**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that the interdisciplinary team had determined that the resident's right to self administer medications was clinically appropriate. Specifically, for 1 out of 21 sampled residents, the Registered Nurse (RN) was observed to leave a residents medications at the bedside in a medication cup and the resident had not been evaluated to determine if they were safe to self administer medications. Resident identifier: 19. Findings included: Resident 19 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, type 2 diabetes mellitus, epilepsy, encephalopathy, alcohol abuse with unspecified alcohol induced disorder, and ataxia. On 12/18/23 at 8:58 AM, an observation was conducted of RN 1 preparing medications for resident 19. The medication cup that RN 1 prepared included pregabalin 50 milligrams (mg), Keppra 500 mg, metformin 1000 mg, aspirin 81 mg, Creon 24,000-76,000 units, omeprazole delayed release 20 mg, potassium 20 milliequivalent, and torsemide 20 mg two tablets. In addition, RN 1 prepared a Lantus injector pen 3 units, Lantus injector pen 51 units, and an insulin aspart injector pen 8 units. RN 1 was observed to administer the Lantus and insulin aspart to resident 19. RN 1 was observed to leave the medication cup with the pills in resident 19's room so resident 19 could self administer the medications. Resident 19's medical record was reviewed on 12/18/23. A quarterly Minimum Data Set assessment dated [DATE], documented that resident 19 had a Brief Interview for Mental Status (BIMS) score of 12. A BIMS score of 8 to 12 would suggest moderate cognitive impairment. No documentation could be located indicating that resident 19 had been evaluated to safely self administer medications. The Home Medication policy within the admission agreement documented During your stay at [facility name removed], all medication must be prescribed by your physician and administered by [facility name removed] nursing staff. Please note the Residents Rights state: You have the right to self-administer medications, upon resident's request, and if the resident's Interdisciplinary Team has determined it is clinically appropriate and safe for the resident to do so. Resident must provide secure method for storage of medication and demonstrate ability to operate chosen storage method, complying with all safety measures for storage and documentation of self-administered medications. On 12/18/23 at 10:35 AM, an interview was conducted with RN 2. RN 2 stated that resident room [ROOM NUMBER] and resident room [ROOM NUMBER] self administered medications. RN 2 stated the facility had a form that the resident, physician, and nurse would sign. RN 2 stated the resident would have to tell the nurse what the medications were, what the medications were used for, and what time the medications were to be administered. RN 2 stated the resident would need to be assessed to determine if they could take the medications safely by themselves. RN 2 stated that resident 19 should not be self administering his medications. RN 2 stated staff tried a few months ago to see if resident 19 could self administer his medications and resident 19 was not able to do it. On 12/18/23 at 10:39 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the resident in room [ROOM NUMBER] had been approved to self administer medications. The DON stated the prior company had a form that they would fill out and quiz the resident on what their medications were. The DON was unsure if resident 19 was approved to self administer medications. The DON stated that resident 19 was pretty independent. On 12/18/23 at 11:09 AM, an interview was conducted with the Corporate Nurse (CN). The CN stated there was no self administration form for resident 19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment that they prevented further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress. Specifically, for 1 out of 21 sampled residents, an allegation of neglect was made and the alleged perpetrator was not suspended pending the investigation and was allowed access to the resident/victim. Resident identifier: 16. Findings included: Resident 16 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, early onset cerebellar ataxia, muscle spasms, insomnia, depression, dysphagia, and dorsalgia. On 12/11/23 through 12/18/23, resident 16's medical record was reviewed. Review of the facility initial investigation, form 358, documented an allegation of neglect by Certified Nurse Assistant (CNA) 1 and CNA 2. On 8/9/23 at 1:00 AM, the report documented that CNA 3 and Licensed Practical Nurse (LPN) 1 became aware of the incident and administration was notified at 1:45 AM. The report documented that CNA 3 found resident 16 on the floor in the bathroom unattended. The report documented that the incident occurred on 8/8/23 at 10:00 PM. The report documented that the resident was frustrated by the situation. The facility follow-up investigation, form 359, documented that CNA reported that they found resident on the floor in bathroom, Reported it to the nurse who assessed the resident and notified DON [Director of Nursing], and began to establish a timeline of events. The summary of the interviews documented that it was determined that there was a miscommunication amongst staff that tasks had been completed when they had not finished their entire task, and safety check were also miscommunicated prior to shift change. The report conclusion documented that the allegation was verified, and staff and resident were able to confirm the incident. The report documented that the plan of care showed that they had a safety check that was not completed and a resident task for a shower had been started and was marked complete. On 8/10/23 at 11:01 AM, an emailed statement by CNA 1 documented, I usually wait until [resident 16's] grandpa leaves before I shower him. That night his grandpa left a little later than usual and that's completely fine. We always get him on the toilet before the shower and he tells us that he'll call when he's ready to get in the shower. He called at about 9:20 [PM]. I helped assist him into the shower and started to wash his hair and handed him the shower head because he completes the rest of it on his own. I laid out his clothes and went to grab a few towels for the floor. He's usually in the shower for about 15 minutes so I assumed I had time. When I walked out to the nurses station the Noc [night] CNAs were telling me that I could leave early because every other task for the night was completed and they would have 3 CNAs that night. I responded with '[resident 16] is still in the shower though'. And they said that was alright. They asked for report which we usually do walking rounds but that night they just asked for it at the nurses station. When giving report about [resident 16] I had told them that I washed his hair and that he would be ready to get out in about 15 minutes or so. Then I proceeded to change one more person before I left and I should've stayed and completed [resident 16's] shower. But I left when he depended on my care and I am so sorry for the insecurity that [resident 16] was left with that night. I apologize to his family for the worry they must feel. I do think that Noc shift should've been checking in (sic) him every hour because we are required to but this is nobodies [sic] fault to blame except for mine. On 8/10/23 at 1:10 PM, an emailed statement by CNA 2 documented, On the night of August the 8th 2023 when I came into work we decided that I would move from hall one onto the flout (sic) aid (sic). I was the one who initially told one of the CNA's that if all their work was done then I would be okay if they left early. Later that night the CNA eventually did leave early. At report I asked if all her meal ticket's [NAME] (sic) and showers were done her response was yes. Walking rounds were not done and neither were the rounds done properly. Later that evening we found one of the residents on the floor where they had been for hours. Review of CNA 1's time card documented the following: a. On 8/8/23, CNA 1 clocked into work at 2:00 PM and clocked out at 9:45 PM. b. On 8/9/23, CNA 1 clocked into work at 12:00 PM and clocked out at 10:00 PM. c. On 8/10/23, CNA 1 clocked into work at 2:00 PM and clocked out at 10:00 PM. On 12/12/23 at 2:27 PM, a telephone interview was conducted with resident 16's mother. Resident 16's mother stated that she was his legal guardian and Power of Attorney (POA). The POA stated that the Administrator (ADM) called the next morning at 10:00 AM, and informed her that there was an incident. The POA stated that she was informed that resident 16 had been left in the shower for an extended period of time and that they were going to gather more information. The POA stated that 10 minutes later the DON called her. The POA stated that she was told that at 1:00 AM, resident 16 had still had not pushed his button for help to bed, and that was when staff found him. The POA stated that resident 16 was found in the shower sitting with his back in the corner. The POA stated that the DON told her resident 16 was in the shower for almost 4 hours. The POA stated that two days after the incident the girl came in to shower him again. The POA stated that it was the same CNA from the shower incident, CNA 1. The POA stated that when she came in she asked her Can we talk for a minute?. The POA stated at that time she just wanted to make sure that whoever was showering resident 16 knew what the process was. The POA stated that she asked the CNA to talk her through the shower process. The POA stated that was when CNA 1 replied, I'm not going to leave the bathroom and I'm going to make sure there are towels in there. The POA stated that she showed the CNA that there were extra towels in the bathroom and CNA 1 replied that she had no idea they were towels. The POA stated at that point she asked the CNA to tell her their name and that was when she discovered it was the same CNA that had left resident 16 unattended. The POA stated that CNA 1 started crying and told them how sorry she was. I told her we had been waiting to hear that. I told her mistakes happen, but you make sure it doesn't happen again. The POA stated that CNA 1 had reported that she told two other people that resident 16 needed help, but no one went back in and checked on him. On 12/12/23 at 3:17 PM, an interview was conducted with the ADM. The ADM stated that he filled out form 358 and 359 for the facility investigation and interviewed staff. The ADM stated that during the investigation they did not suspend CNA 1. The ADM stated that when a staff member was under investigation they should be suspending them pending the investigation results. The ADM stated that the purpose was to keep the individual safe, and not have any repeat occurrences. The ADM stated that CNA 1 quit before the investigation was completed. The ADM stated that CNA 1 was denying some of the allegations and until they could get more conclusive evidence they did not terminate her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that the resident environment remains as free of accident hazards as was possible and that each receives adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 21 sampled residents, facility staff attempted to transfer a resident from her bed to her wheelchair using a Hoyer lift without properly securing the Hoyer straps. Resident identifier: 17 Findings included: Resident 17 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, autonomic dysreflexia, neuromuscular dysfunction of bladder, atherosclerosis of aorta, morbid (severe) obesity due to excess calories, major depressive disorder, contracture of muscle, and dependence on wheelchair. On 10/3/23, the State Survey Agency received a facility reported incident that documented that resident 17 had fallen during a staff assisted transfer from her bed to her wheelchair using a Hoyer lift. Forms 358 and 359 were reviewed. The incident occurred on 10/2/23 at 5:20 PM. The alleged incident was verified to have actually occurred per form 359. Resident 17 received a 1.57 centimeter (cm) abrasion on her left elbow from the incident and was sent to the emergency room for an x-ray. No bone fractures were found. Resident 17's medical record was reviewed from 12/11/23 through 12/18/23. A quarterly Minimum Data Set assessment dated [DATE], documented that resident 17's had a Brief Interview for Mental Status (BIMS) Score of 15. A BIMS score of 13 to 15 would suggest intact cognition. A care plan Focus initiated on 5/10/23 and revised on 5/24/23, documented The resident is risk for falls r/t [related to] dependence on staff for all ADLs [Activities of Daily Living] and dependence on hoyer lift for transfers. The care plan Goal documented The resident will not sustain serious injury through the review date. Interventions included: a. Initiated on 5/10/23, Anticipate and meet the resident's needs. Encourage to wait for assistance. b. Initiated on 5/24/23, Be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. c. Initiated on 5/24/23, Be sure bed was in low position and locked in place. d. Initiated on 5/24/23, Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. e. Initiated on 5/24/23, Follow facility fall protocol. A care plan Focus initiated on 5/10/23 and revised on 5/24/23, documented The resident has an ADL self-care performance deficit r/t hx [history] of MVA [myocardial vascular accident] with neurological trauma, autonomic dysreflexia, muscle contractures, class 3 obesity, depression, pulmonary htn [hypertension] and neurogenic bladder. The care plan Goal documented The resident will maintain current level of function in eating and driving her electric wheelchair through the review date. The Interventions included, but were not limited to: a. Initiated on 5/24/23, BED MOBILITY: The resident is usually able to: perform ADL with total dependence on 1-2 staff and use of hoyer lift for safe transfers. b. Initiated on 5/24/23, TRANSFER: The resident is usually able to: perform ADL with total dependence on 1-2 staff and use of hoyer lift for safe transfers. The ADL Self Performance for Transfers was reviewed for dates between 11/14/23 and 12/12/23. For 42 out of 51 occurrences, resident 17 was totally dependent on staff for transfers. For 3 out of 51 occurrences, resident 17 required extensive assistance from staff for transfers. For 6 out of 51 occurrences, there was no data or there was no transfer. The ADL Transfer Support Provided was reviewed for dates between 11/14/23 and 12/12/23. For 37 out of 51 occurrences, resident 17 was a two-person physical assist for transfers. For 7 out of 51 occurrences, resident 17 was a one-person physical assist for transfers. For 7 out of 51 occurrences, there was no data or there was no transfer. On 10/2/23 at 8:38 PM, a nursing progress note documented, At approximately 1720 [5:20 PM], CNA's [sic] put Hoyer sling under resident, attached clips to Hoyer and lifted resident. Sling loops became unattached from Hoyer clips. Resident fell to floor, approximately 18 inches. CNAs reported left elbow hit the floor first. Vital signs obtained. There is a 1.5 cm abrasion on left elbow; elbow swollen. Resident's head hit floor. Provider, family, and administration notified. Neuro [neurological] checks initiated. Resident sent to hospital via EMS [Emergency Medical Services] for x-rays. Resident returned to facility at approximatley [sic] 1940 [7:40 PM]. No fractures. On 10/2/23 at 10:57 PM, a nursing progress note documented, Resident returned from hospital at approximately 1940. Order to apply ice to left elbow. Neuros and vitals continued. On 12/11/23 at 12:35 PM, Resident 17 was observed laying in her bed in her room and an interview was conducted with resident 17. Resident 17 stated that on 10/2/23, two CNAs were transferring her from her bed to her wheelchair. Resident 17 stated that one of the straps on the Hoyer lift had not been properly secured. Resident 17 stated that she fell onto the floor and injured her left arm. Resident 17 stated that her left arm was bruised. On 12/13/23 at 11:03 AM, an interview was conducted with CNA 4. CNA 4 stated that resident 17 required a Hoyer lift to transfer. On 12/13/23 at 1:03 PM, an interview was conducted with CNA 5. CNA 5 had been present at the time of the incident. CNA 5 stated that resident 17's Hoyer sling had four straps. CNA 5 stated that in the incident with resident 17, one of the Hoyer sling straps was likely not secured to the hook on the Hoyer lift. CNA 5 stated that during the incident, the leg strap on resident 17's Hoyer sling came off and resident 17 slipped through the Hoyer sling and her torso fell sideways out of the opening. CNA 5 stated that it was very unlikely for a Hoyer sling to become unhooked unless the sling was loaded over its weight limit or if the sling was not criss crossed underneath the resident. On 12/13/23 at 2:29 PM, an interview was conducted with CNA 6. CNA 6 had been present at the time of the incident. CNA 6 stated that she had put resident 17's Hoyer sling straps on the Hoyer lift. CNA 6 stated that when she and CNA 5 initially lifted resident 17 off of her bed, nothing had happened. CNA 6 stated that as she and CNA 5 moved the Hoyer lift from underneath resident 17's bed two of the Hoyer straps on the end of Hoyer lift fell off. CNA 6 stated that resident 17's hip hit the floor first, then her elbow. CNA 6 stated that resident 17's head also hit the floor, but not hard enough to cause an injury. On 12/13/23 at 2:57 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 was the nurse that CNA 5 and CNA 6 reported to after resident 17's fall. RN 3 stated that both CNAs were too shocked to remember what had happened. RN 3 stated that when she went into resident 17's room, the Hoyer lift was between the sliding bathroom door and the wall, quite far from resident 17's bed. RN 3 stated that two of the very back sling hooks were not on the Hoyer lift. RN 3 stated that upon assessment of resident 17 she found resident 17's elbow to be bruised and found that resident 17 had hit her head. RN 3 stated that resident 17 was sent out to the hospital for evaluation. RN 3 stated that it would not be possible for the sling to come off of the Hoyer lift if that sling had been secured properly. RN 3 stated the Hoyer sling straps have to be all the way on the Hoyer lift hooks or else the straps would fall off. On 12/18/23 at 10:50 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that during the incident with resident 17, resident 17 had fallen, had a hard time feeling her left elbow, and was sent out to the emergency room. The DON stated that the facility required all nursing staff to complete a mandatory Hoyer lift training and that physical therapy and occupational therapy had assessed resident 17's Hoyer sling after the incident. The DON stated that an audit was completed on the Hoyer lift itself and the facility had been completing twice weekly Hoyer lift audits since the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, for 1 out of 21 sampled residents, a residents medications were not administered as ordered by the physician due to the medications not being available by the pharmacy. Resident identifier: 4. Findings included: Resident 4 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia, acute kidney failure, acute on chronic diastolic heart failure, type 1 diabetes mellitus with diabetic chronic kidney disease, type 1 diabetes mellitus with foot ulcer, generalized anxiety, schizophrenia, major depressive disorder, and attention-deficit hyperactivity disorder. Resident 4's medical record was reviewed on 12/11/23. On 11/30/23 at 10:19 PM, an Orders - Administration Note documented Note Text: Latuda Oral Tablet 20 MG [milligrams] Give 1 tablet by mouth at bedtime related to SCHIZOPHRENIA, UNSPECIFIED . Medication was not delivered with pharmacy order. New pharmacy will be [sic] sent [sic] medication for delivery tomorrow. On 12/1/23 at 2:39 AM, a Nurse's Note documented Note Text: Resident made odd statements regarding invisible friends and had episode of forgetfulness of who nurse was and about medications to which resident is normally aware. NP [Nurse Practitioner] was notified and informed nurse of resident recently having discontinued Latuda r/t [related to] schizophrenia. NP had made order for resident to restart medication, however, medication was not delivered by [name of pharmacy removed] pharmacy. Due to pharmacy company change on 12/1 [23], order was sent to [name of pharmacy removed] pharmacy via fax. Will pass to oncoming shift to follow up about receiving Latuda medication for resident and continue to monitor hallucinations and behaviors per NP order. On 12/1/23 at 6:59 AM, an Orders - Administration Note documented Note Text: CeleBREX Oral Capsule 100 MG Give 100 mg orally three times a day for pain not available from pharmacy. stat [urgent] safe has 200mg only capsule. Will call pharmacy NP notified. On 12/1/23 at 11:43 AM, an Orders - Administration Note documented Note Text: CeleBREX Oral Capsule 100 MG Give 100 mg orally three times a day for pain not here from pharmacy. On 12/1/23 at 11:22 PM, an Orders - Administration Note documented Note Text: Latuda Oral Tablet 20 MG Give 1 tablet by mouth at bedtime related to SCHIZOPHRENIA, UNSPECIFIED . Medication was not delivered by pharmacy. Pharmacy was called, pharmacy stated medication could possibly be delivered between 1-2am. Pharmacist also stated that medication had not been 'cleared' but he would add it to the schedule to be delivered 'for sure' tomorrow. On 12/1/23 at 11:48 PM, an Orders - Administration Note documented Note Text: CeleBREX Oral Capsule 100 MG Give 100 mg orally three times a day for pain Medication was not delivered by pharmacy. Nurse called pharmacy; pharmacist stated that they did not receive order for that medication. Nurse asked if order was sent over tonight, if it will be delivered by tomorrow, pharmacist replied yes. Will send order via fax to be delivered tomorrow. On 12/2/23 at 11:09 AM, an Orders - Administration Note documented Note Text: CeleBREX Oral Capsule 100 MG Give 100 mg orally three times a day for pain not available, pharmacy notified. On 12/2/23 at 1:13 PM, an Orders - Administration Note documented Note Text: CeleBREX Oral Capsule 100 MG Give 100 mg orally three times a day for pain not available, pharmacy notified. On 12/2/23 at 2:20 PM, a Nurse's Note documented Note Text: NP ordered depakote BID [twice daily] to manage symptoms related to schizophrenia until Latuda can become therapeutic. First dose of depakote was given now. Pharmacy was called earlier today and Latuda will be delivered tonight. On 12/2/23 at 7:19 PM, an Orders - Administration Note documented Note Text: CeleBREX Oral Capsule 100 MG Give 100 mg orally three times a day for pain Pharmacy deliver has not gotten here yet. On 12/5/23 at 8:56 PM, an Orders - Administration Note documented Note Text: CeleBREX Oral Capsule 100 MG Give 100 mg orally three times a day for pain Dosage hold ordered by [name removed]. Medication was only provided with 3-day supply from pharmacy, which ran out during the day. Will refax and/or call pharmacy to follow up on medication and request replenished supply. On 12/6/23 at 6:36 AM, an Orders - Administration Note documented Note Text: CeleBREX Oral Capsule 100 MG Give 100 mg orally three times a day for pain Not available from pharm [pharmacy] or stat safe. NP aware. On 12/6/23 at 11:33 AM, an Orders - Administration Note documented Note Text: CeleBREX Oral Capsule 100 MG Give 100 mg orally three times a day for pain not available from pharmacy. Not in stat safe. Pharmmacy [sic] states it will be here tonight. On 12/7/23 at 12:31 AM, an Orders - Administration Note documented Note Text: CeleBREX Oral Capsule 100 MG Give 100 mg orally three times a day for pain Medication arrived late from pharmacy, and resident requested for it to be brought in during 12am or 3am blood sugar check once it arrived. On 12/12/23 at 1:18 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated if he needed to refill a resident medication he would print off a script from the resident Medication Administration Record and fax the script to the pharmacy. LPN 2 stated a lot of times if the pharmacy was not sending the medication he would call the pharmacy and clarify that the refill was received. LPN 2 stated in the past the facility did have problems with the pharmacy not delivering but the facility was also in the process of switching pharmacies. LPN 2 stated the new pharmacy had been much better. LPN 2 stated if he faxed a refill in the morning it should be to the facility by late tonight. LPN 2 stated the pharmacy started their deliveries in Salt Lake City. LPN 2 stated the facility had an emergency medication system that was stocked with medications. LPN 2 stated that resident 4's Celebrex was 100 mg and there were only 200 mg capsules in the emergency medication system. On 12/12/23 at 1:42 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility was integrated with the former pharmacy and with the new pharmacy the facility was not integrated yet so the staff were faxing medication refills. The DON stated the pharmacy delivered daily. The DON stated the pharmacy would deliver STAT medications but the pharmacy was located in Springville so it was a little harder to get the medications to the facility quickly. The DON stated the pharmacy transition was a little bit hard and the new pharmacy thought they were going to be integrated. The DON stated the facility changed pharmacies on 12/1/23. The PHARMACY AGREEMENT dated 10/1/23, documented . ARTICLE 1 RESPONSIBILITIES OF THE PHARMACY 1.1 General. During the Term (as defined below) of the Agreement, the Pharmacy shall: (a) provide the Pharmacy Products to the Facility and its residents in a prompt and timely manner in accordance with all applicable local, state and federal laws and regulations (collectively, 'Applicable Law'); . 1.2 Delivery Schedule. The Pharmacy shall deliver the Pharmacy Products to the Facility daily or as otherwise mutually agreed by the parties in writing. See Exhibit A. Exhibit A Delivery The Pharmacy shall deliver at no charge to the Facility (i) up to four times per day at approximately 10am, 2pm, 5pm and 8pm on non-holiday weekdays and (ii) up to two (2) times per day on weekends and holidays at approximately 2pm and 8pm. The Facility shall place their order at least two hours prior to the applicable departure time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 1 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included hemiplegia affecting right dominant side, traumatic brain injury, neuromuscular dysfunction of the bladder, epilepsy, Crohn's disease, anxiety disorder, major depressive disorder, and osteoarthritis. On 12/11/23 through 12/18/23, resident 1's medical record was reviewed. Review of resident 1's medical record revealed no documentation of the monthly drug regimen review conducted by the pharmacist for November 2023 through January 2023 through. Review of the facility pharmacy binder revealed no documentation of the monthly drug regimen review for July 2023 through November 2023. On 12/11/23 at 3:06 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that they just switched to a new pharmacy last week. The DON stated that the monthly drug regimen reviews were emailed for awhile and she would check the email for the pharmacy reviews from July 2023 through November 2023. On 12/12/23 at 8:18 AM, the DON stated that she had all the pharmacy reviews and recommendations from June 2023 through November 2023 on her computer, but she was not able to print them so she had the pharmacy fax them over to her again. Review of the monthly pharmacy drug regimen reviews revealed that on 11/16/23 the pharmacist had identified that resident 1 had two orders for Diclofenac gel and recommended to consider discontinuing one of the orders and combine the areas of treatment. The provider agreed to the recommendation and signed the form, but did not date it. It should be noted that the recommendation was not contained within resident 1's medical record. On 12/12/23 at 1:42 PM, an interview was conducted with the DON. The DON stated the pharmacy would review the residents offsite monthly and fax the reviews to the DON. The DON stated she would put the recommendations in the doctors box for review. The DON stated once the doctor completed the recommendations the DON would fax the reviews back to the pharmacy. The DON stated that they would now be uploading the recommendations into the resident's medical record. Based on interview and record review, the facility did not ensure the attending physician documented in the resident's medical record that the identified irregularity had been reviewed and what, if any, action had been taken to address the irregularity. If there was to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. Specifically, for 2 out of 21 sampled residents, pharmacy recommendations including the physician's documentation was not included in the resident's medical record. Resident identifier: 1 and 4. Findings included: 1. Resident 4 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia, acute kidney failure, acute on chronic diastolic heart failure, type 1 diabetes mellitus with diabetic chronic kidney disease, type 1 diabetes mellitus with foot ulcer, generalized anxiety, schizophrenia, major depressive disorder, and attention-deficit hyperactivity disorder. Resident 4's medical record was reviewed on 12/11/23. The August, September, October, and November 2023 Consulting Reports documented a Yes as Recommended Changes. The identified irregularities were unable to be located within resident 4's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 1 out of 21 sampled residents, the provider was not notified per the physician's order when a resident's blood glucose (BG) and systolic blood pressure (SBP) were outside of the physician's ordered parameters. In addition, a resident's long acting insulin was held when it should have been administered per the sliding scale physician's order. Resident identifier: 4. Findings included: Resident 4 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia, acute kidney failure, acute on chronic diastolic heart failure, type 1 diabetes mellitus with diabetic chronic kidney disease, type 1 diabetes mellitus with foot ulcer, generalized anxiety, schizophrenia, major depressive disorder, and attention-deficit hyperactivity disorder. Resident 4's medical record was reviewed on 12/11/23. 1. On 9/6/23, a physician's order documented Insulin Lispro Subcutaneous Solution Pen-injector 200 UNIT/ML [milliliter] (Insulin Lispro) Inject as per sliding scale: if 0 - 300 = 0 [sic] 0 units; 301 - 400 = 3; 401 - 600 = 4 [sic] 4 units, recheck BG after 2 hors [sic] and notify provider if > [greater than] 350., subcutaneously one time a day for DM [diabetes mellitus]. The December 2023 Medication Administration Record (MAR) documented on 12/5/23 at 8:00 PM, resident 4's BG was documented as 309. Insulin Lispro was not administered due to 4=Vitals Outside of Parameters for Administration. Resident 4 should have received 3 units of insulin Lispro. 2. On 10/14/23, a physician's order documented hydrALAZINE HCl [hydrochloride] Oral Tablet 10 MG [milligrams] (Hydralazine HCl) Give 1 tablet by mouth as needed for hypertension Notify provider for SBP is greater than 160. The December 2023 MAR documented on 12/1/23 at 6:57 AM, the hydralazine was administered and the SBP was documented as 168. The provider was not notified as ordered. 3. On 10/24/23, a physician's order documented Blood Pressure to be taken TID [three times daily] d/t [due to] elevated blood pressure and Hypertension. Notify provider for systolic greater than 160. three times a day for Hypertension Report SBP >160. A review of the December 2023 MAR documented the following SBP greater than 160 and the provider was not notified as ordered. a. On 12/1/23 at 7:00 AM, 168. b. On 12/1/23 at 2:00 PM, 161. c. On 12/6/23 at 9:00 PM, 166. d. On 12/9/23 at 7:00 AM, 164. e. On 12/10/23 at 7:00 AM, 169. On 12/12/23 at 1:18 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated if he needed to notify the provider he would send a text message to the provider and document in a progress note. LPN 2 stated that way other staff would see what was done for the resident and he would give report. LPN 2 stated that resident 4 would frequently refuse her insulin at night. On 12/12/23 at 1:42 PM, an interview was conducted with the Director of Nursing (DON). The DON stated if the staff were to contact the provider they should be documenting in a progress note. The DON stated the staff would usually call the provider and not text.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not obtain laboratory services to meet the needs of its residents. Specifically, for 1 out of 21 sampled residents, the facility did not obtain a specimen for a lab that was ordered by the provider. Resident identifier: 1. Findings included: Resident 1 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included hemiplegia affecting right dominant side, traumatic brain injury, neuromuscular dysfunction of the bladder, epilepsy, Crohn's disease, anxiety disorder, major depressive disorder, and osteoarthritis. On 12/11/23 through 12/18/23, resident 1's medical record was reviewed. Resident 1's laboratory orders revealed the following: a. On 2/3/23, a Complete Blood Count (CBC), lipid panel, and Keppra serum concentration level was ordered. b. On 2/24/23, a Levetiracetam (Keppra) serum level was ordered. Resident 1's laboratory results revealed no documentation of the above mentioned lab orders. On 2/23/23 at 11:01 AM, the progress note documented that it was noted that the Levetiracetam serum lab that was ordered was not obtained. The provider was notified and the order was rescheduled to be drawn on 2/24/23. On 12/12/23 at 8:18 AM, an interview was conducted with the Director of Nursing (DON). The DON stated she did not have the lab results for the Keppra ordered but found a progress note that stated that it was completed on 3/7/23. The DON stated that she called the lab and they could not find the laboratory results for the Keppra order either. The DON stated that the Keppra ordered on 2/3/23, was not obtained. The DON stated that the Keppra was also not obtained on 2/24/23, and was rescheduled and completed on 3/7/23. The DON stated that the lab process was that as soon as the nurse obtained the results they should note it that day and notify the provider the next morning unless it was a critical value that should be reported immediately. On 12/12/23 at 8:50 AM, the DON emailed results for a CBC and Lipid panel that was obtained for resident 1 on 2/4/21, and not the order for the CBC, lipid panel, and Keppra level that was ordered on 2/3/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that the antibiotic stewardship program that included antibiotic use protocols and a system to monitor the antibiotic use were implemented. Specifically, for 1 out of 21 sampled residents, a resident was prescribed and completed an antibiotic for a suspected urinary tract infection (UTI) even after the urine culture determined no bacterial growth. Resident identifier: 22. Findings included: Resident 22 was admitted to the facility on [DATE] with diagnoses which included sepsis, urinary tract infection, acute kidney failure, dementia, delirium, chronic kidney disease, heart failure, atrial fibrillation, and obstructive and reflux uropathy. On 12/18/23, resident 22's medical record was reviewed. Resident 22's progress notes revealed the following: a. On 8/12/23 at 12:14 AM, the nurse note documented, Resident's blood pressure was low at 88/50, CNA [Certified Nurse Assistant] told nurse at shift change and his medical POA [Power of Attorney] was walking by. We let her know and she said she would contact [provider name omitted. [Provider] called later in the day. He would like to have us continue to make sure we are hydrating him because he doesn't want to change his meds [medications] yet. [Provider] would like us to do a UA [urinalysis] and culture. Resident was really good to drink plenty of water while taking his pills, but after having his catheter tube clamped there was no urine after checking it. I will continue to try to get a sample and send it to [local hospital] asap [as soon as possible]. b. On 8/13/23 at 11:17 AM, the nurse note documented, UA with no cx [culture] results obtained. [Provider] has been notified. voice mail message left with overview of abnormal results. no new orders at this time. c. On 8/13/23 at 1:52 PM, the nurse note documented that resident 22 was seen by the provider and new orders were obtained. New order was for Bactrim double strength (DS), give one tablet by mouth two times a day for seven days. The note also documented that the urine specimen that was collected and sent on 8/12/23, was currently in incubation and results should be available tomorrow. d. On 8/14/23 at 11:28 AM, the nurse note documented, urine cx final results obtained. no growth after 36 hours. [Provider] notified. message left. no new orders at this time. Resident 22's Medication Administration Record for August 2023 documented that the antibiotic Bactrim DS was administered two times a day from 8/13/23 through 8/20/23, for a total of 14 doses received. On 8/12/23, a UA was obtained for resident 22. The abnormal results were the urine appearance was slightly cloudy, 3+ blood, 4+ protein, trace amounts of leukocyte esterase, red blood cells were too numerous to count, and white blood cells were 20-30. On 8/14/23, the urine culture report was received by the facility and documented that no growth after 36 hours. On 12/18/23 at 10:14 AM, an interview was conducted with the facility Infection Preventionist (IP). The IP stated that resident 22 was treated for a suspected UTI with Bactrim. The IP stated that the urine culture showed no bacterial growth after 36 hours. The IP stated that it looked like they could not get a hold of the provider and they left a message with the culture results. The IP stated that we didn't take it upon ourselves to discontinue it. The IP stated that they should have continued to follow up with the provider until they got in contact with him and received an order to either discontinue or continue the antibiotic.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency (SSA) and Adult Protective Services (APS). In addition, the facility did not ensure that all investigations were reported to the SSA within 5 working days of the incident. Specifically, for 4 out of 21 sampled residents, notification to the SSA and APS was not within 2 hours after allegations of abuse, neglect, and injuries of unknown origin were identified and an investigation was reported to the SSA 7 working days of the incident. Resident identifiers: 16, 23, 89, and 90. Findings included: 1. Resident 16 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, early onset cerebellar ataxia, muscle spasms, insomnia, depression, dysphagia, and dorsalgia. On 12/11/23 through 12/18/23, resident 16's medical record was reviewed. Review of the facility initial investigation, form 358, documented an allegation of neglect by Certified Nurse Assistant (CNA) 1 and CNA 2. On 8/9/23 at 1:00 AM, the report documented that CNA 3 and Licensed Practical Nurse (LPN) 1 became aware of the incident and administration was notified at 1:45 AM. The report documented that CNA 3 found resident 16 on the floor in the bathroom unattended. The report documented that the incident occurred on 8/8/23 at 10:00 PM. The report documented that the SSA was notified on 8/9/23 at 5:06 PM, and APS was notified on 8/9/23 at 5:30 PM. On 12/12/23 at 12:20 PM, an interview was conducted with the Administrator (ADM). The ADM stated that for any injury of unknown origin it should be reported to the SSA within 2 hours. The ADM stated for allegations of abuse or neglect that they should be reporting to the SSA within 3 hours. The ADM stated that he was first notified of resident 16's fall in the shower at 1:00 AM. The ADM stated that he did not know all the circumstances of the incident at that time, and the gravity of it did not get relayed to him until the next morning. [Cross-refer F600] 2. Resident 23 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, hereditary ataxia, repeated falls, severe protein-calorie malnutrition, and adult failure to thrive. Review of the facility initial investigation, form 358, documented an allegation of physical abuse. No name of the alleged perpetrator was documented on the form. On 3/13/23 at 6:00 PM, the report documented that staff became aware of the incident. On 3/14/23 at 6:30 AM, the ADM was notified of the allegation. Resident 23 alleged that the nurse held her arm down during a blood draw that resulted in a bruise. The initial report documented a bruise on the right forearm of 3.5 centimeters (cm) x 1.5 cm and was a dark brown color. The report documented that resident 23 was refusing cares and stated that one of her biggest fears was needles and that she did not want to get the blood drawn. The report documented that resident 23 stated that the nurse and the laboratory lady came and held her arm down in order to get the blood draw. The report documented that APS was not informed of the incident, and the SSA was notified on 3/14/23 at 8:30 AM. 3. Resident 89 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, type 2 diabetes mellitus with other specified complication, osteomyelitis right ankle and foot, encounter for orthopedic aftercare following surgical amputation, acquired absence of right great toe, type 2 diabetes mellitus with diabetic polyneuropathy, and essential hypertension. Resident 89's medical record was reviewed on 12/12/23. On 8/9/23 at 5:31 AM, a Nurse's Note documented Note Text: Resident had un-witnessed fall at 0415 [4:15 AM]. Resident was assisting themselves into the bathroom when fall occurred. Resident pressed call light for assistance. CNA arrived to residents room seeing resident on floor. CNA called for assistance. LPN arrived to residents room and assessed residents vitals. Vitals were within normal parameters. Resident had small skin tear on left elbow. Resident had an area of concern on left ring finger knuckle joint. Resident had swelling bump on left anterior scalp. Resident stated having no pain at that time. LPN and CNA assisted resident to the toilet. LPN called MD [Medical Director]. MD requested that resident be sent out to ER [Emergency Room] via non emergent transport. Resident consented to be sent out to ER, at this time resident stated having mild pain in left ring finger. DON [Director of Nursing] was notified. Family was called and voicemail was left. Resident left facility via EMS [Emergency Medical Services] non emergent transport at 0500 [5:00 AM]. Form 358, Facility Reported Incidents, was reviewed. It was documented on the form that the Administrator was notified of the incident on 8/9/23 at 6:00 AM. The Ombudsman and APS were notified on 8/11/23. The SSA Intake Information report documented the SSA was notified of the incident on 8/11/23 at 5:12 PM. It should be noted that the notification to other agencies was two days after the incident had occurred. Form 359, Follow-up Investigation Report, was reviewed. The final investigation report was submitted to the SSA on 8/18/23, 7 working days after the incident had occurred. On 12/12/23 at 3:29 PM, an interview was conducted with the ADM. The ADM stated he had reported late to the SSA because resident 89 had fallen and the response time of the nursing staff was under two and a half minutes. The ADM stated that the DON had inquired as to why he had not reported. The ADM stated resident 89's fall was not neglect or abuse but the DON informed him that he should report. 4. Resident 90 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, diabetes mellitus type 2, chronic diastolic heart failure, chronic kidney disease stage 3, macular degeneration, presence of cardiac pacemaker, and anxiety disorder. Resident 90's medical record was reviewed on 12/11/23. On 4/10/23 at 4:02 AM, a Nursing Progress Note documented Note Text: Two small bruises are noted above [name removed] right inner knee tonight when CNA's are assisting [name removed] with a brief change. The bruises are side by side, dark purple in color and appx [approximately] 1x1 [inches] in diameter each. [Name removed] is asked by this nurse with noc [night] CNA's present if she knows what happened to cause the bruising. She states 'no' she does not know. [Name removed] is asked if any staff may have assisted her in a rough manner, etc that may have caused the bruising, [name removed states 'no' and states again that she is not surewhere [sic] the bruising came from/what caused it. Will enter order for monitoring of the right inner/above knee bruising. Form 358, Facility Reported Incidents, was reviewed. It was documented on the form that the staff became aware of the incident on 4/10/23 at 3:30 AM. The Administrator was notified of the incident on 4/10/23 at 9:30 AM. It should be noted that the Administrator was notified six hours after the staff became aware of the incident. The Ombudsman and APS were notified on 4/10/23 at 10:40 AM. The SSA was notified on 4/10/23 at 10:50 AM. It should be noted that the notification to other agencies was approximately seven hours and 20 minutes after the incident had occurred. On 12/12/23 at 11:23 AM, an interview was conducted with the ADM. The ADM stated that he specifically remembered getting in trouble for the investigation of resident 90 and the timely submission. The ADM stated that he was the Administrator in training at the time of the incident and was brought in as a training moment. The ADM stated he would usually submit the reports to the Ombudsman, APS, and the SSA at the same time. The ADM stated it was possible the submission to the SSA was at 10:40 AM on 4/10/23. On 12/12/23 at 11:44 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated if abuse was suspected or an injury of unknown origin the staff were to notify the ADM immediately and they would also notify the DON. RN 3 stated they had a risk management for the injury of unknown origin. RN 3 stated they would interview the resident immediately and document what was said. RN 3 stated if the resident accused someone specific that person was not going in that room the rest of the day. On 12/12/23 at 12:20 PM, a follow up interview was conducted with the ADM. The ADM stated the reporting requirements if the facility suspected resident abuse, neglect, or injury of unknown origin was two hours. The ADM further stated he had done some education with the staff. The ADM stated that he would report to the SSA first thing and as he was hitting send he would report to APS and the Ombudsman also.

Based on observation and interview, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable. In addition, the facility did not ensure that all drugs and biologicals were stored under proper temperature controls. Specifically, opened insulin injector pens were not labeled with open dates and the insulin injector pens were in the medication cart available for resident use. In addition, the medication refrigerator was found to have low temperatures not compatible with medication storage. Findings included: On 12/18/23 at 8:41 AM, an observation was conducted of Registered Nurse (RN) 1 preparing resident medications. RN 1 prepared an insulin Aspart injection pen. The insulin Aspart injection pen was observed and was open for administration and was not labeled with an open date. RN 1 was immediately interviewed. RN 1 stated that the insulin injection pens were to be dated with the open date. RN 1 stated he thought the insulin Aspart injection pen was opened a week ago. The Director of Nursing (DON) was present and instructed RN 1 to dispose of the insulin injection pen and get a new one. On 12/18/23 at 8:45 AM, an observation was conducted with RN 1 of the medication fridge in the medication storage room. The temperature of the medication fridge was observed at 30 degrees Fahrenheit (F). RN 1 was immediately interviewed. RN 1 stated the medication fridge had been registering low temperatures and some adjustments had been made according to the fridge temperature form. On 12/18/23 at 10:19 AM, an observation was conducted of Licensed Practical Nurse (LPN) 1's medication cart. The medication cart contained an insulin glargine injection pen that was not labeled with an open date. LPN 1 was immediately interviewed. LPN 1 stated that she would discard the injection pen and would get a new one. LPN 1 stated she would date the insulin injection pens with the open date. On 12/18/23 at 10:21 AM, an observation was made of the medication fridge in the medication storage room. The temperature of the medication fridge was observed at 34 degrees F. The medication fridge contained 3 vials of tuberculin purified protein derivative, 3 bulbs of cefepime, 1 bulb of ceftriaxone, 1 vial of influenza vaccine, 4 insulin aspart injection pens, 3 insulin lispro injection pens, 1 insulin lispro vial, 5 insulin lantus injection pens, and 2 insulin levemir injection pens. The December 2023 Fridge Temperature Log was reviewed and documented All fridges in the facility need to have a temperature log on the door of the fridge. It is a state and community requirement to have temperature logs documented once daily. Please keep one log for each fridge and return to the DON at the end of the month. It will be the PM nurse's responsibility to document the temperature nightly, but both AM and PM nurses are responsible for checking the log for documentation daily. Please do not mix resident food with staff food. Food and beverages need to ben [sic] dated and discarded after 3 days according to food content. Normal Temperatures: Fridge: 38-41 F Freezers: Below 0 F Report to maintenance if temperature is not with in normal range. The following temperatures were documented for the medication fridge. a. On 12/1/23, 34 F. b. On 12/2/23, 34 F. c. On 12/3/23, 32 F. d. On 12/4/23, 32 F. e. On 12/5/23, 34 F. f. On 12/6/23, 38 F. g. On 12/7/23, 34 F. h. On 12/8/23, 35 F. i. On 12/9/23, 36 F. j. On 12/10/23, 28 F. k. On 12/11/23, 16 F. l. On 12/12/23, 32 F. m. On 12/13/23, 32 F. n. On 12/14/23, 32 F. o. On 12/15/23, 34 F. p. On 12/16/23, 34 F. q. On 12/17/23, 30 F. On 12/18/23 at 10:28 AM, an observation was conducted of RN 2's medication cart. The medication cart contained 2 insulin glargine injection pens that were not labeled with an open date. On 12/18/23 at 10:39 AM, an interview was conducted with the DON. The DON stated that the medication fridge temperature should be 38 to 41 degrees F. The DON stated that she would have to look at the medication recommendations for storage. The DON stated the nursing staff should be dating insulin when they were opened. The DON stated that insulin was good for 28 days after it was opened. On 12/18/23 at 10:43 AM, an interview was conducted with the Corporate Nurse (CN). The CN stated that the tuberculin purified protein derivative, influenza vaccine, and insulin should be stored at 35 to 46 degrees F. On 12/18/23 at 11:09 AM, an additional interview was conducted with the CN. The CN stated that she had contacted the pharmacy and the intravenous antibiotics should be stored between 35 to 46 degrees F. The CN stated the pharmacy instructed that as long as the medications were not frozen the facility did not need to reorder. The CN stated that the pharmacy instructed that the influenza vaccine came to them on ice and should be fine.

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, there were numerous undated and unlabelled items in both the walk-in refrigerator and freezer, items stored on the floor in both the walk-in refrigerator and freezer, and there was a significant layer of dust on vents located above food preparation and plating areas. Findings included: 1. On 12/11/23 at 8:25 AM, an initial kitchen walkthrough was conducted. In the walk-in fridge, there were boxes of cheese, liquid eggs, tomatoes, strawberries, zucchini, bell peppers, and honeydew stored on the floor. On a sheet pan rack in the walk-in fridge, there were several sheet pans with undated bowls of salad, undated fruit cups, undated cake slices, undated pasta cups, and undated bags of carrots. On the third shelf up from the floor, there was a Ziploc bag of cubed chicken with no date or label. In the walk-in freezer, there was a box of nutritional shakes, frozen rolls, and frozen vegetables stored on the floor. There was an unlabelled undated Ziploc bag filled with ground beef. Two ceiling vents above food preparation tables and plating tables in the kitchen were covered in dust. On 12/11/23 at 8:37 AM, an interview was conducted with the Dietary Aide (DA). The DA stated that food items in the walk-in fridge and freezer were thrown away after seven days. The DA stated that the walk-in fridge and freezer were checked daily. The DA stated that if produce was undated, kitchen staff would check to make sure that the produce looks good before using it. 2. On 12/12/23 at 1:12 PM, a follow up kitchen walkthrough was conducted. The two ceiling vents above food preparation tables in the kitchen were still covered in dust. In the walk-in fridge, there was still an undated and unlabelled Ziploc bag of cubed chicken. There was an open undated bag of shredded cheese. There were two bags of open undated bagels on the top shelf. In the walk-in freezer, there were two boxes of nutritional shakes stored on the floor. There was an open bag of frozen tater tots with no date. There was an unlabelled undated Ziploc bag filled with ground beef. On 12/12/23 at 1:25 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that the walk-in fridge and freezer should be checked daily for expired items. The DM stated that if there was no date on a food item in the fridge, it should be thrown out. The DM stated that leftovers were thrown out the next morning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not 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, including Coronavirus Disease 2019 (COVID-19). Specifically, for 2 out of 21 sampled residents, during a COVID-19 outbreak the facility staff did not dispose of their used Personal Protective Equipment (PPE) correctly, Transmission Based Precautions (TBP) and quarantine was discontinued for a COVID-19 positive resident after only six days of isolation, and staff face masks were observed worn down below the nose and mouth. Resident identifiers: 17 and 133. Findings included: 1. On 12/11/23 at 8:49 AM, an observation was made of Registered Nurse (RN) 4 at the nurse's medication cart near room [ROOM NUMBER]. RN 4 had their facemask down below their nose. RN 4 was observed to assist resident 1 in the hallway with their surgical facemask pulled down below their nose. 2. Resident 17 was admitted to the facility on [DATE] with diagnoses which included autonomic dysreflexia, rosacea, neuromuscular dysfunction of the bladder, uterovaginal prolapse, atherosclerosis of the aorta, hyperlipidemia, morbid obesity, and major depressive disorder. On 12/8/23, the facility COVID-19 resident tracking sheet documented that resident 17 tested positive for COVID-19. The tracking form documented the date of symptom onset as 12/6/23. On 12/8/23 at 11:00 AM, resident 17's antigen testing form documented that resident 17 had symptoms of diarrhea and a temperature of 99.0 Fahrenheit. The COVID-19 antigen test results were positive. On 12/11/23 at 8:51 AM, an observation was made of Certified Nurse Assistant (CNA) 4 exiting resident 17's room. Resident 17's room had a droplet/contact precaution sign posted on the door. CNA 4 was observed to doff a N95 mask and placed it on top of the PPE cart outside the room. CNA 4 then donned a surgical mask and performed hand hygiene. CNA 4 stated that resident 17 was on TBP for COVID-19. CNA 4 was observed to walk away from the room leaving the used N95 mask on top of the clean PPE cart. CNA 4 was observed exiting the room without eye protection donned. 3. Resident 133 was admitted to the facility on [DATE] with diagnoses which included fracture of left femur and left ulna, urinary tract infection, congestive heart disease, atrial fibrillation, chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder, and presence of cardiac pacemaker. On 12/5/23, the facility COVID-19 resident tracking sheet documented that resident 133 tested positive for COVID-19. The tracking form documented the date of symptom onset as 12/5/23. On 12/11/23 at 8:55 AM, resident 133's room was observed with a droplet/contact sign posted on the door and a PPE cart located outside of the room. The door to the room was observed closed. On 12/11/23 at 9:31 AM, resident 133's room was observed with the droplet/contact sign and PPE cart removed. CNA 4 was observed entering the room with only a surgical mask donned. An immediate interview was conducted with CNA 4. CNA 4 stated that the resident was no longer on TBP for COVID-19. The facility Infection Preventionist (IP) stated that resident 133 was on day six of quarantine for COVID-19 and they could be removed from isolation because resident 133 did not have any acute symptoms that required medications such as a fever. The IP stated that this was the guidance that she had received from the local health department representative. The IP stated that they did not conduct a COVID-19 test after the initial test or for the use in discontinuation of quarantine. The IP stated that the guidance provided by their health department representative was that the testing was an option but not required as the resident would most likely continue to test positive. Resident 133 was heard from the hallway with a deep, wet, productive cough. The IP stated that they did not need to continue quarantine for a lingering cough. Resident 133 was observed wheeling herself to the doorway of the room and exiting into the hallway directly outside of her room. The IP was observed to leave to obtain an oxygen tank for resident 133's wheelchair. When the IP returned with the oxygen tank she also instructed resident 133 to donn a surgical mask. On 12/13/23 at 9:31 AM, an observation was made of resident 133 ambulating down the main hallway with the therapy staff. Resident 133 was observed with their surgical mask down below her chin. Resident 133 was heard stating that she was short of breath and needed to sit down. Review of the facility COVID-19 Policy and Procedures documented under Duration of TBP for Resident with SARS-CoV-2 infection that Residents with mild to moderate illness who are not moderately to severely immunocompromised: *At least 10 days have passed since symptoms first appeared and *At least 24 hours have passed without use of fever-reducing medications and *Symptoms have improved *A test-based strategy may be used to discontinue TBP prior to 10 days. The policy documented under the Test-Based Strategy that for residents who were symptomatic TBP could be discontinued if they had the resolution of fever without the use of fever-reducing medications; and symptoms had improved; and results were negative from at least two consecutive respiratory specimens collected 48 hours apart using an antigen or Nucleic Acid Amplification Test (NAAT). The policy was adopted on March 19, 2020 and was last revised on August 4, 2023. Review of the Centers for Disease Control and Prevention guidance for Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic documented under Duration of Transmission-Based Precautions for Patients with SARS-CoV-2 Infection it documented, Patients with mild to moderate illness who are not moderately to severely immunocompromised: At least 10 days have passed since symptoms first appeared and At least 24 hours have passed since last fever without the use of fever-reducing medications and Symptoms (e.g., cough, shortness of breath) have improved, and The criteria for the test-based strategy are: Patients who are symptomatic: Resolution of fever without the use of fever-reducing medications and Symptoms (e.g., cough, shortness of breath) have improved, and Results are negative from at least two consecutive respiratory specimens collected 48 hours apart (total of two negative specimens) tested using an antigen test or NAAT https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html On 12/18/23 at 10:40 AM, a follow-up interview was conducted with the IP. The IP stated that staff should be doffing their PPE upon exit of a TBP room for COVID-19. The IP stated that disposal bins were located inside the resident room next to the door. The IP stated that staff would doff the gown and gloves inside the room before exiting and should remove the N95 mask after exiting the room. The IP stated that the N95 mask should be disposed of in the nearest garbage can. The IP stated that staff should wash their hands and donn a surgical mask. The IP stated that staff should not leave the used N95 mask on top of the PPE cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 2 or 25 sampled residents, that the facility did not ensure that the interdisciplinary team (IDT) had determined that the resident's right to self administer medications was clinically appropriate. Specifically, two residents were not evaluated to determine if they were safe to self administer medications. Resident identifiers: 4 and 125. Findings included: 1. Resident 4 was admitted to the facility on [DATE] with diagnoses which included atherosclerosis of aorta, hypertension, insomnia, low vision right eye, and mild cognitive impairment. On 2/22/22 at 10:21 AM, an interview was conducted with resident 4. An observation was made of 4 medications at the bedside located in a medication cup. Resident 4 stated that they were her morning pills and she had not taken them yet. Resident 4 stated she had her own routine. Resident 4 was observed to swallow one pill and then set the remaining pills down. Resident 4 stated that she loved the medical director and he had her down to 5 pills a day. Resident 4's medical records were reviewed. No documentation could be found for an assessment for a self administration of medication. Review of resident 4's Quarterly Minimum Data Set Assessment on 2/9/22 revealed a Brief Interview for Mental Status (BIMS) score of 15, which would indicate cognitively intact. On 2/23/22 at 3:28 PM, an interview was conducted with the Corporate Resource Nurse (CRN) 1. CRN 1 stated that resident 4 did not have a self administration assessment and does not self administer her medications. CRN 1 stated that they had not done an assessment of resident 4 to determine if she was safe to self administer medication. CRN 1 was informed that medication was found at resident 4's bedside. On 2/23/22 at 3:47 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 4 appeared cognitively intact most of the time. RN 1 stated that resident 4 had the kind of dementia that she talked behind peoples backs, stirred things up, lashed out, had confrontations, and had poor impulse control. RN 1 stated that she did not recall leaving resident 4's pills in her room yesterday morning. RN 1 stated that resident 4 would not be safe dispensing her medication, but she would probably be okay with the task of taking the medication. RN 1 stated that she would want to check back and make sure resident 4 was okay though. RN 1 indicated with a shake of the head, no, that they do not leave medication at the bedside. RN 1 stated that sometimes it was hard when talking to resident 4 to determine there was dementia, but with the right situation you could see it. 2. Resident 125 was admitted to the facility on [DATE] with diagnoses which included orthopedic aftercare, depression, hypertension, asthma, irritable bowel syndrome, gastro-esophageal reflux disease, and obstructive sleep apnea. On 2/23/22 at 9:55 AM, an observation was made of RN 1 during the morning medication administration. RN 1 was observed to dispense resident 125's Aspirin 81 milligram (mg) tablet; Calcium Citrate 200 mg tablet; Vitamin D3 25 microgram (mcg) tablet; Colace 100 mg capsule; Diltiazem 180 mg capsule; Duloxetine 30 mg capsule; Esomeprozole 40 mg capsule; Multivitamin 1 tablet; Equate daily fiber 2 capsules; Simethicone 80 mg tablet; and Valsartan-Hydrochlorothiazide 160/12.5 mg tablet. RN 1 was observed to deliver the medication to resident 125 at the bedside and the medication cup was left on resident 125's bedside table for the resident to take independently. On 2/23/22 at 10:04 AM, an interview was conducted with RN 1. RN 1 stated that resident 125 was care planned to have the pills at the bedside. RN 1 stated that resident 125 stated she did not like the staff watching her swallow her pills. RN 1 stated that the Director of Nursing (DON) informed her that resident 125 was care planned to take her pill independently. RN 1 stated that the criteria was that resident 125 was up and sitting at the bed side with her food in front of her before the medication could be left with with resident 125. Resident 125's medical records were reviewed. No documentation could be found for an assessment for a self administration of medication. Review of resident 125's care plan revealed a focus area that stated, The resident prefers to take her medications one at a time with one bite of food. She has been assessed and deemed appropriate to have meds (medications) at bedside with meals. The care plan was initiated on 2/20/22. Interventions identified were; allow resident adequate time to take medications the way she preferred in accordance with her medication regimen; answer all resident questions in regards to medications; educate resident on safety measures to follow with specific medication routine; and nurse to bring medications into room promptly when resident had her meal tray brought in. On 2/23/22 at 3:28 PM, an interview was conducted with CRN 1. CRN 1 stated that resident 125 did not have an assessment to self administer medications but was care planned to have her medication with breakfast. CRN 1 stated that resident 125 chose to have the medication with meals one at a time. CRN 1 stated that resident 125 did not want to store the medication in her room and some of the medication was different than what she had at home. CRN 1 stated that the care plan should reflect that she could have them at her bedside and take them by herself. CRN 1 stated that resident 125 did not have an assessment showing that resident 125 was able to safely self administer her medications independently. CRN 1 stated that the facility assessment had a portion that asked if the resident could recognize the medication label and dispense the medication. CRN 1 stated that the licensed nurse was dispensing the medication for resident 125. CRN 1 stated that resident 125 was alert and oriented and knew every single pill that she was taking. CRN 1 stated that they did not have any documentation to show that they had assessed resident 125's cognitive ability, ability to recognize the medication, and that she was safe to take the medication independently. On 2/23/22 at 4:30 PM, a follow-up interview was conducted with CRN 1. CRN 1 stated that the process in the past would be to complete the self administration assessment. CRN 1 stated that resident 125 did not want the pill bottles by the bedside. CRN 1 stated that the plan was for the licensed nurse to dispense the medication and resident 125 could take the medication alone with her meals. CRN 1 stated that the actual assessment went through if the resident could locate the container, could read the label, could prepare the medication, and could they dispose of the medication. CRN 1 stated that she contacted her company's resource and they have identified a different self administration assessment template that would be more appropriate for resident 125. The new assessment will address resident 125's ability to recognize the medication, the color, the size, the shape or the label of the medication, and what they are used for. CRN 1 stated that the timeframe for re-evaluation of the assessment was quarterly with the Minimum Data Set assessment and anytime there was change in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 25 sample residents, that the facility did not promote and facilitate the resident's self-determination through support of the resident's choice. Specifically, the resident requested that their breakfast meal tray be left at the bedside with the lid left on and the kitchen staff told the resident no, that it would be returned to the kitchen if not eaten within an hour. Resident identifier: 125. Findings included: Resident 125 was admitted to the facility on [DATE] with diagnoses which included encounter for orthopedic aftercare, depression, hypertension, asthma, gastro-esophageal reflux disease, irritable bowel syndrome, and obstructive sleep apnea. On 2/22/22 at 12:52 PM, an interview was conducted with resident 125. Resident 125 stated that the day before yesterday when the dietary staff delivered the breakfast tray she asked him to leave the tray with the lid on so she could get up in a minute and he said no. Resident 125 stated that the dietary staff told her that he would have to take the tray back to the kitchen if resident 125 was not going to eat it. Resident 125 stated that the dietary staff told her that the tray could only be left in the room for one hour. Resident 125 stated it had not been an hour and she just needed some time to wake up. Resident 125 stated that the dietary staff was antagonistic, threatening, and confrontational. Resident 125 stated that she had to holler to get someone else to come and get him out of the room. Resident 125 stated that licensed nurse (LN) 1 came into the room and asked the dietary staff to leave. Resident 125 stated that the dietary staff had stated that it was a facility policy not to leave food in the room for more than an hour, but again stated that it had not even been an hour. Review of resident 125's progress notes documented that the resident was alert and oriented times four (person, place, time, and situation). On 2/20/21 at 11:15 AM, the progress note documented, Resident has been very emotional and yelled at one of the kitchen staff today, see progress note. No other documentation could be found regarding this incident. On 2/24/22 at 10:01 AM, an interview was conducted with dietary staff (DS) 1. DS 1 stated that he was aware of the incident between resident 125 and DS 2. DS 1 stated that on the day of the incident resident 125 had on her breakfast tray a waffle, an egg, and bacon and sausage. DS 1 stated that resident 125 wanted to sleep for a couple extra hours and they could not leave the tray out for that length of time. DS 1 stated that DS 2 had told resident 125 that he would bring the tray back later when she was awake, but she did not want that. DS 1 stated that DS 2 attempted to take the tray and explained that germs would start to grow. DS 1 stated that resident 125 was not having it, she grabbed the tray, and she yelled for help. DS 1 stated that Certified Nurse Assistant (CNA) 6 went into resident 125's room to help and explain. DS 1 stated that resident 125 was not happy for the remainder of the day. DS 1 stated that resident 125 was provided a meal tray approximately an hour later. On 2/24/22 at 10:21 AM, an interview was conducted with CNA 6. CNA 6 stated that on the day of the incident between resident 125 and DS 2, resident 125 told DS 2 that she was going back to sleep. CNA 6 stated that DS 2 told resident 125 that he would need to take the tray back to the kitchen then. CNA 6 stated that resident 125 had said she was going to sleep for a couple of hours, and DS 2 tried to get a definitive time frame and she said a couple of hours. CNA 6 stated that DS 2 told resident 125 that he could not leave the meal tray because after an hour they had to take it. CNA 6 stated that they explained that after an hour the food was in the temperature danger zone and bacteria could grow and it would become too dangerous to eat. CNA 6 stated that he was not certain what was on the tray to eat, but probably bacon, a pancake or waffle, and some fruit as that was what resident 125 had each morning. CNA 6 stated that resident 125 became upset. CNA 6 stated that resident 125 kept yelling at DS 2 to get out. CNA 6 stated that the nurse then walked into the room and tried to explain the situation to resident 125. CNA 6 stated that they ended up leaving the tray for one hour and then after one hour they removed the tray. CNA 6 stated that resident 125 actually sat up and ate the food before they returned to pick up the tray. CNA 6 stated that they eventually determined to leave the meal tray for that one hour timeframe and then returned for it later. CNA 6 stated that she had reported that she was going to sleep for a few hours. CNA 6 stated that he offered to take it to the kitchen to keep it warm for her, and gave her alternatives. CNA 6 stated that resident 125 was just mad that the tray was not being left for her. CNA 6 stated that resident 125 had a routine and this was off of her routine and it made her upset. CNA 6 stated that they figured out what resident 125's routine was now, but at the time she was new and had only been at the facility for 5 days. On 2/24/22 at 2:46 PM, an interview was conducted with the Director of Nursing (DON) and the Corporate Resource Nurse (CRN) 1. The DON stated that the process was for dietary staff to take meal trays out of the resident room and return it to the kitchen if not eaten right away. The DON stated that the tray could be brought back into the resident at a later time when they were ready to eat. The DON stated that if the resident requested it to be left at the bedside the dietary staff should respect that request. The DON stated that the dietary staff could go back later to check and see if they still would like it or if it needed to be returned to the kitchen. The DON stated that it should never become a power struggle and upsetting to the resident. The DON stated that she had heard that the dietary aide had been confrontational to resident 125. The DON confirmed that it was reasonable to leave the meal tray for the approved amount of time and then return for the tray after that time had passed. The DON stated that if the policy was to not leave it longer than one hour, then at least leave it for one hour. It should be noted that a copy of the facility policy on timeframes for meal trays at the bedside was requested. No documentation or policy was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 25 sample residents, that the facility did not immediately consult with the resident's physician when there was a change in the resident's physical, mental, or psychosocial status or when a decision to transfer the resident from the facility was made. Specifically, the resident was transferred to the local hospital emergency room (ER) for evaluation and treatment of back pain and the physician was not notified. Resident identifier: 22. Findings included: Resident 22 was admitted to the facility on [DATE] with diagnoses which included Friedreich ataxia, mood disorder, cardiomyopathy, gastro-esophageal reflux disease, and muscle weakness. On 2/22/22 at 10:57 AM, an interview was conducted with resident 22. Resident 22 stated that she requested to go to the hospital for back pain and that she thought the rods in her back had been dislocated. Resident 22 stated that she had her family member take her to the ER. Resident 22 stated that it was determined in the ER that the rod placement was correct, and everything was okay. Resident 22's medical records were reviewed. On 12/30/21 at 1:52 PM, resident 22's progress notes documented that resident 22 was complaining of lower back pain, and that resident 22's family member took her to get an x-ray of the lower back. The progress note did not document that the physician was notified of the complaints of back pain, the request for an x-ray, or the transfer to the ER. On 2/24/22 at 10:30 AM, an interview was conducted with Certified Nurse Assistant (CNA) 6. CNA 6 stated he was not certain if resident 22 had gone to the hospital for any reason, but that her family transported her to appointments. On 2/24/22 at 2:18 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that resident 22 went to the ER for complaints of back pain, and it was documented in the nurse's notes. RN 2 reviewed resident 22's progress notes and referred to the note on 12/30/21 at 1:52 PM. RN 2 stated that the ER visit was non-emergent, but usually when a resident went to the hospital it was doctor driven. RN 2 stated that she did not see in the progress note that the physician was notified of the transfer and that would be where it should be documented. On 2/24/22 at 2:33 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the process for a resident transferred to the hospital ER was that they called 911 or a non-emergent transport, depending on the situation. The DON stated that the physician should be notified, and it should be documented in the nurse's progress note. The DON stated that the licensed nurse should document what happened, who they called, and the physician notification. The DON stated that if resident 22 was complaining of back pain and was requesting to go to the hospital the provider should have been made aware of this.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 of 25 sample residents, that the facility did not ensure that the resident had the right to personal privacy and confidentiality of their personal and medical records. Specifically, a licensed nurse was observed to provide a visitor with a resident's personal health information without determining who the visitor was first and if they had access to that information. Resident identifier: 127. Findings included: Resident 127 was admitted to the facility on [DATE] with diagnoses which consisted of congestive heart failure, acute kidney failure, type 2 diabetes mellitus, dementia, and hyperlipidemia. On 2/23/22 at 4:02 PM, an observation was made of a visitor attempting to enter resident 127's room. Resident 127's room had a sign posted on the door that stated isolation precautions, COVID isolation. Droplet precautions were check marked as indicated and the following instructions were listed: Patient to have private room; Surgical mask to be worn by all hospital personnel entering the room; Hospital personnel wear gloves when entering the room; and Perform hand hygiene before leaving the room. Registered Nurse (RN) 1 was heard to instruct the visitor to donn a gown and gloves prior to entering the room. RN 1 then told the visitor that it was for quarantine due to resident 127 not having a COVID-19 vaccine. On 2/23/22 at 4:08 PM, an interview was conducted with RN 1. RN 1 stated that she did not know who the visitor was that had entered resident 127's room. Resident 127's medical records were reviewed. Resident 127's immunization history was reviewed and no documentation could be found for any COVID-19 immunizations. On 2/24/22 at 10:35 AM, an interview was conducted with Certified Nurse Assistant (CNA) 6. CNA 6 stated if he did not know who a person was that was in the facility he would ask if they needed help and if he could take them to a certain room or person to visit. CNA 6 stated that he would identify who the individual was before he provided them with any resident information. CNA 6 stated that it would not be appropriate to provide a visitor information about the resident's vaccination status. CNA 6 stated that they would inform anyone entering a Transmission Based Precaution (TBP) what Personal Protective Equipment (PPE) they needed to wear. CNA 6 further stated that he would also provide instructions on how to donn it, take it off before leaving the room, perform hand hygiene when leaving the room, and to wipe off the goggles when leaving the room. CNA 6 stated that they did not tell any visitors that this was because that individual was not vaccinated for COVID-19. On 2/24/22 at 3:01 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff should educate visitors on the PPE required for TBP rooms and to follow the signs posted on the door. The DON stated that the nursing staff should be compliant with the Health Insurance Portability and Accountability Act (HIPAA). The DON stated that the nurse should not provide information on vaccination status without knowing who the visitor was first.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 25 sample residents, that in response to allegation of abuse the facility did not ensure that all alleged violations involving abuse were immediately, but no later than 2 hours after the allegation was made, if the event that caused the allegation involved abuse. This involved reporting to other officials in accordance with State law. Specifically, the facility did not report when a resident was involuntarily secluded. In addition, the facility did not report within 2 hours to the State Survey Agency when same resident was physically and verbally abused by a family member. Other officials were not contacted regarding both incidents. Resident identifier: 6. Findings include: Resident 6 was admitted to the facility on [DATE] with diagnoses that included Down Syndrome, encephalopathy, respiratory failure, obesity, and depression. Resident 6's electronic medical record review was completed on 3/2/22. 1. Seclusion: On 2/22/22 at 1:13 PM, resident 6 revealed that she was put into room [ROOM NUMBER] overnight from 2/21/22 to 2/22/22. The facility census revealed that resident 6 had been residing in room [ROOM NUMBER] since admission. On 7/31/21, resident 6 had a Preadmission Screening Resident Review (PASRR) Level II completed and revealed that resident 6 was vulnerable to exploitation. Resident 6 displayed increasing cognitive impairment with impaired short-term memory and periods of confusion and disorientation . A nursing note dated 2/21/22 at 9:28 PM, revealed that on 2/21/22, resident 6 was brought to the TV in the common area near the round table after being weighed at approximately 6:00 PM. Resident 6 told the other residents at the table that she was watching television there first. The other residents had decided to listen to music. Resident 6 did not want to listen to music, but watch Western shows. Resident 6 became angry and yelled at staff and residents. Resident 6 was taken to her room (room [ROOM NUMBER]) by CNA 4 and was given her evening medications. At approximately 6:30 PM, resident 6 was still heard hollering, crying and yelling out from her bed room Staff attempted to assist resident 6 to the restroom and to put on her pajamas and offered to let her watch TV in the Cove, a common area where activities take place. Resident 6 continued to holler until approximately 9:00 PM. Staff that attempted to assist resident 6 were Registered Nurse (RN) 3, CNA 4, CNA 7 and CNA 3. Residents complained of the noise and the Director of Nursing (DON) who was acting as the MDS Coordinator gave permission for resident 6 to be moved to a room not as close to other residents if needed. On 2/21/22 at 9:30 PM, an incident report was created because while staff were transferring resident 6 from room [ROOM NUMBER] to room [ROOM NUMBER], her foot was run over by the wheelchair. This incident was created as an injury and revealed that while resident 6 was being moved to room [ROOM NUMBER] (not her room), CNA 4 ran over resident 6's foot. Resident 6 had new pain at the time of the incident and complained of pain at 11:00 PM. A nursing note dated 2/21/22 at 9:30 PM, resident 6 was given the choice to either allow staff to assist her to the toilet and into her pajamas and help her to her recliner to bed, or we would have to move her to another room if she continues to yell and holler keeping other residents awake. Resident 6 yelled at staff continuously, so the decision was made to move her to room [ROOM NUMBER] where she will be further away from other residents. At this time, [Resident 6] is in room [ROOM NUMBER] with the door shut .she refused to allow staff to assist her out of her wheelchair and into recliner as well. Resident was to be checked on every 15 minutes and offered assistance, and staff was awaiting the doctors' orders at that time. On 2/21/21 at 9:30 PM, an Alert Charting note for resident 6 was created and revealed that Resident was being assisted to room [ROOM NUMBER] by CNA [4] because of extreme emotional outbursts since 1815 (6:15 PM), causing fellow residents near her room to complain about noise and not being able to sleep; administration and MD (medical doctor) made aware of need to move resident. [CNA 4] reports as he was pushing resident in her wheelchair to room [ROOM NUMBER] as she continued to yell and holler, at one point resident put her right foot down on purpose on the floor in front of right wheel of wheelchair, causing her foot to get bumped/ran over. Immediately following incident resident refused to allow this nurse to assess for injury, she allowed later at 2300 (11:00 PM) when she complained of pain in her left foot, no apparent signs of injury were noted; no redness, no bruising, no swelling. On 2/23/22 at 3:52 PM, CNA 8 was interviewed. CNA 8 stated that resident 6 had fits and staff took her back to her room and helped her calm. CNA 8 stated that resident 6 did not always like to go to her room, but that's where we take her. CNA 8 stated that resident 6 was placed in her room for an average of 10 minutes. CNA 8 stated that she was told resident 6 was taken to another room so that other residents could sleep, and that resident 6 was only taken, until she calmed down. On 2/23/22 at 4:13 PM, an interview was conducted with RN 3. RN 3 stated that she worked with resident 6 the night of 2/21/22. RN 3 stated that after CNA 4 took resident 6 to get weighed, resident 6 returned to the round table in the common area to find other residents there had changed the channel from resident 6's Western show to music. RN 3 stated that the other residents voted to listen to music, so they outruled resident 6. RN 2 stated that resident 6 became upset and yelled at a few of the residents. RN 2 stated that another nurse, Licensed Nurse (LN) 4 told resident 6 that she could return to her room to watch Westerns. CNA 4 took resident 6 to her room and turned the TV on for resident 6, figuring that resident 6 would calm after a few minutes. RN 3 stated that it was not abnormal to have resident 6 throw a fit and be taken to her room to calm down. RN 3 stated that resident 6 had been given anti-anxiety medication and we hoped it would kick in. RN 3 stated that resident 6 began screaming, crying, and hollering until about 9:00 PM. RN 3 stated that she called the Administrator on Call, the MDS Coordinator who was now the DON and asked if resident 6 could be moved. RN 3 stated that she had permission to move resident 6 to room [ROOM NUMBER]. RN 3 and CNA 4 moved resident 6 to room [ROOM NUMBER]. RN 3 stated that when resident 6 went to the restroom, resident 6 stated that her left foot hurt. RN 3 stated that resident 6's foot may have been run over when CNA 4 was pushing resident 6 to room [ROOM NUMBER]. On 2/24/22 at 6:11 AM, CNA 3 was interviewed. CNA 3 stated that he was working the evening of 2/21/22 when resident 6 had a melt down. CNA 3 stated that resident 6 wanted to watch a different program, but was told that the other residents wanted to listen to something else. CNA 3 stated that resident 6 began screaming and a nurse, Licensed Nurse (LN) 4 told resident 6 in a stern voice to quiet down and to stop behaving like that. CNA 3 stated that resident 6 yelled, I hate you and LN 4 and resident 6 began to argue. Resident 6 also yelled I hate you as CNA 4 was pushing her in her wheelchair to her room. CNA 3 stated that resident 6 was stomping her feet. CNA 3 stated that resident 6 yelled from about 5:30 PM until 3:30 AM. CNA 3 stated that sometimes resident 6's door was closed and sometimes open. CNA 3 stated that resident 6 was moved to room [ROOM NUMBER] between 10:30 PM and 11:00 PM, because other residents were complaining. room [ROOM NUMBER] was located in a hall where there were no other residents in the immediate area. CNA 3 stated that CNA 7 reported that resident 6 screamed until 3:30 AM. CNA 3 stated that resident 6's voice was raspy because she spent 10 hours screaming. CNA 3 stated that there was no training for staff on what to do for resident 6 when her behaviors escalated. CNA 3 stated that he did not feel that the nursing home was a good fit for resident 6. CNA 3 stated that resident 6 needed more attention than we can give. CNA 3 further stated that with resident 6 her emotions came before her thoughts and her brain processed things differently. On 2/24/22 at 7:02 AM, CNA 4 was interviewed. CNA 4 stated that he worked the night shift, including on 2/21/22. CNA 4 stated that after he took resident 6 to be weighed, other residents were at the round table and had changed the television from resident 6's preferred station. CNA 4 stated that resident 6 began yelling abnormally loud compared to her usual frustration. CNA 4 stated that other residents asked staff to take resident 6 to her room. CNA 4 stated that resident 6 was yelling out of rage. CNA 4 stated that he took resident 4 to her room at approximately 6:15 to 6:30 PM, and resident 6 was upset and used profanity about the other residents. CNA 4 stated that resident 6 was stomping her feet and yelling. CNA 4 stated that resident 6 stated that no one appreciated her and she was mad at CNA 4 for taking her to her room. CNA 4 stated that he asked CNA 7 to assist resident 6 because resident 6 was mad at him. CNA 4 stated that resident 6 was moved from her room, room [ROOM NUMBER], to room [ROOM NUMBER] to get her away from some of the other residents that were complaining. CNA 4 stated that resident 6 was grinding her feet into the floor. CNA 4 stated that resident 6 shoved her heels into the floor and pushed herself back in the chair. CNA 4 stated that he asked resident 6 to put her feet up, but she was being more aggressive than usual, and when she put her foot down, her shoe came off and her foot was run over by the wheelchair. CNA 4 stated that when the wheelchair ran over resident 6's foot, she yelled and said, My foot! CNA 4 stated that resident 6 yelled until after 2:00 AM, but he was not assigned to her after taking her to room [ROOM NUMBER]. CNA 4 stated that resident 6 remained in room [ROOM NUMBER] until after he left the facility at approximately 6:30 AM. CNA 4 stated that room [ROOM NUMBER] was the furthest spot away from other residents. On 2/24/22 at 8:37 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the incident was discussed the following morning and the information was turned over to the Administrator. The DON stated that she did not believe that this was an incident of abuse with resident 6's foot being injured in the room transfer. On 2/24/22 at 11:44 AM, the Administrator (ADM) was interviewed. The ADM stated staff had been trained about abuse on January 19, 2022 and reported any abuse to her because she was the abuse coordinator. The ADM stated that if there was an allegation of abuse, she would report to the Ombudsman, corporation and to Adult Protective Services (APS). The ADM stated that she reviewed the incident from the night of 2/21/22 on 2/23/22, and had not been contacted by staff regarding the incident. The ADM stated that resident 6 screamed, yelled, and kicked her legs when she gets upset, which can be scary. The ADM stated that staff decided to separate her from the rest of the group. The ADM stated that staff took resident 6 to another room and asked her to be quiet. The ADM stated that the incident lasted until the morning of 2/22/22 and that resident 6's foot was injured during the episode. The ADM stated that staff had not reported to her because the physician looked at resident 6's foot and there was no apparent injury. The ADM stated that she did not know resident 6 stayed in room [ROOM NUMBER] overnight. The Administrator stated she would not have done an investigation because she did not feel it was involuntary seclusion. The Administrator stated she did not report to the State Survey Agency, APS, or any other agency because she did not see it as involuntary seclusion. The Administrator stated she would have liked to be informed of incidents like this when it happens. [Cross refer F600] 2. Physical and Verbal Abuse: The facility abuse investigations were reviewed on 2/23/22. There was one abuse investigation regarding resident 6 and a family member. The previous facility Administrator reported an abuse allegation on 11/28/21 at 9:55 AM to the State Survey Agency. According to the Initial Entity Report form On 11/27/21 at 12:22 PM, Staff was alerted to the TV area where it was reported that [resident 6's family member] had reached out, slapped and pinched [resident 6]. It was also reported that he had stated 'the (sic) she shouldn't eat because she was to fat.' Staff immediately separated the two residents to prevent any further altercation. [Resident 6's family member] is [resident 6's] father. It should be noted that the incident was reported to the State Survey Agency approximately 22.5 hours after the incident occurred. There were no other documentation regarding APS or local law enforcement being contacted. On 2/24/22 at 11:44 AM, an interview was conducted with the facility ADM. The ADM stated that she was the abuse coordinator. The ADM stated when she received an allegation of abuse she began an abuse investigation. The ADM stated that she would provide a written report to the State Survey Agency, report to the ombudsman, corporate and APS. The ADM stated that she would report to local law enforcement if there was actual harm or a sexual thing. The ADM stated that she had not reviewed any of the previous abuse investigations that were conducted by the previous ADM. [Cross refer F600]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 1 of 25 sample residents, that in response to allegations of abuse the facility did not have evidence that all alleged violations were thoroughly investigated to prevent further potential abuse. In addition if the alleged violation was verified appropriate corrective action was not taken. Specifically, a resident that was involuntarily secluded in a room that was unfamiliar to her and an investigated was not conducted regarding potential abuse. In addition, the same resident was verbally and physically abused by a family member and a thorough investigated was not conducted to prevent possible further abuse. Resident identifier: 6. Findings include: Resident 6 was admitted to the facility on [DATE] with diagnoses that included Down Syndrome, encephalopathy, respiratory failure, obesity, and depression. 1. On 2/22/22 at 12:13 PM, an interview was conducted with resident 6. Resident 6 stated that her voice was hoarse because she was screaming overnight. Resident 6 stated that she was yelling at the other residents and staff and she was told she was going to be taken to another room to yell all you want. Resident 6 stated that staff left her there all night long. Resident 6 stated that her foot was bent back when she was being pushed by [Certified Nurse Aide 4] to room [ROOM NUMBER]. Resident 6 stated that she told Certified Nurse Aide (CNA) 4 No, No, No, stop. Resident 6 stated I put my foot back and he kept pushing me and pushing me. Resident 6 stated that he was too strong for her to resist and ran over her left foot. Resident 6 stated that room [ROOM NUMBER] was scary. On 2/22/22 at 1:33 PM, a follow-up interview was conducted with resident 6. Resident 6 stated that her foot still hurt a little bit. Resident 6 stated that she was placed into room [ROOM NUMBER] in her wheelchair and had ice for her foot. Resident 6 stated that two CNAs were not nice to her. One of the CNAs was CNA 4, who resident 6 referred to as mean, and always will be and the other CNA was described as tall with long dark hair and skinny. Resident 6 later recalled the other CNA's name and identified them as CNA 7. On 2/24/22 at 10:00 AM, an observation was made of room [ROOM NUMBER]. room [ROOM NUMBER] was located in the southwest corner of the facility. There were no other residents residing in that corner of the facility. The Cove activity room was also observed and had doors on the East and [NAME] sides that could be closed. On 3/2/22, resident 6's electronic medical record review was completed. On 10/22/21, resident 6 was assessed during a Minimum Data Set (MDS) evaluation of having a Brief Interview for Mental Status (BIMS) score of 9/15, or mildly impaired. A nursing note dated 2/21/22 at 9:28 PM, revealed that on 2/21/22, resident 6 was brought to the TV in the common area near the round table after being weighed at approximately 6:00 PM. Resident 6 told the other residents at the table that she was watching television there first. The other residents had decided to listen to music. Resident 6 did not want to listen to music, but watch Western shows. Resident 6 became angry and yelled at staff and residents. Resident 6 was taken to her room (room [ROOM NUMBER]) by CNA 4 and was given her evening medications. At approximately 6:30 PM, resident 6 was still heard hollering, crying and yelling out from her bed room . Staff attempted to assist resident 6 to the restroom and to put on her pajamas and offered to let her watch TV in the Cove, a common area where activities take place. Resident 6 continued to holler until approximately 9:00 PM. Staff that attempted to assist resident 6 were Registered Nurse (RN) 3, CNA 4, CNA 7 and CNA 3. Residents complained of the noise and the Director of Nursing (DON) who was acting as the MDS Coordinator gave permission for resident 6 to be moved to a room not as close to other residents if needed. At 9:30 PM, resident 6 was given the choice to either allow staff to assist her to the toilet and into her pajamas and help her to her recliner to bed, or we would have to move her to another room if she continues to yell and holler keeping other residents awake. Resident 6 yelled at staff continuously, so the decision was made to move her to room [ROOM NUMBER] where she will be further away from other residents. At this time, [Resident 6] is in room [ROOM NUMBER] with the door shut .she refused to allow staff to assist her out of her wheelchair and into recliner as well. Resident was to be checked on every 15 minutes and offered assistance, and staff was awaiting the doctors' orders at that time. On 2/21/21 at 9:30 PM, an Alert Charting note for resident 6 was created and revealed that Resident was being assisted to room [ROOM NUMBER] by CNA [4] because of extreme emotional outbursts since 1815 (6:15 PM), causing fellow residents near her room to complain about noise and not being able to sleep; administration and MD (medical doctor) made aware of need to move resident. [CNA 4] reports as he was pushing resident in her wheelchair to room [ROOM NUMBER] as she continued to yell and holler, at one point resident put her right foot down on purpose on the floor in front of right wheel of wheelchair, causing her foot to get bumped/ran over. Immediately following incident resident refused to allow this nurse to assess for injury, she allowed later at 2300 (11:00 PM) when she complained of pain in her left foot, no apparent signs of injury were noted; no redness, no bruising, no swelling. On 2/21/22 at 10:08 PM, a nursing note for an additional 50 mg (milligrams) of Hydroxyzine was ordered to help resident 6 relax. On 2/21/22 at 10:58 PM, a nursing note revealed that resident 6 agreed to take two Hydroxyzine at 10:15 PM and go to the toilet and put on pajamas. Resident 6 complained that her foot hurt, but no discoloration was noted and resident 6 was able to move her foot and wiggle her toes. The resident was able to bear weight on her left foot when needed for transfers. CNA 4 reported that resident 6 put her right foot down under the wheelchair wheel when she was being assisted to room [ROOM NUMBER] earlier this evening . Resident 6 showed no signs of trauma and was provided ibuprofen to treat pains and her legs were elevated in the recliner and ice pack on left foot. She seems more calm at this time, yelling has stopped for now . On 2/22/22 at 4:05 AM, a nursing note revealed that resident 6 had been asleep for about 3 hours. Prior to that she yelled out off and on [for] about 30 minutes intervals in between until she drifted off . On 2/22/22 at 5:26 AM, a nursing note revealed that resident 6 was awake and having a hard time talking and her throat hurts as well as her right ankle. Medicated with Tramadol 5 mg. Discussed she strained her voice with all her yelling last night try to let her voice rest and it will get better On 2/22/22 at 12:01 PM, a nursing note revealed that the doctor examined resident 6 and was given details about the previous night. The doctor ordered a urinalysis to rule out a urinary tract infection. The physician examined resident 6's feet and discerned no bruising. The physician ordered monitoring of resident 6's feet for pain and swelling. No bruising or swelling is noted. [Resident 6] is also able to bare (sp) weight to both feet at this time. [Resident 6] complains of pain in her left foot this morning during AM shift, she is given prn [as needed] medications to treat. [Resident 6's doctor] gives new orders to monitor only, of her bilateral feet for increased pain or swelling at this time; further interventions will be added if needed. On 2/22/22 at 1:32 PM, a nursing note revealed resident 6 was ambulating and complained of pain in her left leg but was able to walk behind her wheelchair. On 2/24/22 at 12:06 PM, a nursing note revealed that resident 6's Power of Attorney (POA) was contacted. Resident 6 had a care plan focus The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t [related to] decreased mobility and cognitive deficit, initiated on 11/1/21. On 2/23/22 at 9:17 AM, RN 2 was interviewed. RN 2 stated that resident 6 had a medication change that may have been part of the issue why resident 6 was out of control. RN 2 stated that staff had offered resident 6 activities and redirection when she was frustrated, and letting resident 6 express herself helped. RN 2 stated that taking resident 6 to her room helped because resident 6 became agitated in larger groups. RN 2 stated that resident 6 liked Western shows and would watch them at the round table in the common area or in her room. RN 2 stated that she did not make resident 6 watch television in her room because she did not want to isolate resident 6. RN 2 stated that resident 6 would accompany RN 2 to the Cove while RN 2 was charting because talking to staff helped calm resident 6. RN 2 stated that if resident 6 was left alone, resident 6 would perseverate about her frustrations. On 2/23/22 at 2:16 PM, a family member (FM) 1 of resident 6 was contacted. FM 1 stated that they visited resident 6 the previous week and resident 6 reported being happy at the facility. FM 1 stated that resident 6 was changed to a new medication that caused her to shake. FM 1 stated that they had not been contacted about the incident with resident 6 on Monday night and that the facility did not communicate well with the family. FM 1 stated that resident 6 needed someone to talk calmly and logically to her to help calm her down. On 2/23/22 at 3:17 PM, the Resident Advocate (RA) was interviewed. The RA stated that the facility did not have a social worker, but had contracted with a consultant. The RA stated that the social worker had not been in the facility since the COVID-19 outbreak began in March, 2020. The RA stated that the social worker had not had contact with resident 6. On 2/23/22 at 3:52 PM, CNA 8 was interviewed. CNA 8 stated that when resident 6 had fits, staff took her back to her room which usually helped her calm down. CNA 8 stated that she would get resident 6 ice water, a snack, have her take a few deep breaths and get her away from whatever had triggered her. CNA 8 stated that resident 6 did not always like going to her room, but that was where she was taken. CNA 8 stated that it was usually about 10 minutes before resident 6 calmed. CNA 8 stated that she had report on Tuesday 2/22/22 that resident 6 was taken to room [ROOM NUMBER]. CNA 8 stated that she would not have left resident 6 alone because CNA 8 did not always know what resident 6 might do. CNA 8 stated that she would talk to resident 6 to help her calm, set up her television and make her comfortable. CNA 8 stated that she was told resident 6 started screaming, kicking, and yelling when staff attempted to calm her down, and was yelling for hours. CNA 8 stated that staff moved resident 6 to a room away from the other residents to help them sleep. On 2/23/22 at 4:13 PM, an interview was conducted with RN 3. RN 3 stated that she worked with resident 6 the night of 2/21/22. RN 3 stated that after CNA 4 took resident 6 to get weighed, resident 6 returned to the round table in the common area to find other residents there had changed the channel from resident 6's Western show to music. RN 3 stated that the other residents voted to listen to music, so they outruled resident 6. RN 2 stated that resident 6 became upset and yelled at a few of the residents. RN 2 stated that another nurse, Licensed Nurse (LN) 4 told resident 6 that she could return to her room to watch Westerns. CNA 4 took resident 6 to her room and turned the TV on for resident 6, figuring that resident 6 would calm after a few minutes. RN 3 stated that it was not abnormal to have resident 6 throw a fit and be taken to her room to calm down. RN 3 stated that there were a few residents that provoked resident 6. RN 3 stated that resident 6 had been given anti-anxiety medication and we hoped it would kick in. RN 3 stated that resident 6 began screaming, crying, and hollering until about 9:00 PM. RN 3 stated that CNA 4, CNA 3 and CNA 7 attempted to calm resident 6, but resident 6 yelled at them, and attempted to kick them. Staff offered to let resident 6 watch TV in her room, but resident 6 wanted to watch television at the round table. RN 3 stated that at 9:30 PM, resident 6 was asked to quiet to allow other residents to sleep. RN 3 stated that resident 6 refused to quiet, so RN 3 called the physician to obtain a prescription for medication to help resident 6 sleep. The physician told RN 3 he would call her back. RN 3 stated that other residents were concerned and asked if resident 6 was okay, due to her screaming and crying. RN 3 stated that she called the Administrator on Call, the MDS Coordinator who was now the DON and asked if resident 6 could be moved. RN 3 stated that she had permission to move resident 6 to room [ROOM NUMBER]. RN 3 and CNA 4 moved resident 6 to room [ROOM NUMBER]. RN 3 stated that she took resident 6's oxygen concentrator, a blanket, and water to room [ROOM NUMBER]. RN 3 stated that resident 6 definitely did not want to go, but RN 3 stated that she felt it was better for everyone else for her to move. RN 3 stated that six residents expressed concern or complaints about resident 6's yelling. RN 3 stated that resident 6 was yelling loudly in the hallway when she was being taken to room [ROOM NUMBER]. In room [ROOM NUMBER], RN 3 placed the oxygen cannula on resident 6. RN 3 stated the physician called back at approximately 10:00 PM, and ordered an extra dose of Hydroxyzine for resident 6 for anxiety. RN 3 stated that it was approximately 11:00 PM when resident 6 agreed to take the Hydroxyzine medication, and allowed staff to toilet her. RN 3 stated that when resident 6 went to the restroom, resident 6 stated that her left foot hurt. RN 3 stated that resident 6's foot may have been run over when CNA 4 was pushing resident 6 to room [ROOM NUMBER]. RN 3 stated that resident 6 was able to move her foot and did not appear to have any bruising. RN 3 stated that resident 6 sat in the recliner in room [ROOM NUMBER] and the nurse examined her right foot as well. RN 3 stated that resident 6 complained of pain, so RN 3 provided as needed (PRN) ibuprofen and staff retrieved some ice for her foot. RN 3 stated that resident 6 was in room [ROOM NUMBER] when she left the facility at 12:00 AM on 2/22/22. RN 3 stated that when she arrived back at the facility on 2/22/22 at 8:00 AM, the previous shift nurse reported that resident 6 complained of right foot pain. RN 3 stated that she saw resident 6 walking with the restorative aide around lunch and was able to walk without a limp. RN 3 stated that resident 6 stated that her foot hurt, but did not request PRN pain medication. RN 3 stated that resident 6 was more agitated. On 2/24/22 at 6:11 AM, CNA 3 was interviewed. CNA 3 stated that he was working the evening of 2/21/22 when resident 6 had a melt down. CNA 3 stated that resident 6 wanted to watch a different program, but was told that the other residents wanted to listen to something else. CNA 3 stated that resident 6 began screaming and a nurse, Licensed Nurse (LN) 4 told resident 6 in a stern voice to quiet down and to stop behaving like that. CNA 3 stated that resident 6 yelled, I hate you and LN 4 and resident 6 began to argue. Resident 6 also yelled I hate you as CNA 4 was pushing her in her wheelchair to her room. CNA 3 stated that resident 6 was stomping her feet. CNA 3 stated that resident 6 yelled from about 5:30 PM until 3:30 AM. CNA 3 stated that sometimes resident 6's door was closed and sometimes open. CNA 3 stated that resident 6 was moved to room [ROOM NUMBER] between 10:30 PM and 11:00 PM, because other residents were complaining. room [ROOM NUMBER] was located in a hall where there were no other residents in the immediate area. CNA 3 stated that CNA 7 reported that resident 6 screamed until 3:30 AM. CNA 3 stated that resident 6's voice was raspy because she spent 10 hours screaming. CNA 3 stated that there was no training for staff on what to do for resident 6 when her behaviors escalated. CNA 3 stated that he did not feel that the nursing home was a good fit for resident 6. CNA 3 stated that resident 6 needed more attention than we can give. CNA 3 further stated that with resident 6 her emotions came before her thoughts and her brain processed things differently. On 2/24/22 at 7:02 AM, CNA 4 was interviewed. CNA 4 stated that he worked the night shift, including on 2/21/22. CNA 4 stated that after he took resident 6 to be weighed, other residents were at the round table and had changed the television from resident 6's preferred station. CNA 4 stated that resident 6 began yelling abnormally loud compared to her usual frustration. CNA 4 stated that other residents asked staff to take resident 6 to her room. CNA 4 stated that resident 6 was yelling out of rage. CNA 4 stated that he took resident 4 to her room at approximately 6:15 to 6:30 PM, and resident 6 was upset and used profanity about the other residents. CNA 4 stated that resident 6 was stomping her feet and yelling. CNA 4 stated that resident 6 stated that no one appreciated her and she was mad at CNA 4 for taking her to her room. CNA 4 stated that he asked CNA 7 to assist resident 6 because resident 6 was mad at him. CNA 4 stated that resident 6 was moved from her room, room [ROOM NUMBER], to room [ROOM NUMBER] to get her away from some of the other residents that were complaining. CNA 4 stated that resident 6 was grinding her feet into the floor. CNA 4 stated that resident 6 shoved her heels into the floor and pushed herself back in the chair. CNA 4 stated that he asked resident 6 to put her feet up, but she was being more aggressive than usual, and when she put her foot down, her shoe came off and her foot was run over by the wheelchair. CNA 4 stated that when the wheelchair ran over resident 6's foot, she yelled and said, My foot! CNA 4 stated that resident 6 yelled until after 2:00 AM, but he was not assigned to her after taking her to room [ROOM NUMBER]. CNA 4 stated that resident 6 remained in room [ROOM NUMBER] until after he left the facility at approximately 6:30 AM. CNA 4 stated that room [ROOM NUMBER] was the furthest spot away from other residents. On 2/24/22 at 8:38 AM, the DON was interviewed. The DON stated that resident 6 had episodes once in a while when she did not understand what was happening, because resident 6 had an intellectual disability. The DON stated that resident 6 was usually redirected within 10 minutes. The DON stated that on 2/18/22, resident 6 was upset over an UNO card game. The DON stated that on Saturday resident 6 was upset about a card game and Sunday resident 6 continued to be upset about music, but went to her room willingly and calmed there. The DON stated that resident 6 appeared to escalate over the weekend, with the episode on Sunday lasting about 30 minutes. The DON stated that on Monday, 2/21/22, the DON received a call at approximately 5:30 PM, and RN 3 told her that resident 6 was upset. The DON stated that she instructed RN 3 to give resident 6 her night time medications and have resident 6 perform her night time routine to help her calm down. The DON stated that RN 3 called the DON at approximately 9:30 PM and stated that resident 6 was still yelling and crying. The DON stated that LN 4 had reported that other residents were concerned about resident 6. The DON stated that she told RN 3 to put resident 6 in a quiet environment and call the physician. The DON stated that RN 3 suggested to move resident 6 to the rooms on the other side of the facility that were a little more quiet. The DON stated that she agreed that it was a good idea. The DON stated that she called LN 4 at approximately 3:30 AM on 2/22/22 and LN 4 stated that resident 6 had fallen asleep. The DON stated that as far as she knew, LN 4 had checked on resident 6 every 15 minutes, but there was no documentation created. The DON stated that resident 6 told her that her voice was hoarse. On 2/24/22 at 10:33 AM, the Resident Advocate (RA) was interviewed. The RA stated that she checked on resident 6 daily to see how her day was going. The RA stated that on 2/22/22, resident 6 stated that she had a tough weekend. The RA stated that resident 6 told her that she had been upset and was yelling, and the RA noticed that resident 6's voice was hoarse. The RA stated that resident 6 reported being taken to another room and that resident 6 was not happy about it and wanted her things moved back into her room. The RA stated that resident 6's oxygen concentrator and mugs were in room [ROOM NUMBER]. The RA stated that resident 6 told her that resident 6 wanted to be in her own room. The RA stated that a medication review was completed for resident 6 and staff determined that they needed to be firm and direct with resident 6, but also to be kind. The RA stated that resident 6 had not seen the Licensed Clinical Social Worker (LCSW) that was contracted for behavioral services because he had not been in the facility since the COVID-19 pandemic began, approximately 2 years ago. On 2/24/22 at 11:44 AM, the Administrator (ADM) was interviewed. The ADM stated staff had been trained about abuse on January 19, 2022 and reported any abuse to her because she was the abuse coordinator. The ADM stated that if there was an allegation of abuse, she would report to the Ombudsman, corporation and to Adult Protective Services (APS). The ADM stated that she reviewed the incident from the night of 2/21/22 on 2/23/22, and had not been contacted by staff regarding the incident. The ADM stated that resident 6 screamed, yelled, and kicked her legs when she gets upset, which can be scary. The ADM stated that staff decided to separate her from the rest of the group. The ADM stated that staff took resident 6 to another room and asked her to be quiet. The ADM stated that residents called their family members and said something bad was going on and it sounded like someone was dying. The ADM stated that the incident lasted until the morning of 2/22/22 and that resident 6's foot was injured during the episode. The ADM stated that staff had not reported to her because the physician looked at resident 6's foot and there was no apparent injury. The ADM stated that she did not know resident 6 stayed in room [ROOM NUMBER] overnight. The ADM stated that there should have been documentation by the nurse and CNAs about 15 minute checks. On 2/24/22 at 1:29 PM, the Corporate Resource Nurse (CRN) 1 was interviewed. CRN 1 stated that RN 3 worked until midnight and assisted resident 6 into her pajamas. CRN 1 stated that CNA 7 conducted checks on resident 6 every 15 minutes, but they did not have any paperwork to demonstrate that this had been completed. CRN 1 stated that the staff did not start the 15 minute check paperwork. CRN 1 stated that there was a 15 minute check form that was indicated for a situation like this, to document incidents like this. CRN 1 stated that CNA 7 reported that resident 6 was comfortable, had intervals of screaming followed by periods of calm, and eventually fell asleep. CRN 1 stated that they did not have a focused timeline of resident 6's behaviors and interventions. On 2/24/22 at 5:16 PM, CNA 7 was interviewed. CNA 7 stated that when resident 6 returned to the round table the other residents had changed the television channel. CNA 7 stated that this was what had initially upset resident 6. CNA 7 stated that one of the other residents started to yell back at resident 6 so CNA 4 and LN 4 went over to intervene. CNA 7 stated that resident 6 had a care plan intervention to take her to her room to calm down, so that was why they initially took her back when she became upset. CNA 7 stated that she went into resident 6's room a few times to check on her and one time she noticed that she was about to fall from the her wheelchair because she was yelling and screaming. CNA 7 stated that CNA 3 and RN 3 went in and talked to resident 6 to try and calm her down. CNA 7 stated that after resident 6 had been crying for approximately 2 hours CNA 4 took her to room [ROOM NUMBER]. CNA 7 stated that as he was wheeling her she was yelling obscenities'. CNA 7 stated that she assisted resident 6 out of her wheelchair into the recliner, and RN 3 assisted with resident 6's toileting. CNA 7 stated that resident 6 did not want CNA 4 to come into the room, she was mad at him. CNA 7 stated that she spent the remainder of the evening in the Cove and set her timer to check on resident 6 every 15 minutes. CNA 7 stated that resident 6 screamed most of the time and somewhere around 4 AM resident 6 fell asleep. CNA 7 stated that she left the facility at 5:15 AM on 2/22/22. CNA 7 stated that resident 6 complained of pain in the left foot. CNA 7 stated that she did not personally see how it was injured. CNA 7 stated that resident 6 told her that her foot got hurt and was run over by her wheelchair. CNA 7 stated that resident 6 did not want to place weight on the injured foot. CNA 7 stated that resident 6 did not walk on the foot, but she did bear weight on it when she was transferred from the wheelchair to the recliner. CNA 7 stated that resident 6 complained of pain in the foot and RN 3 got her ice for it. CNA 7 stated that every time she offered resident 6 the ice pack she declined it. CNA 7 stated that resident 6 was upset that they had moved her. CNA 7 stated that they moved her because she was being loud. CNA 7 stated that to her knowledge resident 6 had not been to that room before. CNA 7 stated that they chose that room because there were not any residents nearby. CNA 7 stated that after resident 6 was moved to room [ROOM NUMBER] the door to the room remained open, but when she was in her own room the door was closed. CNA 7 stated that they took resident 6's oxygen tank, tubing, briefs, blanket, and pajamas to room [ROOM NUMBER]. CNA 7 stated that resident 6's nighttime routine was coloring and watching television. CNA 7 stated that resident 6's TV was on in room [ROOM NUMBER] and they had provided resident 6 a mug of water as well. CNA 7 stated that the move to room [ROOM NUMBER] was explained to resident 6 more than once by RN 3. CNA 7 stated that she did not know if resident 6 thought she was in trouble and that was why she was being moved. On 3/1/22 at 9:39 AM, a follow-up interview was conducted with CRN 1 and CRN 2. CRN 2 stated that the physician was notified of the situation per the nursing note. CRN 2 stated that the staff attempted other interventions prior to the room change such as offers of food and beverages, watching TV in the Cove, and attempts at switching the staff members. CRN 2 stated that resident 6 was also able to self propel herself in the wheelchair. CRN 2 was not able to state if resident 6's foot injury would have impeded her ability to independently mobilize herself in the wheelchair. CRN 2 stated that staff did not determine nor document if resident 6 perceived the move to room [ROOM NUMBER] as punitive or a form of punishment, that's a good question. CRN 2 stated that they reviewed resident 6's behavioral care plan and interventions of a quiet place were updated today. CRN 2 stated that staff have been provided training on dementia and training was about redirection and managing behaviors but it was not specific to intellectual disabilities. On 3/1/22 at 8:17 AM, CRN 1, CRN 2, and the ADM were interviewed. The ADM stated that resident 6 did not have and Specialized Rehabilitative Services. CRN 2 stated that staff were aware of her behaviors and interventions were to have resident 6 take a deep breath and get it back together. CRN 2 stated that they had to balance how to protect the other resident's emotional state, they were complaining about the yelling that continued for hours. CRN 2 stated that the staff transferred resident 6 to room [ROOM NUMBER], assisted her into a recliner and checked on her every 15 minutes. CRN 2 stated that she was not sure if the physician was contacted about the move to the other room. CRN 2 stated that they were looking to see if a Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/ID) would be a better option for resident 6. 2. Abuse investigation for 11/27/21. The facility abuse investigations were reviewed on 2/23/22. There was one abuse investigation regarding resident 6 and a family member. The previous facility Administrator reported an abuse allegation on 11/28/21 at 9:55 AM to the State Survey Agency. According to the Initial Entity Report form On 11/27/21 at 12:22 PM, Staff was alerted to the TV area where it was reported that [resident 6's family member] had reached out, slapped and pinched [resident 6]. It was also reported that he had stated 'the (sic) she shouldn't eat because she was to fat.' Staff immediately separated the two residents to prevent any further altercation. [Resident 6's family member] is [resident 6's] father. The finial investigation dated 12/1/21 revealed the above statement in addition, There has been no further altercation between [resident 6] or [resident 6's family member] and they both have expressed that they want to see each other again. Both have agreed to try to control their emotions with each other. [Resident 6] has no signs or symptoms from this experience. There were no other documents regarding an investigation. On 2/24/22 at 9:48 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated she witnessed the interaction between resident 6 and her family member on 11/27/21. RN 2 stated the she was halfway down the hall when resident 6's family pinched resident 6's arm and struck her on the side of the face. RN 2 stated that resident 6 was crying and gathering her things fast and started toward her room quickly. RN 2 stated that the family member and resident 6 were separated. RN 2 stated later that evening resident 6 and her family member wanted to get back together again. RN 2 stated the staff allowed them together and they were pleasant and cordial to each other. RN 2 stated the staff try to keep them in common areas. RN 2 stated that if they were being amicable, staff checked on them every 30 minutes. RN 2 stated there had been some concerns about this family member being abusive toward resident 6 but it was not charted or documented, just a concern expressed from another family member. RN 2 stated that she thought resident 6 would feel she was verbally abused by the family member because of where she was cognitively. On 2/24/22 at 11:01 AM, an interview was conducted with CNA 5. CNA 5 stated she saw the end of the incident on 11/27/21 with resident 6 and her family member. CNA 5 stated that she heard resident 6 yelling loudly in the television area. CNA 5 stated that she witnessed resident 6's family member pinched her on the back left shoulder. CNA 5 stated she did not see the slap. CNA 5 stated that there were other staff and residents that witnessed resident 6's family member slap her. CNA 5 stated that the Administrator did not interview her regarding the incident. CNA 5 stated that resident 6 was crying and visibly upset. CNA 5 stated there were no special instructions to monitor when resident 6's family member was around. CNA 5 stated there were no interventions after the incident to prevent it from happening again. On 2/24/22 at 11:44 AM, an interview was conducted with the facility Administrator. The Administrator stated that she was the abuse coordinator. The Administrator stated when she received an allegation of abuse she began an abuse investigation. The Administrator stated that she talked to an CNA, staff or family member that were there. The Administrator stated she was not aware of this abuse investigation and had not reviewed the previous abuse investigations. That Administrator was provided a copy of the incident report regarding the incident on 11/27/21. The Administrator stated she would have provided abuse training and what to look out for to the staff. The Administrator stated that she would have educated kitchen staff and department heads on what to look for during meals because resident 6 and her family member ate together [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 25 sample residents, that the facility did not ensure that the transfer was documented in the resident's medical record and included the basis for the transfer, that the services were attempted and could not be provided in the facility, that the transfer was made by the resident's physician, and that the receiving provider was provided all the necessary information to ensure a safe and effective transition of care. Specifically, the resident was transferred to the local hospital emergency room (ER) for evaluation and treatment of back pain without a physician order for the transfer and no documentation could be found of a transfer assessment or documentation that was provided to the receiving provider. Resident identifier: 22. Findings included: Resident 22 was admitted to the facility on [DATE] with diagnoses which included Friedreich ataxia, mood disorder, cardiomyopathy, gastro-esophageal reflux disease, and muscle weakness. On 2/22/22 at 10:57 AM, an interview was conducted with resident 22. Resident 22 stated that she requested to go to the hospital for back pain and that she thought the rods in her back had been dislocated. Resident 22 stated that she had her family member take her to the ER. Resident 22 stated that it was determined in the ER that the rod placement was correct, and was okay. On 2/24/22, resident 22's medical records were reviewed. On 12/30/21 at 1:52 PM, resident 22's progress notes documented that resident 22 was complaining of lower back pain, and that resident 22's family member took her to get an x-ray of the lower back. The progress note did not document that the physician was notified of the complaints of back pain, the request for an x-ray, or the transfer to the ER. No other documentation could be found of resident 22's transfer to the ER on [DATE]. On 2/24/22 at 2:18 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that resident 22 went to the ER for complaints of back pain, and it was documented in the nurse notes. RN 2 reviewed resident 22's progress notes and referred to the note on 12/30/21 at 1:52 PM. RN 2 stated that when a resident was transferred to the hospital they sent the resident with a facesheet that contained the resident demographics, a medication list, and a copy of the Physician Orders for Life Sustaining Treatment (POLST). RN 2 stated that according the the progress note resident 22's family member took her to the ER, and the visit was non-emergent. RN 2 stated that typically when residents go out to the hospital it was doctor driven. RN 2 stated that she did not see in the progress note that the physician was notified of the transfer and that would be where it should be documented. RN 2 stated that the physician should have be notified of the resident's condition. RN 2 stated that they did not fill out a transfer assessment or form. RN 2 stated that they could document in the nurse's note what paperwork was sent with the resident to the hospital, but it was not a typical thing to do. RN 2 stated that they did not have a checklist or an assessment of what to do when they transferred residents. RN 2 stated that usually if a resident was transferred out to the ER and came back with paperwork it would be scanned into the documents folder. RN 2 was observed to look in the Misc. folder for any documents from resident 22's ER visit on 12/30/21. RN 2 stated she was unable to locate any hospital documentation in resident 22's medical records. On 2/24/22 at 2:33 PM, an interview was conducted with the Director of Nursing (DON) and Corporate Resource Nurse (CRN) 1. The DON stated that the process for a resident transferred to the hospital ER was that they called 911 or a non-emergent transport, depending on the situation. The DON stated that the physician should be notified, and it should be documented in the nurse's progress note. The DON stated that the licensed nurse should document what happened, who they called, and the physician notification. The DON stated that the licensed nursing staff would send a facesheet, medication list, and POLST to the receiving provider, and that this should be documented in the progress note as well. The DON stated that the licensed nurse would then call and give report to the receiving provider and document that report was given and who it was given to. The DON stated that resident 22's family member was involved in her care, but that they should have documentation of the incident. The DON stated that if resident 22 was complaining of back pain and was requesting to go to the hospital the provider should have been made aware of this. On 2/24/22 at 4:08 PM, an interview was conducted with CRN 1. CRN 1 stated that the physician visited resident 22 on 12/29/21, the day before the transfer to the ER. CRN 1 stated that the physician increased resident 22's Baclofen to 15 milligram (mg) four times a day. On 2/28/22, resident 22's medical record was reviewed again. Resident 22's Hospital History & Physical (H & P) from 12/30/21 was located in resident 22's medical records. The document contained a faxed date and time stamp of 2/24/22 at 4:48 PM with a cover letter that stated please find the requested documents attached. On 12/30/21 resident 22's Hospital H & P documented that resident 22 presented to the ER with complaints of back pain and had previous rods from her pelvis to her thoracic spine. She has complained of increasing pain of her lower lumbar upper sacral area over the past several days. Patient does have frequent falls out of bed but is only from a very low height. X-rays of the lumbar spine revealed no evidence of acute fracture or acute subluxation. The impression was that the posterior spinal fusion from the sacroiliac joints superiorly, to a level in the upper spine, and was not visualized on the examination. Mild levoscoliosis was present. The radiographs were negative for any acute findings and there was no evidence of infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility did not develop and implement a comprehensive person-centered care plan for 1 of 25 sample residents, consistent with the resident right that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, activities of daily living function/rehabilitation potential, urinary incontinence and indwelling catheter, nutritional status, and dehydration/fluid maintenance were not developed as required. Resident identifier: 6. Findings included: Resident 6 was admitted to the facility on [DATE] with diagnoses that included Down Syndrome, encephalopathy, respiratory failure, obesity, and depression. On 3/2/22, resident 6's medical record review was completed. On 5/10/21, a Pre-admission Screening Applicant/Resident Review (PASRR) was completed for resident 6. Resident 6 had functional limitations in the areas of self-care, learning, and self-direction. Hospital history and physical from resident 6's admission 5/9/21 revealed that resident 6 had a level of maturity being close to [AGE] years old There was a report of a stranger who picked her up and took her home. Resident 6's care plan had a focus stating The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t (related to) decreased mobility and cognitive deficit, initiated on 11/1/21. Interventions were to Invite the resident to scheduled activities and The resident needs assistance/escort to activity functions. Resident 6's care plan with the focus [Resident 6] exhibits/at risk for behaviors; yelling out, arguing with other residents/staff, grunting, rubbing legs and crying was initiated on 5/16/21 and was revised on 1/24/22. Goals were to have .have fewer episodes of described behaviors to 4 days a week or less by review date that was initiated on 1/20/22 and that resident 6 will respond to redirection when having described behaviors with each episode by review date. Interventions included: a. Behavior identified: yelling, crying, moaning, causing disruptions with other residents Intervention used for redirection: invite to return to her room to calm and redirect with a chosen activity of [resident 6's] choice. Initiated 1/20/22 b. Assist the resident to develop more appropriate methods of coping and interacting. Encourage [resident 6] to express feelings appropriately. Initiated 5/16/21 c. Educate [resident 6]/family/caregivers on successful coping and interaction strategies such as. [Resident 6] needs encouragement and active support by family/caregivers when [resident 6] use these strategies. Initiated 5/16/21 d. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Initiated 1/20/22 e. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Initiated 1/20/22 A care plan focus, initiated on 5/16/21, stated [resident 6] wishes to stay long term at SNF (skilled nursing facility). Interventions included Encourage the resident to discuss feelings and concerns. Monitor for and address episodes of anxiety, fear, distress. A care plan focus, initiated on 5/17/21 for resident 6 using an antidepressant had an intervention of Refer to psychologist/psychiatrist as indicated. A care plan focus, initiated on 5/18/21, for resident 6 using anti-anxiety medications included an intervention to refer to psychologist/psychiatrist as indicated. A review of nursing notes and scanned documents revealed that resident 6 did not receive psychologist/psychiatrist services. Nursing notes revealed that resident 6 was educated about locking her wheelchair brakes (1/14/22), medications, wearing her oxygen (10/24/21), signs and symptoms of gastrointestinal (GI) bleeding (12/23/21), eating a balanced diet (12/19/21), and using a call light (10/21/21). On 11/3/21, staff were educated on encouraging resident 6 to be as independent as possible. No information was recorded about educating resident 6 about behaviors, interactions with others, and coping strategies. No documentation was identified that staff attempted to assist resident 6 to develop more appropriate methods of coping and interacting or to express feelings appropriately. On 2/21/22, resident 6 was isolated and screamed after being taken away from a group activity. A nursing note dated 2/21/22 at 9:28 PM revealed that on 2/21/22 resident 6 was brought to the TV in the common area near the round table after being weighed at approximately 6:00 PM. Resident 6 told the other residents at the table that she was watching television there first. The other residents had decided to listen to music. Resident 6 did not want to listen to music, but watch Western shows. Resident 6 became angry and yelled at staff and residents. Resident 6 was taken to her room (room [ROOM NUMBER]) by CNA 4 and was given her evening medications. At approximately 6:30 PM, resident 6 was still heard hollering, crying and yelling out from her bed room . Staff attempted to assist resident 6 to the restroom and to put on her pajamas and offered to let her watch TV in the Cove, a common area where activities take place. Resident 6 continued to holler until approximately 9:00 PM. Staff that attempted to assist resident 6 were Registered Nurse (RN) 3, CNA 4, CNA 7 and CNA 3. Residents complained of the noise and the Director of Nursing (DON) who was acting as the MDS Coordinator gave permission for resident 6 to be moved to a room not as close to other residents if needed. At 9:30 PM, resident 6 was given the choice to either allow staff to assist her to the toilet and into her pajamas and help her to her recliner to bed, or we would have to move her to another room if she continues to yell and holler keeping other residents awake. Resident 6 yelled at staff continuously, so the decision was made to move her to room [ROOM NUMBER] where she will be further away from other residents. At this time, [Resident 6] is in room [ROOM NUMBER] with the door shut .she refused to allow staff to assist her out of her wheelchair and into recliner as well. Resident was to be checked on every 15 minutes and offered assistance, and staff was awaiting the doctors' orders at that time. On 2/21/21 at 9:30 PM, an Alert Charting note for resident 6 was created and revealed that Resident was being assisted to room [ROOM NUMBER] by CNA [4] because of extreme emotional outbursts since 1815 (6:15 PM), causing fellow residents near her room to complain about noise and not being able to sleep; administration and MD (medical doctor) made aware of need to move resident. [CNA 4] reports as he was pushing resident in her wheelchair to room [ROOM NUMBER] as she continued to yell and holler, at one point resident put her right foot down on purpose on the floor in front of right wheel of wheelchair, causing her foot to get bumped/ran over . On 2/22/22 at 4:05 AM, a nursing note revealed that resident 6 had been asleep for about 3 hours. Prior to that she yelled out off and on [for] about 30 minutes intervals in between until she drifted off . On 2/22/22 at 5:26 AM, a nursing note revealed that resident 6 was awake and having a hard time talking and her throat hurts as well as her right ankle. Medicated with Tramadol 5 mg. Discussed she strained her voice with all her yelling last night try to let her voice rest and it will get better On 2/23/22 at 9:18 AM, Registered Nurse (RN) 2 was interviewed. RN 2 stated that resident 6 had been out of control, particularly when she had experienced anxiety caused by peers. RN 2 stated that when resident 6 was taken to her room, resident 6 focused more on the things that were bothering her. RN 2 stated that resident 6 did not know how to set boundaries with other residents, and therefore had frequent negative interactions. On 2/23/22 at 11:33 AM, the Activity Director (AD) was interviewed. The AD stated that when resident 6 became upset during activities, resident 6 would storm off and return later. The AD stated that staff left resident 6 alone until she calmed and returned to the activity. On 2/24/22 at 10:15 AM, the Resident Advocate (RA) was interviewed. The RA stated that resident 6 would benefit from behavior therapy. The RA stated that resident 6 did not receive behavioral therapy due to the COVID-19 pandemic, which interfered with the contracted behavioral therapist entering the facility and providing services. The RA stated that a therapist had not been in the building in over two years.

Based on observation, interview and record review, the facility did not receive registry verification for a nurse aide prior to allowing the staff member to serve as a nurse aide. Findings include: On 2/22/22, an observation was made of Certified Nursing Assistant (CNA) 18. CNA 18 was observed to be working with residents as a CNA. CNA 18 was interviewed. CNA 18 stated her job title was a CNA. On 2/24/22, the Administrator provided a list of staff hired in the last 6 months. On 3/2/22 at 12:00 PM, CNA 18's employee file was reviewed. CNA 18 was hired on 3/12/21 for the nursing department. An Employment Authorization Form for the Direct Access Clearance System (DACS) did not reveal information regarding certification or License information. Review of the February 2022 CNA schedule for the facility revealed that CNA 18 worked on 2/7/22, 2/8/22, 2/10/22, 2/14/22, 2/15/22, 2/21/22, 2/24/22, and 2/28/22. A Nursing Assistant Registry form was provided by Corporate Resource Nurse (CRN) 1. The form was dated 3/2/22 at 12:37 PM. On 3/2/22 at 12:54 PM, CRN 1 was interviewed. CRN 1 stated that the DACS and nurse aide registry were to be checked upon hire prior to the CNA working with residents. CRN 1 stated the nurse aide registry was not overlooked. CRN 1 stated she did not know why the date 3/2/22 was on the nurse aide registry form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined for 1 of 25 sample residents that the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, a resident with intellectual and behavior issues was not evaluated by or treated by a Licensed Clinical Social Worker (LCSW). Resident identifier 6. Findings include: Resident 6 was admitted to the facility on [DATE] with diagnoses that included Down Syndrome, encephalopathy, respiratory failure, obesity, and depression. Resident 6's electronic medical record review was completed on 3/2/22. An MDS was completed on 12/17/21 that revealed that resident 6 had a mood interview, a Patient Health Qustionnaire-9 (PHQ-9). Resident 6 scored 19/27, indicating moderately severe depression. A care plan with the focus of resident 6 exhibits/at risk for behaviors; yelling out, arguing with other residents/staff, grunting, rubbing legs and crying was initiated on 5/16/21 and revised on 1/24/22. Behaviors were identified as yelling, crying, moaning, causing disruptions with other residents . One intervention was initiated on 5/16/21 to Assist the resident to develop more appropriate methods of coping and interacting. Encourage [resident 6] to express feelings appropraitely. Goals were: a. On 1/20/22: [Resident 6] will have fewer episodes of described behaviors to 4 days a week or less by review date. b. On 1/20/22: [Resident 6] will respond to redirection when having described behaviors with each episode by review date. Behavior tracking completed in the CNA Tasks for the previous 30 days, from 1/25/22 to 2/23/22, revealed that resident 6 had the following behaviors documented: a. cursing at others, 4 episodes b. expressing frustration/anger at others, 7 episodes c. screaming at others, 5 episodes d. disruptive sounds, 4 episodes e. accusing of others, 3 episodes f. And 1 episode of the following behaviors: grabbing others, hitting others, kicking others, and pushing others. Interventions for behaviors were to remove from the situation, provide a calm environment, re-approach, provide 1:1 staff attention, redirect, offer food and drink, provide comfort, and toilet resident 6. A care plan focus, initiated on 5/17/21 for resident 6 using an antidepressant had an intervention of Refer to psychologist/psychiatrist as indicated. A care plan focus, initiated on 5/18/21, for resident 6 using anti-anxiety medications included an intervention to refer to psychologist/psychiatrist as indicated. Nursing notes, visit notes, and scanned documents revealed that resident 6 did not meet with a social worker. Physician progress notes revealed the following: a. On 6/16/21 at 6:36 AM, revealed that resident 6 .has some history of behavioral disturbances . we discussed some boundary setting and non-pharmacological interventions that worked well in the past. Nursing notes revealed the following behaviors: a. On 6/17/21 at 11:11 PM, .noted episodes of agitation and anxiety reported on day shift. Staff reported reassurance & give her time to respond to questions upon questioning, with speech at times hard to understand b. On 6/21/21 at 11:44 PM, .noted episodes of agitation and anxiety reported on day shift. Staff reported reassurance & give her time to respond to questions upon questioning, with speech at times hard to understand c. On 6/25/21 at 11:53 PM, .She likes having things done for her often acting like she is unable to do for herself . d. On 8/1/21 at 11:37 PM, Resident 6 became very distraught tonight. She was not able to find her father. He was not in his room or at the table where he normally sits. She was frantically walking around the halls trying to find him while she was crying, where's my dad? I can't find my dad. I need my dad. He was in the dining room. After they were reunited she was able to calm down and return to her coloring until bed time. e. On 8/4/21 at 11:38 PM, Resident 6 .has problems with anxiety and needs to be redirected at times . f. On 8/5/21 and 8/6/21, resident 6 continued with anxiety g. On 9/5/21 through 9/20/21, resident 6 had increased pain for which she received pain medications. h. On 9/21/21 at 9:03 PM, resident 6 was in her room crying and yelling out due to back pain. When the nurse encouraged a deep breath, resident 6 became upset. i. On 10/21/21 at 8:40 PM, resident 6 stated, everyone here hates me, no one cares about me. Resident was reassured that staff did not hate her. j. On 10/24/21 at 5:27 AM, .oh God, no-one likes me . k. On 11/27/21 at 12:38 PM, Resident's father came to visit from the lighthouse. While visiting [resident 6's father] made [resident 6] upset and staff heard her yell stop pinching me! She began to clean up her coloring supplies he reached over and slapped her face. She started to cry and staff separated them. [Her father] was assisted back to the lighthouse l. On 11/28/21 at 4:01 PM, resident 6's Power of Attorney (POA) 1 was contacted. POA 1 was informed that resident 6 was slapped the previous day. POA 1 stated that there was a suspected history of abuse when resident 6 and her father lived together. POA 1 stated that they wanted resident 6 to be kept safe. m. On 12/1/21 at 11:54 AM, the nurse requested that the physician provide assistance with resident 6's sleep, as resident 6 had continued behaviors and up at all hours of the night . n. On 12/17/21 at 11:30 PM, resident 6 had been having frequent emotional outbursts . o. On 12/18/21 at 8:26 PM, resident 6 had emotional outbursts during this shift . p. On 12/19/21 at 11:34 AM, resident 6 was easily frustrated and has loud emotional outbursts if she doesn't get what she wants right away . q. On 12/21/21 at 8:31 PM, resident 6 has been non compliable with staff tonight. Resident has been using vulgar language towards staff . Further behaviors were noted in the nursing notes: a. On 12/22/21 at 9:45 PM, anxious episodes b. On 12/23/21 at 7:35 PM, frequent emotional outbursts and cries frequently c. On 12/30/21 at 4:54 AM, anxiety, stated she couldn't breathe d. On 1/20/22 at 12:24 PM, mood outbursts e. On 1/29/22 at 3:04 AM, resident 6 cried hysterically due to a bad dream and soiling herself f. On 1/30/22 at 11:37 AM, resident 6 was having anxiety and a panic attack in the morning g. On 2/2/22 at 1:29 AM, resident 6 stated she couldn't breathe h. On 2/6/22 at 11:38 PM, resident 6 complained of being shaky i. On 2/19/22 at 6:00 PM, resident 6 was unhappy about a card game and yelled at another resident j. On 2/19/22 at 7:00 PM, resident 6 was yelling at another resident who screamed back at her and was mean and nasty to the aide who took her to her room. The nurse told resident 6 that the doctors orders were that when resident 6 was fighting and being mean to other residents she was to be taken to her room until she could calm down and play nice and treat others kindly. Resident 6 told the aide that she was an awful person and she hated her. k. On 2/21/22, resident 6 had an outburst, was taken to her room where she screamed until she was taken to room [ROOM NUMBER]. Resident 6 was .given the choice to either allow staff to assist her to the toilet .or we would have to move her to another room if she continues to yell and holler keeping other residents awake . l. On 2/22/22 resident 6 was hoarse and was having a hard time talking and her throat hurt as well as her right ankle. On 2/24/22 at 10:15 AM, the Resident Advocate (RA) was interviewed. The RA stated that resident 6 would benefit from behavior therapy. The RA stated that therapy services for resident 6 were missed. The RA stated that the contracted behavioral health provider had not been at the facility since the COVID-19 outbreak, approximately two years ago. On 2/24/22 at 11:44 AM, an interview was conducted with the Administrator (ADM). The ADM stated that the facility would want behavioral interventions for resident 6. The ADM stated that the staff try to get resident 6 everything she wants at meal times to help with behaviors then. The ADM stated that she spent a lot of individual time with resident 6.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility did not provide, for 1 of 25 sample residents, specialized rehabilitative services such as physical therapy and occupational therapy that were required in the resident's comprehensive plan of care. Specifically, a resident was not provided assessed specialized rehabilitation. Resident identifier 6. Findings include: Resident 6 was admitted to the facility on [DATE] with diagnoses that included Down Syndrome, encephalopathy, respiratory failure, obesity, and depression. Resident 6's electronic medical record review was completed on 3/2/22. Resident 6's Preadmission Screening Resident Review (PASRR) Level II, created on 7/31/21 revealed that resident 6 had a diability that limited her in learning, self-direction, and capacity for independent living. The functional assessment revealed that reident 6 showed an inability to learn new skills without aggressive and consistent training. The summary of Specialized Rehabilitative Services (SRS) for Intellectual diaability stated that resident 6 would benefit from an SRS program that works on maintaining as much independence as possible. [Resident 6] will tend to passively allow others to do things for her that she is still capable of doing independently. She would also benefit from recreational opportunities that are geared to her developmental and intellectual level. Additonal recommendations were that resident 6 meets IDRC criteria with an intellectual disability, likely mild, and a seizure disorder . Physician orders revealed that resident 6 had active orders for the following: a. 5/17/21: Speech therapy to evaluate and treat as necessary b. 5/17/21: Occupational therapy to evaluate and treat as necessary A care plan for falls reevaled that resident 6 had an intervention of PT consult for strength and mobility in initiated on 11/1/21 and revised on 1/24/22. Fall reports revealed that resident 6 had a fall on 6/2/21, 10/20/21, 12/7/21, and 1/27/22. A Minimum Data Set, dated [DATE] revealed that resident 6 required staff assistance to stabilize when moving from a seated to a standing position, when moving off and onto the toilet, and when transferring from one surface to another. Resident 6 was unsteady when walking and turning around but was able to stabalize with a walker or wheelchair. Resident 6 required one person assistance with bed mobility, walking, dressing, toileting and for personal hygiene. At the time of the assessment, resident 6 was unable to walk 10 feet, was unable to take a step up or down from a curb, or pick up an object from the floor. The MDS stated that resident 6 last had therapy in October, 2021. An MDS was completed on 12/17/21 that revealed that resident 6 had a mood interview, a Patient Health Qustionnaire-9 (PHQ-9). Resident 6 scored 19/27, indicating moderately severe depression. Nursing notes revealed that resident 6 worked with therapy from admit from 5/15/21 until 7/30/21. There were no additional nursing notes about therapy. A care plan for ADL (activities of daily living) self-care performance deficit r/t (related to) encephalopathy was created on 5/16/21. Resident 6 was to be prvoided nursing rehab/restorative assistance for walking and active range of motion. On 2/24/22 at 10:15 AM, the Resident Advocate (RA) was interviewed. The RA stated that resident 6 would benefit from behavior therapy. The RA stated that resident 6 did not receive behavioral therapy due to the COVID-19 pandemic, which interfered with the contracted behavioral therapist entering the facility and providing services.

Based on interview and record review it was determined that the facility did not maintain evidence demonstrating the results of all grievances for a period of no less than 3 years from the issuance of the grievance decision. Specifically, facility grievance records could not be located prior to November 2021. Findings included: On 2/23/22 the facility grievance binder was reviewed. The Grievance Log documented complaints from 11/9/2021 to 2/10/2022. The log provided the date of the incident, name of person filing the report, name of person investigating, the dates the parties were informed of the findings and the disposition of the complaint. Additional documentation included a Grievance Tracking Report that documented the issue/concern, how the concern was corrected, the date the concern was corrected, and the responsible person. On 2/23/22 at 1:34 PM, an interview was conducted with the Corporate Resource Nurse (CRN) 1. The grievance log from May 2021 to November 2021 was also requested. CRN 1 stated that the previous Administrator had all the grievance forms in his office and when he left the facility they could not locate the grievance forms prior to November 9, 2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility did not ensure that the abuse policies and procedures were implemented to prevent abuse for 3 of 25 sample residents. Specifically, one resident experienced physical, verbal, financial, and emotional abuse and was involuntarily secluded. Resident identifiers: 4, 6, and 14. Findings include: 1. Resident 6 was admitted to the facility on [DATE] with diagnoses that included Down Syndrome, encephalopathy, respiratory failure, obesity, and depression. On 2/22/22 at 12:13 PM, an interview was conducted with resident 6. Resident 6 stated that there were two residents who said mean to her, naming resident 4 and resident 14. Resident 6 stated that the other residents told her to shut up and go to her room when they were at activities. Resident 6 stated that she had fought with her family member (FM 2) who was a resident in another area of the facility, who can visit resident 6 as desired. Resident 6 stated that she was kept in another room overnight, away from her own room. Resident 6 stated that FM 2 had asked her for money. On 2/23/22 at 2:10 PM, resident 6's family member (FM) 1 stated that resident 6 had fought with FM 2 for years. FM 1 stated that FM 2 had pinched and hit resident 6 while in the facility in November, 2021. FM 1 stated that the administration team was aware that when FM 2 was having anger issues, FM 2 could not be around resident 6. FM 1 stated that FM 2 had a history of pounding on the table and throwing things, as well as demeaning resident 6. FM 1 stated that when they were told that FM 2 had slapped resident 6, FM 1 told staff to keep resident 6 safe through whatever means necessary. FM 1 stated that there may have been other forms of abuse from FM 2 to resident 6. FM 1 stated that FM 2 requested money from resident 6 and should not need resident 6's money because FM 2 had money in his possession. FM 1 stated that they were not told about resident 6's involuntary seclusion and did not consent. FM 1 stated that they were aware of conflicts between resident 6 and other residents. Incident reports revealed that resident 6 was pinched and slapped by FM 2 in November, 2021. Staff continued to allow FM 2 access to resident 6. Nursing notes revealed that resident 6 had disagreements with other residents that were not identified as abusive. Staff interviews revealed that resident 6 was emotionally upset and comments were abusive. Resident 6 was taken away from other residents and her room on 2/21/22 and was taken to room [ROOM NUMBER] by staff. Resident 6's family member (FM 2) had taken money from resident 6. Staff had witnessed resident 6's family member (FM 2) ask resident 6 for money but had not identified that the money belonged to resident 6. On 2/24/22, the staff at the facility provided copies of the following policies: Policy on the Prevention of Resident Abuse, Neglect, and Misappropriation of Resident Property, Policy on Preventing Resident to Resident Abuse, Policy on Investigating Allegations of Resident Abuse, Actual Abuse and Neglect of a Resident, Policy on Investigating Misappropriation of Resident Property, Policy on Investigation Injuries of Unknown Origin, Policy on Investigating a Suspected Rape of a Resident, Policy on Protecting Residents during an Investigation of Abuse and Neglect, and Mission Health Services; Abuse Prohibition Education and Information Sheet on 7 Components. The Policy on the Prevention of Resident Abuse, Neglect, and Misappropriation of Resident Property revealed that Each resident living in this Community has the right to be free from abuse, neglect . The Community will enforce polices and procedures that protect each resident from abuse, neglect and misappropriation of property by employees, other residents . family members and legal guardians, friends, or other individuals 'Abuse and Allegations of Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment that result in physical harm, pain, or mental anguish. This definition includes residents who are comatose or are unable to respond due to physical or cognitive deficits to what an individual would normally consider to be physical harm, pain, or mental anguish. 'Verbal abuse' is defined as the use of oral, written, or gestured language that wilfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their ability to comprehend or disability 'Physical abuse' includes hitting, slapping, pinching and kicking 'Mental abuse' includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mental abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff talking . in any manner that would demean or humiliate a resident (s) 'Involuntary seclusion' means separation of the resident from other residents or from their bedroom or confinement in their bedroom against the resident's will or the will of the resident's legal representative. Emergency separation of the resident monitored by employee for a limited time to reduce agitation or to protect other persons is not considered involuntary seclusion All reported incidents of resident abuse and allegations of abuse, neglect and misappropriation of property will be promptly investigated. Measures will be taken to protect residents during an investigation Procedure .6. d. How to recognize signs and symptoms in a resident that could lead to aggressive behavior and how to defuse these situations before physical or verbal abuse occurs. e. Methods to assist a resident to control aggressive and disruptive behaviors. f. How to promptly report any incidents that could be perceived to be abuse, neglect or exploitation of a resident to the nurse responsible for the resident, the employee's supervisor, or any supervisor 9. All employees are responsible for reporting promptly any incident that has the potential to be considered an allegation of abuse, or actual abuse, neglect or exploitation of a resident. From Policy on Preventing Resident to Resident Abuse: Procedure: 1. Residents with a history of physical and/or verbal abuse of other persons will be evaluated prior to admission to ensure that this Community has the services the resident needs to achieve their highest practicable level of functioning and to protect other residents from harm 6. If the resident continues to exhibit behaviors that could harm residents, the interdisciplinary team will meet with the resident, the resident's legal representative and or designated family member to discuss the ability or inability of the Community to meet the resident's needs and the possible and potential need for a move to another residence that can better meet the needs of the resident. Policy on Investigating Allegations of Resident Abuse, Actual Abuse and Neglect of a Resident .Procedure: 1. In the event that an incident that meets or has the potential to meet one of the definitions stated in the policy on abuse or neglect of a resident, the incident is reported to the Administrator and or designee. An investigation of the incident will be commenced promptly. This included incidents in which a resident is injured or had the potential for injury and the cause of the incident is unknown 5. The resident, the resident's legal representative and or designated family member will be informed of the investigation. 6. Information will be compiled of all witnesses and other persons who have knowledge of the event. 7. The following individuals will be interviewed: a. The person making the report. b. Individuals alleged to have been involved in the incident. c. The resident, if able and willing to be interviewed. d. Staff members on duty during the time of the alleged incident. e. Other staff that may have information about the incident. f. Staff that may have had contact with the resident before or after the period of the alleged incident. g. Resident's roommate, family members and visitors. h. Other residents who received care and services from the individual or individuals alleged to have committed abuse or neglect 12. If there is enough evidence to suspect that an individual may have abused or neglected a resident, that individual will be suspended and or denied access until the outcome of the investigation is known 14. In the event the abuse or neglect was perpetrated by a member of the public, this information will be provided to appropriate state agencies. Policy on Protecting Residents during an Investigation of Abuse and Neglect: Procedure: 1. Any employee or employees implicated in an incident where they have committed abuse or neglect of a resident will be placed on administrative leave pending the outcome of an investigation. 2. If the incident involved a resident's family member or visitor: a. The resident will be asked if they wish to continue to receive visits from that individual. b. The resident's designated family member will be notified. c. If the resident has a power of attorney for health care decisions that individual must be approached for a decision. d. If the resident's response is that they want to continue seeing the individual; the visits will be supervised until the investigation is completed. e. The local Ombudsman may be asked to be involved. f. If the resident states that they do not want to see the individual, the individual will be notified by the Administrator/designee of the resident's right to deny visitation. g. Staff will be notified of the denial of visitation or the need for supervised visits. h. Incidents of abuse or neglect or suspected abuse or neglect involving a resident's family member or visitor will be reported to appropriate state agency responsible for adult protective services, including local law enforcement if needed. 3. Staff will be available to the resident for reassurance and support following an incident of abuse and neglect. 4. The resident's legal representative and/or designated family member will be notified when there is an incident that is being investigated as potential or actual abuse, neglect or misappropriation of a resident's property. From the policy entitled Mission Health Services: Abuse Prohibition Education and Information Sheet on 7 Components: . 3. Prevention means providing residents, families, and staff information on how to and to who they may report concerns, incidents, grievances without fear of retribution. Be able to identify potential and or actual abuse, correct and intervene in situations in which abuse, neglect or misappropriation of resident property is more likely to occur. 4. Identification means being able to identify events such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse, and determine the direction of the investigation. 5. Investigation means to investigate different types of incidents, and identify staff members responsible for the initial reporting, investigation, of allegations, and reporting the results to proper authorities. 6. Protection means protecting the resident from harm during the investigation. 7. Reporting means reporting all allegations to the appropriate agencies and take necessary corrective actions, analyze the occurrences to determine changes needed if any, to prevent recurrence An incident report created on 11/27/21 at 11:45 AM, revealed that resident 6's family member (FM 2) was visiting resident 6 when FM 2 made [resident 6] upset and staff heard her yell 'stop pinching me!' She began to clean up her coloring supplies he reached over and slapped her face. She started to cry and staff separated them. [FM 2] was assisted back to the lighthouse . On 11/28/21 at 4:01 PM, a nursing note revealed that resident 6's Power of Attorney (POA) was contacted about FM 2 slapping resident 6 in the face the previous day. The POA requested that staff keep resident 6 safe. In a follow-up letter to the State Agency on 12/1/21, the previous Administrator (ADM 2) revealed that resident 6's FM 2 had also told resident 6 that she shouldn't eat because she was too fat. Resident 6 had a Minimum Data Set (MDS) quarterly evaluation completed on 12/17/22. Resident 6 had a PHQ-9 evaluation for depression. Resident 6 scored 19/27, which indicated moderately severe depression. A physician's note dated 2/4/22 revealed that resident 6's behaviors are up-and-down but seems to be relatively stable with changing of medication . here for long term care . On 2/23/22 at 3:57 PM, FM 2 was observed leaving resident 6's room. Staff were not observed to be present when resident 6 and FM 2 were alone together in resident 6's room. On 2/23/22 at 3:42 PM, Certified Nurse Assistant (CNA) 5 was interviewed. CNA 5 stated that she was familiar with resident 6 and her family member (FM 2). CNA 5 stated that FM 2 got into little tiffs when they were together. CNA 5 stated that staff had to monitor FM 2 and that she witnessed FM 2 hit resident 6. CNA 5 stated that resident 6 was upset and crying when she stomped off to her room. CNA 5 stated that resident 6 took a while to calm. CNA 5 stated that staff separated resident 6 from FM 2 for five days after he slapped resident 6 to ensure her safety. CNA 5 stated that she did not know what interventions prevented FM 2 from slapping resident 6 currently. CNA 5 stated that she had talked to a family member of resident 6 (FM 3) who told CNA 5 that FM 2 had hurt resident 6 a lot when resident 6 was growing up. CNA 5 stated that FM 3 had told CNA 5 that FM 2 had pinched her and was visibly upset. CNA 5 stated that resident 6 had told CNA 5 that FM 2 had hit her. CNA 5 stated that she saw FM 2 pinch resident 6 on the shoulder/back. CNA 5 stated that FM 2 liked to pick a fight with resident 6. CNA 5 stated that she was aware that FM 2 visited resident 6 in her room, but was not aware of any fighting that occurred in her room. CNA 5 stated that there were no special instructions to monitor the two, but if FM 2 was to hit resident 6, CNA 5 would tell the nurse. CNA 5 stated that resident 6 and resident 14 argue all the time. CNA 5 stated that the residents said mean things to each other. CNA 5 stated that resident 14 liked to pick a fight with resident 6 and most games ended with the two swearing at each other. CNA 5 stated that the problems were often with resident 14, sometimes resident 4 would tell resident 6 that resident 6 was whiney, mean and that resident 6 was cheating. CNA 5 stated that when she heard that the residents were planning to play a card game, she knew how it was going to go. On 2/23/22 at 4:13 PM, Registered Nurse (RN) 3 was interviewed. RN 3 stated that the relationship between resident 6 and FM 2 was unstable. RN 3 stated that at times, they got along, but at other times, FM 2 tried to take control of resident 6, and FM 2 really aggravated resident 6 when they were together. RN 3 stated that she worked with resident 6 the night of 2/21/22. RN 3 stated that after CNA 4 took resident 6 to get weighed, resident 6 returned to the round table in the common area to find other residents there had changed the channel from resident 6's Western show to music. RN 3 stated that the other residents voted to listen to music, so they outruled resident 6. RN 2 stated that resident 6 became upset and yelled at a few of the residents. RN 2 stated that another nurse, Licensed Nurse (LN) 4 told resident 6 that she could return to her room to watch Westerns. CNA 4 took resident 6 to her room and turned the TV on for resident 6, figuring that resident 6 would calm after a few minutes. RN 3 stated that it was not abnormal to have resident 6 throw a fit and be taken to her room to calm down. RN 3 stated that there were a few residents that provoked resident 6. RN 3 stated that resident 6 had been given anti-anxiety medication and we hoped it would kick in. RN 3 stated that resident 6 began screaming, crying, and hollering until about 9:00 PM. RN 3 stated that CNA 4, CNA 3 and CNA 7 attempted to calm resident 6, but resident 6 yelled at them, and attempted to kick them. Staff offered to let resident 6 watch TV in her room, but resident 6 wanted to watch television at the round table. RN 3 stated that at 9:30 PM, resident 6 was asked to quiet to allow other residents to sleep. RN 3 stated that resident 6 refused to quiet, so RN 3 called the physician to obtain a prescription for medication to help resident 6 sleep. The physician told RN 3 he would call her back. RN 3 stated that other residents were concerned and asked if resident 6 was okay, due to her screaming and crying. RN 3 stated that she called the Administrator on Call, the MDS Coordinator who was now the DON and asked if resident 6 could be moved. RN 3 stated that she had permission to move resident 6 to room [ROOM NUMBER]. RN 3 and CNA 4 moved resident 6 to room [ROOM NUMBER]. RN 3 stated that she took resident 6's oxygen concentrator, a blanket, and water to room [ROOM NUMBER]. RN 3 stated that resident 6 definitely did not want to go, but RN 3 stated that she felt it was better for everyone else for her to move. RN 3 stated that six residents expressed concern or complaints about resident 6's yelling. RN 3 stated that resident 6 was yelling loudly in the hallway when she was being taken to room [ROOM NUMBER]. In room [ROOM NUMBER], RN 3 placed the oxygen cannula on resident 6. RN 3 stated the physician called back at approximately 10:00 PM, and ordered an extra dose of Hydroxyzine for resident 6 for anxiety. RN 3 stated that it was approximately 11:00 PM when resident 6 agreed to take the Hydroxyzine medication, and allowed staff to toilet her. RN 3 stated that when resident 6 went to the restroom, resident 6 stated that her left foot hurt. RN 3 stated that resident 6's foot may have been run over when CNA 4 was pushing resident 6 to room [ROOM NUMBER]. RN 3 stated that resident 6 was able to move her foot and did not appear to have any bruising. RN 3 stated that resident 6 sat in the recliner in room [ROOM NUMBER] and the nurse examined her right foot as well. RN 3 stated that resident 6 complained of pain, so RN 3 provided as needed (PRN) ibuprofen and staff retrieved some ice for her foot. RN 3 stated that resident 6 was in room [ROOM NUMBER] when she left the facility at 12:00 AM on 2/22/22. RN 3 stated that when she arrived back at the facility on 2/22/22 at 8:00 AM, the previous shift nurse reported that resident 6 complained of right foot pain. RN 3 stated that she saw resident 6 walking with the restorative aide around lunch and was able to walk without a limp. RN 3 stated that resident 6 stated that her foot hurt, but did not request PRN pain medication. RN 3 stated that resident 6 was more agitated. On 2/23/22 at 3:52 PM, CNA 8 was interviewed. CNA 8 stated that resident 6 had family difficulties and that resident 6 and FM 2 had to be monitored when they were together. CNA 8 stated that she had separated resident 6 and FM 2 sometime last week because FM 2 was upsetting resident 6. CNA 8 stated that FM 2 told resident 6 that she needed to stop talking. CNA 8 stated that resident 6 had fits and staff took her back to her room and helped her calm. CNA 8 stated that resident 6 did not always like to go to her room, but that's where we take her. CNA 8 stated that resident 6 was placed in her room for an average of 10 minutes. CNA 8 stated that she was told resident 6 was taken to another room so that other residents could sleep, and that resident 6 was only taken, until she calmed down. CNA 8 stated that resident 6 had problems with other residents and with family members. On 2/24/22 at 7:48 AM, CNA 6 was interviewed. CNA 6 stated that resident 6's family member (FM 2) told resident 6 to calm down often when he visited. CNA 6 stated that after FM 2 hit resident 6, FM 2 was not allowed to come over and visit for three to four days but both resident 6 and FM 2 were upset after the separation. CNA 6 that resident 6 had little disputes with some of the other residents at the facility. CNA 6 stated that one resident in particular that resident 6 had a problem with was resident 14. CNA 6 stated that resident 14 told resident 6 how to behave and resident 6 became upset with resident 14 frequently. CNA 6 stated that staff removed resident 6 from activities if resident 6 became upset and tried to calm her down by leaving her in her room for up to 15 minutes. CNA 6 stated that about half the time, resident 6 would become more upset. CNA 6 stated that resident 6 and resident 14 butted heads and that resident 4 picked on resident 6 for a while. On 2/24/22 at 9:48 AM, RN 2 was interviewed. RN 2 stated that after she saw FM 2 pinch resident 6, there were no marks on resident 6's arm. RN 2 stated that after FM 2 pinched resident 6, resident 6 started to pick up her art supplies when FM 2 struck resident 6 on the side of her face. RN 2 stated that she saw FM 2 hit resident 6 from half way down the hall. RN 2 stated the slap did not appear terribly forceful and did not see resident 6's face turn red. RN 2 stated that resident 6 began crying, cleaned up her things faster, and went to her room. RN 2 stated that she took FM 2 back to his area in the building and then attempted to comfort resident 6. RN 2 stated that staff attempted to get FM 2 and resident 6 back together later that evening to see if they were OK with each other. RN 2 stated that they were cordial to each other later that evening. RN 2 stated that FM 2 told resident 6 to quit being a baby when she was upset, and she does not take that well. RN 2 stated that resident 6 would probably think that was verbal abuse because of where she is cognitively. RN 2 stated that she also thought it was verbal abuse. RN 2 stated that as long as FM 2 and resident 6 were being amicable they could remain together, but staff would check on them every 30 minutes. RN 2 stated that she had heard of concerns from the family about FM 2 being abusive to resident 6, but that there was nothing in the documentation. RN 2 stated that residents enjoyed going to the Cove, a room used for activities. RN 2 stated that residents watched television in the Cove room as well. RN 2 stated that resident 6 sometimes became frustrated, and letting resident 6 express herself helped, along with getting away from large groups. RN 2 stated that resident 6 calmed when she was in her room. RN 2 stated that although resident 6 did not like a lot of stimulation when she was upset, we try not to isolate her. RN 2 stated that she had heard that FM 2 had asked resident 6 for money when they went on van rides together in the community. RN 2 stated that for resident 6, two of the residents set her off and that staff had to watch the interactions between resident 6, resident 14 and resident 4. RN 2 stated that some days the residents got along, and on other days they were out of control. RN 2 stated that she'd heard residents tell resident 6 that nobody liked resident 6 because of the way she acted. On 2/24/22 at 10:50, the Resident Advocate (RA) was interviewed. The RA stated that resident 6 had expressed frustration about FM 2. The RA stated that she was aware that FM 2 made comments about resident 6's eating and that resident 6 was sassy back. The RA stated that she knew FM 2 asked resident 6 for money, but thought that FM 2 had plenty of money and had resident 6 put it in her purse for him. The RA stated that she had heard about FM 2 telling resident 6 she was too fat and that he said things that were not appropriate, even if it's your kid. The RA stated that FM 2 appeared to not be concerned with resident 6's well being. The RA stated that she had watched resident 6 and FM 2 interact, and it's kind of shocking. The RA stated that a lot of the other residents were frustrated with resident 6 because of her behaviors. The RA stated that some of the other residents had pulled resident 6 aside and chided her for her behaviors. The RA stated that this was mainly resident 14. On 2/24/22 at 11:44 AM, ADM 1 was interviewed. ADM 1 stated that she had never witnessed resident 6 and FM 2 fighting, but she had received reports that they have had disagreements. ADM 1 stated that both residents had a right to see each other, and staff needed to be vigilant to watch resident 6 for signs of distress so they could intervene before things got out of hand. ADM 1 stated that she recently read the incident report from November and she would not want resident 6 and FM 2 unsupervised in a room together. ADM 1 stated that she did not know there was a history of abuse. On 2/22/22 at 1:13 PM, resident 6 revealed that she was put into room [ROOM NUMBER] overnight from 2/21/22 to 2/22/22. The facility census revealed that resident 6 had been residing in room [ROOM NUMBER] since admission. On 7/31/21, resident 6 had a Preadmission Screening Resident Review (PASRR) Level II completed and revealed that resident 6 was vulnerable to exploitation. Resident 6 displayed increasing cognitive impairment with impaired short-term memory and periods of confusion and disorientation . d. A nursing note dated 2/21/22 at 9:28 PM, revealed that on 2/21/22, resident 6 was brought to the TV in the common area near the round table after being weighed at approximately 6:00 PM. Resident 6 told the other residents at the table that she was watching television there first. The other residents had decided to listen to music. Resident 6 did not want to listen to music, but watch Western shows. Resident 6 became angry and yelled at staff and residents. Resident 6 was taken to her room (room [ROOM NUMBER]) by CNA 4 and was given her evening medications. At approximately 6:30 PM, resident 6 was still heard hollering, crying and yelling out from her bed room Staff attempted to assist resident 6 to the restroom and to put on her pajamas and offered to let her watch TV in the Cove, a common area where activities take place. Resident 6 continued to holler until approximately 9:00 PM. Staff that attempted to assist resident 6 were Registered Nurse (RN) 3, CNA 4, CNA 7 and CNA 3. Residents complained of the noise and the Director of Nursing (DON) who was acting as the MDS Coordinator gave permission for resident 6 to be moved to a room not as close to other residents if needed. On 2/21/22 at 9:30 PM, an incident report was created because while staff were transferring resident 6 from room [ROOM NUMBER] to room [ROOM NUMBER], her foot was run over by the wheelchair. This incident was created as an injury and revealed that while resident 6 was being moved to room [ROOM NUMBER] (not her room), CNA 4 ran over resident 6's foot. Resident 6 had new pain at the time of the incident and complained of pain at 11:00 PM. A nursing note dated 2/21/22 at 9:30 PM, resident 6 was given the choice to either allow staff to assist her to the toilet and into her pajamas and help her to her recliner to bed, or we would have to move her to another room if she continues to yell and holler keeping other residents awake. Resident 6 yelled at staff continuously, so the decision was made to move her to room [ROOM NUMBER] where she will be further away from other residents. At this time, [Resident 6] is in room [ROOM NUMBER] with the door shut .she refused to allow staff to assist her out of her wheelchair and into recliner as well. Resident was to be checked on every 15 minutes and offered assistance, and staff was awaiting the doctors' orders at that time. On 2/21/21 at 9:30 PM, an Alert Charting note for resident 6 was created and revealed that Resident was being assisted to room [ROOM NUMBER] by CNA [4] because of extreme emotional outbursts since 1815 (6:15 PM), causing fellow residents near her room to complain about noise and not being able to sleep; administration and MD (medical doctor) made aware of need to move resident. [CNA 4] reports as he was pushing resident in her wheelchair to room [ROOM NUMBER] as she continued to yell and holler, at one point resident put her right foot down on purpose on the floor in front of right wheel of wheelchair, causing her foot to get bumped/ran over. Immediately following incident resident refused to allow this nurse to assess for injury, she allowed later at 2300 (11:00 PM) when she complained of pain in her left foot, no apparent signs of injury were noted; no redness, no bruising, no swelling. Additional nursing notes revealed the following: a. On 2/21/22 at 10:58 PM, resident 6 agreed to take two Hydroxyzine at 10:15 PM and go to the toilet and put on pajamas. Resident 6 complained that her foot hurt, but no discoloration was noted and resident 6 was able to move her foot and wiggle her toes. The resident was able to bear weight on her left foot when needed for transfers. CNA 4 reported that resident 6 put her right foot down under the wheelchair wheel when she was being assisted

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 3 of 25 sampled residents, that the facility did not ensure that medication error rates were not 5 percent or greater. Observations of 34 medication opportunities, on [DATE], revealed 5 medication errors which resulted in a 14.71% medication error rate. Specifically, two residents received Levothyroxine with meals, a full dose of Miralax was not administered, Fiber capsules were administered without verification of dosage, and a Symbicort inhaler was administered without verification of the medication expiration. Resident identifiers: 9, 12, and 125. Findings included: 1. Resident 12 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, atherosclerosis of aorta, benign prostatic hyperplasia, chronic obstructive pulmonary disease, emphysema, anxiety disorder, gastro-esophageal reflux disease, hypothyroidism, polyneuropathy, sleep apnea, and dementia. On [DATE] at 8:36 AM, an observation was made of Registered Nurse (RN) 1 during morning medication administration. RN 1 was observed to administer resident 12 Levothyroxine 50 micrograms (mcg) tablet. Resident 12 was observed eating his breakfast meal. On [DATE] at 9:00 AM, RN 1 was observed to obtain resident 12's Symbicort inhaler from the medication cart. The inhaler was stored in a plastic bag and did not have an expiration date listed on the plastic bag or the written on the inhaler. RN 1 stated that without the original medication box she did not have an expiration date for the medication. RN 1 stated that the medication was provided by resident 12's family and was brought from home. RN 1 stated that she was going to give the medication to resident 12 and then order a new refill for resident 12. RN 1 provided resident 12 with the Symbicort inhaler. Resident 12 was observed to administer 2 puffs of the medication to himself with standby assist by RN 1. Resident 12 was observed to pause, hold his breath, and wait between inhalations. Resident 1 declined to rinse his mouth with water after the medication administration. Resident 12's Medication Administration Record (MAR) for February 2020 was reviewed and revealed the following: a. Levothyroxine tablet 50 mcg, give one tablet by mouth in the morning for thyroid. The medication had an administration hour listed at 6:00 AM. b. Symbicort Aerosol 160-4.5 mcg per actuation, give 2 puffs inhale orally two times a day for breathing. The medication had an administration hour listed at 6:00 AM and 6:00 PM. On [DATE] at 10:04 AM, a follow-up interview was conducted with RN 1. RN 1 stated that she did not know if the Symbicort was an expired medication, and without the original package she had no way of knowing. RN 1 stated that she did not know if resident 12 received an effect dose of the medication. RN 1 stated that her concern was not having any medication would cause resident 12 distress, so she went ahead and gave him the medication she had on hand. RN 1 stated the medication would arrive from the pharmacy by 10 PM tonight. RN 1 stated that was that the soonest they could get the medication, but sometimes with antibiotics they could get them sooner. RN 1 stated that the facility had a stat safe for emergency medication but she did not think it had inhalers. RN 1 stated that when they get medication sent from the hospital they sometimes reorder them, but because inhalers were expensive they always kept the medication that was sent with the resident. 2. Resident 9 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure, hyperlipidemia, macular degeneration insomnia, hypothyroidism, chronic kidney disease, morbid obesity, atrial fibrillation, type 2 diabetes mellitus, and sleep apnea. On [DATE] at 8:57 AM, an observation was made of RN 1 administering resident 9's Levothyroxine 100 mcg tablet and Polyethylene Glycol 3350 Powder (Miralax), 17 grams was mixed with 240 milliliters of apple juice. Resident 9 was observed eating her breakfast meal at the time of the medication administration. Resident 9 was observed to drink the apple juice mixed with the Miralax. RN 1 was observed to take the cup from resident 9 and discarded it into the garbage without resident 9 finishing the contents within the cup, leaving approximately 3/4 to 1 inch of liquid in the bottom of the cup. Resident 9's MAR for February 2020 was reviewed and revealed the following: a. Synthroid tablet (Levothyroxine Sodium), give 100 mcg by mouth in the morning for Hypothyroidism. The medication had an administration hour listed at 6:00 AM. b. Polyethylene Glycol 3350 Powder, give 17 gram by mouth in the morning for constipation. The medication had an administration hour listed at 6:00 AM. On [DATE] at 8:59 AM, an interview was conducted with RN 1. RN 1 stated that she did not give the last little bit of liquid [Miralax] because it was too grainy. RN 1 confirmed that the grainy consistency was due to the medication accumulation at the bottom of the cup. RN 1 stated that if she had hot water the medication would have dissolved. RN 1 stated that it was her understanding that she had up to 10% of the medication to discard and it would still be okay. 3. Resident 125 was admitted to the facility on [DATE] with diagnoses which included orthopedic aftercare, depression, hypertension, asthma, gastro-esophageal reflux disease, irritable bowel syndrome, obstructive sleep apnea, and morbid obesity. On [DATE] at 9:55 AM, an observation was made of RN 1 administering Equate daily Fiber, 2 capsules to resident 125. Resident 125's MAR for February 2020 was reviewed and revealed FiberCon Tablet 625 milligrams (mg) (Calcium Polycarbophil), give 2 tablet by mouth two times a day for fiber. The medication had an administration hour listed at 6:00 AM and 6:00 PM. On [DATE] at 10:04 AM, a follow-up interview was conducted with RN 1. RN 1 stated that the Synthroid use to be given 30 minutes before breakfast, but new literature stated that it did not need to be given that way anymore. RN 1 stated that now the Synthroid was given in the morning but not before breakfast. RN 1 was asked what literature she was referencing, and RN 1 clarified that this was the guidance that was provided to her when she started orienting at the facility. RN 1 stated that prior to working at this facility she understood that Synthroid needed to be given on an empty stomach to be absorbed. RN 1 stated that if the Synthroid medication did not have specific parameters for administration then she did not put it in to be administered before breakfast. RN 1 stated that if the resident stated that they took the Synthroid before all the other pills then she would call the physician and get an order to give it at a scheduled time. RN 1 stated that to her knowledge the Synthroid did not have to be given on an empty stomach, but it use to be. RN 1 stated that changed when she came to the facility and had to put her own orders in. RN 1 reviewed resident 125's order for FiberCon Tablet 625 mg and stated that the order read to give 2 tablets for a total dose of 1250 mg. RN 1 reviewed the Equate Daily Fiber bottle that was administered to resident 125 and stated that it did not have normal mg listed on the label. RN 1 calculated that she gave the resident 1600 mg of the Equate Daily Fiber based on the label that read 5 capsules was a serving of 2 grams per serving. On [DATE] at 3:32 PM, an interview was conducted with the Corporate Resource Nurse (CRN) 1. CRN 1 stated that the facility utilized flex medication administration times. CRN 1 asked for the time that the Synthroid medications were given and the time that the MAR had the order scheduled for administration. CRN 1 stated that the expectation was for the licensed nurse to notify the physician if the medication on hand was not the same as the physician order. Review of the Medication Administration Times provided in the entrance conference documentation listed the medication flex times from 4:00 AM to 6:00 AM, then 6:00 AM to 10:00 AM, then 10:00 AM to 2:00 PM then 2:00 PM to 6:00 PM, and then 6:00 PM to 10:00 PM. Review of the Nursing 2022 Drug Handbook guidance stated to give Synthroid medication at the same time each day on an empty stomach, preferably 1/2 to 1 hour before breakfast. Wolters Kluwer. (2022). Nursing 2022 Drug Handbook. Philadelphia, PA. 42nd Edition, p. 878.

Based on observation, record review and interview the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility was found to be in non-compliance with F880, which was cited at an Immediate Jeopardy, scope and severity of L. In addition, one resident was abused and involuntarily secluded with the permission of management, which was cited at an Immediate Jeopardy, scope and severity of H. Resident identifiers: 4,6, 14, 125, and 127. Findings included: 1. Based on interview and record review it was determined that the facility failed to establish an infection prevention and control program designed to prevent the development and transmission of COVID-19. Specifically, the facility failed to ensure that a symptomatic staff members, who subsequently tested positive for COVID-19, were screened accurately and notification and evaluation was completed per the facility protocol, that negative antigen tests were completed, and that symptomatic staff members were provided appropriate Personal Protective Equipment (PPE). The failure resulted in 6 residents exposure and 2 testing positive with a facility outbreak. In addition, staff and visiting essential personnel who have continued to test negative for COVID-19 were also at an elevated risk. Additionally, staff did not wear required PPE for a newly admitted unvaccinated resident. In addition, a nurse was observed to handle residents medications with bare hands. Resident identifiers: 125 and 127. [Cross refer F880] 2. Based on observation, interview and record review it was determined, for 3 of 25 sample residents, that the facility did not ensure residents were free from abuse. This included but was not limited to involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. In addition, the facility must not use verbal, mental, sexual, or physical abuse corporal punishment or involuntary seclusion. Specifically, a resident with intellectual disabilities was verbally abused, physically abused, psychologically abused and involuntarily secluded by residents, a family member and staff members. In addition, staff members were unable to identify and report abuse. The resident was not provided interventions to prevent further abuse by a family member, verbal abuse from other residents, and was involuntarily secluded when behaviors escalated. The facility's failure to protect resident 6 from abuse was determined to constitute Immediate Jeopardy. Resident identifiers: 4, 6, and 14. [Cross refer F600]

Based on interview and record review, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of correction to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance with F880, which was cited at an Immediate Jeopardy, scope and severity of L. In addition, F600, abuse was cited at an Immediate Jeopard, scope and severity of H. Resident identifiers: 6, 125, and 127. Findings include: 1. Based on interview and record review it was determined that the facility failed to establish an infection prevention and control program designed to prevent the development and transmission of COVID-19. Specifically, the facility failed to ensure that a symptomatic staff members, who subsequently tested positive for COVID-19, were screened accurately and notification and evaluation was completed per the facility protocol, that negative antigen tests were completed, and that symptomatic staff members were provided appropriate Personal Protective Equipment (PPE). The failure resulted in 6 residents exposure and 2 testing positive with a facility outbreak. In addition, staff and visiting essential personnel who have continued to test negative for COVID-19 were also at an elevated risk. Additionally, staff did not wear required PPE for a newly admitted unvaccinated resident. In addition, a nurse was observed to handle residents medications with bare hands. Resident identifiers: 125 and 127. 2. Based on observation, interview and record review it was determined, for 1 of 25 sample residents, that the facility did not ensure residents were free from abuse. This included but was not limited to involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. In addition, the facility must not use verbal, mental, sexual, or physical abuse corporal punishment or involuntary seclusion. Specifically, a resident with intellectual disabilities was verbally abused, physically abused, psychologically abused and involuntarily secluded by residents, a family member and staff members. In addition, staff members were unable to identify and report abuse. The resident was not provided interventions to prevent further abuse by a family member, verbal abuse from other residents, and was involuntarily secluded when behaviors escalated. The facility's failure to protect resident 6 from abuse was determined to constitute Immediate Jeopardy. Resident identifier: 6. On 3/2/22 at 5:05 PM, an interview was conducted with the Administrator. The Administrator stated that hand washing and linens were addressed in a QA meeting. The Administrator stated a re-inservice was conducted for staff regarding on testing stuff and glucometer cleaning. The Administrator stated that abuse was not discussed in QA because management performed room rounds daily for the first part of February. The Administrator stated that during room rounds, residents were asked about abuse and being treated roughly. The Administrator stated there were no reports of abuse so it was not addressed in QA.

Based on observation, interview and record review it was determined the facility did not follow policy and procedures for residents with COVID-19 vaccination exemptions. Specifically, staff with COVID-19 vaccination exemptions were not wearing personal protective equipment according to the facility's policy and procedures. Findings include: On 2/23/22, the Administrator provided a list of staff who were fully vaccinated for COVID-19 or had an exemption. Registered Nurse (RN) 2 was listed to have a medical exemption. Certified Nursing Assistant (CNA) 3 had a religious exemption. On 2/23/22, an observation was made of RN 2. RN 2 was observed to be wearing a surgical mask with eye protection. On 2/24/22 at 2:45 PM, an observation was made of RN 2. RN 2 was observed to be wearing a surgical mask with eye protection. On 2/24/22 at 5:45 AM, an observation was made of CNA 3. CNA 3 was observed to be wearing a surgical mask with eye protection. The facility COVID-19 Vaccine Policies and Procedures with no date revealed, .The purpose of this policy and procedure is to outline the community approaches to encourage both care partners and residents to receive a COVID-19 vaccine. The policy further revealed Within 30 days from January 14, 2022, 100% of staff will have received at least one dose of COVID-19 vaccine, or having a pending request for, or have been granted qualifying exemption. Reasonable Accommodations were All staff with exemptions or who are not fully vaccinated will wear a KN95 or a NIOSH-approved N95 or equivalent or higher-level respirator at all times, unless actively eating or drinking during working hours. On 2/24/22 at 4:59 PM, an interview was conducted with RN 2. RN 2 stated that because of her exemption she was told that she had to wear a surgical mask and goggles, and that it had to be worn at all times. RN 2 stated that she had not seen the facility policy and procedure for medical exemptions accommodations. RN 2 stated that she had to screen for signs and symptoms consistent with COVID-19 every day when she started her shift. RN 2 stated that she had to test two times per week based on county transmission rate, and she was not aware if the frequency of testing changed because she had an exemption. On 2/24/22 at 5:12 PM, an interview was conducted with the Corporate Resource Nurse (CRN) 2. CRN 2 confirmed that the facility COVID-19 vaccine policy stated that staff with qualifying exemptions needed to wear a KN95 or N95 mask while inside the facility. CRN 2 stated she was the individual who wrote the policy and that she had educated the staff on the requirements.

Based on observation, interview and record review it was determined the facility did not store, prepare and distribute food in accordance with professional standards for food service safety. Specifically, the dish machine wash temperature was not meeting the manufacture requirements and there were soiled areas in the kitchen. Findings include: 1. On 2/22/22 at 9:09 AM, an initial kitchen tour of the kitchen was conducted. The following was observed: a. There was whipped topping with no open date in the walk in refrigerator. b. There was debris on the floor in the walk in freezer. c. The inside of the microwave was soiled. e. The shelf above the steam table was soiled under the shelf which was above the prepared foods. f. There was food splatter on the wall behind the oven, fryer, griddle and stove. 2. On 2/22/22 at 9:15 AM, an observation was made of the facility dish machine. The wash temperature was 110 degrees Fahrenheit and the rinse temperature was 200 degrees Fahrenheit. The dishes were observed to be removed from the dish machine and placed in the clean dish area. A poster next to the dish machine revealed the dish machine was a high temperature machine. The temperatures for the wash cycle was to be above 150 degrees Fahrenheit and the rinse temperature was to be above 180 degrees Fahrenheit. 3. On 2/22/22 at 9:30 AM, an observation was made of the sanitizer bucket. Dietary Staff (DS) 1 stated he had changed the sanitizer 15 minutes previous. The Dietary Manager (DM) was observed to obtain the temperature of the sanitizer solution which was 87 degrees Fahrenheit. The DM stated the water needed to be colder. DS 1 was observed to place a sanitizer strip into the sanitizer water. The strip did not change color which revealed there was not enough sanitizer. DS 1 stated the strip did not change color so it meant Neutral, nothing. DS 1 was not observed to change the sanitizer solution. 4. On 2/24/22 at 10:26 AM, a follow up observation was made of the dish machine. The following temperatures were obtained: [Note: All temperatures were in degrees Fahrenheit.] a. The wash cycle was 130 and the rinse cycle was 200. b. The wash cycle was 130 and the rinse cycle was 200. The DM was observed to remove the dishes from the dish machine and replace them with clean dishes. The DM stated she had not recorded dish machine temperatures since she started 3 weeks previous. The DM stated she had January 2022 temperatures. The DM provided the temperatures. The Dishwasher Temperature Chart revealed the following: a. On 1/3/22, there were no temperatures for breakfast, lunch, or dinner. b. On 1/4/22, there were no temperatures for breakfast and lunch. c. On 1/5/22, there were no temperatures for breakfast, lunch, and dinner. d. On 1/6/22 through 1/10/22, there were no temperatures for breakfast and lunch. e. On 1/11/22, there were no temperatures for breakfast, lunch, and dinner. f. On 1/12/22 through 1/14/22, there were no temperatures for breakfast and lunch. g. On 1/16/22, there were no temperatures for dinner. h. On 1/17/22 through 1/20/22 there were no temperatures for breakfast and lunch. i. On 1/24/22 through 1/25/22, there were no temperatures for breakfast and lunch. j. On 1/27/22, there were no temperatures for lunch and dinner. k. On 1/28/22, there were no temperatures for breakfast, lunch, and dinner. l. On 1/29/22 through 1/31/22, there were no temperatures for breakfast and lunch. The February Dishwasher Temperature Chart was provided by [NAME] 1. [NAME] 1 stated the temperatures were on the meal carts. The February chart revealed the following regarding the dish machine temperatures: a. On 2/1/22, there was no temperatures for lunch. b. On 2/2/22 through 2/4/22 there were no temperatures for breakfast and lunch. c. On 2/7/22 through 2/8/22, there were no temperatures for breakfast and lunch. d. On 2/9/22, there were no temperatures for lunch and dinner. e. On 2/10/22 through 2/15/22 there were no temperatures for breakfast and lunch. f. On 2/16/22, there was no temperatures for dinner. g. On 2/17/22, there were no temperatures for breakfast and lunch. h. On 2/18/22 and 2/19/22 there were no temperatures for lunch. i. On 2/22/22, there was no temperatures for breakfast. The DM stated if the dish machine was not at the temperature, she notified the Maintenance Director and the dish machine company. The DM stated the dish machine company was in the building the previous week and looked at all the equipment. 5. On 2/24/22 at 10:45 AM, [NAME] 1 stated that she did not change the sanitizer. [NAME] 1 stated that DS 1 changed the sanitizer. DS 1 stated he did not change the sanitizer solution. [NAME] 1 as observed to check the sanitizer solution. The sanitizer strip did not change color. [NAME] 1 stated that it was 0 and there was no sanitizer. [NAME] 1 was observed to change the sanitizer and used a brown rag. [NAME] 1 stated the had brown rags were clean. [NAME] 1 stated that it was 300 Part Per Million (PPM) of Quaternary ammonium (quats). 6. On 2/24/22 at 2:30 PM, an observation was made of the refrigerator in the cove. There was a chocolate shake with no date. 7. On 2/24/22 at 2:53 PM, a follow-up kitchen tour was conducted. The following was observed: a. The microwave was soiled on the inside b. There was food splatter behind the oven, fryer, stove, and griddle. c. The large mixer had food splatter on the back cover of the mixer. d. The shelf above tray line was soiled under the shelf. DS 3 stated that the mixer had not been used for about a month but it needed to be cleaned. DS 3 stated that the shelf above the tray line food and not been cleaned underneath. Cook 1 stated to clean behind the oven, fryer, stove and griddle every thing had to be moved out which was very hard to do. [NAME] 1 stated the wall was cleaned twice a year when the vents were closed. [NAME] 1 stated the the dish machine needed to have a wash temperature above 155 and rinse above 180 degrees Fahrenheit. The DM stated the Microwave was cleaned every couple of days because it got messy from the supper shakes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 17 sample residents, that the facility did not ensure that residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. Specifically, resident recertification visits were not completed timely by the facility Medical Doctor (MD) or the Hospice MD. Resident identifiers: 3 and 14. Findings include: 1. Resident 3 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, hypertensive heart disease, heart failure, aphasia, and diabetes mellitus type 2. Resident 3's medical record was reviewed on 1/23/20. On 12/23/19, a Face to Face for Hospice visit was completed by the Hospice MD. There were 83 days between the visit and resident 3's admission to the facility on [DATE]. [Note: The MD should have seen resident 3 within 30 days but no later than 10 days after the date of the required visit.] 2. Resident 14 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type 2, non-pressure chronic ulcer of right lower leg, venous insufficiency, stage 4 chronic kidney disease, dementia with behavioral disturbance, and hypertensive heart disease. Resident 14's medical record was reviewed on 1/27/20. On 10/28/19, a Physician Progress Note was completed by the facility MD. On 1/13/20, a Subjective Objective Assessment and Plan Note was completed by the facility MD. There were 77 days between the last visit that was completed on 10/28/19. [Note: The MD should have seen resident 14 within 60 days but no later than 10 days after the date of the required visit.] On 1/27/20 at 10:00 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 3 was seen by the Hospice MD in August and December of 2019. The DON stated that the Hospice MD was only required to see Hospice residents every 3 months for the Hospice certification periods. The DON stated that she had contacted the Hospice company and the Hospice MD would not come to visit resident 3 until the visit was required. The DON stated that she would have the facility MD visit resident 3. The DON stated that the facility MD was in the building on Mondays, Wednesdays, and Fridays. The DON stated that if a resident choose to pick their own physician the facility would arrange for the resident to be seen in the physician's office. The DON stated that resident 14 was seen by the facility MD. The DON stated that she had a spread sheet to track when a resident needed to be seen by the facility MD. The DON stated that she would make a list for the facility MD when he was in the building of those residents that were requiring a visit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 17 sample residents, that the facility did not ensure that a resident who used psychotropic drugs was not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Specifically, a resident was receiving trazodone for sleep and behavior monitoring did not indicate that the resident required the medication. Resident identifier: 190. Findings include: Resident 190 was admitted to the facility on [DATE] with diagnoses which included dementia without behavioral disturbance, major depressive disorder, insomnia, stage 3 chronic kidney disease, chronic venous hypertension with ulcer of lower extremity, severe protein-calorie malnutrition, and atherosclerosis of aorta. Resident 190's medical record was reviewed on 1/22/20. A physician's order dated 12/29/19, documented quetiapine fumarate (Seroquel) 25 milligrams (mg) every 24 hours as needed for sleep. On 1/4/20 at 11:55 AM, a Skilled Progress Note documented [Resident 190] has been sleeping most of the day. Her speech is clear, she is able to understand simple direct questions & staff anticipates her needs. She went to the dining room for dinner. On 1/9/20 at 9:49 AM, a Nursing Progress Note documented MD (Medical Doctor) reviewed med (medication) list and new orders made to DC (discontinue) Seroquel and schedule Trazodone 50mg QHS (every bedtime). A physician's order dated 1/9/20, documented trazodone 50 mg at bedtime for insomnia. Order discontinued on 1/14/20. On 1/12/20 at 11:07 AM, a Skilled Progress Note documented [Resident 190] is awake but drowsy this morning. She is resisting cares and medications. She did take her medications for ER (sic) family yesterday, we will try that again today. On 1/13/20 at 1:29 PM, a Skilled Progress Note documented Resident is sleeping. Refused all meds. Pleasant when awake. A physician's order dated 1/15/20, documented trazodone 50 mg at bedtime for insomnia. A review of the Medication Administration Record (MAR) for January 2020 documented that resident 190 had refused the trazodone 3 times out of 7 opportunities for administration. A facility Physician Visit Form dated 1/16/20, documented Increased Confusion. Poor Appetite. Sleeps a lot. On 1/17/20 at 11:38 AM, a Skilled Progress Note documented [Resident 190] is drowsy this morning. She has slept through breakfast and refused her medications. We will try again at lunch. She is un able to use the call light. We anticipate her needs and check on her frequently. Her family is interested in palliative cares, we will assist them with this. A review of the Behavior Documentation Report for January 2020 documented the following entries: a. Anti-Psychotic Monitoring for behaviors of restlessness from 1/1/20 through 1/14/20, documented 2 episodes. b. Anti-Depressant Monitoring for behaviors of depressed comments and insomnia from 1/15/20 through 1/22/20, documented 0 episodes. c. Anti-Anxiety Monitoring for behaviors of anxious comments from 1/15/20 through 1/22/20, documented 4 episodes. On 1/27/20 at 9:22 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 190 would not take pills and would refuse to eat. LPN 1 stated that resident 190 had advanced dementia and would refuse cares from staff. LPN 1 stated that resident 190 would refuse cares provided by the Certified Nursing Assistants. LPN 1 stated that resident 190 did not have behaviors. On 1/27/20 at 12:47 PM, an interview was conducted with LPN 2. LPN 2 stated that resident 190 did not have any troubles with insomnia. LPN 2 stated that if a resident had any thing scheduled for sleep the hours of sleep would be tracked on the resident Treatment Administration Record (TAR). LPN 2 further stated that resident daytime sleep should also be tracked. On 1/27/20 at 1:37 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that if a resident was taking trazodone the staff should be monitoring the residents depression and sleep. The DON stated that if a resident had a complaint of insomnia then hours of restfulness would be monitored. The DON stated that the behavior tracking was on the resident TAR and was recently moved to a new behavior tab attached to the resident MAR and TAR. The DON stated that resident 190's second psychotropic meeting since admission was going to be held this week. The DON stated that resident 190's Ativan was initiated because of combativeness with cares. The DON stated that resident 190 had declined since admission and was not receiving skilled care at this time. The DON stated that prior to a psychotropic medication being ordered the staff would monitor resident behaviors and check with the family. The DON stated that resident 190 was discharged from the hospital with Seroquel for sleep and the staff switched resident 190 to trazodone pretty quickly. The DON stated that she was not sure if resident 190 required the trazodone with her recent decline.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 3 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, hypertensive heart disease, heart failure, aphasia, and diabetes mellitus type 2. Resident 3's medical record was reviewed on 1/23/20. A review of the Minimum Data Set (MDS) Resident Matrix upon entrance to the facility documented that resident 3 was receiving Hospice services. A Telephone/Verbal Orders from the Hospice company dated 9/27/19, documented Admit for Long-Term Care Stay at: [Facility name] To begin on: 10/01/19. An admission MDS assessment with a target date of 10/8/19, documented that resident 3 was not receiving Hospice services While NOT a Resident and While a Resident. The payer for resident 3 was documented as Hospice on the MDS assessment. A Quarterly MDS assessment with a target date of 1/8/20, documented that resident 3 was not receiving Hospice services While NOT a Resident and While a Resident. The payer for resident 3 was documented as Hospice on the MDS assessment. On 1/27/20 at 10:28 AM, an interview was conducted with the MDS coordinator. The MDS coordinator stated that she had marked that resident 3 was receiving Hospice services on the A section of the MDS assessment. The MDS coordinator stated that she was not aware that Hospice services needed to be marked on the O section of the MDS assessment. Based on interview and record review, the facility did not ensure that the Minimum Data Set Assessment was accurate for 3 of 17 sample residents. Resident identifiers: 2, 3, and 41. Findings include: 1. Resident 41 was admitted to the facility on [DATE] with diagnoses that included cellulitis and sepsis. Resident 41's medical record was reviewed on 1/21/20. Nursing progress notes indicated that the resident discharged home on [DATE]. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident discharged to the hospital. On 1/22/20 at 2:00 PM, an interview was conducted with the facility MDS Coordinator. The MDS Coordinator confirmed that the resident did discharge home, and that the MDS dated [DATE] was incorrect. 2. Resident 2 was admitted on [DATE] with diagnoses that included rhabdomyolysis, bilateral primary osteoarthritis, respiratory failure, and diabetes mellitus. Resident 2 ' s medical record was reviewed on 1/21/20. Nursing progress notes indicated that resident was discharged home on 8/29/19. Review of the MDS Assessments for resident 2 indicated a discharge MDS had not been completed. On 1/22/20 at 2:00 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator confirmed that a discharge MDS had not been completed for resident, and that she would do it immediately.

Based on interview and record review it was determined that the facility did not employ a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of food and nutrition services. Specifically, the facility did not a employee a full time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the director of food and nutrition services. Findings include: On 1/21/20 at 9:28 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that she was recently rehired as the DM. The DM stated that the Registered Dietitian was not full time. On 1/27/20 at 2:30 PM, an interview was conducted with the Administrator. The Administrator stated that the DM did not have a certification. The Administrator stated that the DM's original hire date was 2012. The Administrator stated that the DM left June of 2018 and was rehired September 2019.

Based on observation and interview it was determined that the facility did not store, prepare and distribute food in accordance with professional standards for food service safety. Specifically, the sanitizer solution was not at the appropriate amount to sanitize and there were soiled areas in the kitchen. Findings include: 1. On 1/21/20 at 9:28 AM, an initial tour of the kitchen was conducted. The following observations were made: a. There was a sanitizer bucket in the kitchen sink. The Dietary Manager (DM) was observed to test the sanitizer solution. The testing strip did not change color. The DM stated that [NAME] 1 had prepared the sanitizer and she needed to ask her if it was soap or sanitizer. b. There was a plate with meat, potatoes with cheese that was covered with plastic wrap with no date or label. c. The door to the walk in refrigerator was soiled. d. There was a plastic bin with labels and bags in it that was soiled on the outside. e. The wall behind the food preparation area was soiled. f. There were crumbs and debris on the shelf below the preparation table. g. There was dust on the ceiling vent above the food preparation area. h. The fryer was observed to have food a debris in the oil. An interview was conducted with [NAME] 1. [NAME] 1 stated that the fryer had not been used that day. i. The wall behind the griddle, grill and stove was soiled. j. The refrigerator under the grill was soiled on the outside. k. The shelf above the steam table was soiled. l. There was food splatter on the side of the plate warmer. m. The front and side of the deli refrigerator was soiled. Inside the deli station were condiments and there were crumbs and debris behind the door to the top of the refrigerator. In the bottom of the deli station there was a refrigerator that had a brown substance in the bottom. 2. On 1/27/20 at 1:41 PM, a follow-up tour was conducted of the facility kitchen. The following observations were made: a. The DM was observed to test sanitizer solution in a bucket. The sanitizer strip did not change color. The DM asked cook 1 how she prepared the sanitizer. [NAME] 1 stated that she used both the dish soap and the sanitizer solution. [NAME] 1 stated that she always mixed the sanitizer solution and the dish soap. The DM stated that the sanitizer solution was not effective when mixed with dish soap. b. The cloths used for the sanitizer were white with brown stains on them. c. The front and side of the deli refrigerator was soiled. Inside the deli station were condiments and there were crumbs and debris behind the door to the top of the refrigerator. d. The wall behind the food preparation area was soiled. e. There were crumbs and debris on the shelf below the preparation table. f. There was dust on the ceiling vent above the food preparation area. g. The wall behind the griddle, grill and stove was soiled. h. There were Teflon pans with scrapes in the Teflon. An interview was immediately conducted with the DM. The DM stated that the facility had the Teflon pans for a while. The DM stated that the pans needed to be replaced. The DM stated that cleaning behind the griddle, grill and stove was hard because the staff's arms were not long enough. The DM stated that she was revising the cleaning list.

Based on record review and interview, the facility did not adequately conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents. Specifically, the assessment did not include an analysis of the data obtained. Findings include: On 1/23/20, the facility assessment (FA) was reviewed. A. Under the Resident population profile – Function, Mobility and Physical Disabilities section, the following was listed in the FA under Care Requirements: 1. Types of care required - CNA (Certified Nursing Assistant) work for residents needs. Therapists to provide needed therapy for the resident. 2. Services required - CNA work that provides for residents needs. Therapy in the correct areas of function. 3. Staff/Personnel required - CNA ' s, Therapists. 4. Staff Competencies required - CNA course work, and therapy course work. 5. Physical plant environment required - such as campus buildings and physical structures - Plant maintenance director. 6. Medical and non-medical equipment required (including vehicles) 4 vehicles, several oxygen concentrators, air mattresses, wheelchairs. B. Under the Resident population profile - Acuity - Diseases, Conditions and Treatments section, the following was listed in the FA under Care Requirements: 1. Types of care required - Nursing care. 2. Services required - Nursing services. 3. Staff/Personnel Required - Nurses as well as our medical director. 4. Staff Competencies required - Nurses have to going thru (sic) nursing school to gain their license. C. Under the Resident population profile - Cognitive Care Requirements section, the same information was listed as in the Section for Acuity – Diseases, Conditions and Treatments section. D. Under the Cultural Section, the FA did not list accommodations for worship, food and nutrition, daily routines or care requirements specific to different ethnic, cultural or religious factors that may effect residents. E. Under the Staffing, Training, Services and Personnel section, only raw data was entered into the FA, however, no specific analysis or description was provided regarding the data. F. Under the Physical Environment, Technology and Equipment section, only raw data was entered into the FA, however, no specific analysis or description was provided regarding the data. G. Under the All Hazards Risk Assessment section, no specific information was provided, or links to supporting documentation. On 1/27/20 at 1:00 PM, the facility Administrator was interviewed. The Administrator confirmed that this was the complete FA.