**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure dignity was maintained for 1 of 14 residents (Resident #1) reviewed for respect and dignity. The Administrator failed to respect and ensure Resident #1's dignity when he made an obscene hand gesture towards the resident. This failure placed residents at risk for loss of self-worth and emotional distress and failed to ensure the residents' right to be treated with dignity and respect.Findings included: Record review of Resident #1's Transfer/Discharge Report dated 08/27/25 reflected the [AGE] year-old male resident was re-admitted to the facility on [DATE] with a diagnosis of paraplegia. Record review of Resident #1's quarterly MDS dated [DATE] reflected the resident was admitted to the facility on [DATE]. He was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated cognitively intact). In an interview on 08/27/25 at 8:18 AM, the SW stated she began her employment at the facility in April 2025. She stated there was staff turnover around May 2025. She stated on 05/08/25 she was asked to conduct Safe Surveys with the residents due to complaints about the Administrator's inappropriate comments to staff and the residents. She stated the Administrator was suspended 2-3 days while the investigation was conducted by the RNC, but she did not know the specifics. She stated none of the residents she interviewed reported any complaints or concerns regarding the Administrator. In a telephone interview on 08/27/25 at 8:48 AM, the former DON stated Resident #1 informed her the Administrator made an obscene gesture, the middle finger which the resident found to be disrespectful. She stated the obscene gesture and unprofessional comments the Administrator had made to staff and residents to the RDO. She stated about a week after she made the comments the RNC came to investigate. She stated the RNC suspended the Administrator a few days while she conducted the investigation. She stated the RNC did not report the allegations to the State Agency but should have been as required. The former DON stated Resident #1 was not interviewed by the RNC about the specific allegations regarding the Administrator and she believed. She stated the RNC terminated her employment and brought the Administrator back the day after her termination. She stated she believes her termination was retaliation for reporting the Administrator. Record review of the former DON's Disciplinary Action Form dated 05/12/25 revealed, a statement from the former DON, which read, in part, this is done in retaliation to me reporting Administrator, who not only verbally abuse - but also emotionally abused a resident. The form was signed by the former DON and RNC on 05/12/25. Record review of an email from the former DON to the RDO dated 04/30/25 at 7:42 PM which read, in part, I am writing to you today to inform you about something that has been going on in the facility since the Administrator has arrived to the facility. Today a resident by the name of Resident #1 came into my office to explain to me that he felt like he was being mistreated by the administrator. This is not the first time that the resident has voiced to me ill treatment from the Administrator. In this particular instance, the resident came into my office and informed me that yesterday (04/29/25) while he was in the smoking room, the Administrator came up to him in front of an employee and stated Hey Resident #1, I have something for you. At that time the Administrator went into his pocket and pulled out his fist and flipped him off. The resident then informed me that former Housekeeper A saw him do this. He said he felt like this was inappropriate and at no time have he and the Administrator had a relationship in which they would joke around with each other the resident went on to tell me that he and the Administrator do not have a relationship in which it would ever be ok to do those things. In a telephone interview on 08/27/25 at 9:27 AM, the RNC stated the RDO received an email from the former DON alleging the Administrator had verbally abused Resident #1. She stated she suspended the Administrator 3 days, maybe more, while she interviewed the staff who all denied the allegations. She stated she did not interview Resident #1 about the allegations, but she had the SW conduct Safe Surveys and none of the residents, including Resident #1 reported any issues. She stated the decision was made to treat the incident internally and not report the incident to the State Agency. When the RNC was asked by the Investigator if the facility policy was followed regarding reporting, she stated that's a tricky one because everyone denied the allegations. Record review of the RNC's investigation conducted on 05/08/25 reflected a copy of the email from the former DON to the RDO dated 04/30/25, the Safe Surveys conducted by the SW with the residents on 05/08/25 and the RDO's interviews with staff: - The Administrator denied the allegation. - An interview with former Housekeeper B on 5/8/2025 at 2:49 PM reflected, Have you ever been witness to any administrative staff saying or doing anything to a resident/or other staff member that would be considered out of a professional role? If so, can you tell me when, by whom and directed towards who? I was in the smoke room at the same time with Resident #1 when the Administrator came in and spoke with all of us and then told Resident #1, I have something for you and then the Administrator pulled out his hand and flipped Resident #1 off but then tell him he was just playing and then Resident #1 said boy and then they both laughed. Did you report that to anyone? No ma'am I did not I thought they were just playing. - The SW conducted Safe Surveys with 46 residents on 05/08/25, the questions included general questions regarding which included if they were comfortable asking for assistance, if staff treated them with dignity and respect, if they felt safe in the facility, if they felt comfortable telling staff about concerns, if staff had ever physically harmed them and if staff member ever yelled or cursed at them. Resident #1 responded he did not feel comfortable asking staff for assistance; however, there was no further documentation regarding his response. Resident #1 reported no other issues during the Safe Survey. Record review of the Grievances from May 2025 - August 2025 reflected no grievances regarding Resident #1 or the Administrator. In an interview on 08/27/25 at 9:55 AM, the Administrator stated he was informed by the RNC of the allegations made against him and he was interviewed by the RNC. He stated he denied all the allegations in the former DON's email. He stated he did not want to discuss specifics because of legal action taken by the former DON and ADON. He stated he was suspended for an abuse allegation and was off 3 to 4 days pending the outcome of the investigation. He stated he was not privy to whether the incident was reported to the State Agency. He said the facility follows the Provider Letter as the policy regarding investigating and reporting abuse allegations. He stated he feels Corporate probably looked at the Provider Letter and made decisions based on it. He stated the facility had no other policy besides the Provider Letter. Record review of the Long-Term Care Regulation Provider Letter Number: PL 2024-14 dated 08/29/25 reflected a nursing facility must report to the State Agency Abuse, in accordance with applicable state and federal requirements. Allegations of abuse were to be reported immediately, but no later than two hours after the incident occurs or is suspected. During an observation on 08/27/25 at 11:14 AM, Resident #1 was asleep in bed with the covers over his head. In a telephone interview on 08/27/25 at 12:12 PM, former Housekeeper A stated she and former Housekeeper B were on a break out smoking and Resident #1 was outside with them. She stated she heard the Administrator tell Resident #1 he had something for him, but she did not see the hand gesture. She stated former Housekeeper B heard and saw the gesture. She stated Resident #1 said he thought the Administrator was taking things too far with the hand gesture. She stated the RNC came to the facility to investigate the allegations, but the RNC did not interview her. She stated former Housekeeper B did report the incident to the RNC because former Housekeeper B was bothered by the incident. In a telephone interview on 08/27/25 at 12:36 PM, former Housekeeper B stated she was outside on a smoke break with former Housekeeper A and Resident #1. She stated she hear the Administrator tell Resident #1 I have something for you, and then she saw the Administrator take his hand out of his pocket and flip Resident #1 off. She stated Resident #1 told the Administrator Don't disrespect me like that. She stated the Administrator told Resident #1 he was just playing. She stated the Administrator went back inside and Resident #1 said to her, did you see what he did that isn't cool. She stated she reported the incident to the DON and the ADON. She stated she was interviewed by the RNC and told the RNC about the incident. She stated she told the RNC the Administrator was making her and Resident #1 uncomfortable with his inappropriate comments. She stated after she reported the incident the Administrator began kissing Resident #1's ass. In a telephone interview on 08/27/25 at 12:50 PM, former ADON said the former DON sent corporate an email regarding the allegation about the Administrator. She stated Resident #1 came into the office with the former DON to express to us that while he was in the smoke room, the Administrator came in and told him he had something for him, the Administrator went into his pocket, pulled out his hand, and then flipped the resident off. She stated the RNC came to conduct the investigation but did not even interview Resident #1. She stated the Safe Surveys were done but were not specific to allegations regarding the Administrator. She stated, after the DON was terminated, she believed the allegations were not really investigated by the RNC, so she sent the RDO an email and he responded to her email and stated she was terminated. Record review of the email exchange between the former ADON and the RDO dated 05/15/25 reflected at 8:28 AM the former ADON sent the RDO an email entitled URGENT CRITICAL MATTER which read in part, around about on April 29th when Resident #1 came into the office with the DON and myself to express to us that while he was in the smoke room, the Administrator came in and told him he had something for him, went into his pocket, pulled out his hand, and then flipped him off. Resident #1 asked the DON to make the Administrator stop talking to him because he did not like him and they did not have a relationship in which it was considered ok to do those things to him. During the RNC's investigation it was brought to my attention that she failed to talk to half the nursing staff (she only spoke with the staff that worked that date), and she never spoke with the resident (Resident #1) with the compliant. At 2:18 PM the RDO responded via email, thank you for bringing this to our attention. I appreciate your concern, and for sharing these details, I am placing you on a temporary suspension while we conduct an investigation into this matter. Please do not consider this a punitive action but a necessary step in order to conduct a full and fair investigation into these allegations. In an interview on 08/27/25 at 1:54 PM, the SW stated, regarding the Safe Surveys dated 05/08/25, she did not ask the residents anything specifically about the Administrator. She stated she asked the residents the general questions on the Safe Survey sheet. In an interview and observation on 08/27/25 at 2:30 PM, Resident #1 was in bed in his room, his roommate was out of the room. He stated he was reluctant to speak to the investigator because the incident had been a long time ago, the Administrator apologized, and everything had been fine since. He stated the Administrator did flip him off when he was in the smoking area, and he just looked at the Administrator and did not respond. Resident #1 stated he was fine, and the incident did not affect him negatively. He stated he did not feel intimidated and had not changed his usual patterns in the facility. He stated he likes to stay up late and sleep late and staff accommodate him and let him do the things he wants to do. In a telephone interview on 08/27/25 at 4:05 PM, the RNC stated Housekeeper B told her about the incident with Resident #1 and the Administrator's hand gesture. She stated she did not speak to Resident #1, but he did not report any issues in the Safe Survey. She stated she did not feel it was a reportable incident of abuse because a lot of time had passed (from 04/29/25 - 05/08/25 ten days). She stated the Administrator was verbally counseled regarding the incident, but it was not a written counseling. She stated in response to the incident and residents' responses on the Safe Surveys dated 05/08/25 an in-service on abuse was conducted, but no further investigations were conducted into any of the allegations on the surveys. In a telephone interview on 08/27/25 at 4:09 PM, the RDO stated he over saw 20 facility's and it had been sometime since the incidents so he might not remember all the details or the timeline. He stated the former DON and ADON's complaints about theAdministrator were emailed to him. He stated the RNC was tasked with investigating the DON's complaint. He stated he could not remember the details of the complaint or the timeline to say if the allegation was reportable. He stated he believed the RNC shared the results of her investigation with him. He stated the finger gesture was bordering on reportable but sounded like it was reportable. He stated he was not aware Resident #1 was not interviewed by the RNC. He stated he was not sure what action was taken regarding the incident, but he thinks the Administrator was counseled. In a confidential telephone interview it was stated they heard about the Administrator flipping Resident #1 off. They stated they heard Resident #1 tell the former ADON, I don't know why he would feel comfortable doing that with me because we don't have a relationship like that. During the exit conference on 08/28/25 at 1:04 PM the Administrator stated he disagrees with findings. He adamantly denied the allegation he flipped Resident #1 off. He stated he was not counseled by the RNC and all she said was, if you did it don't do it again. Record review of the facility's Resident Rights policy dated December 2016 reflected employees shall treat all residents with kindness respect and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure an allegation of abuse was reported immediately to the State Agency as required for 1 of 14 residents (Resident #1) reviewed for abuse reporting. Resident #1 alleged the Administrator made an obscene hand gesture. The allegation was not reported to the State Agency. This failure resulted in the residents' right to be free from abuse not protected, eliminated the opportunity for a timely investigation by the State Agency and placed all the residents at risk for abuse and psychological harm, which resulted in substandard quality of care. Record review of Resident #1's Transfer/Discharge Report dated 08/27/25 reflected the [AGE] year-old male resident was re-admitted to the facility on [DATE] with a diagnosis of paraplegia. Record review of Resident #1's quarterly MDS dated [DATE] reflected the resident was admitted to the facility on [DATE]. He was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated cognitively intact). In an interview on 08/27/25 at 8:18 AM, the SW stated she began her employment at the facility in April 2025. She stated there was staff turnover around May 2025. She stated on 05/08/25 she was asked to conduct Safe Surveys with the residents due to complaints about the Administrator's inappropriate comments to staff and the residents. She stated the Administrator was suspended 2-3 days while the investigation was conducted by the RNC, but she did not know the specifics. She stated none of the residents she interviewed reported any complaints or concerns regarding the Administrator. In a telephone interview on 08/27/25 at 8:48 AM, the former DON stated Resident #1 informed her the Administrator made an obscene gesture, the middle finger which the resident found to be disrespectful. She stated the obscene gesture and unprofessional comments the Administrator made to staff and residents to the RDO. She stated about a week after she made the comments the RNC came to investigate. She stated the RNC suspended the Administrator a few days while she conducted the investigation. She stated the RNC did not report the allegations to the State Agency but should have been as required. The former DON stated Resident #1 was not interviewed by the RNC about the specific allegations regarding the Administrator and she believed the RNC terminated her employment and brought the Administrator back the day after her termination. She stated she believes her termination was retaliation for reporting the Administrator. Record review of the former DON's Disciplinary Action Form dated 05/12/25 revealed, a statement from the former DON, which read, in part, this is done in retaliation to me reporting Administrator, who not only verbally abuse - but also emotionally abused a resident. The form was signed by the former DON and RNC on 05/12/25. Record review of an email from the former DON to the RDO dated 04/30/25 at 7:42 PM which read, in part, I am writing to you today to inform you about something that has been going on in the facility since the Administrator has arrived to the facility. Today a resident by the name of Resident #1 came into my office to explain to me that he felt like he was being mistreated by the administrator. This is not the first time that the resident has voiced to me ill treatment from the Administrator. In this particular instance, the resident came into my office and informed me that yesterday (04/29/25) while he was in the smoking room, the Administrator came up to him in front of an employee and stated Hey Resident #1, I have something for you. At that time the Administrator went into his pocket and pulled out his fist and flipped him off. The resident then informed me that former Housekeeper A saw him do this. He said he felt like this was inappropriate and at no time have he and the Administrator had a relationship in which they would joke around with each other the resident went on to tell me that he and the Administrator do not have a relationship in which it would ever be ok to do those things. In a telephone interview on 08/27/25 at 9:27 AM, the RNC stated the RDO received an email from the former DON alleging the Administrator had verbally abused Resident #1. She stated she suspended the Administrator 3 days, maybe more, while she interviewed the staff who all denied the allegations. She stated she did not interview Resident #1 about the allegations, but she had the SW conduct Safe Surveys and none of the residents, including Resident #1 reported any issues. She stated the decision was made to treat the incident internally and not report the incident to the State Agency. When the RNC was asked by the Investigator if the facility policy was followed regarding reporting, she stated that's a tricky one because everyone denied the allegations. Record review of the RNC's investigation conducted on 05/08/25 reflected a copy of the email from the former DON to the RDO dated 04/30/25, the Safe Surveys conducted by the SW with the residents on 05/08/25 and the RDO's interviews with staff: - The Administrator denied the allegation. - An interview with former Housekeeper B on 5/8/2025 at 2:49 PM reflected, Have you ever been witness to any administrative staff saying or doing anything to a resident/or other staff member that would be considered out of a professional role? If so, can you tell me when, by whom and directed towards who? I was in the smoke room at the same time with Resident #1 when the Administrator came in and spoke with all of us and then told Resident #1, I have something for you and then the Administrator pulled out his hand and flipped Resident #1 off but then talk him he was just playing and then Resident #1 said boy and then they both laughed. Did you report that to anyone? No ma'am I did not I thought they were just playing. - The SW conducted Safe Surveys with 46 residents on 05/08/25, the questions included general questions regarding which included if they were comfortable asking for assistance, if staff treated them with dignity and respect, if they felt safe in the facility, if they felt comfortable telling staff about concerns, if staff had ever physically harmed them and if staff member ever yelled or cursed at them. Resident #1 responded he did not feel comfortable asking staff for assistance; however, there was no further documentation regarding his response. Resident #1 reported no other issues during the Safe Survey. Record review of the Grievances from May 2025 - August 2025 reflected no grievances regarding Resident #1 or the Administrator. In an interview on 08/27/25 at 9:55 AM, the Administrator stated he was informed by the RNC of the allegations made against him and he was interviewed by the RNC. He stated he denied all the allegations in the former DON's email. He stated he did not want to discuss specifics because of legal action taken by the former DON and ADON. He stated he was suspended for an abuse allegation and was off 3 to 4 days pending the outcome of the investigation. He stated he was not privy to whether the incident was reported to the State Agency. He said the facility follows the Provider Letter as the policy regarding investigating and reporting abuse allegations. He stated he feels Corporate probably looked at the Provider Letter and made decisions based on it. He stated the facility had no other policy besides the Provider Letter. Record review of the Long-Term Care Regulation Provider Letter Number: PL 2024-14 dated 08/29/25 reflected a nursing facility must report to the State Agency Abuse, in accordance with applicable state and federal requirements. Allegations of abuse were to be reported immediately, but no later than two hours after the incident occurs or is suspected. During an observation on 08/27/25 at 11:14 AM, Resident #1 was asleep in bed with he covers over his head. In a telephone interview on 08/27/25 at 12:12 PM, former Housekeeper A stated she and former Housekeeper B were on a break out smoking and Resident #1 was outside with them. She stated she heard the Administrator tell Resident #1 he had something for him, but she did not see the hand gesture. She stated former Housekeeper B heard and saw the gesture. She stated Resident #1 said he thought the Administrator was taking things too far with the hand gesture. She stated the RNC came to the facility to investigate the allegations, but the RNC did not interview her. She stated former Housekeeper B did report the incident to the RNC because former Housekeeper B was bothered by the incident. In a telephone interview on 08/27/25 at 12:36 PM, former Housekeeper B stated she was outside on a smoke break with former Housekeeper A and Resident #1. She stated she hear the Administrator tell Resident #1 I have something for you, and then she saw the Administrator take his hand out of his pocket and flip Resident #1 off. She stated Resident #1 told the Administrator Don't disrespect me like that. She stated the Administrator told Resident #1 he was just playing. She stated the Administrator went back inside and Resident #1 said to her, did you see what he did that isn't cool. She stated she reported the incident to the DON and the ADON. She stated she was interviewed by the RNC and told the RNC about the incident. She stated she told the RNC the Administrator was making her and Resident #1 uncomfortable with his inappropriate comments. She stated after she reported the incident the Administrator began kissing Resident #1's ass. In a telephone interview on 08/27/25 at 12:50 PM, former ADON said the former DON sent corporate an email regarding the allegation about the Administrator. She stated Resident #1 told came into the office with the former DON to express to us that while he was in the smoke room, the Administrator came in and told him he had something for him, the Administrator went into his pocket, pulled out his hand, and then flipped the resident off. She stated the RNC same to conduct the investigation but did not even interview Resident #1. She stated the Safe Surveys were done but were not specific to allegations regarding the Administrator. She stated, after the DON was terminated, she believed the allegations were not really investigated by the RNC, so she sent the RDO an email and he responded to her email and stated she was terminated. Record review of the email exchange between the former ADON and the RDO dated 05/15/25 reflected at 8:28 AM, the former ADON sent the RDO an email entitled URGENT CRITICAL MATTER which read in part, around about on April 29th when Resident #1 came into the office with the DON and myself to express to us that while he was in the smoke room, the Administrator came in and told him he had something for him, went into his pocket, pulled out his hand, and then flipped him off. Resident #1 asked the DON to make the Administrator stop talking to him because he did not like him and they did not have a relationship in which it was considered ok to do those things to him. During the RNC's investigation it was brought to my attention that she failed to talk to half the nursing staff (she only spoke with the staff that worked that date), and she never spoke with the resident (Resident #1) with the compliant. At 2:18 PM the RDO responded via email, thank you for bringing this to our attention. I appreciate your concern, and for sharing these details, I am placing you on a temporary suspension while we conduct an investigation into this matter. Please do not consider this a punitive action but a necessary step in order to conduct a full and fair[PH1] investigation into these allegations. In an interview on 08/27/25 at 1:54 PM, the SW stated, regarding the Safe Surveys dated 05/08/25, she did not ask the residents anything specifically about the Administrator. She stated she asked the residents the general questions on the Safe Survey sheet. In an interview and observation on 08/27/25 at 2:30 PM, Resident #1 was in bed in his room, his roommate was out of the room. He stated he was reluctant to speak to the investigator because the incident had been a long time ago, the Administrator apologized, and everything had been fine since. He stated the Administrator did flip him off when he was in the smoking area, and he just looked at the Administrator and did not respond. Resident #1 stated he was fine, and the incident did not affect him negatively. He stated he did not feel intimidated and had not changed his usual patterns in the facility. He stated he likes to stay up late and sleep late and staff accommodate him and let him do the things he wants to do. In a telephone interview on 08/27/25 at 4:05 PM, the RNC stated Housekeeper B told her about the incident with Resident #1 and the Administrator's hand gesture. She stated she did not speak to Resident #1, but he did not report any issues in the Safe Survey. She stated she did not feel it was a reportable incident of abuse because a lot of time had passed (from 04/29/25 - 05/08/25 ten days). She stated the Administrator was verbally counseled regarding the incident, but it was not a written counseling. She stated in response to the incident and residents' responses on the Safe Surveys dated 05/08/25 an in-service on abuse was conducted, but no further investigations were conducted into any of the allegations on the surveys. In a telephone interview on 08/27/25 at 4:09 PM, the RDO stated he over saw 20 facility's and it had been sometime since the incidents so he might not remember all the details or the timeline. He stated the former DON and ADON's complaints about theAdministrator were emailed to him. He stated the RNC was tasked with investigating the DON's complaint. He stated he could not remember the details of the complaint or the timeline to say if the allegation was reportable. He stated he believed the RNC shared the results of her investigation with him. He stated the finger gesture was bordering on reportable but sounded like it was reportable. He stated he was not aware Resident #1 was not interviewed by the RNC. He stated he was not sure what action was taken regarding the incident, but he thinks the Administrator was counseled. In a confidential interview on 08/28/25 at 7:22 AM, it was said they heard about the Administrator flipping Resident #1 off. They stated they heard Resident #1 tell the former ADON, I don't know why he would feel comfortable doing that with me because we don't have a relationship like that. They stated they followed up with the resident about a week later and the resident said no one had come to talk with him about it but he was told it's been taken care of. They stated they were not interviewed by the RNC regarding the allegation. They stated all the staffing changes made them not feel comfortable to report anything to the Administrator or Corporate. During the exit conference on 08/28/25 at 1:04 PM, the Administrator stated he disagrees with findings. He adamantly denied the allegation he flipped Resident #1 off. He stated he was not counseled by the RNC and all she said was, if you did it don't do it again.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure allegations of abuse were promptly and thoroughly investigated for 7 of 14 residents (Resident #1, #3, #4, #6, #8, #9, and #12) reviewed for abuse prevention. 1) Resident #1 alleged the Administrator made an obscene hand gesture. Resident #1 was not interviewed regarding the allegation and the incident was not reported to the State Agency as required. 2) Residents #3, #4, #6, #8, #9, and #12 alleged staff members were rude and/or yelled at them. The residents' allegations were documented on the Safe Surveys conducted on 05/08/25, the facility did not initiate an investigation on any of the residents' statements. These failures placed all the residents at risk for abuse and psychological harm, which resulted in substandard quality of care. Findings included: Record review of Resident #1's Transfer/Discharge Report dated 08/27/25 reflected the [AGE] year-old male resident was re-admitted to the facility on [DATE] with a diagnosis of paraplegia. Record review of Resident #1's quarterly MDS dated [DATE] reflected the resident was admitted to the facility on [DATE]. He was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated cognitively intact). In an interview on 08/27/25 at 8:18 AM, the SW stated she began her employment at the facility in April 2025. She stated there was staff turnover around May 2025. She stated on 05/08/25 she was asked to conduct Safe Surveys with the residents due to complaints about the Administrator's inappropriate comments to staff and the residents. She stated the Administrator was suspended 2-3 days while the investigation was conducted by the RNC, but she did not know the specifics. She stated none of the residents she interviewed reported any complaints or concerns regarding the Administrator. In a telephone interview on 08/27/25 at 8:48 AM. the former DON stated Resident #1 informed her the Administrator made an obscene gesture, the middle finger which the resident found to be disrespectful. She stated she the obscene gesture and unprofessional comments the Administrator had made to staff and residents to the RDO. She stated about a week after she made the comments the RNC came to investigate. She stated the RNC suspended the Administrator a few days while she conducted the investigation. She stated the RNC did not report the allegations to the State Agency but should have been as required. The former DON stated Resident #1 was not interviewed by the RNC about the specific allegations regarding the Administrator and she believed. She stated the RNC terminated her employment and brought the Administrator back the day after her termination. She stated she believes her termination was retaliation for reporting the Administrator. Record review of an email from the former DON to the RDO dated 04/30/25 at 7:42 PM, which read, in part, I am writing to you today to inform you about something that has been going on in the facility since the Administrator has arrived to the facility. Today a resident by the name of Resident #1 came into my office to explain to me that he felt like he was being mistreated by the administrator. This is not the first time that the resident has voiced to me ill treatment from the Administrator. In this particular instance, the resident came into my office and informed me that yesterday (04/29/25) while he was in the smoking room, the Administrator came up to him in front of an employee and stated Hey Resident #1, I have something for you. At that time the Administrator went into his pocket and pulled out his fist and flipped him off. The resident then informed me that former Housekeeper A saw him do this. He said he felt like this was inappropriate and at no time have he and the Administrator had a relationship in which they would joke around with each other the resident went on to tell me that he and the Administrator do not have a relationship in which it would ever be ok to do those things. In a telephone interview on 08/27/25 at 9:27 AM. the RNC stated the RDO received an email from the former DON alleging the Administrator had verbally abused Resident #1. She stated she suspended the Administrator 3 days, maybe more, while she interviewed the staff who all denied the allegations. She stated she did not interview Resident #1 about the allegations, but she had the SW conduct Safe Surveys and none of the residents, including Resident #1 reported any issues. She stated the decision was made to treat the incident internally and not report the incident to the State Agency. When the RNC was asked by the Investigator if the facility policy was followed regarding reporting, she stated that's a tricky one because everyone denied the allegations. Record review of the RNC's investigation conducted on 05/08/25 reflected a copy of the email from the former DON to the RDO dated 04/30/25, the Safe Surveys conducted by the SW with the residents on 05/08/25 and the RDO's interviews with staff: - The Administrator denied the allegation. - An interview with former Housekeeper B on 5/8/2025 at 2:49 PM reflected, Have you ever been witness to any administrative staff saying or doing anything to a resident/or other staff member that would be considered out of a professional role? If so, can you tell me when, by whom and directed towards who? I was in the smoke room at the same time with Resident #1 when the Administrator came in and spoke with all of us and then told Resident #1, I have something for you and then the Administrator pulled out his hand and flipped Resident #1 off but then talk him he was just playing and then Resident #1 said boy and then they both laughed. Did you report that to anyone? No ma'am I did not I thought they were just playing. - The SW conducted Safe Surveys with 46 residents on 05/08/25, the questions included general questions regarding which included if they were comfortable asking for assistance, if staff treated them with dignity and respect, if they felt safe in the facility, if they felt comfortable telling staff about concerns, if staff had ever physically harmed them and if staff member ever yelled or cursed at them. Resident #1 responded he did not feel comfortable asking staff for assistance; however, there was no further documentation regarding his response. Resident #1 reported no other issues during the Safe Survey. Residents #3, #4, #6, #8, #9, and #12, responded Yes, to the question, Has a staff member ever yelled or cursed at you?, the notes indicated Residents #6, #8, #9, and #12 reported staff was rude no staffs' names were disclosed and/or documented. Resident #4 reported she was yelled at by unnamed female staff. Resident #3 reported staff threatens her that she will be put out if not behaving and staff were rude. Record review of Resident #3's Transfer/Discharge Report dated 08/27/25 the [AGE] year-old female resident was re-admitted to the facility on [DATE] with a diagnosis of bipolar disorder. Record review of Resident #3's quarterly MDS dated [DATE] reflected she was admitted to the facility on [DATE]. She was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated cognitively intact). Record review of Resident #4's Transfer/Discharge Report dated 08/27/25 reflected the [AGE] year-old female was re-admitted to the facility on [DATE] with a diagnosis of diabetes. Record review of Resident #4's annual MDS dated [DATE] reflected she was admitted to the facility on [DATE]. She was cognitively intact with a BIMS score of 14 (a score of 13-15 indicated cognitively intact). Record review of Resident #6's Transfer/Discharge Report dated 08/27/25 reflected the [AGE] year-old female resident was re-admitted to the facility on [DATE] with a diagnosis of acute respiratory failure. Record review of Resident #6's quarterly MDS dated [DATE] reflected she admitted to the facility on [DATE]. She was cognitively intact with a BIMS score of 13 (a score of 13-15 indicated cognitively intact). Record review of Resident #8's admission Record dated 08/28/25 reflected the [AGE] year-old male resident was admitted to the facility on [DATE] with a diagnosis of femur fracture. Record review of Resident #8's quarterly MDS dated [DATE] reflected his BIMS score was 13 which reflected he was cognitively intact (a score of 13-15 indicated cognitively intact). Record review of Resident #9's admission Record dated 08/28/25 reflected the [AGE] year-old female resident was admitted to the facility on [DATE] with a diagnosis of multiple sclerosis. Record review of Resident #9 quarterly MDS dated [DATE] reflected her BIMS score was 12 which reflected she was moderately cognitively impaired (a score of 8-12 indicated moderate impairment). Record review of Resident #12's admission Record dated 08/28/25 reflect the [AGE] year-old male resident was admitted to the facility on [DATE] with a diagnosis of sepsis. Record review of Resident #12's quarterly MDS dated [DATE] reflected he was cognitively intact with a BIMS score of 14 (a score of 13-15 indicated cognitively intact). Record review of the facility's Grievances from May 2025 to August 2025 did not reveal any grievances or investigations related to the results of the Safe Surveys conducted on 05/08/25. There were no grievances regarding the Administrator. In an interview on 08/27/25 at 9:55 AM, the Administrator stated he was informed by the RNC of the allegations made against him and he was interviewed by the RNC. He stated he denied all the allegations in the former DON's email. He stated he did not want to discuss specifics because of legal action taken by the former DON and ADON. He stated he was suspended for an abuse allegation and was off 3 to 4 days pending the outcome of the investigation. He stated he was not privy to whether the incident was reported to the State Agency. He said the facility follows the Provider Letter as the policy regarding investigating and reporting abuse allegations. He stated he feels Corporate probably looked at the Provider Letter and made decisions based on it. He stated the facility had no other policy besides the Provider Letter. Record review of the Long-Term Care Regulation Provider Letter Number: PL 2024-14 dated 08/29/25 reflected a nursing facility must report to the State Agency Abuse, in accordance with applicable state and federal requirements. Allegations of abuse were to be reported immediately, but no later than two hours after the incident occurs or is suspected. During an observation on 08/27/25 at 11:14 AM Resident #1 was asleep in bed with he covers over his head. In a telephone interview on 08/27/25 at 12:12 PM, former Housekeeper A stated she and former Housekeeper B were on a break out smoking and Resident #1 was outside with them. She stated she heard the Administrator tell Resident #1 he had something for him, but she did not see the hand gesture. She stated former Housekeeper B heard and saw the gesture. She stated Resident #1 said he thought the Administrator was taking things too far with the hand gesture. She stated the RNC came to the facility to investigate the allegations, but the RNC did not interview her. She stated former Housekeeper B did report the incident to the RNC because former Housekeeper B was bothered by the incident. In a telephone interview on 08/27/25 at 12:36 PM, former Housekeeper B stated she was outside on a smoke break with former Housekeeper A and Resident #1. She stated she hear the Administrator tell Resident #1 I have something for you, and then she saw the Administrator take his hand out of his pocket and flip Resident #1 off. She stated Resident #1 told the Administrator Don't disrespect me like that. She stated the Administrator told Resident #1 he was just playing. She stated the Administrator went back inside and Resident #1 said to her, did you see what he did that isn't cool. She stated she reported the incident to the DON and the ADON. She stated she was interviewed by the RNC and told the RNC about the incident. She stated she told the RNC the Administrator was making her and Resident #1 uncomfortable with his inappropriate comments. She stated after she reported the incident the Administrator began kissing Resident #1's ass. In a telephone interview on 08/27/25 at 12:50 PM, former ADON said the former DON sent corporate an email regarding the allegation about the Administrator. She stated Resident #1 told came into the office with the former DON to express to us that while he was in the smoke room, the Administrator came in and told him he had something for him, the Administrator went into his pocket, pulled out his hand, and then flipped the resident off. She stated the RNC same to conduct the investigation but did not even interview Resident #1. She stated the Safe Surveys were done but were not specific to allegations regarding the Administrator. She stated, after the DON was terminated, she believed the allegations were not really investigated by the RNC, so she sent the RDO an email and he responded to her email and stated she was terminated. Record review of the email exchange between the former ADON and the RDO dated 05/15/25 reflected at 8:28 AM the former ADON sent the RDO an email entitled URGENT CRITICAL MATTER which read in part, around about on April 29th when Resident #1 came into the office with the DON and myself to express to us that while he was in the smoke room, the Administrator came in and told him he had something for him, went into his pocket, pulled out his hand, and then flipped him off. Resident #1 asked the DON to make the Administrator stop talking to him because he did not like him and they did not have a relationship in which it was considered ok to do those things to him. During the RNC's investigation it was brought to my attention that she failed to talk to half the nursing staff (she only spoke with the staff that worked that date), and she never spoke with the resident (Resident #1) with the compliant. At 2:18 PM the RDO responded via email, thank you for bringing this to our attention. I appreciate your concern, and for sharing these details, I am placing you on a temporary suspension while we conduct an investigation into this matter. Please do not consider this a punitive action but a necessary step in order to conduct a full and fare investigation into these allegations. In an interview on 08/27/25 at 1:54 PM, the SW stated, regarding the Safe Surveys dated 05/08/25, she did not ask the residents anything specifically about the Administrator. She stated she asked the residents the general questions on the Safe Survey sheet. In an interview and observation on 08/27/25 at 2:30 PM, Resident #1 was in bed in his room, his roommate was out of the room. He stated he was reluctant to speak to the investigator because the incident had been a long time ago, the Administrator apologized, and everything had been fine since. He stated the Administrator did flip him off when he was in the smoking area, and he just looked at the Administrator and did not respond. Resident #1 stated he was fine, and the incident did not affect him negatively. He stated he did not feel intimidated and had not changed his usual patterns in the facility. He stated he likes to stay up late and sleep late and staff accommodate him and let him do the things he wants to do. In a telephone interview on 08/27/25 at 4:05 PM, the RNC stated Housekeeper B told her about the incident with Resident #1 and the Administrator's hand gesture. She stated she did not speak to Resident #1, but he did not report any issues in the Safe Survey. She stated she did not feel it was a reportable incident of abuse because a lot of time had passed (from 04/29/25 - 05/08/25 ten days). She stated the Administrator was verbally counseled regarding the incident, but it was not a written counseling. She stated in response to the incident and residents' responses on the Safe Surveys dated 05/08/25 an in-service on abuse was conducted, but no further investigations were conducted into any of the allegations on the surveys. In a telephone interview on 08/27/25 at 4:09 PM, the RDO stated he over saw 20 facility's and it had been sometime since the incidents so he might not remember all the details or the timeline. He stated the former DON and ADON's complaints about theAdministrator were emailed to him. He stated the RNC was tasked with investigating the DON's complaint. He stated he could not remember the details of the complaint or the timeline to say if the allegation was reportable. He stated he believed the RNC shared the results of her investigation with him. He stated the finger gesture was bordering on reportable but sounded like it was reportable. He stated he was not aware Resident #1 was not interviewed by the RNC. He stated he was not sure what action was taken regarding the incident, but he thinks the Administrator was counseled. In an interview on 08/28/25 at 5:35 PM, the Administrator stated he was suspended and not privy to the investigation of the allegations. He stated today (08/28/25) was the first time he had seen the results of the safe surveys, but he believes most of the issues identified in the Safe Surveys have been addressed. He stated he did not flip Resident #1 off and that is not something he does in his personal life and certainly would not do it in his professional life In a confidential staff telephone interview on 08/28/25 at 7:22 AM, staff stated they heard about the Administrator flipping Resident #1 off. The staff stated they heard Resident #1 tell the former ADON, I don't know why he would feel comfortable doing that with me because we don't have a relationship like that. The staff stated they followed up with the resident about a week later and the resident said no one had come to talk with him about it but he was told it's been taken care of. The staff stated they were not interviewed by the RNC regarding the allegation. The staff stated all the staffing changes made them not feel comfortable to report anything to the Administrator or Corporate. In an interview on 08/28/25 at 9:30 AM, Resident #4 stated staff were not rude or abusive to her. She stated sometimes staff tell her they are going to do something and then they don't. In an interview on 08/28/25 at 10:08 AM, the Administrator stated, regarding the residents' responses to the Safe Surveys and the lack of Grievances, the first week in April 2025 the facility had a re-certification survey, and grievances was cited, so he completed his plan of correction for the process. He stated the responses were from 05/08/25 and he could narrow down who the staff in question was. He stated he has done customer service and resident rights in-services but a lot of the staff working during this time, May 2025, were no longer working because the facility had an 80% turnover in aides. In an interview on 08/28/25 at 10:15 AM, Resident #3 stated she liked the facility and did not report any abuse or rudeness from the staff. In an interview on 08/28/25 at 10:52 AM, Resident #8 reported no issues with his care and treatment in the facility. In an interview on 08/28/25 at 10:56 AM, Resident #6 reported no issues or concerns regarding her care or treatment in the facility. In an interview on 08/28/25 at 10:58 AM, Resident #9 had no complaints about her care or treatment in the facility. In interview on 08/28/25 at 11:05 AM Resident #12 reported no issues with his care or treatment in the facility. In an interview on 08/28/25 at 11:38 AM, the SW stated she did the Safe Surveys and gave them to the RNC on 05/08/25, but the RNC did not give her any further instructions. She stated when the Administrator returned from his suspension she gave him a copy of the Safe Surveys. She said she could not remember if she gave him a physical copy or emailed a copy to him In an interview on 08/28/25 at 11:43 AM, the SW said she had no record of emailing the Safe Surveys to the Administrator so she must have handed a copy to him. During the exit conference on 08/28/25 at 1:04 PM, the Administrator stated he disagrees with findings. He adamantly denied the allegation he flipped Resident #1 off. He stated he was not counseled by the RNC and all she said was, if you did it don't do it again.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for narcotic medication being accounted for. 1. LVN A failed to document Resident #1's Oxycodone/Acetaminophen 10/325MG on the MAR after administration. 2. LVN B & RN C failed to document Resident #1's Oxycodone/Acetaminophen 10/325MG on the Narcotic Record Count Sheet after administration. 3. LVN B failed to notify the DON of a discrepancy with Resident #1's Oxycodone/Acetaminophen 10/325MG per facility policy. These failures could place residents at risk for not receiving prescribed medication. Findings include: Record review of Resident #1's, face sheet dated 06/26/2025 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses which included: unspecified fracture of right patella, subsequent encounter for closed fracture with routine healing (broken kneecap), muscle weakness (decreased strength), lack of coordination (inability to coordinate movement). Record review of a Resident #1's admission MDS, dated [DATE] did not reveal a BIMS score. Record review of Resident #1's physician orders, 06/26/2025, revealed an order for Oxycodone/Acetaminophen 10/325MG, give one tablet by mouth every 4 hours as needed for pain. Start date 05/29/2025. Record review of Resident #1's Individual Control Drug Record Narcotic Count Sheet dated 05/29/2025 for Oxycodone/Acetaminophen 10/325MG revealed the facility received 86 whole pills and discarded 5 broken pills on 05/29/2025 at time of admission. Record review of Resident's #1 MAR dated 06/26/2025 revealed Resident #1 was administered 10/325 MG Oxycodone/Acetaminophen on the following dates and times: On 05/29/2025 at 10:21 AM, LVN B documented she administered 1 Oxycodone/Acetaminophen 10/325MG to Resident #1. On 05/30/25 at 5:33PM. LVN B administered 1 Oxycodone/Acetaminophen 10/325MG to Resident #1. On 05/31/2025 at 1:00 AM, RN C administered 1 Oxycodone/Acetaminophen to Resident #1. Record review of Resident's #1 individual Control Drug Record Narcotic Count Sheet dated 05/29/2025 revealed Resident #1 was administered 10/325 MG Oxycodone/Acetaminophen on the following dates and times: On 05/29/2025 at 4:15 PM, LVN A administered 1 Oxycodone/Acetaminophen 10/325MG to Resident #1. On 06/02/2025 at 12:00 PM, LVN A administered 1 Oxycodone/Acetaminophen 10/325MG to Resident #1. On 06/10/2025 at 6:00 AM, LVN B and RN C, signed and documented dropped during count, 82 pills remain. During an interview on 06/26/2025 at 11:50 AM, the ADM stated he was told there was a discrepancy with the Oxycodone/Acetaminophen 10/325MG for Resident #1 when LVN B and RN C changed shift. He stated that LVN B reported she dropped the medication while counting and could not find two of the pills. He stated that LVN B documented to two missing pills on the individual narcotic and failed to report the incident to the ADON or DON. He stated LVN B was terminated for not following the facility policy and procedures for medication discrepancies. He stated LVN B should have reported the incident to the ADON or DON. He stated that RN C had documented the pills were wasted however, she did not witness the pills being wasted. He stated RN C was written up over the incident. He stated the facility started an in-service on the facility procedures for counting narcotics after the incident. During an interview on 06/26/2025 at 12:37 PM, the DON stated he was told by LVN A that there was a discrepancy on the individual narcotic count sheet for Resident #1's Oxycodone/Acetaminophen 10/325MG. He stated on the individual narcotic count sheet LVN B documented 2 pills dropped during count and decreased the total number of pills remaining by 2 from 84 to 82. He stated RN C signed as a witness to the wasted medication, but she did not see the medication be wasted. He stated RN C received a write up over the incident. He stated LVN B reported she had dropped the pills during the counting of the pills. He stated LVN B documented the pills were wasted but failed to report the incident to the ADON or DON. He stated the facility policy was that once the pills were wasted staff would need to nothing the ADON or himself. He stated staff should not sign medication as wasted if they did not witness the wasting of the medication. He stated to waste medication it requires to nurses to see the medication being wasted before signing it was wasted. He stated that Resident #1 had discharged before the incident happened and she did not miss any medication. He stated staff did not follow policy for reporting wasted medication. He stated he completed an audit of the medication carts and there were not any other discrepancies. He stated LVN B was terminated for not following facility policy. During an interview on 06/26/2025 at 2:00 PM, the ADON stated LVN A reported to her that LVN B dropped 2 pills and wasted them, and had RN C sign off that she wasted the pills with LVN B. That RN C did not see the pills being wasted. She stated the administrative staff called LVN B and RN C to ask why they did not follow protocol. She stated LVN B was asked why she did not report the medication she wasted. That LVN B told her she was busy; she forgot and didn't think about it. She stated RN C told her she did not see LVN B throw the pills away, but signed she witnessed them being wasted. She stated she told RN C she would receive a disciplinary action for signing pills wasted when she didn't see the pills wasted. She stated after the incident staff were in-serviced over the narcotics and medication counts. She stated she completed an audit with the DON and there were not any other discrepancies with narcotic medications. She stated at the time of the incident LVN B and RN C did not follow the facility policy for wasted narcotics. She stated if staff needed to waste pills, they would need a witness the verify the medication and verify together the medication was wasted and then to notify the ADON or DON of the incident. During an interview on 06/26/2025 at 2:36 PM, LVN A stated when she arrived for her shift on 06/11/2025 RN C reported two pills were dropped during count by LVN B and stated the pills were wasted. She stated that RN C told her she didn't see the pills being wasted but signed with LVN B the wasted two pills for Resident #1. She stated she had received training from the facility on narcotic medications and if a pill was dropped that staff were to notify the ADON or DON and have them waste the medication together. She stated staff should not sign that a medication was wasted if they did not see it being wasted. She stated if there are any discrepancies with narcotic medication staff should report it to the ADON or DON immediately. During an interview on 06/26/2025 at 3:04 PM, LVN B stated during count at change of shift she dropped some of the Oxycodone/Acetaminophen 10/325MG for Resident #1. She stated she documented on the individual narcotic count sheet that 2 pills were wasted dropped during count. She stated she had RN C sign with her the medication was wasted. She stated she did not notify the ADON or DON because in the past when something like that happened, she did not have to notify them. She stated she told RN C what happened, and two pills were wasted, and RN C signed with her. She stated she had been instructed before if something like that were to happen to notify the DON. She stated at that time the facility did not have a DON and she should have called the ADON. LVN B stated if she signed, she gave medication on the MAR for Resident #1 she gave it and was not sure why it was not on the narcotic count sheet. She stated she had not received training or any in-service for narcotic medication, counting or reporting discrepancies. During an observation on 06/26/2025 at 3:45 PM, the DON, ADON and ADM pulled the Oxycodone/Acetaminophen 10/325MG from the locked medication storage to count and verify the number of pills. The DON counted the pills, and 82 pills were accounted for. During an interview on 06/26/2025 at 3:55 PM, the ADM verified that LVN A documented she gave 1 Oxycodone/Acetaminophen 10/325MG to Resident #1 on 05/29/2025 and 06/02/2025 and documented it on the individual narcotic count sheet and failed to document it on the MAR. He verified LVN B documented on the MAR for Resident #1 that she gave Resident #1, one Oxycodone/acetaminophen 10/325MG on 05/29/2025 at 10:21 AM and another one on 05/29/2025 at 5:33 PM and failed to document it on the individual narcotic count sheet. He verified that RN C documented on the MAR for Resident #1 she gave Resident #1, one Oxycodone/acetaminophen on 05/30/2025 at 1:00 AM and failed to document it on the individual narcotic count sheet. He stated he was not able to upload documents in TULIP and provided copies of documents used for the PIR. During an interview on 06/26/2025 at 3:55 PM, the DON verified that LVN A documented she gave 1 Oxycodone/Acetaminophen 10/325MG to Resident #1 on 05/29/2025 and 06/02/2025 and documented it on the individual narcotic count sheet and failed to document it on the MAR. He verified LVN B documented on the MAR for Resident #1 that she gave Resident #1, one Oxycodone/acetaminophen 10/325MG on 05/29/2025 at 10:21 AM and another one on 05/29/2025 at 5:33 PM and failed to document it on the individual narcotic count sheet. He verified that RN C documented on the MAR for Resident #1 she gave Resident #1, one Oxycodone/acetaminophen on 05/30/2025 at 1:00 AM and failed to document it on the individual narcotic count sheet. He stated if we count for the three pills signed off on the MAR as administered to Resident #1 and the two signed off on the individual narcotic count sheet as administered along with the two signed as wasted there should be 79 pills remaining not 82. During an interview on 06/26/25 at 4:10 PM, LVN A stated she was not sure why she signed the medication for Resident #1 out on the individual narcotic count sheet and not in the MAR. She stated that if she signed it out on the count sheet, she gave it to Resident #1. During an interview on 06/26/25 at 4:45 PM, the DON stated each shift will have to fill out a count sheet for the medication cart to verify date and time and the number of narcotics signed out in the narcotic binder as well as the number of narcotics given in the MAR and turn it into him. He stated he started an in-service for staff over the new form to complete as well as documenting narcotics given. During an interview on 06/26/2025 at 5:18 PM, RN C stated that LVN B told her she dropped the pills for Resident #1. She stated LVN B told her they needed to sign the paper showing the medications were wasted because of the facility policy and she signed the paper. RN C stated she did not see LVN B waste the medication but signed the paper anyway. She stated LVN B told her she had not reported the incident to the ADON or DON, but she would. She stated she did not recall giving the Oxycodone/Acetaminophen 10/325MG to Resident #1 on 05/30/2025. She stated that she will usually make herself a note to sign medication out in the MAR and on the individual narcotic count sheet, because she forgets. She stated she knew she gave Resident #1 her pain medication during her stay at the facility but could not recall which days or times. She stated she had not received any training or in-service from the facility on narcotic medication, counting or reporting discrepancies. During an interview on 06/26/2025 at 7:40 PM Resident #1 stated when she admitted to the facility, she had her prescription of Oxycodone/Acetaminophen 10/325MG. She stated she had the bottle in a Ziplock bag and poured the pills out of the bottle in the bag. She stated she could not recall how many pills she admitted with maybe 20-25 but was not sure. She stated she was only at the facility for a few days before she was discharged . She stated while at the facility she received her pain medication when she asked for it. Record review of the facility PIR dated 06/18/2025 revealed the following documents: Record review of in-service dated 05/30/2025, subject: Narcotic count/sign out/computer, any narcotic you give must have the time on the book match the computer time given. No exceptions please report any missing or discrepancies. Call the ADM/ADON. Please sign book in and out. Signed on 05/30/2025 by LVN A, LVN B and RN C along with additional staff. Record review of in-service dated 06/11/2025, subject: Narcotic Discrepancy - Please call DON/ADON/ADM immediately following any narcotic discrepancies. Do not leave the building until resolved. Report as soon as discrepancy happens. Do not sign WASTED without seeing the medication and throwing it away. Signed by LVN A and RN C along with additional staff. Record review of personnel change form dated 06/12/2025 signed by LVN B revealed last day of employment for LVN B was 06/12/2025 and last day worked 06/10/2025. The document revealed LVN B failed to follow proper policy and procedures regarding medication administration and destruction. Record review of disciplinary action form dated 06/13/2025 for RN C date of offense 06/11/2025, narcotic waste, RN C signed waste but was not present upon disposing. Education provided. Record review of in-service dated 06/26/2025, subject: Narcotic sign out book MAR/TAR - Make sure all Narcotics PRN/Scheduled are signed out in the book as well as the MAR/TAR. No exceptions. Signed by LVN A and RN C along with additional staff. Record review of in-service dated 06/26/2025, subject: Verifying EMAR to Narcotic book - At shift change, the incoming and outgoing nurse will both verify every time a narc was given during the shift, that it is recorded in both the book and the EMAR. The verification count sheet will be filled out and signed by both nurses. LVN A and RN C both signed the in-service along with additional staff. Record review of the facility policy Controlled Substances dated (revised April 2019). Policy Statement: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Policy Interpretations and Implementation: 10. Upon Administration: a. The nurse administering the medication is responsible for recording: (1) name of the resident receiving the medication (2) name strength and dose of the medication (3) time of the administration (4) method of administration (5) quantity of the medication remaining (6) signature of nurse administering the medication 11. Upon Disposition: b. Medication that are opened and subsequently not given (refused or only partly administered) are destroyed. Waste and/or disposal of controlled medication are done in the presence of the nurse and a witness who also signs the disposition sheet. 12. At the End of Each Shift: a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. b. Any discrepancies in the controlled substance count are documented and reported to the director of nursing services immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Resident #1) reviewed for care plans. Resident #1 did not have a care plan for Cognitive Loss/Dementia, Communication, Urinary Incontinence, Behavioral Symptoms, and Pressure Ulcers. Resident #1's care plan also did not include the physician's order for a wander guard or why the wander guard was ordered. Resident #1 did not have a care plan for her behaviors related to her diagnoses. This failure could place residents at risk of not receiving the care required to meet their individualized needs. Findings included: Record review of the face sheet, dated 05/05/2025, revealed Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included the following: benign intracranial hypertension (condition characterized by elevated pressure within the skull), mixed hyperlipidemia (elevated levels of both (bad) cholesterol and triglycerides, increasing cardiovascular risk), Type 2 diabetes Mellitus with Hyperosmolar hyperglycemic with Coma (life-threatening complication of diabetes (when blood glucose is too high)), Intermittent explosive disorder (repeated, sudden bouts of impulsive, aggressive, violent behavior or angry verbal outbursts), cognitive communication deficit, and unspecified Dementia, unspecified severity without behavioral disturbance, mood disturbance, and anxiety (memory loss that deteriorates over time). Record review of Resident #1's admission MDS assessment, dated 04/08/2025, revealed in Section C - Cognitive Patterns, Resident #1 had a BIMS score of 00, which indicated severe cognition impairment. The document also indicated in Section V - Care Area Assessment (CAA) Summary the following Care Planning Revision Areas: • 02. Cognitive Loss/Dementia (dated 04/16/2025) • 04. Communication (dated 04/16/2025) • 06. Urinary Incontinence and Indwelling Catheter (dated 04/16/2025) • 09. Behavioral Symptoms (dated 04/16/2025) • 11. Falls (dated 04/16/2025) • 12. Nutritional Status (04/02/2025) • 16. Pressure Ulcer (dated 04/16/2025) • 17. Psychotropic Drug Use (dated 04/16/2025) Record review of the current care plan for Resident #1, undated, revealed the following problem areas: • (Resident) request code status of: DNR, Date Initiated: 03/27/2025, Revision on: 03/27/2025; • (Resident) has had an actual fall with no injury 3/26/25, 4/1 Fall with abrasion to left knee, Date Initiated: 03/27/2025. Revision on: 04/03/2025; • (Resident) is on a Regular type (of) diet, (Resident) likes mostly everything, prefers to have orange or apple juice, milk, coffee, eggs, toast at breakfast, tea for lunch, fruit punch at dinner, BMI 35.9 (Resident) has a good intake. (Resident) can be confused at times and will usually continue eating if redirected. Further review revealed there were no additional problem areas found on Resident #1's care plan. Record review of Resident #1's active physician's order, dated 5/21/2025, revealed an order for Wander Guard (to left ankle), related to exit seeking. During an observation and interview on 05/20/2025 at 1:21 PM Resident #1 was observed in her room, laying in her bed. A wander guard was observed on Resident #1's ankle. Resident #1 was attempted to be interviewed. However, Resident #1 had trouble communicating verbally and was unable to communicate intelligibly. Resident #1 was observed to have a behavior of tapping her leg repeatedly. During an interview on 05/20/2025 at 3:05 PM LVN A stated Resident #1 had a cognitive impairment and had trouble communicating with staff. LVN A stated Resident #1 had behaviors of repeatedly tapping her hand on objects such as tables and chairs. LVN A stated Resident #1 had a physician's order for a wander guard. LVN A stated Resident #1's behaviors were related to her diagnosis of dementia. LVN A was uncertain if these areas of care were listed on Resident #1's care plan. LVN A stated she knew what Resident #1's needs were based on her physician orders and reports received daily from nursing staff. During an interview on 05/21/2025 at 03:00 PM, the MDS nurse stated she had been responsible for completing and updating residents' care plans for approximately the last 6 months. The MDS nurse stated care plans were completed upon admission and updated immediately as changes arise, as well as reviewed quarterly for changes. The MDS nurse stated it has been a recent, combined effort by the MDS nurse and Interdisciplinary Team (IDT) to update residents' care plans. The MDS nurse stated the facility had been reviewing all residents' care plans to ensure they were accurate and updated. The MDS nurse stated they have been working from the beginning of the alphabet to ensure all care plans were reviewed for accuracy. The MDS nurse stated the IDT team reviewed a resident's diagnoses, medications, and areas of care to personalize each resident's care plan based on their current needs. The MDS nurse stated she was not aware Resident #1's care plan was not completed fully, to include all CAA areas indicated on Resident #1's MDS. The MDS nurse stated this was overlooked. The MDS nurse stated all CAA areas should have been included on Resident #1's care plan, as they applied to her current care. The MDS nurse stated Resident #1's physician order for Wander Guard should have also been included in Resident #1's care plan. The MDS nurse stated it was also the DON and ADON's responsibility to update any changes to a resident's care plan, as changes arise. She stated the facility did not have a DON or ADON at that time. The MDS nurse stated the facility had a system to review care planning tasks at their morning clinical meeting. The MDS nurse stated she would ensure Resident #1's care plan was updated that day, 05/21/2025. The MDS nurse stated if a care plan was not updated or completed properly, it would not be specific to the resident's current care needs. She did not feel it caused a negative impact to the resident, as she stated nursing staff should have been checking the resident's orders as well to ensure the resident's individual needs were being met. During an interview on 05/21/2025 at 3:20 PM, the ADM stated care plans were the responsibility of the entire IDT team. The ADM stated the MDS nurse was responsible for reviewing and completing care plans. The ADM stated care plans were completed upon admission and reviewed quarterly. The ADM stated any changes would have been added as soon as the change of condition was known. The ADM stated the MDS nurse and IDT team had been going through care plans recently, for all residents in the facility, to ensure they were accurate and completed. The ADM stated this was an ongoing task that had not been completed yet. The ADM stated he was responsible for ensuring the MDS nurse and IDT team were updating all residents' care plans. The ADM was not sure if all MDS CAA areas should have been listed on Resident #1's care plan. However, he stated Resident #1's care plan should have been personalized to address her individual needs. The ADM stated Resident #1's physician order for Wander Guard should have also been included in her care plan. The ADM stated care planning tasks were discussed during the facility's morning meetings, and any changes or updates were added, as needed, by each department head. The ADM stated a resident's care plan should have been complete and accurate; however, he stated physician's orders were also in place, so each resident's care would have been based on those orders as well as basic nursing knowledge. The AD stated any resident who did not have a current care plan was at risk of deficient practice by the facility. Record review of the facility's policy titled, Comprehensive Resident Centered Care Plan dated November 2016 with a review date of January 2022 and December 2023, reflected the following: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 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.

Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 9 of 15 confidential residents. The facility failed to ensure 9 of 15 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, were provided access to the Grievance form, were provided information in regard to who the facility grievance officer was, their contact information, and how to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings include: Interviews and Record Review during Resident Council on, 04/08/2025 at 2:30pm, 9 of confidential residents, stated they did not have access to the Grievance form, they did not know they could file a Grievance anonymously, the Grievance procedure had never been discussed in Resident Council, and they had not observed a posting of the Grievance procedure in prominent locations. Residents attending Resident Council did not know where to acquire a grievance form, who to turn the form into, and what happens once a grievance was filed. Nine Residents attended the meeting, the 9 Residents in attendance had all been Residents of the facility for 6 plus months. Observed prominent postings on 4/09/2025 at 3:17pm; the facility did not include instructions regarding the Grievance procedure with any of the prominent postings. Grievance forms were not available and there was no access to submit a Grievance anonymously. Interview with the ADM on 4/10/2025 at 1:14pm; the ADM stated he was the Grievance Officer for the facility. The ADM stated he was responsible for the review of Grievances and assign them to department heads. The ADM stated the Grievance form was kept at the Nurses' Station, the ADM's office, the Activity Director's Office, and all department heads should have Grievance forms. The ADM stated the Residents cannot obtain a Grievance form without asking staff for the form. The ADM stated staff complete Grievance forms for Residents, Residents do not ask for forms and complete them on their own. The ADM stated there was no procedure for Residents to submit grievances anonymously. The ADM stated the facility should resolve grievances as soon as possible once they were submitted. The ADM stated he assigned the grievance to the appropriate department, that department addresses the grievance with the complainant, resolved the grievance, and explained the resolution to the complainant. The resolution was documented on the Grievance form and the completed form was submitted to the ADM for review. The ADM stated completed Grievance forms were kept in a notebook. The ADM stated he monitored the Grievance process for success by following up with the staff member assigned to resolve the Grievance, the ADM stated he will also meet with the complainant to ensure they were satisfied with the resolution. The ADM stated he was responsible for ensuring staff were trained on the Grievance process. The ADM stated he was not aware the Grievance procedure was not being discussed in Resident Council. Record Review of the Grievance Policy last updated in 2017. Policy Statement: All grievances filed with the facility will be investigated and corrective actions will be taken to resolve the grievance. Policy Interpretation and Implementation: 1. The facility will make available information on how to file a grievance available to residents, family, and staff. 2. The Administrator or designed will assign the responsibility of investigating the grievance. 3. Each Resident grievance form will include the date and time and details of the grievance. 4. The Administrator or designee will record and maintain all grievances in the Grievance Log. 5. The Resident Grievance form will be filed with the Administrator or designee and the resolution will be identified within three working days of the concern. 6. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within 3 working days of the filing of the grievance. 7. If during the investigation abuse, neglect, misappropriation and/or injuries of unknown source are identified, the facility will refer to the Abuse Policy. a. Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and b. Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievances for period of no less than 3 years from the issuance of the grievance decision.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs, as well as describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 18 residents (Residents #23 and #36) reviewed for care plans in that: The facility failed to ensure that Resident #23's care plan was revised, updated, and individualized with interventions and goals to address Resident #23's vison. The facility failed to ensure that Resident #36's care plan was revised, updated, and individualized with interventions and goals to address Resident #36's vision, activities, and pressure ulcers. This failure could place residents in the facility at risk of not being provided with the necessary care or services and not having personalized or individualized plans developed to address specific needs or concerns. Findings included: Resident #23: Record review of Resident #23's face sheet, dated 04/10/25, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include: dementia, high blood pressure, major depressive disorder, vitamin D deficiency, insomnia, malignant neoplasm of prostate (prostate cancer that develops when abnormal cells form and grow in the prostate gland). Record review of Resident #23's Comprehensive Minimum Data Set (MDS), dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 12, which indicated the resident's cognition was mildly impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (CAA that triggered and not Care Planned) 16. Pressure Ulcer Section MO100. Determination of Pressure Ulcer/ Injury Risk: Clinical assessment completed and formal assessment instrument/tool. Section MO150. Risk of Pressure Ulcers/Injuries: listed as 1 meaning Resident #23 was at risk for pressure ulcers. No interview was completed with Resident #23 Resident #36: Record review of Resident #36's face sheet, dated 04/08/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include acid reflux, type 2 diabetes, high blood pressure, osteoarthritis, urinary tract infection, retinal vascular appearance, bilateral, major depressive disorder. Record review of Resident #36's Admission's Minimum Data Set (MDS), dated [DATE], revealed: Section B1000. Vision - coded 1 = impaired - sees large print, but not regular print in newspapers/books. Section B1200. Corrective Lenses-Listed as Resident #36 had corrective lenses. Section C Brief Interview for Mental Status score revealed a score of 14, which indicated the resident's cognition was intact. Section M Skin Conditions revealed that Resident #36 was at risk for pressure ulcers but the section for pressure ulcers was left blank and incomplete. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function 10. Activities 16. Pressure Ulcer Record review of Resident #36's care plan, dated 12/20/24, revealed no care plan for visual function. Record review of Resident #36's care plan, dated 12/20/24, revealed no care plan for activities. Record review of Resident #36's care plan, dated 12/20/24, revealed no care plan for pressure ulcers. Resident #36 was not available for interview. During an interview on 04/10/25 at 11:58 AM, the Administrator stated that care plans were updated on admission with the resident and upon occurrences. The Administrator stated that the purpose of care plans would be to provide accurate representation to provide care. The Administrator stated that the negative potential outcome for not completing care plans would be reflective to the care plan status. The Administrator stated that the system in place would be quarterly care plan meetings and randomly audit care plans upon MDS completion. The Administrator stated that he had been trained with care plans a couple of years ago and on the job training. The Administrator stated that the direct care plan staff uses the care plan. The Administrator stated that he would be responsible for overseeing the care plans. During an interview on 04/10/25 at 12:04 PM, the DON stated that she was familiar with the facility's policy on care plans. The DON stated that the purpose of a care plan would be to ensure that the resident plan of care is followed through. The DON stated that it was the instructions for how to care for the resident. The DON stated that the negative potential outcome for not completing care plans would be care not being followed through for the resident and a missed opportunity to care for the resident. The DON stated that the system in place should have been to follow up through morning meetings and completing care plans through the completion of the MDS. The DON stated that care plans should have been completed and it was important to make sure they have been completed. The DON stated that care plans were to be looked at by the IDT team to better plan for resident care. The DON stated that the MDS Coordinator should have updated the care plans. During an interview on 04/10/25 at 1:07 PM, the MDS Coordinator stated that she was familiar with the facility's policies for care plans. The MDS Coordinator stated that the purpose of a care plan is individualized for each resident for their care. The MDS Coordinator stated that the negative potential outcome of not ensuring that care plans were completed was that residents may not receive the care that they would have needed. The MDS Coordinator stated that once the MDS was completed she will make sure that the care plan was lined up with the care plan. The MDS Coordinator stated that they would have also received information about the resident in the morning meeting and she would start to make sure that the care plan reflected the resident's needs. The MDS Coordinator stated that people that use the care plans were everyone actually but mainly nursing staff. The MDS Coordinator stated that she had been trained with care planning with the Regional MDS once in the past six months. The MDS Coordinator stated that a care plan was an individualized plan of care. The MDS Coordinator stated that she was responsible for making sure that care plans were completed along with the DON and ADON. Record review of facility policy, Care Plans, Comprehensive Person Centered, date revised December 2016, revealed: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 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: a. includes measurable objectives and time limits. b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. g. incorporates identified problem areas h. incorporates risk factors associated with identified problems. i. build on the resident's strengths. j. reflects the resident's expressed wishes regarding care and treatment goals. k. reflects the resident's expressed wished regarding care and treatment goals. l. identifies the professional services that are responsible for each element of care. j. reflects the resident's expressed wishes regarding care and treatment goals. k. reflects treatment goals, timetables, and objectives in measurable outcomes. l. identifies the professional services that are responsible for each element of care. m. aid in preventing or reducing decline in the resident's functional status and/or functional levels. n. enhances the optimal functioning of the resident by focusing on a rehabilitative program. o. reflects currently recognized standards of practice for problem areas and conditions. 9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. a. No single discipline can manage an approach in isolation. b. The resident's physician (or primary healthcare provider) is integral to this process. 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 12. The comprehensive, person-centered care plan is developed within 7 days of the completion of the required comprehensive assessment (MDS). 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. 14. The interdisciplinary team must review and update the care plan: a. when there has been a significant change in the resident's condition. b. when the desired outcome is not met. c. when the resident has been readmitted to the facility from the hospital stay. d. at least quarterly, in conjunction with the required quarterly MDS assessment.

Resident #29 Care Planning 04/09/25 02:41 PM record review shows discrepancies' with several of the care plan not being care planned. 04/10/25 12:26 PM It was determined that resident had several triggered MDS items that were not care planned. Resident #40 Care Planning 04/10/25 12:25 PM It was determined that resident had several triggered MDS items that were not care planned. Resident #145 Care Planning

Based on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal (lunch meal) reviewed for palatability, attractiveness, and appetizing. The facility failed to ensure foods were at appropriate temperatures. The facility failed to ensure proper handwashing during preparation of foods. The facility failed to provide edible (unburnt) food to residents. These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and food borne illnesses. The findings included: The following observations were made on 04/09/25 at 11:05 AM during observation of lunch meal preparation: Kitchen staff member A was observed several times with handwashing throughout the cooking process and did not wash her hands for the stated 15 seconds with soap. There were several times throughout the observation process that kitchen staff member had just rinsed her hands with water and then dried her hands. Kitchen staff member A was observed at 11:21 AM, picking up potatoes and a pan with her bare hands and not properly washing hands first then she grabbed gloves and put them on. Kitchen staff member A was observed at 12:41 PM with gloves on and using her fingers to pick up brisket off the serving bar and threw the piece of brisket back on the steam table in with the other brisket. Kitchen staff member was observed serving burnt rolls to the residents. Kitchen staff member was observed using her hands to place rolls on each resident's plate. Kitchen staff member was observed picking out burnt pieces of potatoes while she was putting food on each resident's plate to be served. Kitchen staff member A had left hot dog buns open in the package for approximately 37 minutes. Observations of temperatures taken at 1:06 PM revealed: (regular plate) roast: 120 degrees, potatoes: 101.8 degrees, carrots: 122.9 degrees. (Puree) roast: 139.6 degrees, potatoes: 149.5 degrees, carrots: 135.3 degrees, (Mechanical) roast: 108.7 degrees, potatoes: 115.3 degrees, carrots: 109.8 degrees. During a confidential interview, it was stated that food temperatures of the food served were not warm. During an observation on 04/09/2025 at 1:16 PM, ten plates were left on the table with barely any food being eaten. During an interview on 04/10/25 at 2:06 PM, kitchen staff member A stated that she had been trained in the kitchen by another staff member, nine years ago. The kitchen staff member A stated she was nervous during the observations. The Kitchen staff member A stated that the negative outcome of not following policy was that residents would not eat and then it could affect their weights and health. During an interview on 04/10/25 at 2:29 PM, the Administrator stated he expects that staff will follow the policy and ensure sanitary process is followed. The Administrator stated that the staff should follow kitchen and food safety and overall infection control. The Administrator stated that food should be edible with appearance, taste, and temperature. The Administrator stated that the outcome of not following these policies could cause illness and cross contamination. The Administrator stated that residents should receive food that were safely stored and prepared. The Administrator stated that overall, he was responsible for the staff. The Administrator stated that the staff were trained in the kitchen, and it was the responsibility of the kitchen supervisor to ensure the staff were trained. During an interview on 04/10/25 at 2:59 PM, the Kitchen Supervisor stated she expects staff to follow the policy for food temperatures and hand washing. The Kitchen Supervisor stated that if staff do not follow the policy then residents could get sick. The Kitchen Supervisor stated that she will educate staff through in-services, and she will monitor the effectiveness by closely monitoring and continue education. Record review of the facility policy and procedure titled, Food Preparation and Service, dated April 2019 reflected the following: Policy Statement: Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: 5. Food preparation staff adhere to proper hygiene and sanitation to prevent the spread of foodborne illnesses. Food Service Distribution: 6. Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single use items and are discarded after each use. Food Preparation, cooking, and holding times: 1. The danger zone for food temperatures is between 41 degrees Fahrenheit and 135 degrees Fahrenheit. This temperature range promote rapid growth of pathogenic microorganisms that cause foodborne illnesses. 2. Potentially hazardous foods include meats, poultry, seafoods, cut melon, eggs, milk, yogurt, and cottage cheese. 3. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, PHF must be maintained below 41 degrees Fahrenheit or above 135 degrees Fahrenheit. 4. Potentially hazardous foods held in the danger zone for more than 4 hours (if being prepared from ingredients at room temperature) or 6 hours (if cooked and then recooked) may cause foodborne illness. 7. Fresh, frozen, or canned fruits and vegetables are cooked to a holding temperature of 135 degrees. Food Service Distribution: 1. Proper hot and cold temperatures are maintained during food service. Foods that are held in the temperature danger zone are discarded after 4 hours. 2. The temperatures of foods held in the steam tables are monitored throughout the meal by food and nutrition services staff. 3. Steam tables are never used to reheat food. 4. Food and nutrition services staff, including nursing services personnel, wash their hands before serving food to residents. Employees also wash their hands after collecting soiled plates and food waste prior to handling food trays. 6. Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single use items and are discarded after each use. Record review of the facility policy and procedure titled, Handwashing/ Hand Hygiene, dated August 2019 reflected the following: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 2. All personnel should follow the handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol, or alternatively soap (antimicrobial or non-antimicrobial) and water for the following situations. a. Before or after coming on duty. f. Before donning sterile gloves. m. After removing gloves. o. Before and after eating or handling food. p. Before and after assisting a resident with meals. 9. The use of gloves does not replace hand washing/ hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections. Washing Hands: 1. Wet hands first with water, then apply an amount of product recommended by the manufacturer to hands. 2. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. 3. Rinse hands with water and dry thoroughly with a disposable towel. 4. Use towel to turn off the faucet. 5. Avoid using hot water because repeated exposure to hot water may increase the risk of dermatitis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection 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 6 of 10 residents (Residents #41, #32, #98, #38, #195, #40) reviewed for infection control. 1. MA A failed to sanitize the blood pressure cuff between resident use for Resident #41 and Resident #32. 2. MA A failed to sanitize the blood pressure cuff between resident use for Resident #32 and Resident #98. 3. MA A failed to sanitize the blood pressure cuff between resident use for Resident #98 and Resident #38. 4. CNA C failed to utilize hand hygiene between glove changes during incontinence care with Resident #195. 5. CNA B failed to change gloves and perform hand hygiene during incontinence care with Resident #40. These failures could place residents at risk for cross contamination and infection. The findings include: During a medication administration observation on 4/09/2025 at 8:34AM MA A used the blood pressure cuff to take Resident #41's blood pressure. At 8:38 AM, MA A used the same blood pressure cuff to take Resident #32's blood pressure. No sanitation of equipment was conducted before or after using the blood pressure cuff on Resident #41 or Resident #32. During a medication administration observation on 4/09/2025 at 8:38AM MA A used the blood pressure cuff to take Resident #32's blood pressure. At 8:42 AM, MA A used the same blood pressure cuff to take Resident #98's blood pressure. No sanitation of equipment was conducted before or after using the blood pressure cuff on Resident #32 or Resident #98. During a medication administration observation on 4/09/2025 at 8:42AM MA A used the blood pressure cuff to take Resident #98's blood pressure. At 9:08 AM, MA A used the same blood pressure cuff to take Resident #38's blood pressure. No sanitation of equipment was conducted before or after using the blood pressure cuff on Resident #98 or Resident #38. Record review of Resident #195's undated face sheet revealed a [AGE] year-old female originally admitted on [DATE]. Resident #195 had a past medical history of cerebral infarction (a type of stroke caused by a blockage of blood flow to the brain, leading to tissue damage and potential cell death), type two diabetes, and urinary tract infection. Record review of Resident #195's MDS dated [DATE] Section H- Bladder Bowel revealed she was always incontinent of bowel and bladder. During an observation of incontinence care on 4/09/2025 at 10:28 AM, CNA C cleaned Resident #195's buttocks, removed contaminated gloves, and donned clean gloves. CNA C failed to utilize hand hygiene between glove change. Record review of Resident #40's undated face sheet revealed a [AGE] year-old female originally admitted on [DATE]. Resident 340 had a medical history of major depressive disorder, cerebrovascular disease (conditions that affect the blood vessels and blood supply to the brain), and retention of urine. Record review of Resident #40's MDS dated [DATE] Section H- Bladder Bowel revealed she was always incontinent of bowel and bladder. During an observation of incontinence care on 4/09/2025 at 11:02 AM, CNA B cleaned Resident #40's buttocks, removed dirty brief and placed clean brief on Resident #40. CNA B failed to change gloves and utilize hand hygiene prior to placing clean brief on Resident #40. During an interview on 4/10/2025 at 10:00AM with MA A, she stated the DON was the infection preventionist. She stated she had been rained on infection prevention earlier this year. She stated she had been trained to disinfect the blood pressure cuffs before and after use. She stated the potential negative outcome of not disinfection the BP cuff could be spreading infection between residents. She stated she knew she had to disinfect the BP cuff with the disinfecting wipes but forgot to do so. During an interview on 4/10/2025 at 10:30AM with CNA C, she stated the ADM was the infection preventionist. She stated she had been trained on infection control and the last training occurred March 2025. She stated she had been trained to use hand hygiene between glove changes. She stated the potential negative outcome of not utilizing hand hygiene between glove changes could be spreading infection. She stated the DON and ADON do competencies all the time and will check them off on hand hygiene. She stated she did notice she failed to wash her hands between glove changes but had forgotten to do so. During an interview on 4/10/2025 at 10:36AM with CNA B, she stated the DON and ADON were the infection preventionist. She stated she had been trained on infection prevention and her last training was approximately a month and a half ago. She stated she had been trained to change gloves when going from dirty to clean. She stated the potential negative outcome of not changing gloves when going from an area of dirty to clean could be spreading bacteria. She stated she had changed her gloves once and forgot to change them again after she cleaned the resident's bottom. During an interview on 4/10/2025 at 10:49 AM with the DON, she stated she was the infection preventionist. She stated staff were trained on infection control upon hire, quarterly and as needed. She stated she was unsure of the last training date due to having just started at this facility in January 2025. She stated there was an infection control training scheduled for this month. She stated she expected her staff to wash their hands immediately upon removing their gloves. She stated the potential negative outcome of not changing their gloves and performing hand hygiene could be the spread of infection and an outbreak. She stated staff had been trained to disinfect the blood pressure cuffs and she expects staff to disinfect the blood pressure cuffs before and after resident use. She stated the potential negative outcome of not disinfecting the blood pressure cuff between residents could be the spread of infection. During an interview on 4/10/2025 at 11:27AM with the ADM, he stated the ADM, and DON were the infection preventionist. He stated staff were trained on infection control upon hire, annually and as needed. He stated there was an infection control in-service approximately six weeks ago. He stated staff had been trained on washing their hands when changing gloves. He stated the potential negative outcome of not performing hand hygiene between glove changes could be spreading infection. He stated staff had been trained to change gloves when going from a dirty area to a clean area. He stated the potential negative outcome of not changing gloves and performing hand hygiene could be the spread of infection and contaminants. He stated staff had been trained to disinfect the BP cuff between resident use. He stated the potential negative outcome of not disinfecting the BP cuff could be the spread of contaminants and infection. Record review of facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment last revised October 2018 revealed: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA bloodborne pathogens standard. .c. Non-critical items are those that come in contact with intact skin but not mucous membranes. (1.) Non-critical resident care items include bedpans, blood pressure cuffs . (2.) Most non-critical reusable items can be decontaminated where they are used. Record review of facility policy titled Handwashing/Hand Hygiene last revised August 2019 revealed: .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: .h. Before moving from a contaminated body site to a clean body site during resident care; . .m. after removing gloves;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice for 1 of 6 residents (Resident #1) reviewed for Quality of Care. The facility failed to transfer Resident #1 to bed on 03/03/25 resulting in him staying up in his wheelchair until the following morning (03/04/25). These failures could place residents at risk of not receiving necessary care or appropriate transfer. Findings included: Record review of Resident #1's face sheet, dated 03/11/25, revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include muscle weakness, sleep apnea (sleep disorder characterized by repeated pauses in breathing during sleep), hereditary and idiopathic neuropathy (underlying nerve damage), and major depressive disorder, Transient Ischemic Attack (temporary interruption of blood flow to the brain that causes stroke-like symptoms that resolve within 24 hours). Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 12, which indicated the resident's cognition was mildly impaired. Section GG0115. Functional Limitation in Range of Motion: Impairment on both sides in lower extremity (hip, knew, ankle foot) Section GG0120. Mobility Devices: Wheelchair (manual or electric) Section GG0170. Functional Abilities- admission: Chair to bed transfers:01 Dependent-Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. Section M Skin Conditions M0150. Risk of pressure ulcers/injuries Is this resident at risk of developing pressure ulcers/injuries? Coded 1 = Yes Does this resident have one or more unhealed pressure ulcers/injuries? Coded 0 =No Section V Care Area Assessment (CAA) Summary: CAA Results: 05. ADL Function Record review of Resident #1's care plan, dated 12/02/24, revealed: Problem: Resident #1 had an ADL self-Care performance deficit r/t paraplegia initiated 12/02/24. Goal: Resident #1 would maintain current level of function through the review date. (date initiated. (review period 02/08/25-04/28/25) Interventions: Transfer. Resident #1 was totally dependent on 2 staff for transferring. Initiated 1/28/25. Transfer. Resident #1 required Mechanical lift with 2 staff assistance for transfers. Initiated 1/28/25. Record review of Resident #1's physician order, dated 2/19/25, did not reveal a physician order for the use of a mechanical lift or any other alternative transfer methods. Record review of Resident #1's EMR revealed on 01/13/25 he weighed 286.2 pounds Record review of Resident #1's progress note dated, 1/11/25-03/12/25, revealed: On 03/04/25 at 7:37 AM, the ADM documented he spoke with Resident #1 about his refusal to allow the staff on the morning of 03/04/25 to transfer him to bed, and Resident #1's response was, I don't want to get out of my chair. The ADM documented when he asked Resident #1 if he was comfortable, Resident #1 responded, This chair was custom-made for me where it can go flat and offload. The ADM documented after multiple attempts, Resident #1 agreed to be transferred to his bed. Once the transfer was completed, Resident #1 stated he was comfortable and resting. On 03/04/25 at 8:11 AM, the ADON documented she entered the facility and discovered Resident #1 had not been assisted to bed throughout the PM shift. The ADON asked Resident #1 to allow them to put him to bed, and Resident #1 did not want staff to hurt his back and refused assistance to bed. The ADON documented Resident #1 provided her a letter stating the reason for not being assisted to bed r/t mechanical lift, and the night staff resident signed it. The ADON documented EMS was contacted to assist in putting Resident #1 to bed, and he refused. EMS staff (x3) arrived, but Resident #1 refused. On 03/04/25, LVN B documented Resident #1 needed extra assistance to be transferred into bed. She documented Resident #1 refused help from the EMT and stated it was not the EMT's job to put him in bed; it was facility's responsibility. She documented she attempted to educate Resident #1 on the importance of having an EMT assist with his transfer. Resident #1 continued to refuse. On 03/04/25 at 1:40 PM, RN A documented Resident #1 chose to stay awake and refused to go to bed because he wanted to use the mechanical lift. She documented the mechanical lift only worked for a little while. Record review of a handwritten note, undated, signed by RN A, CNA C, CNA D, and Resident #1 revealed: On this day 03/03/25 to 03/04/25 I CNA C and the other CNA (CNA D) had attempted to use the mechanical lift multiple times to put Resident #1 to bed with multiple attempts. The mechanical lift would not work with multiple attempts. We (CNA C and CNA D) tried plugging it up and unplugging it. The other CNA (CNA D) was able to get it to work for 5 seconds until it no longer decided to work. During an interview on 03/11/25 at 8:21 AM, Resident #1 stated on 03/03/25 the mechanical lift was not working, so he had to sit up in his wheelchair all night until the morning of 03/04/25. He stated he did not remember the names of the staff members who were working. He stated one of the aides started with the letter M. He stated there was one nurse and two aides. He stated that when he requested to go to bed (unsure of the time), the aide (did not know her name) attempted to use the mechanical lift, which was not working. He stated that he was not in any pain, but sitting in his wheelchair was uncomfortable. He stated after he requested to go to bed and they realized that the mechanical lift was inoperable, no additional attempts to put him in bed were made because he told the staff from the beginning that he did not want the staff to get hurt or risk the chance of being dropped. Resident #1 stated that the aide did offer to have him sit at the nurse's station with her and keep her company until they could figure out what to do. He stated he did not know if the staff contacted anyone to tell them that the mechanical lift was not working. He stated he did not feel neglected. He stated he did not have a bowel movement, but if he had one, that would have been challenging. He stated he did not have a need to be changed because he has a suprapubic catheter (urinary catheter that is inserted directly into the bladder) and did not have a bowel movement. Resident #1 stated he had one of the aides write a letter for him because he could not write for himself. He stated he had them sign it. He stated the letter indicated that he could not go to bed because the mechanical lift was not working. He stated the following day when the nurse came in he was told that he could get in trouble for having the aides sign the paper. He stated he did not know the nurse's name, but he gave her the letter and told her that he did get put in bed because the mechanical lift was not working. Resident #1 stated he reported to the nurse did not want the night staff to put him in bed because there were not enough of them. He stated he did not want the staff to get hurt, nor did he want the staff to drop him. He stated he had been dropped at another facility and was afraid of falling. He stated on 03/04/25 the nurse, whom he did not know her name, called the EMS, but he refused their services. He stated he did not want EMS to assist him because in the past, when he was at home, if he called EMS, he was sent a bill. He stated he did not want to pay a bill and he felt like the facility staff were paid to take care of him and they should be the one to put him to bed. He stated after he refused, the ADM came to him and explained that he would not be billed. Resident #1 stated there was only one mechanical lift in the facility. He stated if the mechanical lift were not working, he would need more than three people to lift him. He stated that he was tall, and he was dead weight. He stated, in the past, he had at least three people on each side. He stated on 03/04/25 it took 8 people to transfer him. He stated he had three people on each side, one at his head and one at his foot. He stated he could not remember the names of the staff members who helped transfer him but was confident that the DOR assisted him. He said he felt safe and comfortable with the transfer on the morning of 03/04/25. During an interview on 03/11/25 at 10:39 AM, the DOR stated she believed 03/06/25 was when the mechanical lift stopped working, and they had to assist in transferring Resident #1 from his wheelchair to the bed. She said it took a total of 8 people for safety and because of the weight of Resident #1. She stated Resident #1 was 300 plus pounds. She stated it was around 9:45 AM. She said she could not remember who had assisted, but she remembered it was her, the OT, the ADON, the ADM, CNA E, and maybe some other therapist and aides. She stated she did not know the details of how long he had been in his wheelchair. She stated Resident #1 came from a different facility and had always used the mechanical lift because of his size. She stated the nursing staff was responsible for training the clinical staff on the alternative transfer method if the mechanical lift was inoperable. She stated if the resident was on therapy services, therapy would have input. She stated determining an appropriate transfer for residents was for safety, weight bearing, skin integrity and ensuring that doctor orders were followed. She said nursing determined the transfer unless the resident was under therapy services. She said the facility had one mechanical lift. She said that Resident #1 alternative transfer when the mechanical lift was not working was a minimum of 4 staff should be used. She stated that it was a guess that a minimum of 4 staff should be used. She stated she was unaware of residents being left in their wheelchair for long periods. During an interview on 03/11/25 at 11:05 AM, the ADON stated the purpose of determining an appropriate transfer was to maintain overall safety. She stated therapy was responsible for determining a resident transfer. She stated if the mechanical lift was not working, the alternative was to get staff to put them in bed. She stated there were more staff during the day, and they could use therapy staff to their advantage. The ADON stated recently, there was an incident where a resident gave her a note. She stated she had discovered that the resident had been in his chair all night. The ADON said once this was brought to her attention, she started working on getting him in bed. She stated the resident did not want the staff to transfer him because he stated they (the staff) had families and did not need to hurt their backs. The ADON stated she called EMS. The ADON stated the resident said he was not going to bed and they, (the staff) could not make him. The ADON identified the resident as Resident #1. She stated she was not notified by either of the 3 staff (RN A, CNA C, and CNA D) that the mechanical lift was not working. The ADON stated that they only have 1 mechanical lift. The ADON stated that Resident #1 transfer alternative was two people when the mechanical lift was not working. She said she did not help transfer Resident #1 to bed the morning (03/04/25) after he stayed up all night. During an interview on 03/11/25 at 11:59 AM, RN A stated she worked the night shift that started on 03/03/25 and ended on 03/04/2025. She said on 03/03/25, she offered to put Resident #1 to bed, and Resident #1 refused. She stated the reasoning that Resident #1 gave was because he did not want anyone to get hurt. RN A stated that it was reported to her by the aides who worked on 03/03/25 that the mechanical lift was not working. RN A stated she did not attempt to operate the mechanical lift. She said she did not test the mechanical lift because she never had the opportunity to do so. RN A said she did not report the issue with the mechanical lift or that they could not place Resident #1 in bed the entire night because Resident #1 was not in any pain. She said Resident #1 seemed to want to be up all night. She said Resident #1 did not say specifically that he wanted to be up all night. She said she assumed he wanted to be up all night because he was up all night talking to staff. She stated she did attempt to put him in bed, but he refused because he did not want to hurt the staff. She said Resident #1 was up all night and did not sleep. She said it was customary that he stayed up late. She stated she had not received any training on the mechanical lift. She stated she had not been trained on what to do if the mechanical lift was not working. She stated that she believed they may have been able to place Resident #1 in the bed, or they could have called EMS. During an interview on 03/11/25 at 12:15 AM, the OT stated that 03/04/25 he assisted with transferring Resident #1 from his wheelchair to his bed. He stated there were 3-4 staff on the same side that he was on. He said there were 3 to 4 staff on the other side and at least one staff supervising. He stated Resident #1 was nervous but the more staff that showed up to help Resident #1 became more comfortable. The OT stated he did not check the mechanical lift because he does not normally deal with the mechanical lift. He stated he assumed the mechanical lift had already been checked, which was why they performed the transfer. He said he assumed Resident #1 had been up since breakfast but was unsure how long Resident #1 had been up in his wheelchair. He said he does not feel like 2 people could safely do Resident #1's transfer manually because it would be unsafe due to his size. During an interview on 03/11/25 at 12:24 PM, MA F stated she worked on 03/03/25 and 03/04/25. She said she left late on 03/03/25 at 9:00 PM. She said she observed Resident #1 up in his wheelchair. She said it was not unusual for Resident #1 to be up late at night in his wheelchair. She said she returned the next day, on 03/04/25, at 7:00 AM, and noticed Resident #1 was still in his wheelchair. She said Resident #1 told her that he stayed up all night and never went to bed. She said Resident #1 said the mechanical lift was broken. She said Resident #1 wanted to wait for the DON, ADON, and the ADM so that he could talk with them. MA F said the ADON called EMS to help, but Resident #1 refused the help. She said Resident #1 said it was the facility's job to put him in bed. She said Resident #1 did not mention anything about staff attempting to put him in bed on the overnight shift. She said the mechanical lift had not stopped working before. She said this was the first time she knew Resident #1 had stayed up for 24 hours. She said if the mechanical lift was not operational, she does not believe two staff could transfer him because he was on the heavier side. She said it was her understanding that it took at least 5 people to transfer him, but she did not assist because she was on the other side of the facility. She said she did not observe the transfer but knew he was scared to be transferred as he did not want to hurt the staff. She said for sure with Resident #1, it would take at least 4 staff to transfer Resident #1 manually. She said she had not received mechanical lift training at the facility. She said there was one mechanical lift at the facility and that she had never been trained on what to do if the mechanical lift was inoperable. During an interview on 03/11/25 at 12:33 PM, CNA E stated on 03/04/25, she did not assist with transferring Resident #1 to his bed. She stated she could not help because there were too many people. She stated it was about 8 people in the room. She said that EMS was called, but Resident #1 refused their help because Resident #1 said placing him in bed was the facility staff's job. She said the mechanical lift had been out on 03/03/25. She said they had done bed baths on 03/03/25 because the mechanical lift was not working. She reported the issue to the DON, and the ADON looked at the mechanical lift. She said the mechanical lift will sometimes not work if you do not plug it up. CNA E said she had been trained in using the mechanical lift and that the facility only had one. She said if the mechanical lift does not work, they will let the residents stay in bed and check on them every two hours. She said regarding Resident #1, no one knew what to do. She said they called the EMS, and Resident #1 did not want to get in bed. During an interview on 03/11/25 at 1:01 PM, CNA G stated 03/03/25 they got Resident #1 up that morning with the mechanical lift. She said the battery was not staying charged. She said they could get him in the chair with the mechanical lift. She said they asked him if he wanted to return to bed when they saw the mechanical lift not operating correctly. CNA G stated Resident #1 said he wanted to stay up in his wheelchair. She said she reported the incident to LVN I. She said she thought everyone knew about it because Resident #1 said he would also tell everyone about it. She said the next day, on 03/04/25, Resident #1 was still up in his wheelchair and was told that the mechanical lift battery would not say charged. She said she spoke with CNA C and was told that they attempted to lay him down multiple times during the night shift, and Resident #1 was reused. She said Resident #1 did not want them (the staff on the morning of 03/04/25) to lay him (Resident #1) down. CNA G said Resident #1 wanted to wait for the ADM to come in. She said she immediately called the DON and reported Resident #1 was still up, the mechanical lift was not working, and Resident #1 refused to allow them to lay him down in bed. CNA G said the DON was unaware that Resident #1 had been up all night. CNA G said they offered to lay Resident #1, and the EMS staff also tried, but Resident #1 refused. She said after the ADM came in; Resident #1 agreed to have staff lay him down. CNA G said it took 4-5 staff to transfer Resident #1 to bed. She said CNA C told her she did not report the incident because Resident #1 refused when they tried to lay him down. She said she had been trained in the use of the mechanical lift. She said the facility only had 1 mechanical lift. She said this was the first time the mechanical lift had stopped working, so they had not been trained to do anything, but it also depended on Resident #1 if he refused or not. During an interview on 03/11/25 at 12:46 PM, CNA J stated Resident #1 used the mechanical lift with two people. She said she had been trained to get as many people as possible if the mechanical lift was not working. She said she had not been trained at the current facility but had worked with Resident #1 at another facility. She said in the past, it took at least four staff members to transfer Resident #1. She said she had no additional information regarding Resident #1 staying up all night. During an interview on 03/11/25 at 2:09 PM CNA C stated she worked on 03/03/25 and ended her shift on 03/04/2025. She said on 03/03/25 at 11:00 PM Resident #1 requested to be put in bed. She said okay and went to retrieve the mechanical lift. She stated that she attempted to move the mechanical lift with the remote, but the machine was inoperable. She stated that she could not get the mechanical lift arm to move up and down. She stated she asked CNA D to come and look at the mechanical lift. She stated they both tried to get the mechanical lift to work. She stated they plugged it in and checked back with the machine within 30 minutes. CNA C stated the mechanical lift was still not operating correctly. She stated CNA D told her (CNA C) that she was able to get the mechanical lift to work. CNA C stated she tried the machine again and the mechanical lift still was inoperable. She said the mechanical lift did move for about 4 minutes, but they did not have Resident #1 in the machine. CNA C stated she reported to RN A that the mechanical lift was not working. She said RN A said she would contact the DON. CNA C said she asked Resident #1 what he wanted to do, and he told her that he did not want them to try to get him in bed because he was too heavy. CNA C said she offered to make Resident #1 coffee and he accepted. CNA C said they only had 1 mechanical lift. CNA C said the mechanical lift had never stopped working before. She stated she had not been trained on the mechanical lift since she had been employed at the facility. She said she had been employed at the facility since 01/13/25. She said Resident #1 used the mechanical lift because his left leg does not work and he was a big dude. She stated that they had not been trained on what to do if the mechanical lift was inoperable, and she felt that with the three staff that worked the night of 03/03/25, they would not have been unable to transfer Resident #1 safely. She said she believed it would take 5-6 people. She stated she was on the only staff that checked on Resident #1 as she was assigned to his hall. She stated she never observed any other staff checking on Resident #1. She said Resident #1 asked her to write a letter for him. She stated she cannot remember what the letter said exactly but it stated, I CNA C have tried to put Resident #1 down multiple times with the mechanical lift and it did not work. CNA C stated she signed it and CNA D signed it. She stated that she had not use the mechanical lift prior to attempting to put Resident #1 to bed. She stated she believed that someone had told CNA D that the mechanical lift was causing staff issues earlier in the day. An observation was made on 03/11/25 at 3:15 PM of the facility's only mechanical lift. It was not plugged in. CNA K used the remote and observed that the mechanical lift arm went all the way up and the mechanical lift arm went all the way down. The locks worked properly. The mechanical lift legs opened and closed. No observations were made of any glitches or malfunctions in the operation of the machine. During an interview on 03/11/25 at 3:28 PM, the Maintenance Supervisor said he was unaware of any issues with the mechanical lift. He stated he did not know much about the incident where the mechanical lift was not working, and Resident #1 stayed up all night. He stated he heard about it and was asked by the ADM to go and look to see if it was charged. He stated he was unaware of the exact date, but when he looked at the mechanical lift, it was operational and did not malfunction. He stated he had no documentation to reflect when he had conducted the check. During an interview on 03/11/25 at 3:59 PM, the DON stated the purpose of an appropriate transfer for residents was to prevent injury to the staff and residents. The DON said that they have two mechanical lifts at the facility. She said there was one on each side of the hall and that they had two batteries as backup. She said regarding Resident #1, if the mechanical lift was not operating, it would take 3-4 staff members, depending on their body type. She stated that on 03/04/25, she received a call from CNA G. She reported Resident #1 stayed up all night in his chair. The DON said she attempted to contact RN A, but she (RNA) did not answer. The DON stated she told CNA G to ensure Resident #1 was placed in bed. She stated she told CNA G to get staff together to assist. The DON stated the ADON and CNA G had told her that the mechanical lift was not working. The DON stated the ADON told her that Resident #1 reported that he did not allow the staff overnight to transfer him because he did not want to hurt the staff. She reported that Resident #1 refused EMS services because putting him in bed was not their (EMS) job. The DON said she knew that something was going on with the mechanical lift around 3:00 PM on 03/03/25, but it was her understanding that the ADM and the maintenance supervisor had checked it. The DON said she did not look at the mechanical lift because she trusted that the ADM said he was taking care of it. The DON stated Resident #1 had a history of refusing treatment. She said she expected to be called if the mechanical lift was not working and Resident #1 refused to go to bed. During an interview on 03/11/25 at 4:23 PM, the ADM stated the purpose of having appropriate transfers was to transfer residents safely. He said the facility only had one mechanical lift. He said it was purchased 3-4 months ago, and the Maintenance Supervisor put it together. He said when he came in on 03/04/25, it was around 7:40 AM. He said the ADON explained to him that Resident #1 was still in his chair from the previous night and that they had contacted EMS. The ADM stated that the ADON told him Resident #1 refused EMS services. The ADM stated he explained to Resident #1 that he (Resident #1) would not be billed and was not taking emergency services away from anyone as Resident #1 had told the ADM those were his concerns. The ADM stated he convinced Resident #1 to allow staff to transfer him. The ADM stated he was focused on ensuring Resident #1 was placed in his bed because he (Resident #1) had an appointment on 03/04/25 at 2:00 PM. The ADM stated that he was unsure but believed it took 3-4 staff to transfer him. The ADM asked Resident #1 about the previous night, and he was told that the mechanical lift was not working and he (Resident #1) did not want the staff to get hurt by transferring him manually. The ADM stated he explained to Resident #1 that the staff were trained to transfer him. He stated after he and his staff transferred Resident #1 on 03/04/25, he checked the mechanical lift, and it worked. The ADM stated no one reported to him on 03/03/25 that the mechanical lift was malfunctioning. He said he was unaware if the Maintenance Supervisor looked at the mechanical lift. The ADM stated they had another battery that was on order. The ADM stated Resident #1 was in a 0-gravity chair which helped relieved pressure. The ADM stated Resident #1 had the right to refuse to be transferred. The ADM stated he was unaware if Resident #1 had a history of refusing ADL care. During an interview on 03/11/25 at 5:32 PM, CNA D stated the mechanical lift was inoperable on 03/03/25. She stated she believed it was the battery. She stated they offered to lift Resident #1 out of his wheelchair manually to the bed but Resident #1 refused stating that he wanted the ADM to see him. CNA D stated Resident #1 said it was the ADM responsibility to make sure the mechanical lift was working. CNA D stated she had been trained by the ADON that three people could transfer Resident #1 if the mechanical lift was not working. CNA D stated that she had been trained on the use of the mechanical lift. CNA D stated that Resident #1 did not allow them to try and transfer him because he was scared and did not believe the staff could do it. An observation was made on 03/12/25 at 11:12 AM of two staff (CNA G and CNA L) operating the mechanical lift to transfer the ADM from the bed to a chair. The mechanical lift did not malfunction throughout the duration of the transfer. Staff demonstrated their ability to operate the mechanical lift safely. During an interview on 03/12/25 at 11:39 AM the ADON stated regarding quality of care the facility did not have a policy. She said the purpose of quality of care was to maintain continuity. She said the facility could not run properly without a standard of quality of care. The ADON stated that quality of care was a must for taking care of their residents. The ADON stated that the PNO of subpar quality of care could become unsafe for the residents. She said there could be a break in continuity of care. She said good quality of care included the proper transfer and functioning of equipment. The ADON said she was unaware of the mechanical lift was as not working on the night of 03/03/25, She said she was unaware Resident #1 was up the entire night. She said the facility's system to monitor quality of care was they (management) review things such as progress notes daily. She said they also speak with residents and also speak with staff. The ADON stated she had been at the facility since 01/31/25 and she had not had any specific training on quality of care nor had her staff. The ADON stated she expected that quality of care be at 100 percent. She said that since she had been at the facility, she had observed broken systems, but none were related to the mechanical lift and patient transfers. The ADON stated everyone was responsible for the quality of care. She said she was unaware of why Resident #1 did not receive the quality of care he needed or was able to be placed in bed on the night of 03/03/25. During an interview on 03/12/25 at 12:00 PM the DON stated regarding quality of care they did not have a facility policy. She said the purpose of quality of care was to ensure each resident was receiving the best care that they can receive according to what their wants and desires were. She said quality of care was how the resident wants to be treated. She said the resident had the right to refuse to go to bed. She said the PNO if quality of care was subpar was it could lead to neglect or abuse. She said she was unaware of the incident and at the time it happened. She said when she was made aware on 03/04/25 she started telling staff what they needed to do. She said her system to ensure quality of care was acceptable was to check with the staff, residents and utilization of the SW and safe surveys when there was any concerns with ANE. The DON stated as a nurse she had been trained on the importance of quality of care. She stated she expected the quality of care to be superb at the facility. She said everyone was responsible. She said the clinical nursing staff were especially responsible because they have the most interaction and they were at the forefront of quality of care. She said she does not know the exact reason why Resident #1 did not receive the quality of care he wanted but she believed it had a lot to do with him refusing care. She said it was her understanding that Resident #1 said there were not enough staff members to transfer him on 03/03/25. She said she felt like Resident #1 did not allow the staff to transfer him. She said she felt that Resident #1 had not been educated on what the circumstances may have been. During an interview on 03/12/25 at 12:37 PM the ADM stated in regard to quality of care there was no specific policy but that he was familiar with the concept of quality care. He said it was self-explanatory. The ADM said quality of care was providing good competent care. He said the PNO of subpar quality of care was anything can have a negative outcome. He said he felt as a non-clinician he did not know if he could state what the negative outcome was accurately. The ADM stated he was unaware Resident #1 was not placed in bed on 03/03/25. He stated his system for monitoring quality of care was ensuring staff was had their competencies. He stated he makes rounds throughout the day and he also spoke with staff and residents about quality of care. He stated he had not had any specific training on quality of care but understands what quality of care was. The ADM said he was ultimately responsible for anything that happened in the facility. Attempted to contact LVN B on 03/14/25 and 03/18/25 and the attempts were unsuccessful. Attempted obtain the EMS records electronically on 03/12/25, 03/13/25 and 03/14/25 and all attempts were unsuccessful. Record review of facility sign, undated, revealed the following: For all clinical Calls (change of condition, accident/incident, falls etc.) Contact the DON [phone number listed] Record review of the facility policy, Pressure Injury Risk Assessment, date revised March 2020, revealed: Purpose The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries (PIs). Risk factors that increase a resident's susceptibility to develop or to not heal PIs include, but are not [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder or had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 Residents (Resident #1) reviewed for catheter care in that: The facility failed to ensure Resident #1 had physician orders for a urinary catheter. This failure had the potential to affect residents by placing them at an increased risk of not receiving the appropriate care or services related to the urinary catheter. Findings include: Record review of the admission record for Resident #1, dated 01/31/25, revealed a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: unspecified sequelae of cerebral infarction (long-term effects of a stroke in the brain), type 2 diabetes (blood sugar problems), essential hypertension (high blood pressure), and urinary tract infection (bladder infection). Record review of Resident #1's quarterly MDS assessment, dated 12/20/24 revealed Resident #1 had a BIMS score of 15 which indicated the resident's cognition was intact. The MDS revealed Resident #1 had an indwelling catheter. Record review of Resident #1's order summary report, dated 01/31/25, revealed no physician order for a foley catheter. Observation on 01/31/25 at 9:52 AM revealed Resident #1 in bed and a foley catheter bag was noted hanging on the side of the bed. Interview on 01/31/25 at 10:50 AM, Resident #1 stated she has had a urinary catheter for about 2 weeks. Resident #1 stated she was unsure why she received a catheter. Resident #1 stated staff cleaned her catheter when they changed her brief and emptied the bag at least twice daily. Interview on 01/31/25 at 11:14 AM, LVN A stated this was her first day working at the facility and she was not familiar with Resident #1's care. LVN A stated the floor nurse was responsible for ensuring residents had physician orders for urinary catheters. LVN A stated there could be a potential for infection concerns or the urinary catheter could need to be irrigated and the staff would not know without physician orders for catheter care. Attempted phone interview on 01/31/25 at 11:25 AM with LVN B. No answer. Left a voice message with a call back number. Interview on 01/31/25 at 11:35 AM, the DON stated her first day working at the facility was this past Tuesday (01/28/25) and she was still trying to audit and get everything in place. The DON stated it was unknown why the urinary catheter was placed on Resident #1 but she believes hospice nurses ordered and placed the catheter. The DON stated she was unsure if hospice would keep the urinary catheter for Resident #1 as she was unsure what the actual diagnosis was for Resident #1's urinary catheter. The DON stated a potential negative outcome for the resident was urosepsis (a bladder infection that spreads to the kidneys and enters the bloodstream), infection, and septicemia (blood poisoning). Interview on 01/31/25 at 12:05 AM, the Interim ADM stated she expected the residents who had a urinary catheter to have a current physician's order for the catheter and catheter care. The Interim ADM stated the floor nurse was responsible for ensuring the residents on her hall had physician orders for urinary catheters if they had a urinary catheter. The Interim ADM stated the DON and ADON were also responsible for auditing the resident's charts to ensure the proper physician's orders were in place and being followed. The Interim ADM stated a potential negative outcome to the resident was not receiving catheter care or monitoring. Record review of Resident #1's progress note, dated 12/16/24 at 05:20 AM, created by LVN B: Foley cath changed to 18 fr [French] with 10 cc [ml] bulb. Small amt [amount] of bloody urine noted when inserted and sent to lab for UA [Urinary Analysis]. Resident tolerated procedure well Record review of Resident #1's progress note, dated 12/16/24 at 05:22 AM, created by LVN B: order to obtain UA with C/S [culture/sensitivity] after foley placed tonight. One time only for 1 day. 18FR [French] foley cath [catheter] changed per sterile technique. Resident tolerated well. Resident had very small amt [amount] of bloody urine noted. Small amt [amount] of urine sent to lab for UA. Record review of the facility policy and procedure titled, Catheter Care, Urinary, with a revised date of August 2022 revealed the following: Purpose: The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Catheter Evaluation: 1. Review and document the clinical indications for catheter use prior to inserting. 2. Nursing and the interdisciplinary team should assess and document the ongoing need for a catheter that is in place. Use a standardized tool for documenting clinical indications for catheter use

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on obervation, interviews and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administration of drugs that meet the needs of all residents for 1 of 5 residents (Resident #1) reviewed for pharmacy services. ADON failed to make sure that drugs and biologicals are prepared and given by the same person by preparing a medication and giving it to CNA to administer to Resident #1, on 12/30/2024 around 10:30 AM per anonymous complaint dated 12/31/2024. This failure could place residents at risk for not receiving medications correctly. Findings included: Record Review of Resident #1's facesheet dated 01/08/2025 revealed that Resident #1 was initially admitted to the facility on [DATE] with a readmission on [DATE]. Resident #1 had a medical history of acute respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), epilepsy (disorder in which nerves cell activity in the brain is disturbed, causing seizures), insomnia (makes it difficult to fall asleep or stay asleep), anxiety (intense, excessive, and persistent worry and fear about everyday situations), depression (loss of pleasure or interest in activities for long periods of time), dysphagia (swallowing difficulties), cerebral palsy (congenital disorder of movement, muscle, tone, or posture), and congenital hypertonia (overly toned muscles that cause muscles to be stiff and difficult to control). Record review of Resident #1s MDS dated [DATE] revealed, Section C- Cognitive patterns revealed a BIMS score of 10 which indicated Resident #1 had a moderate cognitive impairment. Section GG- Functional Abilities: A. revealed a score of 2 for eating, which indicated Resident #1 needed substantial/maximal assistance. Section K- Swallowing/Nutritional Status C. revealed coughing or choking during meals or when swallowing medications. K0520 revealed mechanically altered diet. Record review of Resident #1 s care plan dated 08/19/2020 revealed problem: Resident #1 has an ADL self-performance deficit related to cerebral palsy. Goal to maintain current level of function in ADL's through the review date. Date initiated 07/23/2022. Interventions: Eating: Resident #1 requires extensive assist x 1 with eating. 04/20/21 Resident #1 requires extensive assist x 1 with eating. She has a regular diet, foods cut up into bite size pieces. She has difficulty with swallowing, so requires attention. She has ROM deficits in upper extremities requiring assist with feeding. Initiated on 08/19/2020. Revision on 10/06/2023. Record review of Resident #1s physician order dated 02/13/2024 for Resident #1 to receive ST skilled service 3 x week for 30 days for dysphagia management. Record review of Resident #1s Nutritional Review assessment dated [DATE]: 8. Current Diet/Supplement Order: Regular pureed diet with nectar thicken liquids. 9. Appropriateness of Diet Order: Appropriate. 10. Ability to Chew/Swallow: Ok. 13. Ability to feed self: Dependent. 24. Comments: Resident #1 is alert to person and place and can communicate needs. Record review of Resident #1's Nursing Monthly Summary dated 12/13/2024 revealed: Section A. Level of Consciousness/Orientation/Cognition: Resident #1 is alert and oriented to person and place, with episodic confusion. Section H. ADLs- Eating is total dependence of one person. Diet order: thickened liquids, pureed. Record review of Resident #1's December 2024 Medication Administration Record revealed an order for Tylenol Extra Strength oral tablet 500 mg. Give one tablet by mouth every 6 hours as needed for pain. There is no documentation on 12/31/2024 that the medication was given. During an interview on 01/08/2025 at 8:40 AM, the ADON stated that it had been a hectic day and she was running behind with the medication pass. ADON stated that her family member, CNA, came by and asked if she needed any help. ADON stated that she remembered it was during the morning med pass on 12/30/2024, and Resident #1 was crying out. ADON stated that she poured a Tylenol Extra Strength tablet into a medication cup and asked CNA to go administer the medication to Resident #1. ADON stated that CNA also does transportation for the facility and knows her residents very well. ADON stated it was just an OTC medication, and she would not have done that with any of the other medications. ADON stated that she would never to that again, it was just a spur of the moment decision. ADON revealed CNA is not certified to administer medications. During an interview on 01/08/2025 at 9:34 AM, Confidential Person A stated that she observed the ADON give a medication cup to CNA. Confidential Person A stated they did not know what was in the cup, but they knew a CNA should not be giving medications. During an observation on 01/08/2025 at 9:54 AM, Resident #1 was observed resting with eyes closed, head of bed up at 30 degrees, and had oxygen administering via nasal cannula. No signs or symptoms of distress. During a phone interview on 01/08/2025 at 10:40 AM, Regional RN stated, oh no, they can not do that, regarding the ADON giving CNA a medication to administer to Resident #1. During an interview on 01/08/2025 at 11:16 AM, CNA stated that Monday 12/30/2024 had been a crazy day, and she was checking with other staff to see if she could help them with anything. CNA stated her family member, ADON was passing medications, and CNA asked her if she needed her to do anything. ADON poured a Tylenol Extra Strength tablet into a medication cup and asked her to go administer it to Resident #1. Resident #1 took the medication without incident. CNA stated that she was just trying to help out, and it was just an OTC medication. Regarding the risks to a resident if someone did not know the resident had an order for thickened liquids, CNA stated that she had been certified for 10 years, and as a CNA she knows that about her residents. CNA stated that Resident #1's head of bed is always elevated. CNA stated that she did not have her certification to administer medications. CNA stated that she would never do it again and stated that she would not have done that if it had not been her family member. During an interview on 01/08/2025 at 11:25 AM, Confidential Person B stated that they were concerned about an uncertified person giving medications, because they may not know what they are giving, or whether or not that resident has thickened liquids, or possibly the unlicensed person could give the medication to the wrong person. During an interview on 01/08/2025 at 11:46 AM, LVN A revealed the risks to a resident that is administered medications by an uncertified person includes not knowing what medication they are giving, what the side effects are, if there are parameters that need to be checked prior to administration, or there might be possible drug interactions with other medications. LVN A stated that if a person is not certified in medication administration, they should not be giving medications. During an interview on 01/08/2025 at 12:20 PM, ADON stated that a lot of things could happen to a resident with an uncertified person giving medications. ADON stated, I did it, but I will never do it again. During an interview on 01/08/2025 at 12:30 PM, Resident #1 was awake, made eye contact and smiled. Investigator asked how she was doing. It took a little while for her to get her words out. Resident #1 voiced she was doing ok. Resident #1 denied any concerns regarding the staff or her care. Resident #1 could not recall what medications she had on 12/30/2024. During an interview on 01/08/2025 at 1:47 PM, the Interim DON stated that the ADON had just told her about giving a medication to her family member, CNA, to administer to Resident #1. Interim DON stated, that is not good. Interim DON stated that the risks to a resident being given medication by an uncertified person could result in the resident choking or aspirating, or they may give the medication to the wrong person. During an interview on 01/08/2025 at 2:27 PM, LVN B, stated that the risks of an uncertified person giving medications include they could give the medication to the wrong person, or they may not give the resident the medication and take it themselves, the uncertified person may not know what the medication is for, or know what the side effects might be. LVN B stated there could be a lot wrong with an uncertified person administering medications. During an interview on 01/08/2025 at 3:15 PM, Physician stated that the risks of an uncertified person administering medications that they did not prepare, first you would be relying on what someone else was telling you the medication was. Physician stated, it is just not good practice. Record review of Disciplinary Action Form dated 01/08/2025 for ADON. Safety violation: Unsafe Practice. Detailed description of offense: Not following the policy for Medication Administration. Employee comments: Will follow the facility policy. Action taken: Written Warning. Signed and dated by ADON and Interim DON. Record review of Disciplinary Action Form dated 01/08/2025 for CNA. Safety violation: Unsafe Practice. Detailed description of offense: Not following the policy for Medication Administration. Employee comments: Will follow the facility policy. Action taken: Written Warning. Signed and dated by CNA and Interim DON. Record review of in-service dated 01/08/2025: Medication Administration: Only licensed personnel or personnel permitted by the state to prepare, administer, and document the administration of medication can do so. The following policy reviewed: Administering Medications, 2001 Med-Pass, Inc. (Revised April 2019) Policy Statement: Medications are administered in a safe and timely manner, as prescribed. Policy Interpretation and Implementation: 1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to ensure each resident drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 5 residents (Resident #1) reviewed for pharmacy services. A. The facility failed to monitor, review, and reconcile Resident #1's medication administration record from April 2024- October 2024. This failure placed residents at risk for not receiving prescribed medications and drug diversion. Findings included: Record review of Resident #1's face sheet, dated 10/17/24, reflected a [AGE] year-old, who was admitted to the facility on [DATE]. He was diagnosed with Dementia (the loss of cognitive functioning), Alzheimer's disease (memory loss), and altered mental status. Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: *Section C Brief Interview for Mental Status score revealed a score of 02, which indicated the resident's cognition was severely impaired. *Section B0800. Ability to understand others, Resident #1 had unclear speech, rarely/never could himself understood and rarely understood others. *Section N- Medications. Indicated that Resident #1 took antidepressants but no other high-risk medications in any other drug class. (N0415). Record review of Resident #1's care plan, dated 7/14/22, reflected the following: Aa focused area, initiated on 7/14/2022, Resident #1 was on pain medication therapy r/t disease process (takes morphine and Tylenol 325 MG). The goal initiated on 7/14/2022, was that Resident #1 will be free of any discomfort or adverse side effects from pain or medication through the review date. The Intervention initiated 7/14/2022, was that staff was supposed to administer medications as ordered. Record review of Resident #1's Order Summary Report, viewed on 10/17/2024, reflected the resident was ordered morphine sulfate 100 Mg/5 ML and was to be given .25 ML by mouth or sublingual every 4 hours as needed or as directed for pain or air hunger; Ordered 06/13/2024. Record review of the medication administration log for Resident #1 from the pharmacy revealed the following: LVN A received the morphine (undated) and it contained 30 ML LVN B administered the medication at the dose of .25 ML on 06/17/24 (29.75 ML), 06/21/24 (29.50 ML), 06/23/24 (29.25 ML), and 06/26/24 (29 ML). LVN A administered the medication at the dose of .25 ML on 06/30/24 (28.75 ML). LVN B administered the medication at the dose of .25 ML on 07/7/24 (28.5 ML), 07/21/24 (28.25 ML) and 07/26/24 (28 ML). LVN C administered the medication at the dose of .25 ML on 10/09/24 (27.75 ML). Record review of the medication administration log for Resident #1 from the EMR revealed the following: LVN B administered the medication at the dose of .25 ML on 06/21/24, 06/22/24, 7/08/24 and 07/26/24. Record review of a picture of Resident #1's morphine dated 10/10/24 revealed the following: A black and white photo of the Resident #1 morphine box handwritten that the bottle was received 4/17/24. A black and white photo of the morphine bottle with partial of Resident #1's name shown. The liquid in the bottle is right under the 20 ML mark. Handwritten reflect that the liquid should have been under the 28 ML. Record review of Resident #1's pain level summary report undated revealed the following pain values on the coinciding days the liquid morphine was administered: 06/17/24: LVN B documented a pain level of 5 at 9: 21 PM, 5 at 9:22 PM, 6 at 10:14 PM 06/21/24: LVN B documented a pain level of 3 at 8:43 PM, 6 at 10:44 PM and 2 at 1:03 AM. 06/23/24: LVN B documented a pain level of 2 at 9:33 PM 06/26/24: LVN B documented a pain level of 2 at 9:24 PM and 11:27 PM. 06/30/24: No documentation for this date. 07/07/24: LVN B documented a pain level 1 at 9:34 PM and 6 at 9:17 PM. 07/21/24: 0 all day 07/26/24: LVN B documented a pain level of 3 1:25 AM 10/09/24: 0 all day Record review of Resident #1's progress notes, dated 03/16/24-10/17/24, revealed the following: LVN B documented on 6/17/24 at 10:23 PM Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML Give 0.25 ml by mouth every 4 hours as needed for Pain or Air Hunger; PRN Administration was: Effective; Follow-up Pain Scale was: 0 Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML Give 0.25 ml by mouth every 4 hours as needed for Pain or Air Hunger very agitated. LVN B documented on 6/21/24 at 1:03 AM Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML Give 0.25 ml by mouth every 4 hours as needed for Pain or Air Hunger; PRN Administration was: Effective; Follow-up Pain Scale was: 2 Note Text : Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML Give 0.25 ml by mouth every 4 hours as needed for Pain or Air Hunger told son he was hurting and he requested pain meds LVN B documented on 7/08/24 at 2:35 AM Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML Give 0.25 ml by mouth every 4 hours as needed for Pain or Air Hunger; PRN Administration was: Effective; Follow-up Pain Scale was: 1 LVN B documented on 7/26/24 at 9:25 PM Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML Give 0.25 ml by mouth every 4 hours as needed for Pain or Air Hunger; PRN Administration was: Effective; Follow-up Pain Scale was: 0 LVN B documented on 7/26/24 at 4:26 AM Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML Give 0.25 ml by mouth every 4 hours as needed for Pain or Air Hunger; PRN Administration was: Effective; Follow-up Pain Scale was: 0 The DON documented on 10/10/24 at 6:11 PM Notified Family Member I of the discrepancy in his medication. Explained that we are actively looking into it. Also explained that it has not affected his care or well-being in any way During an interview on 10/17/24 at 9:00 AM, the DON stated LVN D was a new nurse who had come to work the previous week and found a discrepancy in Resident #1's morphine count. She said LVN E was the nurse who was getting off, and LVN D was the oncoming nurse. She said LVN D reported to her that Resident #1's morphine was reported under the documented amount on the MAR. She said she and the ADON looked; about 8 MLs were missing. She stated she looked at the log and found discrepancies in the documentation, which did not coincide with what was in the bottle. She said she looked at the EMR, and the documentation there also did not coincide with what was in the bottle and what was on the paper MAR. During her investigation, she reviewed that LVN B had administered 7 of the 9 doses that Resident #1 received. She said that it was difficult to determine when the discrepancy happened other than the documentation. She said the discrepancy could have occurred between April 2024 and October 2024. She said that only nurses have access to the narcotics. She said that the last time the morphine was filled was in April 2024. She said she was responsible for ensuring that nurses followed the policy and counted the medications. She said she had not checked the carts before the discrepancy was identified. She said the ADON, and registered nurses were responsible for maintaining the carts and count sheets. She said this had not happened before. She said the potential negative outcome was that the resident's morphine could be missing and that residents could potentially miss doses of medication. She said Resident #1's morphine was PRN, and he did not miss any doses. She said she was unaware that the liquid morphine was not being counted. She said she never physically saw them count but could hear the nurses outside of her office counting. She said she was familiar with and trained on the medication administration policy. She said training over the medication process and shift change was taught upon hire and through in-services periodically. She said new nurses shadow a tenured staff for a couple of days before they work alone. She said medication training, including medication count, was standard nurse training, and none of her nurses are new nurses. She said she did not have any documentation to indicate that nurses had been trained specifically on the facility shift change medication count process. She said it was her expectation that the oncoming and off-going nurse count all medications to include liquid morphine. She said the nurses were responsible for accurate counts, and she believed the reason that no one was counting the liquid morphine was because it was not being administered frequently. She said all the nurses trusted each other's word that liquid morphine was accounted for. She said Resident #1's morphine was no longer in the facility as it was picked up the day before the interview. She said she had pictures and would provide them. She said that she indicated in writing where the morphine level was and where it should have been. During an interview on 10/17/24 at 9:05 AM, the ADM stated she was familiar with and had been trained on the medication administration policy. She stated that the potential negative outcome of not following the policy and not reconciling medications was that there could be oversight of medication administration and missing medications. She said this could place residents at risk for missing medications. She said staff could also be impaired if they took the medications and provided care for residents. She said she was unaware that Resident #1's liquid morphine was not being counted during shift change. She said it was her expectation that the facility process and policies were followed. She said that what should have been happening was that at shift change, medication counts should have occurred with the oncoming nurse and outgoing nurse. She said they both should confirm all medication inventory, including liquid medications. She said she was ultimately responsible for all the activities that were carried out in the facility. She said the reason she was given why the discrepancy was missed was the nurses were not counting the liquid morphine and had become relaxed in the process. She said the nurses were taking each other's word that the medication had not been given. During an interview on 10/17/24 at 11:26 AM, the Pharmacy Operations Manager stated that they did chart reviews when the consultant was in the facility. He stated he was not sure if the counts were audited. He said a count sheet was sent with each medication and reconciled after each dispense. The said the facility filed the sheet when they were done with the medications. He said they sent a count sheet to reconcile the count, which was how they could track medications. If the resident was out of the medication earlier than usual, the facility has to start the request process over, order, and give a reason why the medication was out. It depends on the documentation as to how soon the medication could be refilled, and this could cause a delay in the resident receiving their medication. During an interview on 10/17/24 at 11:32 AM, Pharmacy Consultant F stated she has not been going to the facility since May 2024. She said Pharmacy Consultant G has been going in her place. She said when she was attending in person, she would talk to them about anything they needed to be aware of. She would complete a medication storage review. She checked the carts and did a control drug audit simultaneously. If it were drug destruction day, she would participate in the destruction. The controlled drug audit was random, where she would go through the cart and pick at least 5 drugs and made sure that everything they signed out was given was in PCC. She said she tried to check liquid morphine but did not always. She said liquid morphine was hard to measure and that it typically came with a little more than 30 ML. She said 1-2 MLs were hard to see, but 8 MLs were a significant amount missing, which was concerning. She said during her audits, she had never seen any issues outside of documentation. She said there were times when the medications were given but not documented, but they could be reconciled with PCC, paper MAR, and the medication. Attempted to contact Pharmacy Consultant G on 10/17/24 at 11:57 AM and she did not answer. A message was left, but no return call was received. During an interview on 10/17/24 at 12:04 PM, the ADON stated Resident #1 did not use the morphine often and that the morphine had been in the facility since April 2024. She said the discrepancy in the morphine should not have happened, and she and all of her staff should have been counting the liquid morphine every day. She said during shift change, they were not counting but were verbally stating whether or not they used the morphine that day. She said the staff were never physically laying eyes on the morphine bottle. She stated she had never been present at any time the morphine was used but was in the facility one time when LVN C had administered the medication. She said she was unsure of the date but that it was the day or so before the discrepancy was identified. The ADON stated she had never checked the MAR (paper or in the EMR). She said it was not one of her job duties before the discrepancy in the morphine was identified by LVN D. She said she did not know who was responsible for monitoring the count sheets before the discrepancy in the morphine was identified. She said every nurse employed at the facility was not counting the liquid morphine, and she knew this because she interviewed them all, and they admitted that they were not counting them. She said she was told by the nurses that they knew better, and they were not counting the liquids. She said that because of the discrepancy, all nurses were reprimanded. She said she had not cross-checked the resident's pain scale with the administration of the morphine for Resident #1. She said the potential negative outcome of not following the medication administration policy and counting all medications was there could be missing doses, especially if the staff did not know that the medication was gone. She said it could affect the resident because he may not have the needed medication. She said Resident #1 did not miss any doses as it was a PRN medication. She said a new bottle of morphine usually had a little over 30 MLs. She said she had been trained in medication administration and was familiar with the medication administration policy. Medication administration was a part of being a nurse. She said she expected that all medications, including liquid morphine, would be counted during each shift and that each person who took the medication cart would be responsible for completing the task of counting the medications. She said she did not have a reason why the liquid morphine was not counted but that she had been working all over the place due to staffing and did not have a reason to audit. She said she did not realize it was a problem until it was. During an interview on 10/17/24 at 12:35 PM, LVN H stated Resident #1 rarely ever needed pain medication outside his scheduled pain medication. She stated she did not notice the discrepancy in the morphine. She said that they would eyeball the morphine but that they all trusted each other, and that was why it was not being counted. She said she had been trained to count all medication. She said she was unaware that there was morphine missing. She said the potential negative outcome was that morphine could go missing. During an interview on 10/17/24 at 12:54 PM, LVN D stated she worked roughly at the facility for about a week. She was unsure of the date, but it was at least a week ago, and it had to be her 2nd day working at the facility. She said she believed it could have been Thursday, 10/10/24. She stated she came in and did the counts with LVN E. She said the medications were accurate, but the liquid morphine for Resident #1 was not. She said she immediately called and notified the ADON and DON. She said she observed the liquid morphine under 20 ML, but the sheet said 27.75 ML. She said morphine was always over, and that amount missing was alarming. She said the DON and ADON told her they would address it once they arrived at the facility. She said the count sheet looked like someone noticed it, and someone wrote over it on 07/26/24. She said it was her understanding that no one was counting the liquid morphine and that they had become relaxed about counting it. She said LVN C had said they were taking each other's word. She said that as a nurse, it was a part of their education to count all medications, but she had not specifically been trained at the facility. She said that on her first day, she worked the floor, and the day she identified the discrepancy was her second day. She said that she did not even know Resident #1 had liquid morphine. She said she did not count it on her first day. She said the sheet for it was hidden behind another sheet in the count book. She said she had to make a tab and label it liquids. Attempted an interview on 10/17/24 at 1:35 PM with LVN C and it was unsuccessful because the phone number was incorrect. During an interview on 10/17/24 at 1:41 PM, LVN A stated she no longer worked at the facility and had not worked there for about a month. She said she had never administered morphine to Resident #1. She said she could not verify that it was her signature on the MAR without seeing it. She said Resident #1 usually did not need morphine. She said they counted all medications at shift change and did not need to count the morphine because it was not given that she was aware of. During an interview on 10/17/24 at 1:46 PM, LVN E worked the night shift before the discrepancy in the morphine was identified. She stated she was unsure of the exact date. She said when she came on shift, she did not know that Resident #1 had any morphine but noticed it when she was getting off. She said the documentation said there should have been 27 ML, but there was 22 ML. She said she had never counted the liquid morphine and was unsure when the last time it was counted. She said the narcotic box was deep, and it was hard to see in the back. She said this was why she did not see it before. She said it was nursing 101 that you count all the medications when you come on shift and when you go off shift. She said she was an agency nurse and did not receive any specific training on medication administration when she came to the facility. During an interview on 10/17/24 at 1:52 PM, LVN B stated she no longer worked at the facility. She said she only administered liquid morphine to Resident #1 a few times. She said a few times was at least two times over a few months. She said she knew when he needed pain medication because of his behavior. She said usually, if an aide said he moaned while being changed, she would know he was in pain. She said she had been trained to count all medications, including liquids. She said when she worked at the facility, they counted all medications. She said one nurse would call out the number, and they would look at the medication together. During an interview on 10/17/24 at 2:49 PM, Resident #1 could not answer any questions about his medication administration. During an interview on 10/17/24 at 3:00 PM, the DON stated that there was no written policy that specified all medications should be counted. She stated that this was under the standard of practice. During an interview on 10/17/24 at 3:05 PM, the ADM stated that the medication administration policy was generalized and that they would intervene as appropriate if it was not followed. During an interview on 10/22/24 at 4:07 PM, LVN C stated that he was unaware that there was any morphine missing until the ADON told him. He stated that he was the last to administer medication to Resident #1. He said the amount he documented on the MAR sheet was the correct amount left after administering the medication. He said he was unaware if staff had become relaxed in counting but that he counted all medicines, including the liquid morphine. He stated he believed that the bottle was switched. He said he had been trained to count all medications and could not speak for other nurses as to whether they were counting all medications during shift change. He said each individual nurse was responsible. He said the potential negative outcome was staff could be taking the residents' morphine. He said only the nurses had access to the nurses' cart. Record review of the facility policy, Administering Oral Medications, revised October 2010 revealed: Purpose The purpose of this procedure is to provide guidelines for the safe administration of oral medications. Preparation Assemble the equipment and supplies needed. Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure. Medication Administration Record The policy did not reveal any further information regarding the documentation and reconciliation process, but did refer to the facility policy, Documentation of Medication Administration. Record review of the facility policy, Documentation of Medication Administration, revised April 2007 revealed: Policy Statement The facility shall maintain a medication administration record to document all medications administered. Policy Interpretation and Implementation A nurse or certified medication aide (where applicable) shall document all medications administered to each resident on the residents' s medication record (MAR). Administration of medication must be documented immediately after (never before) it is given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices based on the comprehensive assessment of residents for one of five residents (Residents #2) reviewed for wound care. The facility failed to follow physician's orders for wound care for Residents #2. The failure placed residents at risk of wound deterioration and infection. Findings included: Record review of Resident #2's clinical record reflected a face sheet, dated 09/12/24, which indicated the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #2's diagnoses included ORIF Left hip (Surgical hip replacement), Epilepsy (seizure disorder), end stage renal disease (kidney disease), and major depressive disorder (mental health condition that causes a persistently low or depressed mood and loss of interest in activities). Review of Resident #2's Quarterly MDS Assessment, dated 08/23/24, reflected the resident cognition was moderately impaired with a BIMS score of 08 . Review of Resident #2's physician's orders, dated 09/12/24, reflected: Order date: 08/16/24, Daily dry dressing changes to incisions LLE. No alcohol, betadine, peroxide, or ointments to incisions. Ok to shower and allow soapy water to run over incisions. rinse well and pat dry and apply new dry dressing. no soaking in any body of water. one time a day Daily and PRN. Review of Resident #2's September 2024 treatment administration record reflected there was documentation indicating Resident #2's wound to the left hip was treated on 09/06/24 by LVN C. Review of Resident #2's electronic medical records progress note dated 09/12/24 reflected no documentation related to Resident #2's wound to the left hip was treated on 09/05/24. Review of the Resident #2's weekly skin assessment dated [DATE] revealed she had other existing skin issue: surgical incision. During an interview on 09/12/24 at 08:51 AM with CNA F, she stated on 09/07/24 at 06:30 AM she found Resident #2 on her bed with blood soaked through her dressing, fitted sheet, and draw sheet. She stated she reported it to the charge nurse LVN D. During an interview on 09/12/24 at 09:16 AM with LVN D, she stated at approximately 06:30 AM CNA F reported to her Resident #2 was oozing over her dressing and had blood on her sheets. She stated she observed Resident #2's wound, checked wound care orders, and gathered supplies to complete Resident #2's wound care. She stated she took a picture of the date and time of the wound's dressing that was dated 09/05/24 at 19:30 (07:30 PM). She stated the dressing had old and new blood. She stated she cleaned the wound which did not have pus and it was oozing serosanguinous and was not purulent (thick, milky discharge) but did have a foul odor. She stated the odor was from the wound dressing not the wound. She stated the odor had improved on 09/08/24. She stated the dressing was change by the night nurse on 09/05/24 and was not changed again until 09/07/24 by her. She stated she did not notify the physician but Resident #2 needed frequent dressing changes. She stated a fresh surgical wound should be changed and not wait for two days to change it, especially since there are specific doctor's orders. She stated she reported to the on call ADON on 09/07/24 at 06:49 AM Resident #1 dressing was not changed on 09/06/24. Record review of a photo on 09/12/24 taken by LVN D revealed Resident #2 wound dressing dated 09/05/24 at 1930 (time) with LVN E's initials. On 09/12/24 at 11:45 AM and 12:57 PM a call placed to LVN C with no answer. During an interview on 09/12/24 at 02:29 PM with the ADON, she stated the dressing change for Resident #2 not being done was reported to her on 09/07/24. During an interview on 09/12/24 at 02:30 PM with the DON, she stated due to low census the medication nurse did do the wound care between medication passes. She stated all nursing staff was notified on 09/05/24 in a group text. She stated if there was no documentation it was not done. She stated she was not sure why the dressing change was not done. She stated Resident #2's dressing should have been changed with a date, time and initials. She stated Resident #2's orders were for dressing changes daily and prn. She stated that all staff had been trained on how to document treatments. The DON stated monitoring was done daily by the DON and ADON. She stated the potential negative outcome could be not providing the residents with care, infection, and the wound could worsen. During an interview on 09/12/24 at 03:05 PM with the Admin, she stated all physician's orders should be followed and documented at the time the treatment was done. She stated training and monitoring was done by the DON or designee. She stated all staff should have been trained. She stated the potential negative outcome could be infection, poor healing at the site, but not at site could lead to sepsis if left unattended. Record review physician progress note dated 09/10/24 reflected exam today revealed patient has serosanguineous drainage from the left hip. Patient arrives to clinic in a wheelchair for ambulation with dry dressings over her left hip incision. On physical examination her wound is draining serosanguineous fluid of the left side. Follow up: patient will be admitted tot he hospital today through the emergency department. We will plan on irrigation debridement to the leg as needed. Record review of facility's policy titled Wound Care with a revision date October 2010, reflected: .Documentation The following information should be recorded in the resident's medical record: 1. The type of wound care given 2. The date and time the wound care was given . 4. The name and title of the individual performing the wound care . 10. The signature and title of the person recording the data .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed ensure residents with wounds receive the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure ulcers from developing or spreading for 1 of 2 Residents (Resident #1). The facility failed to follow physician's orders for Resident #1's pressure ulcer. This failure placed Residents at risks for infection and the development of new or worsening pressure injuries or wounds. Resident #1 Record review of Resident #1's clinical record reflected a face sheet, dated 09/12/24, which indicated the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included hypotension (low blood pressure), multiple sclerosis (chronic autoimmune disease), schizoaffective disorder (mental illness), bipolar disorder (mental illness that causes extreme mood swings, energy changes and difficulty concentrating), major depressive disorder (mental health condition that causes a persistently low or depressed mood and loss of interest in activities), seizures, and anxiety (feeling of fear and worry). Review of Resident #1's Quarterly MDS Assessment, dated 08/06/24, reflected the resident was cognitively intact with a BIMS score of 15 . Review of Resident #1's physician's orders, dated 09/12/24, reflected: Order date: 08/15/24, Wound Care: to coccyx (upper buttock) : Cleanse with wound cleanser, pat dry, apply triad, cover with bordered gauze or silicone dressing. Everyday shift for wound care. Review of Resident #1's September 2024 treatment administration record reflected there was no documentation indicating Resident #1's wound to her coccyx was treated on 09/10/24 . Review of Resident #1's electronic medical records progress notes from 09/09/24 through 09/12/24 reflected no documentation of Resident #1's wound to her coccyx. Review of the Resident #1's weekly skin assessment dated [DATE] revealed she had an existing pressure ulcer on the coccyx and treatment was done daily. During an interview on 09/12/24 at 11:23 AM with LVN A, he stated he was the charge nurse on station 2 on 09/10/24 and he did not do the wound care for Resident #1. He stated the medication nurse on station 1 did medications and all wound care. He stated LVN B was on station 1 on 9/10/24 and he did see him doing wound care on station 2 but was not sure if he did Resident #1's would care. During an interview on 09/12/24 at 11:55 AM with LVN B, he stated he was the medication nurse on station 1 on 09/10/24. He stated he was not aware he was to do all the wound care on station 2. He stated he did assist with wound care as needed. He stated he did not do wound care for Resident #1 on 09/10/24. During an interview on 09/12/24 at 02:30 PM with the DON, she stated due to low census the medication nurse did do the wound care between medication passes. She stated all nursing staff was notified on 09/05/24 in a group text. She stated if there was no documentation it was not done. She stated she was not sure why the dressing change was not done. She stated Resident #2's dressing should have been changed with a date, time, and initials. She stated Resident #2's orders were for dressing changes daily and prn. She stated that all staff had been trained on how to document treatments. The DON stated monitoring was done daily by the DON and ADON. She stated the potential negative outcome could be not providing the residents with care, infection, and the wound could worsen. During an interview on 09/12/24 at 03:05 PM with the Admin, she stated all physician's orders should be followed and documented at the time the treatment was done. She stated training and monitoring was done by the DON or designee. She stated all staff should have been trained. She stated the potential negative outcome could be infection, poor healing at the site, but not at site could lead to sepsis if left unattended. Record review of facility's policy titled Wound Care with a revision date October 2010, reflected: .Documentation The following information should be recorded in the resident's medical record: 1. The type of wound care given 2. The date and time the wound care was given . 4. The name and title of the individual performing the wound care . 10. The signature and title of the person recording the data .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 2 of 2 residents (Residents #1 and #3) and 3 of 3 (LVN D, CNA G and CNA H) staff reviewed for infection control. LVN D failed to follow enhanced barrier precautions, change gloves, and wash her hands or use ABHR during Resident #1's and #3's wound care and Resident #3's transfer to bed. CNA G failed to follow enhanced barrier precautions before entering and exiting Resident #3's room. CNA H failed to follow enhanced barrier precautions before entering and exiting Resident #3's room and during the transfer of Resident #3 to bed. These failures could place residents at risk for spread of infection and cross contamination. Findings include: Resident #1 Record review of Resident #1's clinical record reflected a face sheet, dated 09/12/24, which indicated the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included hypotension (low blood pressure), multiple sclerosis (chronic autoimmune disease), schizoaffective disorder (mental illness), bipolar disorder (mental illness that causes extreme mood swings, energy changes and difficulty concentrating), major depressive disorder (mental health condition that causes a persistently low or depressed mood and loss of interest in activities), seizures, and anxiety (feeling of fear and worry). Review of Resident #1's Quarterly MDS Assessment, dated 08/06/24, reflected the resident was cognitively intact with a BIMS score of 15. Record review of Resident #1's care plan dated 06/06/24 reflected no care plan for wounds . Record review of Resident #1's physician orders dated 09/12/24 reflected Wound Care: to coccyx. Cleanse with wound cleanser, pat dry, apply TRIAD, cover with bordered gauze or silicone dressing. Every day shift for wound care, dated 08/15/24. During an observation on 09/12/24 at 10:49 AM revealed LVN D cleaned Resident #1 coccyx (upper buttock) wound with wound cleanser and gauze and patted dry with gauze. LVN D applied triad ointment and covered the wound with bordered gauze. LVN D removed gloves and repositioned resident. LVN D did not wash her hands or use ABHR when changing gloves between dirty and clean dressing and LVN did not wash hands or use ABHR after removal of gloves. LVN D did not wear proper PPE during wound care. Resident #3 Record review of Resident #1's clinical record reflected a face sheet, dated 09/12/24, which indicated the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #3's diagnoses included anxiety (feeling of fear), dementia (memory loss), hypertension (high blood pressure), and atrial fibrillation (irregular heartbeat). Review of Resident #3's Annual MDS Assessment, dated 07/25/24, reflected the resident's cognition was severely impaired with a BIMS score of 05. Section M - skin condition reflected resident had an unhealed stage 3 pressure ulcer. Record review of Resident #3's care plan dated 08/04/24 reflected a focus area Resident #3 had stage 3 pressure ulcer to the left hip with interventions for an air mattress . Record review of Resident #3's physician orders dated 09/12/24 reflected Wound Care: right abd: cleanse with wound cleanse, pat dry, skin prep area, cover with tegaderm. Every day shift and as needed for wound care, dated 08/27/24. Wound Care: to left hip: cleanse with wound cleanse, pat dry, apply TRIAD, and cover with border gauze. Every day shift for wound care, dated 08/27/24. During an observation on 09/12/24 at 01:15 PM revealed LVN D put gloves on and LVN D did not wash her hands or use ABHR. CNA H put gloves on and CNA H did not wash her hands or use ABHR. CNA H and LVN D entered Resident #3's room to transfer the resident to bed. LVN D and CNA H did not wear proper PPE. LVN D came out to the treatment cart and picked up Sani wipes. LVN D re-entered the resident's room and cleaned the bed side table. LVN D removed her gloves and put on new gloves and gathered supplies. While LVN D was standing at treatment cart outside of Resident #3's room, CNA G entered the room and CNA G did not wash his hands or use ABHR. CNA G went to Resident #3's bedside. CNA G exited the room and CNA G did not wash his hands or ABHR. Observation of EBP sign posted beside door reflected Stop ENHANCED BARRIER PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. After CNA G exited Resident #3's room, LVN D left the treatment cart with gloves on and went to another cart at the nurse's station. LVN D then went into the supply room. Observed LVN D walking in the hallway with gloves on carrying wound cleanser. LVN D held up the wound cleaner to the surveyor and stated, I got a new bottle. LVN D returned to the cart and gathered supplies and entered Resident #3's room. LVN D placed the supplies on the bedside table and removes her gloves. LVN D did not wash her hands or use ABHR. LVN D opened the gauze using her bare hands and sprayed the gauze with wound cleanser . LVN D put on gloves and LVN D did not wash her hands or use ABHR. LVN D picked up gauze off bedside table and cleaned the abdomen wound (Wound #1). LVN D removed gloves and used ABHR and put gloves on and applied skin prep and cover dressing to abdomen wound. LVN D opened a new dressing, put triad ointment in cup, put hand in pocket to get a marker, wrote on the dressing, put marker back in pocket, put wound cleaner on the gauze, opened a smaller dressing, put hand back in pocket to get a marker, wrote on the gauze and placed the marker on bedside table. LVN D removed her gloves then used ABHR and put on new gloves. LVN D cleaned left hip wound (Wound #2) then opened Q-tip and gauze. LVN D then patted left hip wound dry, applied triad ointment to left hip wound bed and covered with dressing . LVN D picked up a marker and wrote on the abdomen dressing on Resident #3 abdomen . LVN D removed gloves and used ABHR. During an observation on 09/12/24 at 10:49 AM and 01:15 PM revealed a sign on the wall beside resident #1 and #3 door that reflected, Stop ENHANCED BARRIER PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. Providers and staff must also: wear gloves and a gown for the following high contact resident care activities. Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, wound care: any skin opening requiring a dressing . During an interview on 09/12/24 at 01:35 PM with LVN D, she stated I should have changed my gloves when going from clean to dirty. I thought I did with as many glove changes as I did. She stated she did not see a problem with wearing gloves down the hallway and then touching supplies because they were all considered dirty until they opened them. She stated she did not recall touching supplies with her bare hands. When asked about wearing proper PPE she stated, I did not realize she (Resident #3) was in isolation. She stated the sign outside the resident door (Enhanced Barrier Precautions) was on everyone's door. When asked if she had been trained on enhanced barrier precautions she stated, Apparently not enough. When asked if she was required to wear a gown she stated, that's what the paper (sign posted outside Resident #3 door) says, but I have not seen anyone in this facility wear a gown. When asked about handwashing between glove changes and before entering or exiting a room LVN D stated Thank you. and walked away. During an interview on 09/12/24 at 02:00 PM with CNA G, he stated he did not wash his hands before entering or when exiting Resident #3 . He stated he had been trained on enhanced barrier precautions. He stated the potential negative outcome could be the spread of infections to other residents. During an interview on 09/12/24 at 02:30 PM with the DON, she stated LVN D should have changed her gloves between dirty and clean and either used ABHR or soap and water. She stated hands should have been washed or use ABHR before any treatment. She stated gloves were not to be worn in the hallways and LVN D should know that because she was a senior nurse. She stated gloves should have been changed between wounds (wound #1 and #2) . She stated staff should never put gloved hands in their pocket to get items, it should all be on the bedside table. She stated during wound care and transferring a resident the staff should have been wearing gloves and gown. She stated gloves and gown were required for any direct care of the resident. She stated all staff had recently been trained on enhance barrier protections. She stated the ADON/DON were responsible for monitoring and training staff. She stated the potential negative outcome could be spread of infections. During an interview on 09/12/24 at 03:05 PM with the Admin she stated gloves should be changed when going from dirty to clean. She stated supplies should not be touched by bare hands. She stated the new enhanced barrier protection does require gloves and gowns for direct care. She stated all staff had been trained. She stated the DON was responsible for staff training and in-services. She stated the potential negative outcome could be spread of infection. During an interview on 09/12/24 at 03:30 PM with CNA H, she stated she did not wash her hands or use ABHR before putting on gloves. She stated she did not wear a gown while transferring Resident #3 into bed. She stated there was no reason she did not wear a gown other than she forgot. She stated she had been trained on enhanced barrier protection and has read the stop sign outside Resident #3 door. She stated the potential negative outcome could be spread of germs and infection. Record review Hand Hygiene Competency Checklist, dated 07/22/24 for CNA H, reflected competency goals met. Record review Donning and Doffing PPE Competency Checklist, dated 07/22/24, for CNA H reflected competency goals met. Record review Enhanced Barrier Precautions Sign undated for CNA H, reflected CNA H's signature across the page. Record review in-service title Proper Wound Care, dated 07/12/24, reflected LVN D's signature. Record review Clean Dressing Change Competency dated 08/23/24, for LVN D reflected Yes checked for skill had been demonstrated to show competency. Record review Hand Hygiene Competency Checklist dated 09/12/24, for LVN D reflected competency goals met. Record review Donning and Doffing PPE Competency Checklist, dated 09/12/24, for LVN D reflected competency goals met. Record review Enhanced Barrier Precautions Sign undated for LVN D, reflected LVN D's initials on page. Record review facility policy titled Enhanced Barrier Precautions dated August 2022 reflected the following: Policy Statement - Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation . 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident . 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: . c. transferring . h. wound care (any skin opening requiring a dressing) . 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and or indwelling medical devices regardless of MDRO colonization. 6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk . 10. Signs are posted on the door or wall outside the resident room indicating the type of precautions and PPE requires . Record review facility policy titled Wound Care, revised date October 2010, reflected the following: Purpose: the purpose of this procedure is to provide guidelines for the care of wounds to promote healing . Steps in the procedure . 4. Put on exam gloves. Loosen and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves . 9. Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound . 14. Be certain all clean items are on clean field .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to respect the resident's right to personal privacy for 1 of 1 residents (Resident #3 reviewed for privacy issues in that: 1. CNA A failed to provide full privacy for Resident #3 during peri care by not completely closing privacy curtains or providing a towel or sheet during peri care. 2. ADON failed to provide privacy by not providing a sheet or towel to cover the resident and not fully drawing Resident #3's curtain during peri care and wound care. This failure could cause residents to feel uncomfortable, disrespected, and possible exposure to anyone passing by. Findings include: Resident #3: Record Review of Resident #3 face sheet dated 07/07/2024 originally admitted on [DATE] with a readmission date of 06/27/2024 reveals a [AGE] year-old female with a diagnosis of: metabolic encephalopathy (chemical imbalance in the blood that causes a problem with the brain), urinary tract infection, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), depression, high blood pressure, anemia, type 2 diabetes, fibromyalgia (a long-term condition that causes widespread pain and tiredness), Sjogren syndrome (an immune system illness that causes dry eyes and dry mouth), type 2 diabetes, acid reflux disease. Record review of resident #3 MDS with a date of 06/09/2024, reveals a BIMS score of 12 which indicates resident is moderately impaired. During an observation of peri care with CNA A for Resident #3 on 07/08/2024 at 1:07 PM. CNA A failed to provide complete privacy for Resident #3 during peri care. CNA A did not provide a sheet for maximum privacy during peri care. CNA A did not pull the curtains all the way during peri care causing Resident #3's body to be exposed during peri care . CNA A gathered peri care supplies and went into Resident #3's room to provide peri care. CNA A shut Resident #3's room door but did not close the curtain dividing the door from the resident all of the way. CNA A did not pull the privacy curtain to the full extent to cover the bed. CNA A removed Resident #3 removed clothing from the waist down to provide peri care and completed peri care while not providing a sheet for maximum privacy. Observed a camera at the end of Resident #3's bed for family to be able to view Resident #3. CNA A completed peri care with Resident #3. During an observation of wound care with ADON for Resident #3 on 07/08/2024 at 1:54 PM. ADON entered Resident #3's room to provide wound care and did shut the door but did not close privacy curtain all the way around the resident to provide optimum privacy. The curtain was only halfway drawn on the right side of the resident that divides the resident from the door. ADON removed Resident #3's clothing from the waist down. There was a camera where the family could view the entire procedure. While Resident #3's pants were pulled down and the brief was open, a CNA walked into the room. There was no sheet that had been provided to cover the resident. ADON and CNA completed peri care and ADON completed wound care and exposed Resident #3 the entire time. During an Interview with ADON on 07/08/2024 at 3:03 PM, she stated that she should have provided more privacy for the resident's by shutting the door, making sure blinds are closed, and closing the curtains. ADON stated that the policy stated that staff should provide privacy during care. ADON stated that the negative potential outcome for not providing privacy during care is that the resident is being exposed and it may make them feel bad or upset. ADON stated that she had been trained in privacy by in-services when needed or quarterly. During an Interview with DON on 07/08/2024 at 3:24 PM, she stated that she expects that when staff walks in a resident's room to provide resident care they should close the door, close the blinds, close all curtains and cover the resident to provide privacy. The DON stated that the negative potential outcome would be that resident's may not want other people to see their business and may also cause them to become embarrassed. DON stated that the facility provides training quarterly, monthly, and as needed by in-services. During an Interview with CNA A on 07/08/2024 at 3:46 PM, she stated that she did know to provide complete privacy for residents. She stated that she wasn't thinking about pulling the curtain closed, just providing peri care. CNA A stated that the negative potential outcome of not providing privacy is that someone could walk in and see the resident. CNA A stated that she had been trained in providing privacy for residents by in-services, monthly. Record review of facility policy, labeled, Resident Rights date Revised December 2016, revealed: Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: a). a dignified existence b). be treated with respect, kindness, and dignity. t). privacy and confidentiality. Record review of facility provided in-services, labeled, Peri Care, dated June 20, 2024, revealed: 1. Enters room and identifies self and patient/resident. 2. Explains the procedure addresses questions and other PPE as indicated. 3. Provide privacy 4. Washes hands, applies disposable gloves and other PPE as indicated. 5. Assembles supplies at bedside. 6. Raise bed to comfortable working height; assists the resident to a supine position.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Residents #1) reviewed for care plans. The facility failed to implement a care plan area for physician order for pressure ulcer treatment of coccyx (the small bone at the bottom of the spine), left thigh, coccyx, and left hip. The facility did not have a care plan area for Resident #1 removing his own dressing from his pressure ulcers. These failures could place residents at risk of not receiving the care required to meet their individualized needs. Findings include: Record review of Resident #1 face sheet revealed a [AGE] year-old male, admitted on [DATE] with a primary diagnoses of lung cancer, anemia, low potassium, high blood pressure, hyperlipidemia, atherosclerotic heart disease, nicotine dependence, cancer in bone, tachycardia, congestive heart failure, acid reflux. Record review of Resident #1's admission MDS dated [DATE] revealed Resident #1 had a BIMS of 9 which indicates Resident #1 is moderately impaired cognition. Under Bladder and Bowel Resident #1 is listed as always being incontinent with urinary and bowel. Under skin conditions Resident #1 is listed as being a risk of developing pressure ulcers but is not listed as having any pressure ulcers upon admission. Record review of Resident #1's Care Plan date revealed: on 06/03/2024, Resident #1 was care planned for wound care with interventions of: monitor ulcers for signs of infection, notify provider if no signs of improvement on current wound regimen, provide wound care per treatment orders. There is no care plan for Resident #1 removing his own bandages. Record review of Resident #1's Order Summary, date received 06/04/2024, revealed: On 05/27/2024 verbal orders were given for wound care to the coccyx. Cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure as needed for wound care. On 05/27/2024 verbal orders were given for wound care to the coccyx. Cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care. On 05/27/2024 verbal orders were given for wound care to the left hip. Cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure as needed for wound care. On 05/27/2024 verbal orders were given for wound care to the left hip. Cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care. On 05/27/2024 verbal orders were given for wound care to the left thigh. Cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure as needed for wound care. On 05/27/2024 verbal orders were given for wound care to the left thigh. Cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care. Record review of Resident #1's Treatment Administration Record for June 2024, date received of 06/04/2024, revealed: Wound Care: coccyx, cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care, start date: 05/27/2024 at 6:00 PM. Treatment record indicated that June 1st and 2nd wound care was provided. There was nothing indicated for the 3rd. Wound Care: left hip, cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care, start date: 05/27/2024 at 6:00 PM. Treatment record indicated that June 1st and 2nd wound care was provided. There was nothing indicated for the 3rd. Wound Care: left thigh, cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care, start date: 05/27/2024 at 6:00 PM. Treatment record indicated that June 1st and 2nd wound care was provided. There was nothing indicated for the 3rd. Wound Care: coccyx, cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care, start date: 05/27/2024 at 6:00 PM. There was nothing indicated for PRN. Wound Care: left hip, cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care, start date: 05/27/2024 at 6:00 PM. There was nothing indicated for PRN. Wound Care: left thigh, cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care, start date: 05/27/2024 at 6:00 PM. There was nothing indicated for PRN. Observation had been made of Resident #1 on 06/03/2024 at 8:37 PM, revealed the ADON went with the Surveyor to show Resident #1's pressure ulcers. The ADON gathered a few supplies to cover Resident #1's pressure ulcers when completed with observation. Resident #1 was lying on his back in his room, sleeping. Resident #1 awakened to interview and allowed observations of his pressure ulcers. It was observed that Resident #1's pressure ulcer on his left thigh was uncovered, and with no dressing. Resident #1's pressure ulcer on his coccyx was observed with having a dressing hanging off the backside above the pressure ulcer and being exposed, the dressing was dated 06/02/2024 with initials. Resident #1's pressure ulcer to his coccyx was observed with a dressing soaked with drainage from the wound. The dressing had a watery brown drainage from the pressure ulcer on the dressing that was hanging off the top of the pressure ulcer. Resident #1 had blood on the backside and side of his gown and bedding. Observed the ADON following physician's orders per cleaning all wounds and covered with foam dressings with date and initials. Interview on 06/03/2024 at 8:32 PM with CNA A revealed she said that she checks the residents every 2 hours. The CNA C stated that she was not aware that Resident #1's pressure ulcers were uncovered but she had just come onto shift and had not had a chance to make her rounds. The CNA C stated that she had seen Resident #1's pressure ulcer uncovered before. The CNA C stated that she is not sure if Resident #1 had removed the dressing or if someone didn't cover the pressure ulcers. The CNA C stated that she had not witnessed staff not covering the pressure ulcers. The CNA C stated that if she had seen the pressure ulcers uncovered, she would report it to the LVN, the ADON, or DON. CNA C stated that she would check to make sure that the pressure ulcers were covered. Interview on 06/03/2024 at 8:50 PM with ADON revealed that Resident #1's orders did call for the pressure ulcers to be cleaned and covered. The ADON stated that she did not know why the pressure ulcers were uncovered. The ADON stated that the pressure ulcers are scheduled to be cleaned and covered for night shift. The ADON stated that night shift begins at 6 pm to 6 am. The ADON stated that she would assume that the staff had not had time to cleanse and cover the pressure ulcers yet but as long as it had gotten completed before the end of the night shift, it would be fine. ADON stated that usually the staff will make rounds every 2 hours, so they would report to the nursing staff if pressure ulcers were uncovered. Interview on 06/03/2024 at 9:18 PM with Resident #1 revealed that he is pain because of the open wounds and them not being covered. Resident #1 stated that he had not taken off any bandages. Resident #1 stated that the nursing staff do treat his wounds and usually covers them but stated he could not tell that they were uncovered until he moves around a little. Interview on 06/03/2024 at 9:10 PM with LVN B revealed that he was unaware of Resident #1's pressure ulcers because he is only PRN and had not worked in the facility for a while. The LVN B stated that he would get to the pressure ulcers when he finished medication pass. Interview on 06/04/2024 at 5:32 PM with ADON revealed that she is not sure why there is not a dressing on the left leg pressure ulcer. The ADON stated that the orders do state to put a dressing on all pressure ulcers for Resident #1. The ADON stated that all nursing staff are responsible for making sure that the dressing is on. The ADON stated, Resident #1 does take off the dressings sometimes. There was no dressing observed by Surveyor in the room on the bed or on the floor to show that the resident might have removed it from the pressure ulcer. The ADON stated that the negative potential outcome of the pressure ulcers being uncovered is that it could cause infection, bigger pressure ulcers could occur, and potentially be hospitalized . Interview on 06/04/2024 at 5:45 PM with DON revealed that she does agree with the physician's orders for pressure ulcers for Resident #1. The DON stated that she expects the staff to follow physician's orders. The DON stated that she did expect staff to let someone know when a pressure ulcer is uncovered so that staff could cover the pressure ulcer as soon as possible and not wait the whole shift. The DON stated that she and the ADON are responsible for training staff. The DON stated that she had provided training for pressure ulcers monthly by in-services. The DON stated that the negative potential outcome for not following physician's orders for Resident #1's uncovered pressure ulcers would be they could get worse and possibly get infected. Interview on 06/04/2024 at 6:01 pm with Administrator revealed that she expects the staff to follow physician orders and cover pressure ulcers. The Administrator stated that the DON is responsible for the training for the staff and the staff have been trained. The Administrator stated that the pressure ulcer could worsen or get infected if they are not treated according to physician orders. Requested policy for Care Plan from DON and care plan policy was not provided on 06/04/2024 at 5:15 PM. DON stated that she had contacted corporate, and they had stated that there is not a policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure Resident 1's Physician Ordered dressings for the left thigh, coccyx, and left hip, based on the comprehensive assessment of a resident the resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for (Residents #1) resident reviewed for pressure ulcer care, in that: 1. Resident #1's pressure ulcer on his left thigh was observed being uncovered with no dressings. Resident #1's pressure ulcer on coccyx (a small bone at the base of the spinal column) was observed with having a dressing hanging off the backside above the pressure ulcer with the pressure ulcers being exposed. Resident #1's pressure ulcer to the coccyx was observed with the dressing soaked with drainage from the pressure ulcer. These failures could place residents with wounds at an increased and unnecessary risk of complications such as pain, acquiring new pressure ulcers, worsening of existing pressure ulcers, and infection. Findings included: Findings include: Record review of Resident #1 face sheet revealed a [AGE] year-old male, admitted on [DATE] with a primary diagnoses of lung cancer, anemia, low potassium, high blood pressure, hyperlipidemia, atherosclerotic heart disease, nicotine dependence, cancer in bone, tachycardia, congestive heart failure, acid reflux. Record review of Resident #1's admission MDS dated [DATE] revealed Resident #1 had a BIMS of 9 which indicated Resident #1 is moderately impaired cognition. Under Bladder and Bowel Resident #1 is listed as always being incontinent with urinary and bowel. Under skin conditions Resident #1 is listed as being a risk of developing pressure ulcers but is not listed as having any pressure ulcers upon admission. Record review of Resident #1's Care Plan date revealed: on 06/03/2024, Resident #1 was care planned for pressure ulcers care with interventions of: monitor ulcers for signs of infection, notify provider if no signs of improvement on current wound regimen, provide wound care per treatment orders. There is no care plan for Resident #1 removing his own dressings. Record review of Resident #1's Order Summary, date received 06/04/2024, revealed: On 05/27/2024 verbal orders were given for wound care to the coccyx. Cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure as needed for wound care. On 05/27/2024 verbal orders were given for wound care to the coccyx. Cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care. On 05/27/2024 verbal orders were given for wound care to the left hip. Cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure as needed for wound care. On 05/27/2024 verbal orders were given for wound care to the left hip. Cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care. On 05/27/2024 verbal orders were given for wound care to the left thigh. Cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure as needed for wound care. On 05/27/2024 verbal orders were given for wound care to the left thigh. Cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care. Record review of Resident #1's Treatment Administration Record for June 2024, date received of 06/04/2024, revealed: Wound Care: coccyx, cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care, start date: 05/27/2024 at 6:00 PM. Treatment record indicated that June 1st and 2nd wound care was provided. There was nothing indicated for the 3rd. Wound Care: left hip, cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care, start date: 05/27/2024 at 6:00 PM. Treatment record indicated that June 1st and 2nd wound care was provided. There was nothing indicated for the 3rd. Wound Care: left thigh, cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care, start date: 05/27/2024 at 6:00 PM. Treatment record indicated that June 1st and 2nd wound care was provided. There was nothing indicated for the 3rd. Wound Care: coccyx, cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care, start date: 05/27/2024 at 6:00 PM. There was nothing indicated for PRN. Wound Care: left hip, cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care, start date: 05/27/2024 at 6:00 PM. There was nothing indicated for PRN. Wound Care: left thigh, cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care, start date: 05/27/2024 at 6:00 PM. There was nothing indicated for PRN. Observation had been made of Resident #1 on 06/03/2024 at 8:37 PM, revealed the ADON went with the Surveyor to show Resident #1's pressure ulcers. The ADON gathered a few supplies to cover Resident #1's pressure ulcers when completed with observation. Resident #1 was lying on his back in his room, sleeping. Resident #1 awakened to interview and allowed observations of his pressure ulcers. It was observed that Resident #1's pressure ulcer on his left thigh was uncovered, and with no dressings. Resident #1's pressure ulcer on his coccyx was observed with having a dressing hanging off the backside above the pressure ulcer with the pressure ulcer being exposed, with the dressing being dated 06/02/2024 with initials. Resident #1's pressure ulcer to his coccyx was observed with a dressing soaked with drainage from the pressure ulcer. The dressing had a watery brown drainage from the pressure ulcer on the dressing that was hanging off the top of the pressure ulcer. Resident #1 had blood on the backside and side of his gown and bedding. Observed the ADON following physician's orders per cleaning all wounds and covered with foam dressings with date and initials. Interview on 06/03/2024 at 8:32 PM with CNA A revealed she said that she checks the residents every 2 hours. The CNA C stated that she was not aware that Resident #1's pressure ulcers were uncovered but she had just come onto shift and had not had a chance to make her rounds. The CNA C stated that she had seen Resident #1's pressure ulcers uncovered before. The CNA C stated that she is not sure if Resident #1 had removed the dressing or if someone didn't cover the pressure ulcers. The CNA C stated that she had not witnessed staff not covering the pressure ulcers. The CNA C stated that if she had seen the pressure ulcers uncovered, she would report it to the LVN, the ADON, or DON. CNA C stated that she would check to make sure that the pressure ulcers were covered. Interview on 06/03/2024 at 8:50 PM with ADON revealed she said that Resident #1's orders did call for the pressure ulcers to be cleaned and covered. The ADON stated that she did not know why the pressure ulcers were uncovered. The ADON stated that the pressure ulcers are scheduled to be cleaned and covered for night shift. The ADON stated that night shift begins at 6 pm to 6 am. The ADON stated that she would assume that the staff had not had time to cleanse and cover the pressure ulcers yet but as long as it had gotten completed before the end of the night shift, it would be fine. ADON stated that usually the staff will make rounds every 2 hours, so they would report to the nursing staff if pressure ulcers were uncovered. Interview on 06/03/2024 at 9:18 PM with Resident #1 revealed that he said that he is pain because of the open pressure ulcers and them not being covered. Resident #1 stated that he had not taken off any bandages. Resident #1 stated that the nursing staff do treat his wounds and usually covers them but stated he could not tell that they were uncovered until he moves around a little. Interview on 06/03/2024 at 9:10 PM with LVN B revealed he said that he was unaware of Resident #1's wounds because he is only PRN and had not worked in the facility for a while. The LVN B stated that he would get to the pressure ulcers when he finished medication pass. Interview on 06/04/2024 at 5:32 PM with ADON revealed she said that she is not sure why there is not a dressing on the left leg wound. The ADON stated that the orders do state to put a dressing on all pressure ulcers for Resident #1. The ADON stated that all nursing staff are responsible for making sure that the dressings is on the pressure ulcers. The ADON stated, Resident #1 does take off the dressings sometimes. There was no dressing observed by Surveyor in the room on the bed or on the floor to show that the resident might have removed it from the pressure ulcer. The ADON stated that the negative potential outcome of the pressure ulcers being uncovered is that it could cause infection, bigger pressure ulcers, and potential to be hospitalized . Interview on 06/04/2024 at 5:45 PM with DON revealed she said that she does agree with the physician's orders for pressure ulcers for Resident #1. The DON stated that she expects the staff to follow physician's orders. The DON stated that she did expect staff to let someone know when a pressure ulcer is uncovered so that staff could cover the pressure ulcer as soon as possible and not wait the whole shift. The DON stated that she and the ADON are responsible for training staff. The DON stated that she had provided training for pressure ulcers monthly by in-services. The DON stated that the negative potential outcome for not following physician's orders for Resident #1's uncovered pressure ulcers would be they could get worse and possibly get infected. Interview on 06/04/2024 at 6:01 pm with the Administrator revealed she said that she expects the staff to follow physician orders and cover pressure ulcers. The Administrator stated that the DON is responsible for the training for the staff and the staff have been trained. The Administrator stated that the pressure ulcers could worsen or get infected if they are not treated according to physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 4 Residents observed for infection control for practices (Resident #2, #3, #4) in that: 1. CNA A failed to wash her hands before or during providing incontinent care for Resident #2. CNA A failed to wash her hands for the 15 seconds per facility policy. 2. CNA A failed to wash her hands before, during, and after providing incontinent care for Resident #3. 3. CNA A and CNA B failed to wash their hands before, during, and after providing incontinent care for Resident #4. These failures could place residents at risk for infection through cross contamination of pathogens. The findings included: Resident #2: Record Review of Resident #2's face sheet revealed a [AGE] year-old male, admitted on [DATE] with a primary diagnoses of dementia, atherosclerotic heart disease (damage or disease in the heart's major blood vessels), retention of urine, high blood pressure, depression, upper respiratory infection, pneumonia, hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone). Records Review of Resident #2's admission MDS dated [DATE] revealed Resident #2 had a BIMS of 6 which means Resident #2 had severe cognitive impairment. Record Review of Resident #2 Care Plan dated 04/24/2022 revealed: Resident #2 had a pressure ulcer on the right gluteal (buttocks) fold with limited mobility with the interventions of: assess/record/monitor wound healing (Tuesday, Thursday, Saturday) measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the doctor. Record Review of Resident #2's Care Plan dated 04/24/2022 revealed pressure ulcer on left gluteal fold with limited mobility. Resident #2's care staff to follow facility policies/protocols for the prevention/treatment of skin breakdown. Resident #2 had pressure ulcer on left gluteal fold with limited mobility with interventions of Administer Resident #2 treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing (Tuesday, Thursday, Saturday) measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the doctor. Educate Resident #2's family/caregivers as to causes of skin breakdown, including transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Resident #2's nursing care staff to follow facility policies/protocols for the prevention/treatment of skin breakdown. Record Review of Resident #2's Care Plan dated 04/24/2022 revealed pressure ulcer on right abdominal fold with limited mobility with the interventions of administer Resident #2 treatments as ordered and monitor for effectiveness, assess/record/monitor Resident #2's wound healing (Tuesday, Thursday, Saturday) measure length, width and depth were possible, assess and document status of wound perimeter, wound bed and healing progress, report improvements and declines to the doctor, educate Resident #2's family/caregivers as to causes of skin breakdown, including transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Record Review of Resident #2's Orders dated 01/17/2023 revealed: apply moisture barrier ointment to the right and left buttocks, coccyx, and right and left ischium (the curved bone forming the base of each half of the pelvis) after each incontinent episode. Record Review of Resident #2's Orders dated 01/17/2023 revealed: apply moisture barrier ointment to right and left buttocks, coccyx, and right and left ischium after every shift to prevent skin break down. Observed incontinent care with CNA A for Resident #2 on 06/04/2024 at 10:28 AM revealed Resident #2 was sitting in a wheelchair in the dining room when he was moved to his room by CNA A and he was soaking wet, stating, I guess I peed everywhere. The CNA A put on clean disposable gloves and did not wash her hands before providing incontinent care. The CNA A removed the urine-soaked pants off Resident #2 and put them to the side in a plastic bag. The CNA A removed the urine soaked brief and disposed of it in the trash. CNA A provided incontinent care. The CNA A did not change gloves or wash her hands. The CNA A turned Resident #2 to the left side and proceeded to complete incontinent care of the buttocks area. The CNA A placed the clean brief underneath Resident #2 and laid him on his back. The CNA A fastened the front side of the brief. The CNA A placed the new clean dry pants on Resident #2 and covered him with a blanket. The CNA A washed her hands in Resident #2's restroom by turning on the faucet, placing two squirts of soap in her hand, lathering the soap using friction for 10 seconds and then rinsing. The CNA A used a clean, dry paper towel to dry her hands and turned off faucet. The CNA A gathered all trash and took with her to throw away. Resident #3: Record Review of Resident #3 face sheet revealed a [AGE] year-old female, admitted on [DATE] with a primary diagnoses of sepsis (a life-threatening complication of an infection), low blood pressure, kidney failure, cellulitis (a common and potentially serious bacterial skin infection), respiratory failure, chronic obstructive pulmonary disease (a group of lung diseases that block the airflow and make it difficult to breath), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood glow), anxiety disorder, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone), anemic (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin), heart failure, acid reflux, osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wear down). Observed the CNA, A providing assistance with toileting Resident #3 on 06/04/2024 at 1:35 PM. The LVN A did not wash her hands but put on clean gloves to help Resident #1 with using the restroom. The CNA A placed on clean gloves and did not wash her hands before, during, or after providing incontinent care or assisting with toileting. The CNA A was observed assisting Resident #3 with cleaning her with wipes after Resident #3 had used the restroom in the toilet. The CNA A proceeded in taking one wipe and cleaning Resident #3. The CNA A then turned Resident #3 to the left side and began cleaning the buttocks area. The CNA A proceeded in grabbing a clean brief and placing it underneath the resident and then laying Resident #3 on her back. The CNA A fastened Resident #3's brief and pulled up her pants and covered her with the blanket. The CNA A did not wash her hands before leaving Resident #3's room. Resident #4: Record Review of Resident #4 face sheet revealed a [AGE] year-old female, admitted on [DATE] with a primary diagnosis of depression, type 2 diabetes, high blood pressure, urinary tract infection, osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down). Record Review of Resident #4's admission MDS dated [DATE] revealed Resident #4 had a BIMS of 13 which means Resident #4 is cognitively intact. The MDS indicated that Resident #4 uses extensive assistance for toilet use with substantial and max assistance. The MDS listed Resident #4 as urinary and bowel incontinent. Record Review of Resident #4's care plan dated 11/15/2023 revealed that Resident #4 has bowel and bladder incontinence with impaired mobility and generalized weakness with interventions of: clean peri-area with each incontinence episode. Monitor and document intake and output as per facility policy. Observed the CNA A and CNA B providing incontinent care for Resident #4 on 06/04/2024 at 2:29 pm. CNA A did not wash her hands prior to gathering incontinent supplies. The CNA A and CNA B did not wash their hands prior to starting incontinent care for Resident #4. CNA A and CNA B did not wash their hands while gathering incontinent supplies for Resident #4. The CNA A and CNA B put on clean disposable gloves. Observed Resident #4's brief wet with urine. The CNA A and CNA B did not wash hands during incontinent care. The CNA B did not wash hands or change gloves before placing on clean brief. The CNA B did not perform hand hygiene after providing incontinent care for Resident #4. The CNA A did perform hand hygiene after providing incontinent care and disposing of gloves. Interview on 06/04/2024 at 4:18 PM with CNA A revealed that she knew that she should have washed her hands while caring for residents but failed to do it because she was nervous. The CNA A stated that she had been doing care for residents so long that she had just gotten into routine. The CNA A stated that she had been trained in infection control practices and handwashing through in-services and skills checks, monthly. The CNA A stated that she understood that she should have washed her hands. The CNA A stated that she just was not paying attention and did not think to wash her hands. The CNA A stated to make sure to wash hands and use gloves. The CNA A stated that the negative potential outcome is spread of infections. Interview on 06/04/2024 at 4:26 PM with the ADON revealed she said, that she and the DON are responsible for the training for the staff. The ADON stated that she expects staff to always wash their hands. The ADON stated that they have trained the staff for infection control and had staff to return demonstration. The ADON stated that the facility had given the staff the tools to provide adequate infection control practices and they are just not utilizing the tools. The ADON stated that the policy stated to wash hands while providing care and anytime going from dirty to clean. The ADON stated that they provide in-services and competency checks monthly. The ADON stated that the negative potential outcome of not washing hands is the spread of infection and germs. Interview on 06/04/2024 at 4:44 PM with CNA B revealed that she said that she understands where she went wrong and should have washed her hands before, during, and after care. The CNA B stated that she had been trained in handwashing by in-services, skill-checks, with return demonstration with either the ADON or DON, every month. The CNA B stated that policy states to wash hands before, during, and after resident care. The CNA B stated that the negative potential outcome for not washing hands is the spread of infection and germs. Interview on 06/04/2024 at 5:49 PM with the DON., the DON revealed she said that the policy states that staff should wash their hands before, during, and after providing care for residents and before preparing their supplies. The DON stated that she expects staff to follow policy and procedure guidelines and to wash their hands. The DON stated that she and the ADON are responsible for providing training for infection control practices/ handwashing. The DON stated that they provide competency checks for handwashing with return demonstration and in-services for infection control practices, monthly. The DON stated that the negative potential outcome for not using proper infection control practices/ hand washing would be the spread of germs. Interview on 06/04/2024 at 6:03 PM with the Administrator revealed she said that she expects the staff to wash their hands and use infection control practices. The Administrator stated that the staff have all been trained through competency checks and in-services approximately monthly. The Administrator stated that the staff should know after all the training that they should use infection control practices when providing care. The Administrator stated that the DON and ADON is responsible for overseeing the training. The Administrator stated that the negative potential outcome is the spread of infection and germs. Record review of the facility policy titled; Infection Control date revised 10 2018 revealed: Policy Statement: This facility's infection control policies are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and Implementation: 1. This facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, [NAME] or veteran, or prayer source. 2. The objectives of our infection control policies and practices are to: b). Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public. .4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities. Record review of the facility policy titled; Handwashing/ Hand Hygiene date Revised August 2019 revealed: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: .2. All personnel shall follow the handwashing hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. .6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a). When hands are visibly soiled 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations. b). Before and after direct contact with residents. d). Before performing any non-surgical invasive procedures. e). Before and after handling an invasive device (urinary catheters, IV access sites) g). Before handling clean or soiled dressing, gauze pads, etc. h). Before moving from a contaminated body site to a clean body site during resistant care. i). After contact with a resident's intact skin. j). After contact with blood or bodily fluids. k). After handling used dressings, contaminated equipment, etc. m). After removing gloves. n). Before and after entering isolation precaution setting. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/ hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 10. Single-use disposable gloves should be used: a). Before aseptic procedures. b). When anticipating contact with blood or body fluids. c). When in contact with a resident, or the equipment or environment of a resident, who is on contact precautions. Procedure: Washing Hands. 1. Wet hands first with water, then apply an amount of product recommended by the manufacturer to hands. 2. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. 3. Rinse hands with water and dry thoroughly with a disposable towel. 4. Use towel to turn off the faucet. 5. Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis. Using Alcohol-Based Hand Rubs: 1. Apply generous amount of product to palm of hand and rub hands together. 2. Cover all surfaces of hands and fingers until hands are dry. 3. Follow manufactures directions for volume of product to use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have physician orders for the resident's immediate care, at the time each resident was admitted for 1 of 3 residents (Resident #23) reviewed for admission Physician Orders. The facility failed to have Physician orders for dialysis treatments, graft dressing, changes and resident care before and after dialysis for Resident #23. This failure could place residents at risk of not receiving proper medical care related to dialysis services which could result in a decline in health. Findings include: Record review of Resident #23's face sheet dated 02/27/24 revealed an admission date of 01/03/24 with diagnoses which included: chronic systolic congestive heart failure (heart disease), end stage renal disease (kidney disease), and dependence on renal dialysis (kidney treatments). Record review of the facility's document titled, Resident Matrix, dated 02/27/24 revealed Resident #23 received hemodialysis treatments. Record review of Resident #23's comprehensive MDS, dated [DATE], revealed Resident #23 was understood and had a BIMS score of 15 which indicated her cognition was intact. Record review of Resident #23's Care Plan initiated on 01/22/24 revealed; Problem: Resident #23 needs hemodialysis related to renal failure; Goal: [Resident #23] will have immediate intervention should any of signs or symptoms of complications from dialysis occur through the review date. [Resident #23] will have no signs or symptoms of complications from dialysis through the review date; Interventions: Encourage [Resident #23] to go for the scheduled dialysis appointments. [Resident #23] receives dialysis three times weekly. Monitor/document/report PRN any signs or symptoms of infection to access site: redness, swelling, warmth, or drainage. Record review of Resident #23's order summary report dated 02/27/24 revealed there were no orders for dialysis treatments, graft dressing changes or care of the resident before and after dialysis treatments. Interview on 02/29/24 at 9:17 AM, LVN A stated Resident #23 does go to dialysis treatments offsite and she has seen transportation taking Resident #23 to dialysis every Tuesday, Thursday, and Saturday. LVN A stated there were no physician orders for dialysis treatments or dialysis graft care at the facility. LVN A stated the nurses were responsible for ensuring residents who went to dialysis had orders for dialysis treatments, graft dressing changes and care. LVN A stated she was unsure why the orders were not in Resident #23's physician orders. LVN A stated the potential negative outcome to the resident was they could get an infection at the graft site. Interview on 02/29/24 at 9:24 AM, the DON stated she did not know why Resident #23 was missing physician orders for dialysis treatments, graft dressing changes or care of the resident before and after dialysis. The DON stated all of the nurses were responsible for ensuring physician orders for dialysis care were in place. The DON stated her and the ADON were responsible for ensuring dialysis care orders were in place after admission. The DON stated the potential negative outcome to the resident was there may be issues with the graft that the facility was unaware of and made the resident at risk to not get a dialysis treatment. Interview on 02/29/24 at 9:31 AM, the ADM stated the admitting nurse was responsible for ensuring dialysis orders were in place and the DON and ADON were responsible to follow-up and review the admission orders. The ADM stated she was unsure why the dialysis orders were missing for Resident #23. The ADM stated the potential negative outcome was the resident could miss a dialysis treatment. Record review of the facility policy titled, End-Stage Renal Disease, Care of a Resident with, with a revised date of September 2010, reflected the following: Policy Statement: Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure new residents were not admitted with mental disorders unless the State mental health authority had determined, based on an independent physical and mental evaluation performed by a person or entity other than the state mental health authority, prior to admission for 3 of 19 residents (Residents #11, #28 and #43) reviewed for PASARR screenings. The facility failed to ensure Residents #11, #28 and #43 had an accurate PASARR Level 1 assessment when they had a diagnosis of mental illness. This failure could place residents at risk for not receiving care and services to meet their needs. The findings were: 1. Record review of Resident #11's face sheet, dated 02/07/24, reflected a [AGE] year-old female with an initial admission date of 01/10/23 and readmission on [DATE]. Resident #11 had primary admitting diagnoses which included metabolic encephalopathy (alteration in consciousness caused due to brain dysfunction) dated 10/25/23 and additional diagnoses dated 01/10/13 were major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and schizoaffective disorder (mental illness),post-traumatic stress disorder (flashbacks, nightmares, serve anxiety and uncontrollable thoughts about an event) and bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs and lows) dated 01/26/21. Record review of Resident #11's physician orders, dated 02/27/24, reflected a diagnosis which included schizoaffective disorder. The resident was prescribed Escitalopram Oxalate 20mg by mouth one time a day dated 10/25/23. Record review of Resident #11's psychological services progress, note dated 02/27/24, reflected resident diagnoses which included schizoaffective disorder (mental disorder in which people interpret reality abnormally) and post-traumatic stress disorder. Record review of Resident #11's care plan, reflected a focus: [Resident #11] has a depressive disorder date initiated 07/02/20. Record review of Resident #11's PASARR assessment Level 1 Screening, dated 04/13/15, under Section C0100 reflected documentation which indicated Resident #11 did not have a mental illness. The PASARR Level I screening was also certified by the Assessor on 04/13/15 which indicated the information was true and accurate. Record review of Resident #11's Quarterly MDS assessment, dated 02/18/24, reflected Resident #11 had a BIMS score of 12, which indicated the resident's cognition was moderately impaired. Section I (Active Diagnoses) reflected a diagnosis of depression, bipolar disorder (mental illness - unusual mood swings), schizophrenia (mental disorder in which people interpret reality abnormally) and post-traumatic stress disorder. During an interview on 02/28/24 at 03:45 PM with the DON, she stated the last PASARR Level 1 done for Resident #11 was in 2015. She stated she was not sure why a new PASARR Level 1 was not done when she got the new diagnosis. She stated she was sending in a new PL1 today (02/28/24). 2. Record review of Resident #28 electronic face sheet reflected a [AGE] year-old male most recently admitted to the facility on [DATE]. Resident #28 had a diagnosis which included schizoaffective disorder (mental disorder in which people interpret reality abnormally), bipolar type (mental illness - unusual mood swing). Record review of Resident #28's Quarterly MDS, dated [DATE], reflected Active Diagnoses which included schizoaffective disorder, bipolar type. Resident #28 had a BIMS of 15, which indicated the resident was cognitively intact. Record review of Resident #28 , undated, care plan reflected a focus area and diagnosis of schizoaffective disorder, bipolar type, this problem started on 07/03/2024. Resident #28 was prescribed Venlafaxine extended release 5 mg once a day. Record review of Physician progress notes for Resident #28, dated 02/29/2024, reflected under current medications, Resident #28 was prescribed Venlafaxine extended release 75mg once a day for bipolar II disorder (mental illness - unusual mood swings). Record review of Resident #28's Preadmission Screening and Resident Review Level One (PL1) form, dated 5/19/2021, reflected under section C0100 Mental Illness an answer of No, which indicated the resident did not have a mental illness. 3. Record review of Resident #43's electronic face sheet reflected a [AGE] year-old female most recently admitted to the facility on [DATE]. Resident #43 had a diagnosis which included major depressive disorder (Mental health condition that causes a persistently low or depressed mood and loss of interest in activities). Record review of Resident #43's Quarterly MDS, dated [DATE], reflected under Section I, Active Diagnoses, a diagnosis of major depressive disorder. Under Section C, Cognitive Patterns, reflected a BIMS of 13, which indicated the resident was mildly cognitively impaired. Record review of Resident #43's , undated, care plan reflected a focus area and diagnosis of major depressive disorder, this problem started 09/01/2023. Resident #43 was prescribed Fluoxetine HCl Capsule 20 MG and Mirtazapine Oral Tablet 7.5 MG once a day. Record review of Physician progress notes for Resident #43, dated 02/29/2024, reflected under current medications, Resident #43 was prescribed Fluoxetine HCl Capsule 20 MG and Mirtazapine Oral Tablet 7.5 MG once a day address her diagnosis of major depressive disorder. Record review of Resident #43's Preadmission Screening and Resident Review Level One (PL1) form, dated 12/02/2022, reflected under Section C0100, Mental Illness an answer of No, which indicated the resident did not have a mental illness. During an interview on 02/29/24 at 11:15 AM with the Administrator, she stated Residents #28 and #43 had a diagnosis of mental illness. The ADM stated Residents #28 and #43 did not have a PASARR 2 Evaluation as their PASARR 1s were negative. The ADM stated the purpose of the PASARR 1 was to identify if a Resident required additional services. She said if the PASARR 1 was positive then it was put into an online system and they reached out to the necessary people to ensure a PASARR 2 Evaluation was done. She said the MDS nurse was responsible for entering the PASARR 1 into the system, the MDS nurse was also responsible for ensuring PASARR 1s were accurate by comparing them to medical records. The ADM stated the potential harm if a resident with a diagnosis of a mental illness who had a negative PASARR 1, and no subsequent level PASARR 2 evaluation was the residents could potentially go without services. During an interview with the DON on 02/29/24 at 11:55 AM, she stated Residents #28 and #43 had diagnosis of mental illnesses. The DON stated Residents #28 and #43 did not have PASARR 2 Evaluation as their PASARR 1s were negative. The DON stated it was the MDS nurses' responsibility to ensure every resident admitted to the facility had an accurate PASARR 1. The DON stated it was the MDS nurses' responsibility to ensure PASARR 1s were completed accurately by comparing them to the residents' medical records. The DON stated a positive PASARR 1 should be referred to the local mental health authority for completion of a PASARR 2 Evaluation. The DON stated the potential harm to a resident without an accurate PASARR 1 and a subsequent PASARR 2 Evaluation was the resident would not receive the services they needed. Record review of the facility's Preadmission Screening and Resident Review (PASARR) Policy, Revised March 2019, reflected: all applicants admitted to a Medicaid-certified nursing facility are evaluated for mental health prior to admissions and offered the most appropriate setting for their needs. If the PASARR level one screening indicated the individual may have an Intellectual Disability or a Mental Illness diagnosis the facility will confer with local mental health providers to complete a PASARR level two screening. Following the completion of the level two screening a care plan will be developed by the facility in order to meet the needs of a resident with an Intellectual Disability or a Mental Illness diagnosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 3 of 19 residents (Residents #9, #11 and #160) reviewed for care plans. This facility failed to develop a care plan for Residents #9, #11 and #160 to include bedrails. This failure could place residents at risk of not receiving the care required to meet their individualized needs. Findings include: Resident #9 Record review of the admission record for Resident #9, dated 02/27/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: urinary tract infection (bladder infection), fecal impaction (difficult bowel movements), and acute kidney failure (kidney disease). Record review of the comprehensive MDS assessment dated [DATE] revealed that Resident #9 was understood and had a BIMS score of 00 indicating that the resident's cognition was severely impaired. Record review of the current care plan for Resident #9, undated, revealed there was no specific care plan regarding bedrails. Observation on 02/27/24 at 10:41 AM revealed Resident #9 was noted to have ¼ side rails on right and left side of bed. Resident #11 Record review of the admission record for Resident #11, dated 02/27/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: metabolic encephalopathy (problem in the brain), acute and chronic respiratory failure (lung disease), and pneumonia (lung infection). Record review of the comprehensive MDS assessment dated [DATE] revealed that Resident #11 was understood and had a BIMS score of 12 indicating that the resident's cognition was intact. Record review of the current care plan for Resident #11, undated, revealed there was no specific care plan regarding bedrails. Record review of the active physician orders for Resident #11, dated 02/27/24, revealed the following order: May use siderails for positioning and ease of mobility as an enabler every shift for siderails with an order start date of 09/29/22. Resident #160 Record review of the admission record for Resident #160, dated 02/27/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: cerebral palsy (motor disability), seizures (neurological disorder), and muscle weakness. Record review of the comprehensive MDS assessment dated [DATE] revealed that Resident #160 was usually understood and had a BIMS score of 15 indicating that the resident's cognition was intact. Record review of the current care plan for Resident #160, undated, revealed there was no specific care plan regarding bedrails. Record review of the active physician orders for Resident #160, dated 02/27/24, revealed the following order: 1/4 side rails for bed mobility and positioning with a start date of 06/29/20. During an interview on 02/29/24 at 12:07 PM, the DON and the ADON stated they were both responsible for ensuring the care plans for the residents were completed. The DON and the ADON stated they were unsure why Residents #9, #11 and #160 were missing care plans for bed rails. The DON and ADON stated the care plans were audited last week but they did not look for bedrails in the care plan at that time. The DON stated the potential negative outcome to the residents was the bed rails would not be followed up on and assessed to see if they were still appropriate for the residents. During an interview on 02/29/24 at 12:16 PM, the ADM stated the DON and ADON were responsible for ensuring the care plans were completed. The ADM stated the facility had a change in nursing management last year and ensuring bed rails were care planned fell through the cracks. The ADM stated the potential negative outcome to the residents was staff could not be aware and it could cause a possible injury of some sort. Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, with a revised date of December 2016, reflected the following: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Residents #23) reviewed for dialysis. The facility failed to ensure Resident #23 had physician's orders for dialysis treatments, graft dressing changes related to dialysis or resident care before and after dialysis. This failure could place residents at risk of not receiving proper medical care related to dialysis services which could result in a decline in health. The findings were: Record review of Resident #23's face sheet dated 02/27/24 revealed an admission date of 01/03/24 with diagnoses which included: chronic systolic congestive heart failure (heart disease), end stage renal disease (kidney disease), and dependence on renal dialysis (kidney treatments). Record review of the facility's document titled, Resident Matrix, dated 02/27/24 revealed Resident #23 received hemodialysis treatments. Record review of Resident #23's comprehensive MDS, dated [DATE], revealed Resident #23 was understood and had a BIMS score of 15 which indicated her cognition was intact. Record review of Resident #23's Care Plan initiated on 01/22/24 revealed; Problem: Resident #23 needs hemodialysis related to renal failure; Goal: [Resident #23] will have immediate intervention should any of signs or symptoms of complications from dialysis occur through the review date. [Resident #23] will have no signs or symptoms of complications from dialysis through the review date; Interventions: Encourage [Resident #23] to go for the scheduled dialysis appointments. [Resident #23] receives dialysis three times weekly. Monitor/document/report PRN any signs or symptoms of infection to access site: redness, swelling, warmth, or drainage. Record review of Resident #23's order summary report dated 02/27/24 revealed there were no orders for dialysis treatments, graft dressing changes or care of the resident before and after dialysis treatments. Interview on 02/29/24 at 9:17 AM, LVN A stated Resident #23 does go to dialysis treatments offsite and she has seen transportation taking Resident #23 to dialysis every Tuesday, Thursday, and Saturday. LVN A stated there were no physician orders for dialysis treatments or dialysis graft care at the facility. LVN A stated the nurses were responsible for ensuring residents who went to dialysis had orders for dialysis treatments, graft dressing changes and care. LVN A stated she was unsure why the orders were not in Resident #23's physician orders. LVN A stated the potential negative outcome to the resident was they could get an infection at the graft site. Interview on 02/29/24 at 9:24 AM, the DON stated she did not know why Resident #23 was missing physician orders for dialysis treatments, graft dressing changes or care of the resident before and after dialysis. The DON stated all of the nurses were responsible for ensuring physician orders for dialysis care were in place. The DON stated her and the ADON were responsible for ensuring dialysis care orders were in place after admission. The DON stated the potential negative outcome to the resident was there may be issues with the graft that the facility was unaware of and made the resident at risk to not get a dialysis treatment. Interview on 02/29/24 at 9:31 AM, the ADM stated the admitting nurse was responsible for ensuring dialysis orders were in place and the DON and ADON were responsible to follow-up and review the admission orders. The ADM stated she was unsure why the dialysis orders were missing for Resident #23. The ADM stated the potential negative outcome was the resident could miss a dialysis treatment. Record review of the facility policy titled, End-Stage Renal Disease, Care of a Resident with, with a revised date of September 2010, reflected the following: Policy Statement: Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 3 of 19 residents (Resident #9, # 11 and #160) reviewed for bed rails. The facility failed to obtain consent prior to installing and utilizing bedrails for Residents #9, #11 and #160. This failure could place residents at risk for potential injuries. Findings include: 1. Record review of the admission record for Resident #9, dated 02/27/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #9 had diagnoses which included: urinary tract infection (bladder infection), fecal impaction (difficult bowel movements), and acute kidney failure (kidney disease). Record review of the comprehensive MDS assessment, dated 01/11/24, reflected Resident #9 was understood and had a BIMS score of 00, which indicated the resident's cognition was severely impaired. Record review of Resident #9's, undated, care plan reflected there was no specific care plan regarding bedrails. Record review of the active physician orders for Resident #9, dated 02/27/24, reflected there were no orders for bed rails. Record review of Resident #9's electronic medical records reflected no signed consent for bed rails . Record review of Resident #9's electronic medical record reflected no signed consent for bedrails . Observation on 02/27/24 at 10:41 AM revealed Resident #9 was noted to have ¼ side rails up on right and left side of bed . 2. Record review of Resident #11's face sheet, dated 02/07/24, reflected a [AGE] year-old female with an initial admission date of 01/10/23 and readmission on [DATE]. Resident #11 had primary admitting diagnoses which included metabolic encephalopathy (alteration in consciousness caused due to brain dysfunction), depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), schizoaffective disorder (mental illness), post-traumatic stress disorder (flashbacks, nightmares, serve anxiety and uncontrollable thoughts about an event) and bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs and lows). Record review of Resident #11's Quarterly MDS assessment, dated 02/18/24, reflected Resident #11 had a BIMS score of 12, which indicated the resident's cognition was moderately impaired. She required partial/moderate assistance with toileting, bathing, and personal hygiene. She required partial/moderate assistance with lying to sitting on side of bed, sit to stand, transfers and walking. Section P reflected she used bed rails daily. Record review of Resident #11's Care Plan dated 12/8/23 reflected no care plan for bed rails. Record review of Resident #11's physician orders, dated 02/27/24, reflected may use siderails for positioning and ease of mobility as an enabler, dated 09/29/22. Record review of Resident #11's treatment administration record, dated 02/28/24, reflected an order may use siderails for positioning and ease of mobility as an enabler every shift for siderail start date 09/29/22. Record review of Resident #11's Bed Rail Safety Review, dated 02/20/24 , reflected alternatives to bedrails were attempted and bedrails enable Resident #11 to turn and position. The resident used half rails on both sides. Record review of Resident #11's electronic medical records reflected no signed consent for bed rails. Observation on 02/27/24 at 11:00 AM revealed Resident #11 sitting in her wheelchair beside the bed. Resident #11's bed had half rails in an up position on both sides of bed. During an interview on 02/28/24 at 04:00 PM with the DON, she stated they did not have a consent signed for bedrails. She stated she was not aware a consent was needed . During an interview on 02/28/24 at 04:00 PM with the ADON, she stated when a resident needed bedrails, the nurse would complete a bedrail assessment, obtain order and care plan. She stated she was not aware a consent was needed. 3. Record review of the admission record for Resident #160, dated 02/27/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #160 had diagnoses which included: cerebral palsy (motor disability), seizures (neurological disorder) and muscle weakness. Record review of the comprehensive MDS assessment, dated 03/08/23, reflected Resident #160 was usually understood and had a BIMS score of 15, which indicated the resident's cognition was intact. Record review of Resident #160's, undated, care plan reflected there was no specific care plan regarding bedrails. Record review of the active physician orders for Resident #160, dated 02/27/24, reflected the following order: 1/4 side rails for bed mobility and positioning with a start date of 06/29/20. Record review of Resident #160's electronic medical record reflected no signed consent for bedrails . Observation on 02/27/24 at 10:43 AM revealed Resident #160 was noted to have ¼ side rails up on right and left side of bed . During an interview on 02/29/24 at 11:48 AM with the DON, she stated bed rails require a consent per her facility policy. She stated she was not aware consent was needed for bed rails. She stated bed rails were used for repositioning but can be a restraint. She stated the bed rails were put in place before she was hired as DON and was not sure shy no consent was obtained. She stated consent should be obtained before bed rails were put in place. She stated nurses were responsible for obtaining consent. She stated the potential negative outcome was adverse effect from bed rails and could be a liability issue if resident was injured. She stated she started training all nursing staff on Wednesday (2/28/24). During an interview on 02/29/24 at 11:57 AM with the ADM, she stated all residents who use bed rail require a consent. She stated there was no system in place to monitor for bed rail consents. She stated she was not sure why consents were not obtained prior to bed rail being put on bed. She stated the potential negative of using bed [NAME] could be resident injury. She stated he expectations were for all residents with bed rails to have consent signed before bed rails is placed on bed. Record review of the facility's policy titled Bed Safety and Bed Rails, dated August 2022, reflected: Policy Statement: Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met . 8. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 1 of 1 kitchen reviewed for dietary services. 1. The facility failed to ensure pots, pans and mixing bowls were stored in a manner to prevent contamination. 2. The facility failed to ensure foods were covered when being served out of the dining room. These failures could place residents at risk for food contamination and foodborne illness. The findings include: Observation during initial tour of the kitchen on 02/27/24 at 09:30 AM revealed pots and pans stored upright under the metal prep table. Mixing bowls were stacked inside each other stored right side up under the metal prep table. Observation during meal service on 02/27/24 at 12:10 PM revealed hall trays being prepared. DS A placed a fruit bowl on each tray which was uncovered. During observation of the kitchen on 02/28/24 at 09:45 AM revealed pots and pans stored upright under metal prep table. Mixing bowls were stacked inside each other stored right side up under the metal prep table. Observation during meal service on 02/28/24 at 12:00 PM revealed the hall trays were being prepared. DS B placed fruit bowl and drinks on each tray which was uncovered. During an observation of hall trays being delivered to station 1 revealed staff parked the tray cart between room [ROOM NUMBER] and 5. Staff removed trays from the cart and delivered to each room carrying uncovered food down the hall. Two staff were observed standing outside room [ROOM NUMBER] holding a tray with uncovered food and drinks while talking before they delivered the trays to room [ROOM NUMBER] and 13. During an interview on 02/29/24 at 11:10 AM with the DM, she stated the pots and pan should be stored upside down. She stated the mixing bowl were stored stacked inside each other right side up because when upside down it was hard to keep them from falling on the floor. She stated they should be stored upside down. She stated all dietary staff were responsible for making sure pots, pans and bowl were properly stored. She stated she was responsible for making sure dietary staff stored pots, pans and mixing bowls properly. She stated the potential negative outcome could be cross contamination. She stated all food that left the dining room should be covered. She stated all staff were trained. She stated the potential negative outcome was cross contamination while being delivered. She stated she did not have lids for the bowl used for fruit. She stated the drink glasses should have a lid on them. She stated she did not know why they were sent out of the kitchen uncovered. During an interview on 02/29/24 at 11:20 AM with DS B, she stated she did not cover the drinks, fruit bowl or vegetable when placed on the tray. She stated she normally worked as a cook, and she forgot to cover them. She stated she was trained. She stated all food that left the dining room was to be covered. She stated the potential negative outcome was cross contamination. During an interview on 02/29/24 at 11:48 AM with the ADM, she stated pots, pans and bowls should be stored properly to prevent contamination. She stated the DM was responsible for monitoring the kitchen staff. She stated all staff were trained. She stated the potential negative outcome could be cross contamination. She stated her expectations were for all items be stored properly. She stated all food should be covered when it left the dining room. She stated the DM and cook was responsible for making sure all food was covered. She stated all staff were trained on covering food items. She stated her expectations were for all staff to be cross trained and serve food properly. She stated the potential negative outcome could be cross contamination to food while delivering food to residents. Record review of the facility's policy, titled Nutrition Polices and Procedure, dated 2015, reflected: Subject: Ware washing using dishwashing machine . 12. Store clean sanitized dishes and utensils in a clean, dry location not exposed to splash or other contamination. Record review of the facility's policy, titled Nutrition Polices and Procedure, dated 2015, reflected the following: Subject: Meal Delivery . 9. Cover all food and beverages during transport through hallways

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law through established procedures for 2 of 5 (Resident #1 and Resident #2) reviewed for neglect. The ADM and DON failed to report Resident #1 fall that resulted in the resident sustaining 2 head laceration and being transported to a local emergency room. The ADM and DON failed to report Resident #2 fall that resulted in a Compression fracture of lumbar vertebra . These failures could place residents at risk of allegations not being reported and residents being at risk for emotional and physical abuse and exposure to alleged perpetrators. Findings Included: Record review of Resident #1's face sheet, dated [DATE], revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include dementia (memory loss), muscle weakness, cellulitis (skin infection that causes redness and swelling). Record review of Resident #1's Quarterly Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section GG 120. Mobility Devices C. Wheelchair Record review of Resident #1's care plane revealed the following: [DATE] Problem: Resident #1 is high risk for falls related to impaired cognition, weakness and unable to stand. Intervention: Anticipate and meet Resident #1 needs Review past falls and attempt to determine cause of the falls. Record review of the facility incident report from [DATE] to [DATE] revealed the following: Resident #1 had a witnessed fall on [DATE] Record review of Resident #1 progress notes revealed the following: [DATE] 9:55 AM Resident was being pushed out of dining room after breakfast, while being pushed her feet got caught up under wheelchair and resident fell out of chair hitting her head on the floor. Resident has a laceration to forehead with bleeding noted, resident did yell in pain when CNA tried to put sock back on her foot. Resident is being sent to ER via ambulance for a more in-depth evaluation of head. Author: LVN C Record review of Form 3613 dated and signed [DATE] revealed that on [DATE] CNA A was transporting Resident #1 from the dining room. CNA B noticed Resident #1 feet dragging and CNA B yelled for CNA A to stop. When CNA A stopped Resident #1 fell forward. Investigation findings was unfounded. Record review of CNA A's witness statement, dated [DATE], stated that he was pushing Resident #1 down the hall at 10:00 AM when she put her foot down and her forward momentum threw her out of the wheelchair. Review of CNA B's witness statement, dated [DATE], stated that she saw CNA A pushing Resident #1 in her wheelchair. CNA B said she told him to stop dragging Resident #1 feet and this was the reason Resident #1 was yelling. She stated she went to the Activity Director's office. At this time she had to tell CNA A again to stop because he was dragging Resident #1 feet under the chair and that was when she heard a loud bang and looked out and Resident #1 was on the floor. Record review of hospital records dated [DATE] revealed the following: admission Diagnoses: Laceration without foreign body of unspecified part of head and Laceration without foreign body of unspecified part of neck. Physical Exam Constitutional: She is in acute distress Hent: Patient has a 2.5 centimeter vertical laceration mid forehead with oozing bleeding and gaping. A Second laceration is noted above the left eyebrow triangular in nature and not gaping. It had been steri-stripped by the nursing home. Dermabound would be appropriate for this wound. Neck: Patient is in a c-collar Discharge instructions: Wound should be kept clean and dry. Glue will flake off in 7-10 days. Sutures should be removed in 7 days. Those can be done by urgent care or some primary care or she can return to the emergency room if needed. Record review of Resident #2's face sheet, undated, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with altered mental status, anxiety disorder (increased feeling of worry, fear and uneasiness), cellulitis (skin infection that causes redness and swelling) and muscle weakness Record review of Resident #2's Quarterly Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 13, which indicated the resident's cognition was cognitively intact. Section GG 120. Mobility Devices C. Wheelchair Record review of Resident #2's care plan revealed the following: [DATE] Problem: Resident #2 is resistive to care such as refusing to lay in bed to avoid falls out of wheelchair. Resident is redirected multiple times to avoid injuries and future falls. Resident #1 prefers to stay in chair while she sleeps and leans over in wheelchair despite redirection and education. [DATE] Resident #1 continues to get up without assist. She leans forward in the chair also causing herself to fall forward out the chair. Resident #1 took herself to the toilet and upon return to the bed she slid down onto her knees. Resident #1 does have Skin tears, first aid given, back to bed in lowest position, call light visible and within reach. Resident #2encouraged to utilize call light and wait for assistance. Intervention: o If possible, negotiate a time for ADLs so that the resident participates in the decision making process. Return at the agreed upon time. Date Initiated: [DATE] Problem: The resident #2 has had an actual fall with no injury's r/t Poor Balance, Psychoactive drug use, Unsteady gait [DATE]: Resident #2 forgot to lock her w/c, Resident #2 leaned forward and fell out to the floor. Resident #2 Left knee, treated by CN. Frequently Remind Resident #2 to lock her wheel chair, Frequent rounding on residents. Keep call light visible and within reach, anticipate residents needs, respond timely. [DATE] Resident #2 was reported to be on the floor in her room by her roommate. Resident #2 states she went to the bathroom and did not scoot far enough back into the wheelchair landed on floor causing multiple skin tears and a [NAME]. Reminded Resident #2 to utilize the call light and wait for assist. Continue POC. [DATE] Resident #2 on the floor. Assessed for injury and does have skin tears. [DATE]: Resident #2 leaned forward in her wheelchair causing her to fall Date Initiated: [DATE] Revision on: [DATE] Intervention: [DATE]: Resident #2 asleep in her w/c, dreamed she was dancing and fell out of wheelchair. Date Initiated: [DATE] Resident #2 fell out of her wheelchair outside leaning forward and hit her head. She did not want to go to the ER states, I barely hit my head. Date Initiated: [DATE] Record review of the facility incident report from [DATE] to [DATE] revealed the following: Resident #2 had a witnessed fall on [DATE] Record review of Resident #1 progress notes revealed the following: [DATE] Resident was found on the floor in her room. Wheelchair was upright and locked. Resident states that she slipped out of her wheelchair while leaning over to pick something up. Resident is short of breath, and has non-verbal signs and symptoms of pain to left lower leg and back. Noted new hematoma to proximal left lower leg, resident unable to toe touch pressure to lower extremity. This nurse called ambulance for transportation. Author: LVN D Record review of hospital records dated [DATE] revealed the following: Chief Complaint: Fall Clinical Impression: Compression fracture of lumbar vertebra (one or more of the vertebrae in the spine crumple) (New vertebral body height loss of L4 and L5 compared to t [DATE]). Discharge instruction: Please wear your brace whenever you are up and out of bed. Avoid bending, twisting, pulling, tugging or twisting your back. During a confidential interview, it was stated that the CNA was suspended on [DATE]. They stated that the incident was not reported regarding Resident #1 until [DATE] because the ADM said she wanted people to shut up about it. They stated the incident/fall with Resident #1 and with Resident #2 was not reported. They stated that the person responsible for reporting was the ADM. She said the ADM was the abuse coordinator. After Resident #1 fell out of her wheelchair, the Regional Clinical Director completed an in-service about wheelchair safety. They stated they had been trained to report unwitnessed falls, misappropriation of property, injuries, and anything dealing with abuse to the state entity. They said not reporting makes the facility appear to be hiding something. They said not reporting and not investigating incidents could result in a decrease in the level of care. They said the injury could progress into something worse if they do not thoroughly look into it. They said it could make the residents involved and other residents feel unsafe if they were cognitive enough to know the facility did not address it. They stated they did not know much about Resident #2's fall but that it had happened at night, and it was also not reported. During a confidential interview, it was stated It was their understanding that the only reason Resident #2 incident/fall was reported was because there had been an uproar made. The uproar was staff talking about it and questioning the death of the resident and why the incident with Resident #1 was not reported. They stated they had expressed to the DON that something was not right. They indicated that the DON had reassured them that everything was ok, that Resident #1 was checked at the hospital, and that the facility had done everything they were supposed to do. They said because of the response they were getting, it made them not want to talk about it anymore. They stated that due to the staff talking about Resident #1, the ADM would speak with them separately and tell them the gossiping needed to stop. They said that during their turn with the ADM, they expressed that they felt something was not right with the incident with Resident #1. They stated the Regional Clinical Director told them that because of the staff talking and not letting it go, the facility had to self-report the incident with Resident #1's fall. They stated that once it was reported, they were relieved. They stated regarding Resident #2 fall, she was told that she went to the hospital, and during updates, we were told that she had broken her back. They said they did not know if Resident #2 fall/injury had been reported. They stated that failure to report and investigate could make the residents scared and unsure of their care. They stated the abuse coordinator was the ADM. They stated they understood that the ADM had to be the one to call the incidents in. They said they do not know why Resident #1's incident was not called in, nor Resident #2. During a confidential interview, they stated they asked the DON if Resident #1's fall/incident had been reported. The DON told them it had not been reported. They said they were confused, especially since CNA A had been suspended, confirmed, and terminated. They stated they knew they had a 2-hour window to report it to the state. They said they knew that if there was no injury, they had 24 hours. They stated they were present when Resident #2 fell. When Resident #2 fell, the resident would not let the nurse touch her leg. There was a large lump on Resident #2 leg. They stated they placed Resident #2 in the wheelchair with the help of another staff. They said Resident #2 was in a lot of pain because we would not allow staff to touch her without wincing. They stated they asked the DON if Resident #2's fall had been reported, and again, they were told it had not been reported. They said they were told by the ADM that the incident with Resident #1 and Resident #2 was not reported because they knew what happened in both instances. They stated that they were concerned that both falls should have been reported. They said they reported their concerns about the ADM not reporting the falls and other concerns with how the staff were treated and were told that her supervisor would address it. They said many staff had concerns with fear of retaliation from the ADM, which was why they do not want to report or say anything. During a Confidential Interview, it was stated that they heard CNA B yell stop. Before that, they heard Resident #1 yelling. They said Resident #1 yells, but this particular day ([DATE]), the yell was elongated. Resident #1's yell was abnormal. After that, we heard the fall. They said they went to assist. They stated there were two lacerations, and they were not able to get the bleeding to stop. They stated when the local ambulance arrived, one of the lacerations was still bleeding. They said the major laceration had 7 or 8 stitches. They stated that they were asked questions by the ADM and were told that CNA A would be suspended so that an investigation could be conducted. They said everything that was told in this interview was told to the ADM. They stated that they did not have any information about Resident #2's fall but that he heard it was bad. During a confidential interview, it was stated that she was present on the day of Resident #1's fall. She said that she heard Resident #1 screaming, and it was elongated and abnormal. Shortly after that, they heard a thud. By the time they got to Resident #1, CNA A was trying to turn her over. They said they observed a lot of blood, and it was running down into Resident #1 eyes. They stated they were with Resident #1 until the local ambulance arrived. They stated that it was her understanding that the fall was not reported because it was witnessed. They said they did not have any information on Resident #2 fall. During a confidential interview, they stated they were present the day Resident #1 fell. They said they heard Resident # 1 screaming, and it lasted longer than usual. They stated they heard the sound of Resident #1 yelling getting closer. They said as they looked towards the entry of the dining room that was when they could see Resident #1 coming out of the chair and hitting the floor. They stated Resident #1 hit the ground with such an impact that her ponytail holder came out of her head. They said they did not know anything about Resident #2's fall. During a confidential interview, they stated they were working with Resident #1 on the day that she fell. She said she was present on the day of the fall and saw everything. They stated Resident #1 had a habit of dragging her feet, especially if she does not want to go somewhere. She stated all staff knew about Resident #1 putting her feet down during transport. They said they heard another staff member repeatedly tell him (CNA A) to stop, and CNA A kept pushing Resident #1. They stated CNA A was not going fast, but he continued to push her. They said they did not see CNA A stop or readjust her until it was too late, and she had fallen. They stated CNA B tried to stop him by verbally telling him, but he did not listen. They said that Resident #1 continued to bleed until the local ambulance arrived. They stated they were unsure if the bleeding stopped when Resident #1 left. They stated that the CNA was suspended and fired. They stated they observed CNA A keep pushing even after CNA B said to stop. During a confidential interview, they stated they were pulled to the floor to help the staff because another staff member was sick. They said it was near mealtime. They stated they observed Resident #1 yelling. She stated she observed Resident #1 feet under the chair. They stated they told CNA A that Resident #1's feet were under the chair and that he was dragging Resident #1's feet. They said they told CNA A that was why Resident #1 was yelling. They stated that the Activity Director called them, and when CNA A passed the door, they again told CNA that they were still dragging Resident #1 feet. They stated shortly after that moment, they heard the fall. They said when they told CNA A, he never readjusted her, checked her (Resident #1) feet, or even responded to them. They stated he kept pushing her. They stated they did not have any information about Resident #2 fall. During a confidential interview, it was stated that they were in the kitchen area when Resident #1 fell. They said they heard Resident #1 hollering first as if she was in pain. They stated they heard CNA B yell that CNA A was dragging her feet. They said that Resident #1 had swollen feet. They stated that CNA A did not readjust Resident #1 in her wheelchair but kept pushing her from the dining table to the dining room exit. They said they did not know anything about Resident #2's fall. During an interview on [DATE] at 1:25 PM, the ADM stated that she was walking near the nurse's station. She said she heard someone yell stop. She stated that CNA A turned his head, and Resident #1 fell and hit her head. She stated she could not tell if Resident #1 feet were tangled based on where she was. She stated Resident #1's feet are large, as well as her legs. She said that after the resident fell, several staff members went to assist her. She stated Resident #1 went to the hospital and came back the same day with 7 or 8 stitches. She stated she suspended CNA A immediately. She said he was later terminated due to having a bad attitude, being late, and the incident with Resident #1. She said it was not working out for him. She stated that she watched the video, and according to the video, you could not see the position of her feet and could not tell if CNA A was going too fast. She stated she had no surveillance for the investigator to review because it was erased after three days. She stated she did not call it in because it was not intentional on CNA A behalf. She stated she went ahead and called Resident #1 in because she had passed away, and staff were making a big deal about it. She said Resident #1 fell on [DATE], and she died on [DATE]. The ADM stated she was on off on [DATE] and called it in on [DATE]. She stated she spoke with the Regional Clinical Director, and she also did not see the need to call in the falls for Resident #1 and Resident #2. She stated that they did not consider stitches a major injury. She stated Resident #1 fracture to her back was not reported because she could tell her exactly what happened. She stated Resident #1 was alert. She stated that once the resident came back to the facility, she knew it was fractured but did not see a reason to report it. She said she uses the guidelines listed in the provider letter 19-17. During an interview on [DATE] at 2:27 PM, Resident #1 stated that she broke her back on Thanksgiving day. She said she had fallen while at her son's home, and that was when she started having back spasms. She stated he reported this to staff when she returned. She stated that last fall, she was in her room alone at the end of December. She said she fell while going to the restroom. She said she was in a lot of pain when she fell. She stated no one asked her about her fall besides the staff who assisted her in getting Resident #2 up that night at the end of December. During an interview on [DATE] at 1:34 PM, the DON stated the potential negative outcome for not reporting or not investigating an incident of abuse or neglect was that it could place residents in danger. She said it could affect the quality of care. She stated she was aware of the fall, with Resident #2 not being reported. She stated the Regional Clinical Director told her that Resident #2 was coherent and could say to them what happened; therefore, it was not reportable. She stated she was told that the guidelines have changed and that certain things that were once reportable are no longer reportable. She said she had concerns and spoke with the Regional Clinical Director and spoke with the ADM. She stated the rationale that she was given was that the resident was coherent. She said she was aware that Resident #1 fall was not reported. She stated the ADM told her that since the fall was witnessed and since CNA A was terminated, they did not have to report it. She said that she did not think there was a system in place at the facility that assisted in monitoring that things that should be reported were reported. She stated she had been trained on what to report to the state. She said anything out of the norm should be reported to the state. She stated unwitnessed falls, injuries, complaints of theft, any sexual activity, and anything that was not a part of day-to-day activity that can cause harm to the residents. She stated that Resident #1's and #2's falls were out of the norm and should have been reported. She stated both falls resulted in serious bodily injury. She stated although they fall frequently, their treatments as a result of the fall require higher levels of care. She stated the ADM was the abuse coordinator. The DON stated that CNA A should have stopped and readjusted the resident before pushing Resident #1. She stated this was neglectful on CNA A's part. She stated she did not report either fall but did investigate Resident #1 fall. When asked if she investigated why the provider investigation report was unfounded, she stated she was unaware that Resident #1's fall had not been thoroughly investigated. She stated the ADM instructed her on who to speak to. She stated she was asked to talk to LVN E, the Activity Director, LVN F, LVN C, and CNA A. She stated that during her interviews, she found that CNA A should have stopped, and this would have prevented the fall. She stated she never saw any of the investigation paperwork and was told it was unfounded because CNA A did not mean to do it. She stated CNA A never told her that he did not mean to do it, but it was told to her that he told other staff this. She stated that before the interview with the investigator, she was under the impression that the ADM was responsible for the entire investigation process. She stated that she was never asked for any documentation from what she found out through her interviews. She stated she was only aware of her role in the investigation process on the day of the interview on [DATE]. She stated she learned that she and the ADM are both responsible. She stated that she thought investigations were on the ADM as she was the abuse coordinator. She stated she was instructed to terminate CNA A because of the fall. She stated she, as the DON, did not report Resident #1 or Resident #2 falling within 2 or 24 hours. She stated she did not report the falls because she had asked about them and was given a rationale for why they did not need to be reported. She stated that regarding Resident #2, she did not investigate or talk with any of the staff on duty. She stated not preventing incidents or accidents could result in a decline in residents' health. She stated that future incidents may occur. She stated she was not present the day Resident #2 fell. She stated she expected staff to adhere to verbal commands, especially if it kept residents safe. She said she expected the CNA to stop and readjust to prevent accidents. She stated they are all responsible for preventing accidents. She stated that although she does not believe he intentionally hurt Resident #1, he did not take any actions to avoid it either. She stated she was unaware of any history of CNA having difficulty hearing. During an interview on [DATE] at 2:05 PM, the ADM stated that regarding reporting the incident, the potential negative outcome was that all residents could be affected. She did not expound how. She said she did report Resident #1 incident/fall, but she reported it late. She stated she did not report Resident #2's incident/ fall because she was following the provider's letter and did not believe it met the requirement. She said regarding systems to help monitor what to report versus what not to report was the provider letter that was issued by the state. She stated that she expected all things that met the state requirements per the provider letter to be reported. She said she did not report those based on the requirements listed in the provider letter. She stated that she and the DON were responsible for reporting appropriate items to the state. She said she felt that Resident #2 did not meet the requirements of the provider letter because Resident #2 could tell staff what happened. She stated she did not report Resident #1 because it also did not meet the requirements based on the requirements of the provider letter. She said she did not suspect abuse or neglect and believed in regard to Resident #1 and CNA A it was an accident. She stated she suspended CNA A as a part of the initial investigation. She stated she always suspended the staff as a part of the investigation process. She stated she was investigating the fall, not abuse or neglect. She stated that he was terminated for other things, not the fall. She stated that she was unaware that the DON had terminated CNA A. She stated that the things he was terminated for were addressed at once at the time of the fall and not as they happened during his employment. She stated that she heard CNA B yell stop once, and that was when the fall occurred. She said on the video, she observed CNA A stop once CNA B yelled, and that was when the resident fell. She stated that during the observation of the video surveillance, she did not see CNA A stop to readjust Resident #1 in her wheelchair. She stated that regarding Resident #1, she could not determine if receiving sutures was serious because she was not clinical. She said she did not report either of the incidents to the police or the local ombudsman. Regarding investigating the incident, she stated she unfounded the incident because she did not believe he (CNA A) intended to hurt Resident #1. She stated she did not know who yelled. She stated she did not think or suspect abuse or neglect. She stated things such as punching as an example of abuse. She stated that she only obtained witness statements from CNA A and CNA B because CNA A was involved, and CNA B told me she saw what happened. She stated she believed she had talked to everyone who was there that day. She stated she did not speak with any kitchen staff. She stated she only chose people who saw Resident #1 fall. She stated regarding Resident #2, she only took the word of the DON and did not go any further. She stated that she spoke with Resident #2, and she was able to tell her what happened, and she did not suspect abuse. She stated that failure to investigate could compromise the residents. She stated she had been trained to investigate. She stated she and the DON were responsible for conducting investigations. Regarding preventing accidents and hazards, she stated the potential negative outcome was the safety of the residents. She stated that the video did not reveal that the resident feet were under the wheelchair. She stated she did not see him readjust her or check for positioning in the video. She stated she did not interview any residents because no residents were in the dining room. She stated she was unaware if CNA A had any hearing problems. During an interview on [DATE] at 2:38 PM, the Regional Clinical Director stated that she did not consider a laceration to be a serious injury. She stated a laceration was minor. She said serious was when surgical repair was needed. She stated urgent care was more. She stated she was unaware of Resident #2 injuries until the investigator was in the facility. She said that she did not feel that Resident #1 fall was reportable. She stated when she called the other regional nurse, she was instructed that if they were unsure, then the incident needed to be reported. She stated the ADM had initiated an investigation, and CNA A had already been terminated. She said they allow the DON and ADM to oversee the facility and have yet to read the self-report submitted regarding Resident #1. She said they did not report Resident #1 because it was perceived as a minor injury. She stated Resident #2 was unaware of it. During an interview on [DATE] at 2:38 PM at 2:52 PM, CNA A stated he did not mean for Resident #1 to fall. He stated he did not know her feet were under the wheelchair. He stated he did not feel a difference in pushing her. He said he did not hear anyone tell him to stop. He stated that he was the only CNA on the side where Resident #1 resided. He stated that he believed this was why he did not pay attention. He said he was worried about getting everyone out of the dining room by himself. He stated there was no other staff in the dining room with him. He stated there were other residents in the dining room. He stated the kitchen staff was in the kitchen. He said he was unaware that Resident #1 would put her feet down. He stated that she had large legs and had previously inquired about leg rest for another resident. He said he had not asked for leg rest for Resident #1. He stated he was told by housekeeping staff that maintenance would get them. He said he brought this to maintenance attention and was told it would be taken care of. He stated he felt that he did not receive adequate training. He stated he was on the floor one day with another staff and that training did not include getting to know the other residents but instead included asking him to help with the larger residents and telling him to change people on his own. He was never informed that Resident #1 would drop her feet. He stated if he had been trained about Resident #1, he would have checked her feet. He said he pushed her, and she fell out of the chair. He stated he only stopped because he saw her fall forward. He stated he never stopped until she started falling forward. Record review of the ADM witness statement dated [DATE] revealed the following: On [DATE], she was in the hallway on station 1 when she heard someone yell, Stop !She stated she looked down the hallway and saw CNA A look back. She stated he turned his head. He stopped pushing the wheelchair, and at this time, Resident #1 fell forward. She was assessed and sent to the hospital for evaluation. Record review of a confidential witness statement revealed the following: They assisted in the assessment of Resident #1. During the course of providing care to Resident #1, they overheard the Activity director tell CNA A, We told you to stop pushing her; her legs were under her wheelchair. They stated they addressed the ADM about reporting the resident death to the state and were told by the ADM that they knew how and why she died. They said the ADM told them that when a resident was on hospice, they were filled with morphine, and then they die. Record review of a confidential witness statement revealed the following: They were not present the day Resident #1 fell but were notified that Resident #1 was being pushed by CNA A and, after being told to stop, failed to stop. She stated that while others rendered aid, 911 was called. Resident #1 was sent to the hospital and received 7-8 stitches. They said that during a meeting, Resident #1 death was brought up. They stated the ADM stated she would report it since there was a lot of discussion about it. They stated that the ADM said she would report it because if the Activity Director quits, she would ultimately report it. Record review of a confidential witness statement revealed the following: They heard Resident #1 screaming for at least 5 seconds. They stated they recognized her scream because when Resident #1 did not want to be moved, she would scream. They looked at another staff and then took a step where they could see out the door. They saw Resident #1 mid-fall. They stated Resident #1 hit her head first. They stated they heard CNA A say they

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for 2 of 5 allegations reviewed for reporting alleged resident abuse (Resident #1 and Resident #2). The facility failed to ensure an allegation of neglect for Resident #1 was thoroughly investigated. The facility failed to ensure an allegation of neglect for Resident #2 was thoroughly investigated. these failures could place residents at risk of unidentified abuse due to allegations not being investigated as required. Findings included: Record review of Resident #1's face sheet, dated [DATE], revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include dementia (memory loss), muscle weakness, cellulitis (skin infection that causes redness and swelling). Record review of Resident #1's Quarterly Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section GG 120. Mobility Devices C. Wheelchair Record review of Resident #1's care plane revealed the following: [DATE] Problem: Resident #1 is high risk for falls related to impaired cognition, weakness and unable to stand. Intervention: Anticipate and meet Resident #1 needs Review past falls and attempt to determine cause of the falls. Record review of the facility incident report from [DATE] to [DATE] revealed the following: Resident #1 had a witnessed fall on [DATE] Record review of Resident #1 progress notes revealed the following: [DATE] 9:55 AM Resident was being pushed out of dining room after breakfast, while being pushed her feet got caught up under wheelchair and resident fell out of chair hitting her head on the floor. Resident has a laceration to forehead with bleeding noted, resident did yell in pain when CNA tried to put sock back on her foot. Resident is being sent to ER via ambulance for a more in-depth evaluation of head. Author: LVN C Record review of Form 3613 dated and signed [DATE] revealed that on [DATE] CNA A was transporting Resident #1 from the dining room. CNA B noticed Resident #1 feet dragging and CNA B yelled for CNA A to stop. When CNA A stopped Resident #1 fell forward. Investigation findings was unfounded. Record review of CNA A's witness statement, dated [DATE], stated that he was pushing Resident #1 down the hall at 10:00 AM when she put her foot down and her forward momentum threw her out of the wheelchair. Review of CNA B's witness statement, dated [DATE], stated that she saw CNA A pushing Resident #1 in her wheelchair. CNA B said she told him to stop dragging Resident #1 feet and this was the reason Resident #1 was yelling. She stated she went to the Activity Director's office. At this time she had to tell CNA A again to stop because he was dragging Resident #1 feet under the chair and that was when she heard a loud bang and looked out and Resident #1 was on the floor. Record review of hospital records dated [DATE] revealed the following: admission Diagnoses: Laceration without foreign body of unspecified part of head and Laceration without foreign body of unspecified part of neck. Physical Exam Constitutional: She is in cute distress Hent: Patient has a 2.5 centimeter vertical laceration mid forehead with oozing bleeding and gaping. A Second laceration is noted above the left eyebrow triangular in nature and not gaping. It had been steri-stripped by the nursing home. Dermabound would be appropriate for this wound. Neck: Patient is in a c-collar Discharge instructions: Wound should be kept clean and dry. Glue will flake off in 7-10 days. Sutures should be removed in 7 days. Those can be done by urgent care or some primary care or she can return to the emergency room if needed. Record review of Resident #2's face sheet, undated, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with altered mental status, anxiety disorder (increased feeling of worry, fear and uneasiness), cellulitis (skin infection that causes redness and swelling) and muscle weakness Record review of Resident #2's Quarterly Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 13, which indicated the resident's cognition was cognitively intact. Section GG 120. Mobility Devices C. Wheelchair Record review of Resident #2's care plane revealed the following: [DATE] Problem: Resident #2 is resistive to care such as refusing to lay in bed to avoid falls out of wheelchair. Resident is redirected multiple times to avoid injuries and future falls. Resident #1 prefers to stay in chair while she sleeps and leans over in wheelchair despite redirection and education. [DATE] Resident #1 continues to get up without assist. She leans forward in the chair also causing herself to fall forward out the chair. Resident #1 took herself to the toilet and upon return to the bed she slid down onto her knees. Resident #1 does have Skin tears, first aid given, back to bed in lowest position, call light visible and within reach. Ms. [NAME] encouraged to utilize call light and wait for assistance. Intervention: o If possible, negotiate a time for ADLs so that the resident participates in the decision making process. Return at the agreed upon time. Date Initiated: [DATE] Problem: The resident #2 has had an actual fall with no injury's r/t Poor Balance, Psychoactive drug use, Unsteady gait [DATE]: Resident #2 forgot to lock her w/c, Resident #2 leaned forward and fell out to the floor. Resident #2 Left knee, treated by CN. Frequently Remind Resident #2 to lock her wheel chair, Frequent rounding on residents. Keep call light visible and within reach, anticipate residents needs, respond timely. [DATE] Resident #2 was reported to be on the floor in her room by her roommate. Resident #2 States she went to the bathroom and did not scoot far enough back into the wheelchair landed on floor causing multiple skin tears and a [NAME]. Reminded Resident #2 to utilize the call light and wait for assist. Continue POC. [DATE] Resident #2 on the floor. Assessed for injury and does have skin tears. [DATE]: Resident #2 leaned forward in her wheelchair causing her to fall Date Initiated: [DATE] Revision on: [DATE] Intervention: [DATE]: Resident #2 asleep in her w/c, dreamed she was dancing and fell out of wheelchair. Date Initiated: [DATE] Resident #2 fell out of her wheelchair outside leaning forward and hit her head. She did not want to go to the ER states, I barely hit my head. Date Initiated: [DATE] Record review of the facility incident report from [DATE] to [DATE] revealed the following: Resident #2 had a witnessed fall on [DATE] Record review of Resident #1 progress notes revealed the following: [DATE] Resident was found on the floor in her room. Wheelchair was upright and locked. Resident states that she slipped out of her wheelchair while leaning over to pick something up. Resident is short of breath, and has non-verbal signs and symptoms of pain to left lower leg and back. Noted new hematoma to proximal left lower leg, resident unable to toe touch pressure to lower extremity. This nurse called ambulance for transportation. Author: LVN D Record review of hospital records dated [DATE] revealed the following: Chief Complaint: Fall Clinical Impression: Compression fracture of lumbar vertebra (one or more of the vertebrae in the spine crumple) (New vertebral body height loss of L4 and L5 compared to t [DATE]). Discharge instruction: Please wear your brace whenever you are up and out of bed. Avoid bending, twisting, pulling, tugging or twisting your back. During a confidential interview, it was stated that they were standing in the doorway with another staff member. They observed CNA A go retrieve Resident #1. When CNA A and Resident #1 passed by, Resident #1 screamed, and CNA B yelled to CNA A, CNA A, her feet!. They stated they heard a noise, and they looked out, and Resident #1 was on her face. They said they heard the ADM tell CNA A to turn her over, and this was before any nurse had come. They stated the ladies from therapy may have witnessed it as well. There was a therapy staff on the floor keeping her calm, and nursing staff assessed her. They stated that what concerned them was that they were never interviewed or asked for a statement. They stated that it was customary that if something of this magnitude happened all staff were interviewed that were there that day. They stated this could not have happened since they were not interviewed. They said because of the response they were getting, it made them not want to talk about it anymore. They said they could not understand why they did not have to give a statement, and at this time, no one still had asked them what they knew or saw. They stated that failure to report and investigate could make the residents scared and unsure of their care. She said regarding Resident #1 fall, CNA A was the only CNA working on the floor on his side, and not investigating it, the facility may not see that this may have also been a factor. They stated the quality of care may decrease if not enough people are working. They said there were times when there was just one CNA, and there were unwitnessed falls. They stated the abuse coordinator was the ADM. They stated they did not feel that Resident #1's incident/fall was investigated because they were present that day, and no one asked them about the incident or took a statement. They stated they don't know much about Resident #2's fall. During a confidential interview, they stated they interacted with Resident #1 before her fall. The resident was not acting abnormally. They said they were not present the day Resident #1 fell but were present the day after she had fallen. They stated that they observed the wound, and Resident #1 still had matted-up blood in her hair. They said Resident #1 was vocally crying and moaning but did not have tears. They stated they were present when Resident #2 fell. When Resident #2 fell, the resident would not let the nurse touch her leg. There was a large lump on Resident #2 leg. They stated they placed Resident #2 in the wheelchair with the help of another staff. They said Resident #2 was in a lot of pain because we would not allow staff to touch her without wincing. They said they were never interviewed about Resident #2 fall. They stated they were not interviewed after both falls. During a confidential interview, it was stated that she was present on the day of Resident #1's fall. She said that she heard Resident #1 screaming, and it was elongated and abnormal. Shortly after that, they heard a thud. By the time they got to Resident #1, CNA A was trying to turn her over. They said they observed a lot of blood, and it was running down into Resident #1 eyes. They stated they were with Resident #1 until the local ambulance arrived. They said the ADM never interviewed them. During a confidential interview, they stated they were present the day Resident #1 fell. They said they heard Resident # 1 screaming, and it lasted longer than usual. They stated they heard the sound of Resident #1 yelling and getting closer. They said as they looked towards the entry of the dining room that was when they could see Resident #1 coming out of the chair and hitting the floor. They stated Resident #1 hit the ground with such an impact that her ponytail holder came out of her head. They said they never interviewed her to see what they saw or heard. During a confidential interview, they stated they were not working with Resident #1 on the day that she fell. They said she was present on the day of the fall and saw everything. They stated they were not interviewed. They stated Resident #1 had a habit of dragging her feet, especially if she does not want to go somewhere. They stated all staff knew about Resident #1 putting her feet down during transport. They said they heard another staff member repeatedly tell him to stop, and CNA A kept pushing her. They stated CNA A was not going fast, but he continued to push her. They said they did not see CNA A stop or readjust her until it was too late, and she had fallen. They stated CNA B tried to stop him by verbally telling him, but he did not listen. They said that Resident #1 continued to bleed until the local ambulance arrived. They stated they were unsure if the bleeding stopped when Resident #1 left. They stated that the CNA was suspended and fired. They stated they observed CNA A keep pushing even after CNA B said to stop. During a confidential interview, it was stated that they were in the kitchen area when Resident #1 fell. They said they heard Resident #1 hollering first as if she was in pain. They stated they heard CNA B yell that CNA A was dragging her feet. They said that Resident #1 had swollen feet. They stated that CNA A did not readjust Resident #1 in her wheelchair but kept pushing her from the dining table to the dining room exit. They stated that no one came and interviewed her about what she had seen. During a confidential interview, it was stated that she was not present when Resident #2 fell when she broke her back. They said Resident #2 falls a lot. They stated they had never been questioned at all when Resident #2 fell. They stated that all they knew was Resident #2 was in the hospital. They said she was present often during the overnight shift. During a confidential interview, it was stated that they were present the night Resident #2 fell and broke her back. They stated that they were not interviewed by anyone regarding the incident. They said Resident #2 hit the call light, and the resident was on the floor when they went in. They stated they asked Resident #2 what happened, and Resident #2 said she was trying to sit in her chair, and it moved. They stated Resident #2 hit her bottom. They stated they retrieved another staff to help and assess. They said Resident #2 was in pain. They stated they sent her out to the hospital, and she was gone for about a week. They stated that they had not been interviewed about Resident #2's fall when she broke her back, nor had she ever been interviewed about any of her falls. They stated Resident #2 falls a lot. During an interview on [DATE] at 1:25 PM, the ADM stated that she was walking near the nurse's station. She said she heard someone yell stop. She stated that CNA A turned his head, and Resident #1 fell and hit her head. She stated she could not tell if Resident #1 feet were tangled based on where she was. She stated Resident #1's feet are large, as well as her legs. She said that after the resident fell, several staff members went to assist her. She stated Resident #1 went to the hospital and came back the same day with 7 or 8 stitches. She stated she suspended CNA A immediately. She said he was later terminated due to having a bad attitude, being late, and the incident with Resident #1. She said it was not working out for him. She stated that she watched the video, and according to the video, you could not see the position of her feet and could not tell if CNA A was going too fast. She stated she had no surveillance for the investigator to review because it was erased after three days She said Resident #1 fell on [DATE], and she died on [DATE]. The AD stated she was on off on [DATE] and called it in on [DATE]. She stated she spoke with the Regional Clinical Director, and she also did not see the need to call in the falls for Resident #1 and Resident #2. She stated that they did not consider stitches a major injury. She stated Resident #1 fracture to her back was not reported because she could tell her exactly what happened. She stated Resident #1 was alert. She stated that once the resident came back to the facility, she knew it was fractured but did not see a reason to report it. She said she uses the guidelines listed in the provider letter 19-17. During an interview on [DATE] at 2:27 PM, Resident #1 stated that she broke her back on Thanksgiving day. She said she had fallen while at a family members home during the hoiday, and that was when she started having back spasms. She stated he reported this to staff when she returned. She stated that last fall, she was in her room alone at the end of December. She said she fell while going to the restroom. She said she was in a lot of pain when she fell. She stated no one asked her about her fall besides the staff who assisted her in getting Resident #2 up that night at the end of December. During an interview on [DATE] at 1:34 PM, the DON stated the potential negative outcome for not reporting or not investigating an incident of abuse or neglect was that it could place residents in danger. She said it could affect the quality of care. She stated she was aware of the fall, with Resident #2 not being reported. She stated the Regional Clinical Director told her that Resident #2 was coherent and could say to them what happened; therefore, it was not reportable. She stated she was told that the guidelines have changed and that certain things that were once reportable are no longer reportable. She said she had concerns and spoke with the Regional Clinical Director and spoke with the ADM. She stated the rationale that she was given was that the resident was coherent. She said she was aware that Resident #1 fall was not reported. She stated the ADM told her that since the fall was witnessed and since CNA A was terminated, they did not have to report it. She said that she did not think there was a system in place at the facility that assisted in monitoring that things that should be reported were reported. She stated she had been trained on what to report to the state. She said anything out of the norm should be reported to the state. She stated unwitnessed falls, injuries, complaints of theft, any sexual activity, and anything that was not a part of day-to-day activity that can cause harm to the residents. She stated that Resident #1's and #2's falls were out of the norm and should have been reported. She stated both falls resulted in serious bodily injury. She stated although they fall frequently, their treatments as a result of the fall require higher levels of care. She stated the ADM was the abuse coordinator. The DON stated that CNA A should have stopped and readjusted the resident before pushing Resident #1. She stated this was neglectful on CNA A's part. She stated she did not report either fall but did investigate Resident #1 fall. When asked if she investigated why the provider investigation report was unfounded, she stated she was unaware that Resident #1's fall had not been thoroughly investigated. She stated the ADM instructed her on who to speak to. She stated she was asked to talk to LVN E, the Activity Director, LVN F, LVN C, and CNA A. She stated that during her interviews, she found that CNA A should have stopped, and this would have prevented the fall. She stated she never saw any of the investigation paperwork and was told it was unfounded because CNA A did not mean to do it. She stated CNA A never told her that he did not mean to do it, but it was told to her that he told other staff this. She stated that before the interview with the investigator, she was under the impression that the ADM was responsible for the entire investigation process. She stated that she was never asked for any documentation from what she found out through her interviews. She stated she was only aware of her role in the investigation process on the day of the interview on [DATE]. She stated she learned that she and the ADM are both responsible. She stated that she thought investigations were on the ADM as she was the abuse coordinator. She stated she was instructed to terminate CNA A because of the fall. She stated she, as the DON, did not report Resident #1 or Resident #2 falling within 2 or 24 hours. She stated she did not report the falls because she had asked about them and was given a rationale for why they did not need to be reported. She stated that regarding Resident #2, she did not investigate or talk with any of the staff on duty. She stated not preventing incidents or accidents could result in a decline in residents' health. She stated that future incidents may occur. She stated she was not present the day Resident #2 fell. She stated she expected staff to adhere to verbal commands, especially if it kept residents safe. She said she expected the CNA to stop and readjust to prevent accidents. She stated they are all responsible for preventing accidents. She stated that although she does not believe he intentionally hurt Resident #1, he did not take any actions to avoid it either. She stated she was unaware of any history of CNA having difficulty hearing. During an interview on [DATE] at 2:05 PM, the ADM stated that regarding reporting the incident, the potential negative outcome was that all residents could be affected. She did not expound how. She said she did report Resident #1 incident/fall, but she reported it late. She stated she did not report Resident #2's incident/ fall because she was following the provider's letter and did not believe it met the requirement. She said regarding systems to help monitor what to report versus what not to report was the provider letter that was issued by the state. She stated that she expected all things that met the state requirements per the provider letter to be reported. She said she did not report those based on the requirements listed in the provider letter. She stated that she and the DON were responsible for reporting appropriate items to the state. She said she felt that Resident #2 did not meet the requirements of the provider letter because Resident #2 could tell staff what happened. She stated she did not report Resident #1 because it also did not meet the requirements based on the requirements of the provider letter. She said she did not suspect abuse or neglect and believed in regard to Resident #1 and CNA A it was an accident. She stated she suspended CNA A as a part of the initial investigation. She stated she always suspended the staff as a part of the investigation process. She stated she was investigating the fall, not abuse or neglect. She stated that he was terminated for other things, not the fall. She stated that she was unaware that the DON had terminated CNA A. She stated that the things he was terminated for were addressed at once at the time of the fall and not as they happened during his employment. She stated that she heard CNA B yell stop once, and that was when the fall occurred. She said on the video, she observed CNA A stop once CNA B yelled, and that was when the resident fell. She stated that during the observation of the video surveillance, she did not see CNA A stop to readjust Resident #1 in her wheelchair. She stated that regarding Resident #1, she could not determine if receiving sutures was serious because she was not clinical. She said she did not report either of the incidents to the police or the local ombudsman. Regarding investigating the incident, she stated she unfounded the incident because she did not believe he (CNA A) intended to hurt Resident #1. She stated she did not know who yelled. She stated she did not think or suspect abuse or neglect. She stated things such as punching as an example of abuse. She stated that she only obtained witness statements from CNA A and CNA B because CNA A was involved, and CNA B told me she saw what happened. She stated she believed she had talked to everyone who was there that day. She stated she did not speak with any kitchen staff. She stated she only chose people who saw Resident #1 fall. She stated regarding Resident #2, she only took the word of the DON and did not go any further. She stated that she spoke with Resident #2, and she was able to tell her what happened, and she did not suspect abuse. She stated that failure to investigate could compromise the residents. She stated she had been trained to investigate. She stated she and the DON were responsible for conducting investigations. Regarding preventing accidents and hazards, she stated the potential negative outcome was the safety of the residents. She stated that the video did not reveal that the resident feet were under the wheelchair. She stated she did not see him readjust her or check for positioning in the video. She stated she did not interview any residents because no residents were in the dining room. She stated she was unaware if CNA A had any hearing problems. Record review of an untitled, undated document provided by the DON on [DATE] revealed the following: The DON was not involved in the self-report process. It stated that she was notified by LVN C about the incident with Resident #1. It said that on the date she terminated CNA A, it was at the ADM's request. It stated that she spoke with LVN P, LVN Q, the Activity Director, and CNA A on the same date. (The outcome of the interviews was not included in this document). Record review of the facility policy titled abuse investigation and Reporting, revised [DATE], revealed the following: Policy Statement All reports of resident abuse, neglect, exploitation, misappropriation of rcsident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Role of the Investigator: The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; i. Interview other residents to whom the accused employee provides care or services; and j. Review all events leading up to the alleged incident. The following guidelines will be used when conducting interviews: a. Each interview will be conducted separately and in a private location. b. The purpose and confidentiality of the interview will be explained thoroughly to each person involved in the interview process. c. Should a person disclose information that may be self-incriminating, that individual will be informed of his/her rights to terminate the interview until such time as his/her rights are protected (e.g., representation by legal counsel). d. Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it. 3. The investigator will notify' the ombudsman that an abuse investigation is being conducted. The ombudsman will be invited to participate in the review process. a. If the ombudsman declines the invitation to participate in the investigation, that information will be noted in the investigation record. The ombudsman will be notified of the results of the investigation as well as any corrective measures taken. 4. The investigator will consult daily with the Administrator concerning the progress/findings of the investigation. 5. Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the Administrator. Record review of the facility policy titled Accidents and Incidents-Investigating and reporting, revised [DATE], revealed the following: Policy Statement All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: a. The date and time the accident or incident took place; b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The name(s) of witnesses and their accounts of the accident or incident; f. The injured person's account of the accident or incident; g. The time the injured person's attending physician was notified, as well as the time the physician responded and his or her instructions; h. The date/time the injured person's family was notified and by whom; 1. The condition of the injured person, including his/her vital signs; j. The disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work, etc.); k. Any corrective action taken; 1. Follow-up information; m. Other pertinent data as necessary or required; and a. The signature and title of the person completing the report. 3. This facility is in compliance with current rules and regulations governing accidents and/or incidents involving a medical device. 5. The nurse supervisor/charge nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the director of nursing services within 24 hours of the incident or accident. 6. The director of nursing services shall ensure that the administrator receives a copy of the Report of Incident/Accident of form for each occurrence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident had the right to be free from abuse, neglect, misappropriation of property, and exploitation for 1 of 5 residents (Resident #1) reviewed for misappropriation of property and exploitation. The facility failed to prevent the misappropriation of Resident #1's money and debit card, when CNA A allowed Resident #1 to purchase a meal for her in the amount of $27.03 using Resident #1's debit card number. Shortly after the purchase of the meal approximately 23 transactions were attempted to transfer money from Resident #1's account to Cash App. Seven of the attempted transactions were to CNA A's name. This failure could place residents at an increased risk for misappropriation of their property. Findings include: Record review of Resident #1's undated faces sheet indicated the resident was admitted to the facility on [DATE]: Her diagnosis include depression, acute kidney failure, diabetes mellitus, and heart failure. Record review of Resident #1's MDS dated [DATE] indicated a BIMS of 14 indicating cognitively intact. During an interview on 08/15/2023 at 9:00 AM, the Administrator stated it was reported to her that Resident #1 had purchased a meal for CNA A on the night of 07/29/2023 in the amount of $27.03. That Resident #1 had her debit card number written down in a book in her room and CNA A used her personal cell phone to call and place the order for the food, using the debit card number for Resident #1. The Administrator stated Resident #1 had received a call from the fraud department with her local bank alerting to possible fraud regarding multiple attempts of withdrawal from Resident #1's account to CNA A via Cash App, along with two other unknown names for Cash App. The Administrator stated Resident #1 reported the fraud department had stopped the transactions. The Administrator stated she suspended CNA A pending the investigation. The Administrator stated Resident #1 had the local bank take her a printout of the attempted transactions. The Administrator stated there were multiple attempts to withdrawal money from Resident #1 and several of the attempts did have CNA A's name listed. The administrator stated there were two other names listed and they were not employees of the facility. The Administrator stated she did interview CNA A and CNA A admitted to allowing the resident to purchase food for her on 07/29/2023, and that she did use her personal cell phone to order the food and Resident #1's debit card number was used to purchase the food. The Administrator stated CNA A denied attempting to withdrawal money from Resident #1 account/debit card via Cash App and was not sure why her name was used to attempt to make the withdrawals. The Administrator stated CNA A told her she did not have Cash App on her phone and did show her the cell phone. The Administrator stated that the facility policy is that staff will not take money, gifts anything from residents, and CNA A did admit to accepting the meal that valued $27.03 from Resident #1. The Administrator stated if CNA A had not accepted the meal from Resident #1 then the whole situation would not have happened. The Administrator stated the facility did report the incident to Health and Human Services and to the Local Police and provided the police report number 23-22643. The administrator stated the facility did in-service staff over exploitation of the elderly and financial abuse. During an interview on 08/15/2023 at 12:00 PM, Resident #1 stated that she enjoys doing things for others and she knows the staff worked their butts off. She stated that she was not feeling well on 07/29/2023 and CNA A had been going in her room taking care of her. Resident #1 stated she wanted to but CNA A, a meal and offered to order pizza for her. Resident #1 stated CNA A accepted the offer. Resident #1 stated she did not have her debit card with her however had the number written down in her green book that she kept in a basket near her bed. Resident #1 stated that CNA A told her that she didn't need to use her phone that CNA A would use her own cell phone. Resident #1 stated she thought that was unusual but let CNA A use her own phone. Resident #1 stated CNA A called the restaurant on speaker phone and placed the order and then Resident #1 read her card number off. Resident #1 stated CNA A did help her repeat some of the numbers from her debit card to restaurant. Resident #1 stated that since she had not been feeling well that evening after ordering the food she went back to bed. Resident #1 stated that the next day she did receive three calls form a 1-800 number and that she doesn't do 1-800 number, so she didn't answer. Resident #1 stated that the 1-800- number was from the fraud department at her local bank and they were trying to alert her of possible fraud charges to her account and asked her if she had authorized the charges. Resident #1 stated that the fraud department told her there had been something like 26 attempts to withdrawal money. Resident #1 stated the bank offered to bring her a copy of the statement showing the attempted transactions to her at the facility. Resident #1 stated when she received the statement, she was able to see CNA A's name on the statement with something about a cash thing you can put on your phone but didn't know what that was. Resident #1 stated that she was trying to be nice and buy a meal for CNA a, that she knew CNA A had six children with six different baby daddies and she was trying to help and be nice. Resident #1 stated some of the transaction attempts were to other people she didn't know and thought it was probably one of CNA A baby daddies or her boyfriend. Resident #1 stated it upset her that she was trying to be nice and buy CNA A the meal and that CNA A would have taken her debit card information and try to get money from her account. Resident #1 stated she didn't think what CNA A had done was right and that she would hope that CNA A would not be able to work with people in a nursing home again. Record review of a copy of the bank statement for Resident #1 dated 07/31/2023 revealed on 07/29/2023, a pre-authorized debit Cash App CNA A's name, ($250.00), 07/29/2023 a pre-authorized debit Cash App CNA A's name ($50.00) two times and on 07/29/2023, a pre-authorization debit ($5.00), one additional transaction dated 07/29/2023 a pre-authorization debit Cash App Name Unknown C ($5.00). On 07/30/2023 there were 16 pre-authorization debit Cash App Name Unknown C for ($5.00) each, one pre-authorization debit Cash App CNA A's name ($50.00) and one pre-authorization debit Cash App Name Unknown D ($5.00). During an interview on 08/15/2023 at 10:42 AM, CNA A stated that she did work at the facility on 07/29/2023 and did provide care for Resident #1 on that date. She stated that Resident #1 had offered to buy her food in the past and she had always said no, but that day she agreed and let Resident #1 but her the pizza. CNA A stated that Resident #1's phone was not working like no service or something so she told Resident #1 that she would just call form her cell phone. CNA A stated that she called the restaurant from her cell phone and placed the call on speaker phone. She stated that she ordered a medium pizza and a soda, and the total was about $27.00 dollars and then Resident #1 had a green book in her room and opened it up and read her debit card number out loud. CNA A stated she had to repeat some numbers for Resident #1 because the person taking the call could not understand what Resident #1 had said. CNA A stated Resident #1 was not feeling well so after placing the order she left the room. CNA A stated she received a call from the Administrator to come to the facility and give a statement about the incident and what had happened. CNA A stated she went to the facility and told them that she did not use Resident #1 card to try and withdrawal money to Cash App. CNA A stated she told the Administrator she doesn't have Cash App on her phone and doesn't know why her name would have shown on the records that she was trying to get money. CNA A stated she didn't know the other two names listed as trying to get the money. CNA A stated she showed the Administrator her phone so she could see there wasn't Cash App on her phone. CNA A stated she doesn't have a bank account only an App that allows her to like deposit her checks and she received paper checks from the facility. CNA A stated she had used Cash App in the past but not recently and did not have that App on her phone. CNA A stated she had received training from the facility on abuse, neglect, misappropriation, and exploitation when she started in June 2023, but was not aware that she could not allow a resident to buy her food. Record review of CNA A's Individual Timecard for date range 07/16/2023 - 07/31/2023 revealed CNA A was working on 07/29/2023, CNA A clocked in at 5:33 PM and clocked out at 6:01 AM. Record Review of CNA A's receipt and acknowledgement of facility Code of Conduct dated revised 01/2013 revealed CNA A signed the documents acknowledging she had read the document and understood she was responsible for knowing and adhering to the principles and standards of the code. Gift and Gratuities on page 7 revealed, employees may not accept monetary gifts or gifts of any value from residents, their responsible party or legal representative. CNA A signed the document on 06/23/2023. Record Review of CNA A acknowledgment of receipt of employee handbook undated, revealed CNA A signed the document on 06/23/2023 that she had received a copy of the employee handbook, and was to comply with all the terms of the handbook, and continued employment depended on full compliance with all company rules and policies; and federal, state, and local laws governing long-term care facilities. Page 2 of the handbook revealed employees, shall not solicit, or accept any personal gift or favor from any facility resident or residents' family member without the express approval of facility administrator. During an interview on 08/15/2023 at 1:02 PM, LVN B stated he had worked as the charge nurse on 08/15/2023 with CNA A. He stated that CNA A came to the nurse's station and said, Resident #1 had bought pizza if he wanted any. He stated he told CNA A no and that she did not need to let any resident buy her anything. LVN B stated he has told the staff that they should not let residents buy them anything, or run errands for residents, to just do their work. LVN B stated the facility had provided training often on abuse, neglect, misappropriation, and exploitation. During an interview on 08/15/2023 at 2:30 PM, CNA E stated she had worked on 07/29/2023 with CNA A. CNA E stated that she had split the hall with CNA A and CNA A had provided care for Resident #1 that shift. CNA E stated that CNA A told her that Resident #1 had bought CNA A, a pizza. CNA E stated she had been trained on abuse, neglect, misappropriation, and exploitation by the facility usually monthly and that she knew not to accept any gifts or money from a resident. Record review of facility in-service dated 07/31/2023 Exploitation of Elderly and Financial Abuse signed by 24 staff members. Record review of facility policy Gifts, Gratuities, and Payments dated (Revised February 2008), revealed: Policy statement: Our facility prohibits employees from receiving or giving any gift, gratuity, or payment for services rendered; the making of any promise(s) on behalf of the facility; or engaging in any activity, practice, or act which conflicts with the interest of the facility or its residents. Policy Interpretation and Implementation 2. The giving or accepting of anything of value by our employees to or from any of our suppliers, residents, family members, visitors, or other employees in any form whatsoever is prohibited. Such conduct may be criminal under certain laws. 5. Any employee(s) who receives a gift which is prohibited by this policy must report it to the administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident with a mental disorder was accurately screened prior to admission for 2 of 3 of (#18 and #23) residents reviewed for PASRR: The facility did not correctly identify Resident #18 on the PASRR Level 1 Screening Form as having a mental illness and did not submit a request to correct their PASRR negative screening. The facility did not correctly identify Resident #23 on the PASRR Level 1 Screening Form as having a mental illness and did not submit a request to correct their PASRR negative screening. This failure could affect residents with mental illness that were not considered to be a positive PASRR level one and could result in a failure to receive a PASRR level two evaluation and individually specialized services to meet their needs. The Findings were: Resident #18: Record review of Resident #18's electronic facesheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included recurrent major depressive disorder (onset date of 04/10/2019), anxiety disorder due to know physiological condition (onset date of 04/10/2019), and psychosis not due to a substance or know physiological condition (onset date of 04/10/2019). Dementia was not listed in the diagnosis information. Record review of Resident #18's Quarterly MDS, dated [DATE], revealed under section I Active Diagnoses, psychiatric/mood disorder revealed diagnoses of anxiety disorder, depression, and psychotic disorder. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS of 15 Record review of Resident #18's most recent care plan dated 01/04/2023 revealed a focus area which reflected in part that Resident #18 is at risk for adverse consequences r/t receiving antidepressant medication for treatment of depression. He takes Cymbalta BID (twice daily) and Wellbutrin XL BID with interventions in place that included Assess/record effectiveness of drug treatment. Monitor and report signs of sedation, anticholinergic and or EPS (extrapyramidal symptoms - side effects from antipsychotics). Monitor Resident #18's mood and response to medication. Pharmacy consultant review. Additionally, the care plan contained a focus area which reflected The resident uses antidepressant medication Cymbalta r/t Depression with interventions in place that included Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms. Monitor/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt loss, n/v, dry mouth, dry eyes. Record review of Resident #18's Preadmission Screening and Resident Review Level (PL1) One form dated 04/10/2019 and completed prior to admission revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. During an interview with Resident #18 conducted on 01/13/2023 at 1:20 PM, he said he had his diagnosis of major depressive disorder (MDD) going on ten years or so, prior to being admitted to the facility. He said he lost both parents and two brothers as well and those events made his depression worse. He said he did not get any specialized services pertaining to his diagnosis of MDD at the facility. He said other than taking medication for his MDD, the facility was not doing anything else. He said some days he feels like the medication is helping and some days he feels like he could use some extra help. During an interview with the MDS Coordinator conducted on 01/12/23 at 11:09 AM, she said she has been at the facility since October of 2022. She said some residents come in with the PL1 screening already done and said she was responsible for reviewing them to double check that they were accurate. She said if they were not accurate, she should have contacted the local mental health authority to verify diagnoses of the resident that are considered mental illnesses. She said that MDD is a mental illness that should be indicated as a yes for section C0100 on the PL1 screening form. She said she does not know why Resident #18's PL1 shows an answer of no for section C0100. She said she should have conducted a new PL1 and had a PL2 evaluation done for the resident. She said the risk of an inaccurate PL1 screening would be the resident missing out on extra services needed for them to receive optimal care. She said it could hinder the overall well-being of the resident. During an interview with the MDS Coordinator conducted on 01/13/23 at 09:35 AM, she said she is in the process of updating the PL1 for Resident #18 to accurately reflect his diagnosis and will be contacting the local mental health care authority to have a level 2 evaluation done. She said she would provide a copy of the updated PL1 as well as a facility policy pertaining to PASRR Level 1 Screenings. During an interview with the MDS Coordinator and the PASRR Coordinator from the local mental health authority conducted at 01/13/23 at 2:27 PM, they stated that Resident #18 was being evaluated this evening. Resident #23: Record review of the 1/10/23 Order Summary Report and face sheet revealed Resident #23 was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Paranoid Schizophrenia, Generalized Anxiety Disorder, Anxiety Disorder, Unspecified, and Wandering In Diseases Classified Elsewhere. Further record review of the face sheet for Resident #23 revealed that one of her admitting diagnoses was paranoid schizophrenia on 1/08/20. Record review of the admission MDS for resident #23 dated 1/16/22 documented that the resident had diagnosis of anxiety and schizophrenia. It was also documented that the resident had a BIMS score of 13. Record review of the quarterly MDS for resident #23 dated 11/16/22 documented that the resident had diagnosis of anxiety and schizophrenia. It was also documented that the resident had a BIMS score of 15. Record review of the current undated care plan for Resident #23 revealed a problem that reflected, [Resident #23] is/has potential to be verbally aggressive, yelling at staff and suspicious behavior toward staff. She has the dx of Dementia and Paranoid Schizophrenia. She has auditory and visual hallucinations. She refuses counseling and psych. services . Date Initiated: 07/16/2020. Revision on: 08/06/2020. A documented Intervention reflected, Administer medications as ordered. Monitor/document for side effects and effectiveness Record review of the PASRR Level 1 screening for Resident #23 dated 1/3/2020 revealed the resident was documented as negative for mental illness, intellectual disability, or developmental disability. This PASRR screening was conducted by the resident's discharging hospital. A record review was conducted of the facility provided PASRR list dated 1/10/23. The list consisted of residents in the facility that were positive on a PASRR Level 1 screening for mental illness, intellectual disability, or developmental disability and had a PASRR Evaluation. There were 3 residents listed and Resident #23 was not on the list. On 1/10/23 at 5:54 PM an observation and interview were conducted with Resident #23. During this conversation, the resident expressed delusional thoughts and her conversation was agitated and confused. On 1/13/23 at 11:57 AM an interview was conducted with Resident #23's Appointed Guardian who stated he had been her guardian for a few years and that the resident had a history of mental illness. On 1/11/23 at 5:20 PM an interview was conducted with the MDS Coordinator regarding Resident #23's PASRR Level 1 screening. She stated she thought Resident #23 had a diagnosis of schizophrenia after admission and was diagnosed with dementia at some time during her stay. She stated in 2020 the facility had a managing company change and she was not able to find a PASRR Evaluation developed from the PASRR Level 1 screening. She stated she had been the MDS Coordinator since 2022. She stated residents could miss out on mental health services if incorrect PASRR Level 1 screenings were conducted. Further record review of the face sheet for Resident #23 dated 1/10/23 revealed that one of Resident 23's admitting diagnoses was paranoid schizophrenia on 1/08/20. During an interview with the Administrator conducted on 01/13/23 at 9:48 AM, she said it was the MDS Coordinator's responsibility to review PL1 screenings for accuracy when residents come another facility. She said if a resident came from home, the MDS Coordinator or social worker should complete the PL1. When asked what the risks for a resident could be if they did not receive an accurate PL1 or subsequent PL2 evaluation, she said she couldn't really think of any risks because she thinks they offer the same services. During an interview with the Administrator conducted on 01/13/23 on 1:27 PM, she said they currently do not have a full-time social worker at the facility. She said they have a part time social worker who comes to the facility in the evenings and is currently not at the facility. Record review of Form 1012, Texas Health and Human Services Mental Illness/Dementia Resident Review found at https://www.hhs.texas.gov/regulations/forms/1000-1999/form-1012-mental-illnessdementia-resident-review (accessed on 01/17/2023) reflected in part, .Examples of MI (mental illness) are: a schizophrenic, mood disorder (bipolar, major depression, or other mood disorder), paranoid disorder; somatoform disorder; schizoaffective disorder; panic or other disorder that may lead to a chronic disability diagnosable under the current Diagnostic and Statistical Manual of Mental Disorders .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure, based on a comprehensive assessment, that PRN orders for psychotropic drugs were limited to 14 days and could not be renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication for 1 of 24 residents on psychoactive medications (Resident #22), in that: 1)The facility failed to ensure that Resident #22 had orders for psychotropic medications (Lorazepam) that did not contain PRN orders beyond 14 days without a stop date and reassessment. This failure could place residents at risk for receiving unnecessary medications and adverse drug reactions. The findings include: Record review of the 1/10/23 physician Order Summary Report and face sheet revealed the Resident #22 was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Malignant Neoplasm Of Unspecified Part Of Left Bronchus Or Lung (Lung Cancer), Squamous Cell Carcinoma Of Skin Of Left Lower Limb, Including Hip(Skin Cancer), Depression, Unspecified, Type 2 Diabetes Mellitus With Hyperglycemia(High Blood Sugar), Chronic Obstructive Pulmonary Disease, Unspecified(Breathing Disorder), Personal History Of Transient Ischemic Attack (Tia - Mini Stroke), And Cerebral Infarction Without Residual Deficits (Stroke), Colostomy Status (Bowel Reroute), Acute Upper Respiratory Infection, Unspecified, And Anxiety Disorder, Unspecified. Record review of the admission MDS dated [DATE] for Resident #22 revealed the resident had received an antidepressant in the last seven days and a hypnotic in the last five days. The resident had a BIMS score of 14. Record review of the current undated care plan for Resident #22 revealed a problem listed as, The resident uses anti-anxiety medications Lorazepam 1 MG r/t (related to) Anxiety disorder. Date Initiated: 12/19/2022. Revision on: 01/11/2023. The gold reflected, The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Date Initiated: 12/19/2022. Revision on: 01/11/2023. Target Date: 02/19/2023. Interventions reflected, Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Date Initiated: 12/19/2022 .Monitor/document/report PRN any adverse reactions to ANTI-ANXIETY therapy . Date Initiated: 12/19/2022 Record review of the Order Summary Report for Resident #22 dated 1/10/23 revealed the following order, LORazepam Tablet 1 MG Give 1 tablet by mouth every 6 hours as needed for Pain - Mild related to MALIGNANT NEOPLASM OF UNSPECIFIED PART OF LEFT BRONCHUS OR LUNG (C34.92) Prescriber Written. Status: Active. Order Date:12/14/2022. Start date:12/14/2022 Record review of the Medication Administration Report dated 1/11/23 for 1/1/23 through 1/31/23 revealed Resident #22 received Lorazepam 1 mg from the PRN order for the first time on 1/07/23 (7:32 PM) and again on 1/08/23 (9:47 PM). Record review of the Consultant Pharmacist Medication Regimen Review dated 1/8/2023 revealed the following for Resident #22, Priority: normal. This resident is currently receiving lorazepam 1 mg Q6 hours PRN 'pain'. This order began 12/14/22. Please evaluate current diagnosis, behaviors and usage patterns and evaluate continue need. PRN, psychotropic orders cannot exceed 14 days with the exception that the prescriber documents their rationale in the resident's medical record and indicate the duration of the PRN order. Please consider: -Discontinue PRN lorazepam. -New order for PRN: lorazepam 1 mg Q6 hours PRN____ (reason for use) for ____ days. -Adjust routine order to _____. Effective 11/28/17: 483.45 (e)(3) residents do not receive psychotropic drugs, pursuant to a PRN order, unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and, 483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5) if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rational in the resident's medical record and indicate the duration of the PRN order . Record review of the Progress Notes for Resident #22 from 12/14/22 through 1/10/23 revealed no documentation of a reassessment for the PRN lorazepam order by the physician. On 1/13/23 at 3:30 PM an interview was conducted with the DON regarding the PRN Lorazepam order for Resident #22. She stated she had talked to staff about their psychoactive medication procedures. She stated the ADON was responsible for making sure the resident did not have PRN psychoactive medication orders. She stated the current ADON had only been employed a week. She stated previously the ADON monitored this, but she had been gone several months. She further stated that in the interim, she (DON) tried to monitor psychoactive medication orders. She stated she expected staff to have caught the PRN psychoactive medication issue and followed up on it. She stated residents could be at risk of becoming dependent on the PRN psychoactive medication if used beyond the 14 days. On 1/13/23 at 4:32 PM an interview was conducted with the Administrator regarding PRN psychoactive medication use beyond 14 days. She stated she expected that staff should have a stop date on the psychoactive medications. She stated the PRN use of psychoactive medications beyond 14 days could affect the resident's overall health. Record review of the facility policy, titled Operational Policy and Procedure Manual For Long-Term Care, revised December 2016, Quality Of Care - Medication, Administration, Antipsychotic Medication Use, revealed the following documentation, Policy Statement. Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavior. Symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Policy Interpretation, And Implementation . 13. Residents will not receive PRN doses of psychotropic medication to unless that medication is necessary to treat a specific condition that is documented in the clinical record. 14. The need to continue PRN orders for psychotropic medications. Beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order Record review of the facility policy, titled Nursing Services Policy and Procedure Manual for Long-Term Care, Revised July 2016, Orders, Receiving and Transcribing, revealed the following documentation, Medication and Treatment Orders. Policy Statement. Orders for medication and treatments will be consistent with principles of safe and effective order writing. Policy Interpretation, and Implementation . 9. Orders for medications must include. b. Number of doses, start and stop date, and/or a specific duration of therapy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to ensure a medication error rate of less than or equal to 5%. The medication error rate was 17% with 6 errors in 34 opportunities involving 2 staff (Medication Aide's A and C) and 2 Residents (Residents #34 and #58) reviewed for medication pass. Medication Aide A failed to administer the correct medications as ordered for Resident #58, and Medication Aide C failed to ensure all medications administered to Resident #34 had an active physician's order. This facility failure can cause residents to not receive their medications as prescribed according to physician's orders and facility policy and procedures. Findings Include: Record review of the Annual MDS for male Resident #34 dated 5/01/21 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. Further record review revealed that the resident had diagnosis of coronary artery disease, benign prostatic hyperplasia, peripheral vascular disease, hyperlipidemia, hypertension, wound infection and diabetes mellitus. Record review of the physician Order Summary dated 1/10/23 revealed female Resident #58 was admitted to the facility on [DATE] and was [AGE] years old. Further record review revealed that the resident had diagnosis of Further record review revealed that the resident had diagnosis of Essential (Primary) Hypertension, Diabetes Mellitus Due To Underlying Condition With Diabetic Polyneuropathy, Chronic Obstructive Pulmonary Disease, Unspecified, Presence Of Coronary Angioplasty Implant And Graft, Unspecified Atrial Fibrillation, Gastro-Esophageal Reflux Disease Without Esophagitis, Acquired Absence Of Right Leg Below Knee, Hyperlipidemia, Unspecified, Depression, Unspecified, Elevated [NAME] Blood Cell Count, Unspecified, Local Infection Of The Skin And Subcutaneous Tissue, Unspecified, Other Specified Soft Tissue Disorders. Record review of the admission MDS dated [DATE] revealed the resident had a BIMS score of 15. Observation of medication pass for resident #58 with Medication Aide A on 01/11/23 at 7:08 AM revealed resident #58 was administered the following medications: Esomeprazole DR 40MG by mouth Diltiazem 24H ER CD 120MG by mouth Record review of resident #58's order summary report with active orders as of 01/11/23 reflected she had orders for the following medications: Esomeprazole Magnesium packet 40MG by mouth every day Diltiazem HCL 120MG by mouth every day Observation of medication pass for resident #34 with Medication Aide C on 01/11/23 at 7:28 AM revealed resident #34 was administered the following medications: Acidophilus with Pectin by mouth Multivitamin with Zinc by mouth Zinc 50MG by mouth Record review of resident #34's order summary report with active orders as of 01/11/23 reflected he had orders for the following medications: Multiple Vitamin tablet by mouth every day Stress Formula/Zinc tab (multivitamin with minerals) DAW dispense as written Record review of the order summary report with active orders as of 01/11/23 revealed Resident #34 did not have an order for Zinc 50MG by mouth every day. Resident #34 did not have an order for Multivitamin with Zinc. Interview on 01/11/23 at 11:33 AM Medication Aide A said she had been trained on the different variants that medication comes in such as delayed release and controlled dose. When asked if she had been checking for the different variances of medications before administering them to a resident she said no and she had just gone through her cart to check for things that might be wrong on the med cart. She said she was aware of it now. When asked the last time she was trained over the different medication variants, she said it had been a while. She said the potential negative outcome for a resident could include the resident getting, have an allergic reaction, and overall a decline in health. She said she would start paying close attention to make sure the numbers and letters variations matched appropriately on the medications. Interview on 01/13/23 at 12:20 PM with Medication Aide C about the medication errors observed during medication pass revealed when asked about the medication is given versus what was on the physicians' orders Medication Aide C said she follows exactly what the doctor orders. She said she asked the facility about the stress formula vitamin not being available and she was told the combination of vitamin B6 and zinc would be the same or equal to the stress formula vitamin. She said the stress formula was a B complex combination. She stated instead of following what they told her she should've put the medication as unavailable. When asked what the potential negative outcome could be for a resident if the orders were not followed, exactly as written, she said it could be a life-or-death situation and could cause a whole lot of bad things such as nerve or brain damage. Interview with the Regional DON on 01/11/23 at 1:10 PM, she said the multivitamin with zinc was the stress formula. She said putting the multivitamin with zinc and the vitamin B complex tab together was an exchange for the ordered stress formula/zinc tab (multivitamin with minerals) medication. She stated the pharmacy was not able to get the physician's ordered stress formula/zinc tab (multivitamin with minerals) and sent the multivitamin with zinc and complex B instead. She said it was an exchange for what was supposed to be sent. She said the staff should have called the doctor and got it changed if the pharmacy did not have the exact medication; the nurse should have received clarification from the doctor. In an interview on 01/13/23 at 12:48 PM with the DON, after being notified the medication error rate was 17%, the DON stated all the medication's that were in question were taken off the medication cart. She said the facility audited the medication carts and got order clarifications for the medications that were given in the medication pass. When asked if she trained her staff over medications, she said yes. When asked how often her staff were trained she said they were in-serviced anytime something came up related to medications. The DON said she expected her staff to report to her if they did not understand the orders, if something looked abnormal like the pill looks different than it normally does, or if the physician's orders don't match what is on the electronic medication administration error. When asked what that potential negative outcome could be for residents she said that not giving the medication properly was dangerous and anything could happen to the resident. She said the facility would do a medication error report, notify the family and the doctor as well. Record review of the facility's policy and procedure dated April 2014, titled Adverse Consequences and Medication Errors documented the following: Policy Interpretation and Implementation: 5. A medication error is defined as the preparation or administration of drugs, or biological, which is not in accordance with physician's orders, manufacturer specifications, or excepted professional standards, and principles of the professional providing services. 6. Examples of medication errors include: A. Omission - a drug is ordered, but not administered. B. Unauthorized drug - a drug is administered without a physician's order. F. Wrong drug (e.g., Vibramycin ordered, vancomycin given). H. Failure to follow, manufacture instructions, and/or excepted professional standards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the menu was followed for 6 of 6 residents (Residents #1, 31, 38, 51, 53, and 312), who consumed 2 of 3 food forms (mechanical soft and pureed), in that: The facility failed to ensure 6 residents received the correct portions that were called for on the menu at 1 of 3 meals observed. These resident meal trays had foods omitted and had lesser amounts of food served than called for on the menu. These failures could place residents at risk for unwanted weight loss and hunger. The findings include: -Record review of the physician order Summary dated 1/12/23 revealed male Resident #1 was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Pain In Unspecified Joint, Hypothyroidism, Unspecified, Essential (Primary) Hypertension, Angina Pectoris, Unspecified, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Unspecified Intellectual Disabilities, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety, Atrophy Of Thyroid (Acquired), Fracture Of Unspecified Part of Neck Of Right Femur, Sequela, and Unspecified Osteoarthritis, Unspecified Site. Record review of the Order Summary Report dated 1/12/23 revealed Resident #1 had an order start date of 7/14/22 that reflected, Regular diet Pureed texture, Thin consistency, divider plate- Double Portions for diet order. Record review of the current undated tray card for Resident #1 revealed a listing of Likes that included double portions all but not printed as part of the physician diet order section of the card. -Record review of the and Order Summary Report dated 1/12/23 revealed male Resident #38 was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Unspecified Cirrhosis Of Liver, Hepatic Failure, Unspecified Without Coma, End Stage Renal Disease, Anemia In Chronic Kidney Disease, Hypertensive Chronic Kidney Disease With Stage 1 Through Stage 4 Chronic Kidney Disease, Or Unspecified Chronic Kidney Disease, Hemiplegia, Unspecified Affecting Left Dominant Side, Unilateral Inguinal Hernia, With Obstruction, Without Gangrene, Not Specified As Recurrent, Gastro-Esophageal Reflux Disease Without Esophagitis, Anxiety Disorder, Unspecified, Insomnia, Unspecified, and Psychotic Disorder With Delusions Due to Known Physiological Condition. Record review of the current undated tray card and Order Summary Report dated 1/12/23 revealed Resident #38 had an order start date of 12/01/22 that stated, Regular diet Pureed texture, Honey consistency, for diet. -Record review of the Order Summary Report dated 1/12/23 revealed Resident female #31 was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Parkinson's Disease, Edema, Unspecified, Constipation, Unspecified, Anemia In Other Chronic Diseases Classified Elsewhere, Hypothyroidism, Unspecified, Type 2 Diabetes Mellitus Without Complications, Unspecified Protein-Calorie Malnutrition(E46), Disease Of Thymus, Unspecified, Major Depressive Disorder, Recurrent Severe Without Psychotic Features, Other Chorea, Sleep Apnea, Unspecified, Essential (Primary) Hypertension, Chronic Obstructive Pulmonary Disease, Unspecified, Gastro-Esophageal Reflux Disease Without Esophagitis, Dyskinesia Of Esophagus, Gastroparesis, Pain In Unspecified Joint, Overactive Bladder, Dysphagia, Unspecified, and Gastrostomy Status. Record review of the current undated tray card and Order Summary Report dated 1/12/23 revealed Resident #31 had an order start date of 6/15/22 that stated, Regular diet Pureed texture, Nectar consistency, as tolerated. -Record review of the Order Summary Report dated 1/12/23 revealed female Resident #51 was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Syncope and Collapse, Unspecified Atrial Fibrillation, Essential (Primary) Hypertension, Hyperlipidemia, Unspecified, Gastro-Esophageal Reflux Disease Without Esophagitis, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. Record review of the current undated tray card and Order Summary Report dated 1/12/23 revealed Resident #51 had an order start date of 9/01/22 that stated, Regular diet Mechanical Soft texture, Regular/Thin consistency. -Record review of the Order Summary Report dated 1/12/23 revealed Resident male #53 was admitted to the facility on 823/22 and was [AGE] years old. The resident had diagnoses of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety, Essential (Primary) Hypertension, Mixed Hyperlipidemia, Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms, Muscle Weakness(Generalized), Need For Assistance With Personal Care, Dementia In Other Diseases Classified Elsewhere, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Edema, Unspecified. Record review of the current undated tray card and Order Summary Report dated 1/12/23 revealed Resident #53 had an order start date of 8/25/22 that stated, Regular diet Mechanical Soft texture, thin consistency. -Record review of the Order Summary Report dated 1/12/23 revealed female Resident #312 was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Disorder Of Muscle, Unspecified, Congenital Hypertonia, Rash And Other Nonspecific Skin Eruption, Age related Osteoporosis Without Current Pathological Fracture, Hypothyroidism, Unspecified, Other Specified Depressive Episodes, Muscle Weakness (Generalized), Dysphagia, Oral Phase, Other Seizures, Other Lack Of Coordination, Nail Dystrophy, Covid-19, Cerebral Palsy, Unspecified, Anxiety Disorder, Unspecified, Insomnia, Unspecified, Constipation, Unspecified, and Vitamin Deficiency, Unspecified. Record review of the current undated tray card and Order Summary Report dated 1/12/23 revealed Resident #312 had an order start date of 8/20/22 that stated, Regular diet Pureed texture, Regular/Thin consistency, Please add extra gravy for her food related to DYSPHAGIA, ORAL PHASE (swallowing disorder). - The following observations were made during a kitchen tour that began on 1/10/23 at 11:35 AM and concluded at 1:01 PM: On 1/10/23 at 12:01 PM the following foods were observed on the steamtable: Pasta and meatballs Puréed Swedish meatballs served with a #8 scoop (1/2 cup/4ounces) Puréed noodles served with the #10 scoop (3 ounces) Mechanically altered Swedish meatballs serve with the #6 scoop (2/3 cup) Gravy served with a 2 ounce ladle Chicken noodle soup Beef patty Swedish meatballs served with a 4 ounce ladle Carrots served with a 4 ounce ladle Puréed carrots served with a #16 scoop (1/4 cup/2 ounces) Noodles served with a 4 ounce ladle Puréed bread served with a #30 scoop (1 - 1.5 ounces) Sausage Record review of the fall/winter 2022 Diet Spreadsheet Week 4 Day 23 Lunch revealed residents on a puréed diet were to receive two #8 scoops (1cup total) of Swedish meatballs puréed, one #10 scoop (3 ounces) of parsley noodles puréed, one #16 scoop (1/4 cup) of seasoned carrots puréed and one #30 scoops (1-1.5 ounces) of puréed bread. Further record review of the menu revealed residents on mechanical altered/soft diet were receive a #6 scoop (2/3 cup) of Swedish meatballs, #8 (4 ounce) scoop of parsley noodles, 1/2 cup (4 ounce) of soft mashed carrots, and puréed bread. Further record review of this menu also revealed residents on mechanical altered/soft diets received a #6 scoop (2/3 cup) of Swedish meatballs, #8 (4 ounce) scoop of parsley noodles, 1/2 cup (4 ounce) of soft mashed carrots, and puréed bread. On 1/10/23 at 12:34 PM revealed Resident #1 was plated one #16 scoop of purée carrots, one #8 scoop of puréed Swedish meatball, one #10 scoop of purée noodles, and one #30 scoop of puréed bread. The resident should have received four #8 scoops of Swedish meatballs puréed, two #10 scoop of parsley noodles puréed, two #16 scoop of seasoned carrots puréed and two #30 scoops of puréed bread due to his double portions order. On 1/10/23 at 12:35 PM Resident #312 was plated one #10 scoop of pureed noodles and one #8 scoop of puréed Swedish meatballs. The resident should have received two #8 scoops of Swedish meatballs puréed. The resident disliked carrots and bread. On 1/10/23 at 12:38 PM Resident #38 was plated one #8 scoop of puréed Swedish meatballs, one #10 scoop of purée noodles, one #30 scoop of puréed bread, and two #16 scoops of puréed carrots. The resident should have received two #8 scoops of Swedish meatballs puréed. On 1/10/23 at 12:40 PM Resident #51 was plated a mechanical soft diet with ½ cup carrots, ½ cup noodles, and #6 scoop of mechanically altered Swedish meatballs with gravy. She did not receive bread. On 1/10/23 at 12:41 PM Resident #53 was plated a mechanical soft diet with #6 scoop of mechanically altered Swedish meatballs with gravy, ½ cup noodles and ½ cup carrots, but did not receive bread. On 1/10/23 at 12:56 PM Resident #31 was plated one #16 scoop of puréed carrots, one #30 scoop puréed bread, one #8 scoop of puréed Swedish meatballs and one #10 scoop puréed noodles. The resident should have received two #8 scoops of Swedish meatballs puréed. On 1/10/23 at 1:07 PM an interview was conducted with Dietary staff A and she stated Resident #51 and Resident #53 did not receive bread because they needed speech evaluations. She stated dietary staff have said that bread was not served because they were on mechanical soft diets. On 1/12/23 at 6:04 PM an interview was conducted with Dietary staff A. She stated she was told about the residents only receiving one scoop of purée Swedish Meatball instead of two as called for on the menu. She stated Dietary staff D previously went over scoop sizes with her regarding the meat and serving two scoops. She stated she forgot about it during the meal service. Regarding the missing bread for Residents #53 and #51, she stated she missed the bread on them. She stated residents could lose weight if foods were omitted or not served the correct amounts. On 1/13/23 at 9:29 AM an interview was conducted with the Dietary Manager. She stated she had conducted in-services in the last 3 months for the staff. Regarding following the menu, she stated she went over portion sizes before this meal. She stated staff think they knew the residents and that they could change the servings on their own. She stated she tells staff to serve correctly. She further stated that residents on mechanical soft diets receive puréed bread. She stated residents' nutritional status was at risk and weight loss could result if residents did not receive the correct serving sizes of food. She also stated she was responsible for ensuring the menu was followed. She stated training for new employees usually lasted three days and she assesses training with them and conducts additional training if needed. Record review of the In-Service Training Reports from October 2022 through December 2022 revealed there was no specific documentation related to the subject of following the menu. On 1/13/23 at 4:32 PM an interview was conducted with the Administrator. She stated she expected staff to follow the menu. She further stated residents' weight could be affected if the menu was not followed. Record review of the facility policy, titled Nutrition, Policies, and Procedures, Complete Revision: 10/2/2017, revealed the following documentation, SUBJECT: Menus. Policy: menus will be planned to meet the nutritional needs and preferences of the patient's/residents and are in accordance with recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences. Menu requirements may vary, per state regulation. A computerized nutrient analysis is available for the base menu. Procedures: 2. Use the menus without modification the first time through the menu cycle. 8. Substitutions offer similar nutritive value to the food being replaced. Record review of the facility policy, titled, Nutrition, Policy, and Procedures, Complete Revision: 10/2/2017, revealed the following documentation, SUBJECT: Therapeutic Diets. Policy . Therapeutic and mechanically altered diets are ordered by the physician and planned by a dietitian. The Definition . a mechanically alter diet is a diet specifically prepared to alter the consistency of food in order to facilitate oral intake. Examples include mechanical soft - ground meat, puréed foods and chopped meat. Procedures. 6. Portion sizes are evident for each item on the menu extensions. 8. Prepared serve all therapeutic and mechanically altered diets as planned. 9. Check all trays for accuracy before they are served to the patient/resident.

Based on observation, interview and record review, the facility failed to provide food that was palatable, and at a safe and appetizing temperature for 1 of 1 breakfast meals from 1 of 1 kitchen. 1) The facility failed to provide food that was palatable for 1 of 1 breakfast meal observed (1/12/23). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings include: Two of 7 residents confidentially interviewed, and ate in their rooms on Station 1, voiced concerns related to food palatability. One resident stated, Our food is cold, and my roommate gets cold eggs. Another resident stated her eggs were cold and that breakfast was cold often. Record review of the Resident Council Minutes dated 12/7/22 revealed, under New Business, residents stated an issue of cold food at dinner time. Record review of the Resident Council Minutes dated 1/4/23 revealed, under Old Business, Dietary - Cold food at dinner time. During an interview on 1/12/22 at 7:07 AM, the Dietary Manager was informed of a test tray request. During a kitchen observation on 1/12/23 at 7:30 AM, temperatures were taken of the foods on the steam table by the Dietary Manager. The temperatures were as follows: Over Easy Eggs no temperature taken Toast no temperature taken Eggs scramble 174.2°F Oatmeal 198 3°F Sausage patty 192°F. Bacon no temperature taken Puréed sausage 154°F Gravy 167°F Cream of wheat 181°F Puréed eggs, 160.1°F Purée bread 149°F On 1/12/23 at 7:44 AM an observation revealed the Dietary Manager started serving/preparing the Station 2 hall cart trays. The cart left the dining room at 7:58 AM. It was observed that the plates had insulated covers, but the cart was not heated. It was also observed that the over easy eggs were plated on the stove and covered with plates. At 7:58 AM preparation started for the Station 1 cart. The last tray was prepared for the Station 1 cart at 8:07 AM and preparation began for the test trays. The test tray preparation ended at 8:10 AM. The hall cart for Station 1 left the dining room at 8:11 AM and arrived on the Station 1 at 8:11 AM. At 8:12 AM two staff (CNAs B and D) started serving trays on Station 1. The last tray on the Station 1 cart was served to Resident #167 at 8:34 AM. The resident began eating at 8:35 AM. Observation on 1/12/23 at 8:39 AM, the test trays were sampled by surveyors with the following results: Puréed, eggs - lukewarm cold, 100.4°F. Puréed sausage with gravy - cold, salty, 97.5°F. Puréed bread - cold, 97.5°F Bacon- cold Scrambled Eggs - lukewarm/cold, 106°F Sausage- cold, 92.1°F Toast - cold Over easy eggs - cold, 99.4°F Oatmeal - warm, 135.8°F Cream of wheat - lukewarm, 119.6°F The test ended at 8:50 AM. On 1/13/23 at 9:29 AM an interview was conducted with the Dietary Manager regarding the cold and lukewarm foods on the test tray. She stated it took longer to serve; staff were late, and nurses delayed. She stated breakfast would get cold fast, and the facility had no heated carts. She stated staff encouraged dining room dining to ensure residents received meals that were at palatable temperatures. She stated they usually finished serving everyone by 8:00 AM and they have a new person working in the kitchen. She stated the dietary staff have met with the residents about menus and alternates. She stated she was responsible for ensuring foods were palatable. She stated residents would not eat the food if the foods were not palatable. A policy related to food palatability was requested at this time. On 1/13/23 at 4:32 PM an interview was conducted with the Administrator regarding food palatability. She stated staff were expected to serve food that was palatable. She stated residents could be unhappy if their food was not palatable. A policy specific for food palatability was not provided at the time of the exit on 1/13/23 at 6:45 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public, in 2 of 2 common resident baths (Station 1 and 2) and 4 of 12 resident rooms on Station1 (Rooms 2, 3, 9 and 16), in that: 1)The facility failed to ensure the shower bed/gurney padded overlay was not damaged with splits and torn areas that exposed the foam interior, 2) The facility failed to ensure oxygen tanks were stored in a secure manner (rooms [ROOM NUMBERS]), 3) The facility failed to ensure resident use hot water was at comfortable temperatures (room [ROOM NUMBER]), 4) The facility failed to ensure chemicals were stored in a safe manner and inaccessible to residents ((Station 2 bath), 5) The facility failed to ensure the resident environments were in good repair (2 of 2 common baths, and room [ROOM NUMBER]). These failures could lead to resident injuries, spread of infections and cause the facility to have an unsightly appearance. The findings include: On 1/10/23 at 1:59 PM, observation of room [ROOM NUMBER] revealed a freestanding oxygen tank that had a gauge indicating there was oxygen still in the tank. It was nearest the A bed area. Residents #22 and #58 resided in this room. On 1/10/23 at 2:20 PM, observation of room [ROOM NUMBER] revealed a freestanding oxygen tank near the commode chair. The level on the oxygen tank gauge indicated that there was still oxygen in the tank. Resident #165 resided in this room. On 1/10/23 at 6:05 PM, observation of room [ROOM NUMBER] revealed an approximately 8-foot section of window trim missing under the window ledge next to Resident #17's bed. It exposed nail heads that extended out from the wall. On 1/10/23 at 6:26 PM, observation of room [ROOM NUMBER] revealed a freestanding oxygen tank in the room. During an interview with Resident #58 at this time the resident revealed the oxygen tank had been in the room since Resident #22 had moved into the room. The resident was unsure of the date. On 1/10/23 at 6:49 PM, observation of room [ROOM NUMBER] revealed an oxygen tank was freestanding and not secured. On 1/10/23 at 6:50 PM an interview was conducted with the Administrator. Regarding the unsecured oxygen tanks, she stated the facility had to watch hospice staff related to oxygen storage to ensure the tanks were stored appropriately. On 1/10/23 at 6:51 PM an interview was conducted with Resident #22. Regarding the freestanding oxygen tank in her room (room [ROOM NUMBER]), she stated the oxygen tank was from hospice. She stated the tank had been in her room for a week. On 1/11/23 at 8:42 AM, observation of room [ROOM NUMBER] revealed the temperature of the hand sink hot water peaked at 117.5°F then declined to 114 degrees F which the 114 degrees F temperature was witnessed by RN A. It was checked with the surveyor's digital thermometer. Resident #23 resided in this room, used a wheelchair and had confusion. Record review of the current undated American Burn Association SCALD INJURY PREVENTION Educator's Guide revealed that 100 degree F water was a safe temperature for bathing. Water at 120 degrees F would cause a third degree burn (full thickness burn) in 5 minutes On 1/11/23 at 8:57 AM an interview was conducted with the Maintenance Supervisor. He stated the facility water circulating system began at room [ROOM NUMBER]. He stated he had not experienced any plumbing problems related to hot water. He stated he tested the hot water every week in random resident rooms. He stated four rooms were tested each week, two on each hall. He also stated he tested hot water at random times and random days of the week, using a digital thermometer. Record review of the Hot Water Temperature Logs between October 2022 and 1/9/23 revealed that temperatures were taken in resident rooms 40 times. 38 of the 40 test times were between 9:30 AM and 11:30 AM. The temperatures ranged from 101.2°F to 105.4°F. Further record review of the instructions documented on the Hot Water Temperature Logs sheet revealed the following, . Hot water in wash sink must be 110°F or above . Water for handwashing must be between 100°F and 110°F On 1/11/23 at 8:58 AM an interview was conducted with the Housekeeping Supervisor regarding freestanding oxygen in the rooms. She stated some oxygen tanks from hospice were moved, but did not specify when. She stated on 1/10/23 she asked LVN A to retrieve the oxygen tank from room [ROOM NUMBER]. She further stated she failed to follow up to see if the oxygen tank had been removed from the room. On 1/11/23 at 11:30 AM an observation was made of the Station 2 bath. The door was fully open, and the room was unattended. There were spray bottles of chemicals on a lower shelf in an unlocked cabinet, which included Comet with Bleach cleaner/disinfectant which was labeled, If swallowed drink a glass of water. Call physician immediately , Micro Kill Q 10 disinfectant labeled .Causes moderate eye irritation. Avoid contact with eyes and clothes. and a spray bottle of a purple liquid that had an unclear label. The heat and exhaust fans were not operational. There was an unshielded fluorescent light in the room. Two of two shower area circular ceiling lights were not operational. On 1/11/23 at 11:35 AM an observation was made of Station 1 bath and the door was open. There was a spray bottle of Comet with Bleach on the top shelf above resident toiletries. The face plate was missing from an electrical outlet at the sink/toilet area which exposed the interior of the wall. A privacy curtain was missing between the 2 shower stall areas. On 1/11/23 at 11:37 AM CNA A was asked about the shower stalls in the Station 1 bath. She stated both shower units worked, but one (sprayer) had a lower water pressure than the other. She further stated there used to be privacy curtains between the stalls. She stated when they had a leak in the ceiling the privacy curtain was gone after that. On 1/11/23 11:38 AM an interview was conducted with CNA B regarding the privacy curtain that was missing in the Station 1 bath. She stated she noticed the privacy curtain missing a month ago. She further stated she did not report this to anyone. On 1/11/23, 11:45 AM an interview was conducted with the Maintenance Supervisor. Regarding the process he used to know about needed maintenance services, he stated the facility had a logbook and a calendar for scheduled maintenance services. He stated staff placed their maintenance requests in the logbook that was located at Station 2 in a purple binder. He stated he tried to check the book daily, but usually residents or nurses told him the issue. He stated he had been the Maintenance Supervisor for two years. On 1/11/23 at 1:03 PM an observation was made of room [ROOM NUMBER]. There was an approximately 8-foot section of missing window trim that had three areas where nail heads extended beyond the wall at the B bed. On 1/11/23 at 1:31 PM an observation was made of the shower bed at Station 2 with CNA A. During an interview with her at this time, she stated the only residents that used the shower bed were those needing it, such as Resident #4. Observation of the foam overlay of the shower bed revealed an approximately 3-inch split on the underside that exposed the foam interior. There was also a corner piece that had a sharp edge on the PVC frame. The CNA stated the corner piece had been that way a couple of days and maintenance was going to repair it today. On 1/12/23 at 9:40 AM an observation was made of the Station 2 bath. The door was fully open and unattended. The cabinet was unlocked and had spray bottles of a poorly labeled bottle of a purple liquid, Comet with Bleach and Micro Kill Q 10 disinfectant. On 1/12/23 at 9:45 AM an interview was conducted at Station 2 with CNA C. She stated she did not know what chemical was in the spray bottle of purple liquid, but the other two bottles were disinfectants used on shower chairs. She stated staff should store those chemicals in the housekeeping room. Regarding the accessible, improperly stored and labeled chemicals, she stated it would not be good if residents got into the chemicals. Regarding the ceiling heat unit and exhaust fans not being operational, she stated she noticed the ceiling heater unit and exhaust fan not working on 1/11/23. She stated she had not mentioned this to anyone. On 1/12/23 at 9:58 PM an interview was conducted with the Maintenance Supervisor regarding repairs and how he knew when they were completed. He stated he writes done by the request in the logbook but sometimes he forgets to do so. He also stated he was not aware of the Station 2 circular shower lights, ceiling heater and the exhaust fan not working. Regarding the missing Station 1 privacy curtains, he stated he was not sure how long the curtain had been gone. He stated his repair schedule was driven mostly by what was in the logbook. He stated residents also stop and tell him about repairs. He stated he was not aware of the missing window trim in room [ROOM NUMBER]. He stated residents could get hurt if items were left unrepaired. Regarding oxygen storage, he stated an in-service was conducted on oxygen a few months ago. He added, oxygen should not be free and loose. He stated the storage problem was with the nurses. He further stated staff were trained to know oxygen should be secured. He stated he corrected improperly stored oxygen if seen. He further stated that he was not aware of any issues with hospice staff related to oxygen storage. Record review of the maintenance logbook revealed that between October 2022 and 1/9/23 there were 38 requests documented for facility repairs/maintenance services. There was only written documentation of four of the requests being completed. None of the identified maintenance issues discovered during the survey were documented in the maintenance log. On 1/13/23 at 1:06 PM the shower bed/gurney was observed in the Station 2 corridor and the foam overlay still had an approximately 3-inch split on the underside, exposing the foam interior. On 1/13/23 at 3:30 PM an interview was conducted with the DON. She stated she talked to staff about oxygen storage and did an in-service. Record a review of the In-Service Training Report dated 10/5/22 revealed the Subject: E Cylinder, which was conducted by the DON/ADON/designee. Summary of in-service: the E cylinder . when in use, empty or full, must never be freestanding. They must be in a proper stand, container or rolling stand. Take empty tanks out to the proper locked area. Freestanding E cylinders are dangerous if they fall over! . The attached document to this in-service further stated, . Oxygen Guidelines. E cylinders should never be left standing on the floor anywhere. On 1/13/23 at 4:32 PM an interview was conducted with the Administrator. Regarding the storage of oxygen and repairs she stated she expected staff to report repairs. She was asked what could result from these issues and she stated safety issues. Record review of the facility policy, titled Operation Policy and Procedure Manual for Long-Term Care, Revised December 2009, Physical Environment - Maintenance, revealed following documentation, Maintenance Service. Policy Statement. Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation, and Implementation. 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: a. Maintaining the building in compliance with current federal, state and local laws, regulations, and guidelines. b. Maintaining the building in good repair and free from hazards. f. Establishing priorities in providing repair service. i. Providing routinely schedule maintenance service to all areas. j. Others that may become necessary or appropriate. 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner Record review of the facility policy, titled, Operational Policy and Procedure Manual for Long-Term Care, Revised May 2011, Physical Environment - Fire Ants, Life Safety, revealed the following documentation, Fire Safety and Prevention. Policy Statement. All personnel must learn methods of fire prevention and must report conditions that could result in a potential fire hazard. Policy Interpretation, and Implementation. Oxygen Safety . f. Store, oxygen cylinders in racks with chains, sturdy, portable carts, or approve stands. Never leave oxygen cylinders, freestanding. Do not store oxygen cylinders in any resident room or living area. p. Ensure that staff using oxygen equipment is adequately trained in its operation and in oxygen safety and has the knowledge of the manufactures instructions for using the equipment.

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 for 4 of 4 staff (Dietary Staff A, B, C and D) in 1 of 1 kitchen, in that: 1) Dietary staff A, B, and C failed to serve or process foods in a manner to prevent contamination. 2) The facility failed to ensure Time/Temperature Controlled for Safety (TCS)/Potentially Hazardous (PHF) pureed foods were rapidly reheated to 165 degrees F. 3) Dietary staff A failed to handle food contact equipment in a manner to prevent contamination These failures could place residents at risk for food contamination and foodborne illness. The findings include: - The following observations were made during a kitchen tour that began on 1/10/23 at 11:35 AM and concluded at 1:01 PM: Dietary staff A was observed preparing puree foods. Prior to her placing noodles in the processor pot, the underside of the processor blade was wet. She placed the noodles in the pot, pureed the noodles and then placed the noodles a pan. Next, she was about to place the Swedish meatballs in a processor pot, but the surveyor intervened before she put the Swedish meatballs into the processor. The surveyor showed Dietary staff A there was a piece of food debris on the inside of the processor pot. She took the processor to the dishwasher to be rewashed. Dietary staff D washed the processor parts and then shook the parts in order to remove excess water. The blade was still wet from the dishwasher. Dietary staff A then placed the meatballs in the processor which had a wet blade and puréed the food. She then placed the puree in a pan and put it on the steam table. She took the processor pot to the dishwasher. After washing the processor, she showed the surveyor the blade which was still wet. When she showed the surveyor the wet blade, she picked up the blade with her bare hands. Dietary staff A had fingernails that were at least 2 inches long and she handled the blade top with her bare fingers. She then placed the blade back in the processor and placed carrots in the processor and puréed the carrots. After puréeing the carrots, she placed them in a pan and then placed the pan on the steam table. Record review of the label on the sanitizer container for the dishwasher, Ecolab Ultra San, revealed the following, . Directions for use . Sanitization. Tableware Sanitizer and Destainer for Mechanical Spray Warewashing Machines. Air dry or follow with a potable water rinse . On 1/10/23 at 12:01 PM temperatures were observed taken on the steam table by Dietary staff A: Pasta and meatballs, no temperature taken Puréed Swedish meatballs 122°F. On 1/10/23 at 12:01 PM Dietary staff A stated she had just puréed the meatballs after noting that the temperature of the purée Swedish meatballs was 122°F. Dietary staff A did not reheat the food and continued to take temperatures on the steamtable. The puréed bread was not on any heat source and no was temperature taken. The sausage was in a pot of water on the stove and there was no heat on. Dietary staff B took containers of thickened liquids, cranberry (2 cartons), and lemon flavored water (1 carton), from the refrigerator and held it against her chest and carried it to a cart where she poured the liquids into glasses. - The following observations were made during a kitchen tour that began on 1/10/23 at 5:03 PM and concluded at 5:35 PM: Temperatures were observed taken on the steam table at 5:07 PM by Dietary staff C of the following foods: Hamburger patty, Puréed sweet potatoes, Puréed cabbage, Purée pulled pork sandwich, Chicken noodle soup, Regular pulled pork, Ground pulled pork, and Cabbage, As Dietary staff C was observed taking temperatures she allowed the upper plastic casing of the thermometer, and casing areas past the probe, to fall into the foods. Between foods she cleaned the probe, but not the casing areas that fell in the foods. This was done after taking temperatures of each food. On 1/12/23 at 6:04 PM an interview was conducted with Dietary staff A. She stated really had not been told about rapidly reheating food to 165 degrees F and had learned about it today. She stated the last in-services that were conducted were related to getting ready for the state survey. She stated the in-service covered the basics. She stated dietary staff had training on not handling equipment with their bare hands. She stated the dietary issues occurred due to her being in a hurry. She stated the subject of allowing equipment to air dry was not brought up in the in-service training. She stated residents could get sick as a result of her observed dietary actions. On 1/12/23 at 6:30 PM an interview was conducted with Dietary staff B about holding the cartons of drinks against her clothing and chest. She stated she thought the reason that happened was because she had been running behind. She stated everything on her clothes would get on the food if she carried foods against her body. On 1/13/23 at 9:29 AM an interview was conducted with the Dietary Manager. Regarding staff not rapidly reheating foods to 165 degrees F, processing food in wet processors, and handling of equipment, she stated Dietary staff A was nervous and late. Regarding foods being held against the body of staff, she stated Dietary staff B moved from nursing, and this was her first week of training. She stated training for new employees usually lasted three days and she reassessed training with them and conducted additional training if needed. The Dietary Manager stated she had conducted in-services for the staff. She stated cross-contamination could occur from the problems observed in the dietary department. She stated she was the person responsible to ensure correct dietary sanitation procedures were implemented. Record review of the In-Service Training Reports from October 2022 through December 2022 revealed the following topics: 10/12/22 - Cleaning procedures - Attended by Dietary staff A, C and D 11/29/22 - State Regulations, Summary of in-service: handwashing, glove use, labeling and heating food, temperature logs, teamwork, and food handlers - Attended by Dietary staff A, C and D 12/7/22 - Serving time. Attended by Dietary staff A and C On 1/13/23 at 4:32 PM an interview was conducted with the Administrator regarding dietary sanitation. She stated she expected staff to implement correct dietary procedures. She stated the observed dietary sanitation problems could result in possible contamination. Record review of a posted sign near the service line revealed the following documentation: Food temperatures. Are you doing everything to keep food hot Hot food 135 (degrees F) and higher If not at least 135 (degrees F) must reheat to 165 (degrees F) and hold for 15 seconds. Reheat your purée and mechanical food to ensure temperature . Thermometer stem cleaned/sanitized between testing of each food. Record review of the facility policy, titled Nutrition, Policies, and Procedures, Complete Revision: 10/2/2017 revealed the following documentation, SUBJECT: Safe Food Handling. Policy: food acquisition, storage, and distribution will comply with accepted food handling practices. Proper food handling is essential in preventing foodborne illness. Procedures: General statements . 6. Follow all local, state, and federal regulations when handling food . Food/Beverages Prepared and Served By Facility Staff For Patients/Residents: 1.All facility staff, (culinary, nursing, therapy, activities, etc.) involved in the preparation and service of food adheres to safe food handling techniques . 4.All foods are stored, prepared and served at temperatures that prevent bacterial growth. Hot foods are maintained at 140°F or higher in cold foods are maintained at 40°F or below at point of service . At point of delivery, hot foods should be 120-1 40°F, cold food 41-40 5°F or per state regulations . 6. Food is served with clean, sanitized utensils. There is no bare hand contact Record review of the facility policy, titled Nutrition, Policies, and Procedures., Complete Revision: 10/2/2017, SUBJECT: Safe Food Preparation. POLICY: During the food production process, food will be handled by methods to minimize contamination and bacterial growth to prevent foodborne illness. Procedures: 1. Prepare foods in a sanitary manner with minimal handling. When feasible, foods are prepared the same day as service and as close to the time of service as possible . 9. Hands do not touch areas of utensils, dishware, or silverware, where the food or mouth is placed Record review of the facility policy titled, Subject: Safe, Food Temperatures, Complete Revision: 10/2/2017. revealed the following documentation, POLICY: Food temperatures will be maintained at acceptable levels during food storage, preparation, holding, serving, delivery, cooling and reheating. The steam table may not be used to reheat food . Procedures 7. Check and record tray line food temperatures on the food temperature record before each meal. If the food temperatures are not within acceptable parameters, reheat the food to at least 165°F for 15 seconds (for hot foods) or discarded . GUIDELINES FOR CHECKING FOOD TEMPERATURES . Note: the thermometer must be cleaned and sanitized between each product that is tested . 4. If temperatures do not meet requirements, notify the Nutrition Services Director (NSD) for direction . USING THE THERMOMETER CORRECTLY: 1.Do not submerge the entire thermometer into the liquid portion of the food; this could damage the thermometer