant medications should not have been crushed and he initiated an audit to include specific do not crush specification on the medication administration orders for all medications that are contraindicated to be crushed. Review of the facility policy revised April 2019 titled Administering Medications indicated medications are administered in a safe and timely manner, and as prescribed.