**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that the resident assessment accurately reflected the residents' status. Specifically, for 2 out of 38 sampled residents, the facility indicated on the resident assessment that the residents did not have a serious mental illness despite the residents' Preadmission Screening and Resident Review (PASRR) level II assessments that documented the residents had a serious mental illness. Resident identifiers: 45 and 68. Findings Included: 1. Resident 45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to, paranoid schizophrenia, generalized anxiety disorder, post-traumatic stress disorder, and major depressive disorder recurrent moderate. Resident 45's medical record was reviewed on 3/17/25 through 3/20/25. Resident 45's admission Minimum Data Set (MDS) assessment dated [DATE], was reviewed. The response to Question A1500 on the assessment, which stated, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? was marked as no. Resident 45's PASRR level II dated 4/22/24, was reviewed. The PASRR level II evaluator indicated that resident 45 was seriously mentally ill. 2. Resident 68 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to, anxiety disorder and schizoaffective disorder depressive type. Resident 68's medical record was reviewed on 3/17/25 through 3/20/25. Resident 68's admission MDS assessment dated [DATE], was reviewed. The response to Question A1500 on the assessment, which stated, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? was marked as no. Resident 68's PASRR level II dated 11/15/24, was reviewed. The PASRR level II evaluator indicated that Resident 68 was seriously mentally ill. On 3/18/25 at 3:36 PM, an interview was conducted with the MDS Coordinator. The MDS coordinator stated that a previous MDS coordinator had completed the assessments for the two residents and that she would need to review the assessments. The MDS coordinator stated that some examples of diagnoses that would indicate for her to mark that a resident had a serious mental illness on the resident's assessment included autism and epilepsy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure residents received the appropriate treatment and assistive devices to maintain vision and hearing abilities. Specifically, for 2 out of 38 sampled residents, a resident with impaired vision had a referral sent to the eye doctor in January and the resident had not see the eye doctor. In addition, a resident with vision and hearing concerns . Resident identifiers: 2 and 63. Findings included: 1. Resident 63 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, type 2 diabetes mellitus without complications. On 3/17/25 at 11:12 AM, an interview was conducted with resident 63. Resident 63 stated the facility told her that someone would be in for the glasses but she had not heard anything. Resident 63 stated that she hoped she did not miss them because she needed new glasses. Resident 63 stated that she told someone that she needed new glasses but could not remember who. Resident 63's medical record was reviewed on 3/18/25 through 3/20/25. On 1/28/25 at 9:21 AM, a Social Service Note documented Note Text: Referral sent to [name redacted] vision and dental. Resident declined hearing services at this time. On 2/3/25 at 8:53 AM, a Minimum Data Set (MDS) Note documented Note Text: Resident assessed today for functional abilities. Resident has impaired vision with glasses. Resident has been added to the eye doctor list per her request, and social services has been notified to provider [sic] her with new glasses. On 3/19/25 at 8:32 AM, an interview was conducted with the Resident Advocate (RA). The RA stated if a resident requested that they wanted to see vision she would present them with two options. The RA stated the resident could either see the in-house vision provider or they could make an appointment with an outside optometrist. The RA stated if the resident requested to see an outside provider Transportation would schedule the appointment. The RA stated she was unsure if resident 63 was seen for vision and would need to check with the in-house vision provider to see what the recommendation was and or if the resident was seen. On 3/19/25 at 9:50 AM, a follow up interview was conducted with the RA. The RA stated that she confirmed with the in-house vision provider that they received the referral for resident 63. The RA stated that the in-house vision provider had not updated their data census which indicated who was on dental, hearing, and vision. The RA stated that she would send the referral and the in-house vision provider would come into the building. The RA stated when the in-house vision provider came back to the facility the provider would see who wanted to be on services. The RA stated that the in-house vision provider came to the facility once a quarter. The RA confirmed that it was not appropriate for a resident to wait a quarter to be seen if they needed glasses. 2. Resident 2 was admitted to the facility on [DATE] with diagnoses which included, chronic obstructive pulmonary disease, heart failure, dysphagia, and cognitive communication deficit. On 3/17/25 at 10:37 AM, an interview was conducted with resident 2. Resident 2 stated she did not receive a vision assessment, new glasses, hearing aid evaluation, or dental care during her stay at the facility. Resident 2's medical record was reviewed. On 1/15/25 at 12:21 PM, a Minimum Data Set Note documented, Resident assessed today for functional abilities. Resident reports she has difficulty hearing with background noise and would like hearing aids. Resident reports she has lost her glasses and would like new ones to be able to read. Social services notifiedof [sic] resident's request for hearing aids and glasses. Resident is able to speak clearly and understand others. Social services notified of request. On 3/20/25 at 8:53 AM, an interview was conducted with the RA. The RA stated that a different social worker handled referrals when resident 2 was admitted . The RA stated she was unaware of the request and had not submitted a referral for services. The RA stated that dental services visit monthly, based on resident needs, and optometry and hearing services visit quarterly. The RA stated she would look to see if resident 2 had the referrals sent in. On 3/20/25 at 9:41 AM, a follow-up interview was conducted with the RA. The RA stated resident 2 had not yet been referred. The RA stated she typically submitted referrals immediately once informed but noted the previous social worker was responsible to do this at the time. The RA stated she would now follow through to ensure resident 2 was referred for services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 38 sampled residents, a resident that was a high fall risk did not have interventions implemented to prevent future falls. Resident identifier: 81. Findings included: Resident 81 was admitted to the facility on [DATE] with diagnoses which included, dementia, rheumatism, chronic pain syndrome, and essential hypertension. Resident 81's medical record was reviewed on 3/17/25 through 3/20/25. An admission Morse fall risk assessment was performed on 12/16/24. Resident 81's Morse score was 90. A score of 45 and higher indicated a high-risk for falling. A review of resident 81's care plan interventions for falls revealed: a. Answer call lights promptly. Date initiated: 2/15/25. b. Clean up spills immediately. Date initiated: 2/15/25. c. Educate resident to use wheelchair. Date initiated: 3/12/25. d. Encourage resident to stay in common area while during awake hours. Date initiated: 3/5/25. e. Ensure resident was in the center of bed during rounds. Date initiated: 3/15/25. f. Ensure resident was not seated too close to edge of bed prior to transfers. Date initiated: 3/17/25. g. Visible sign to the back of the door to remind resident to use his call light or call for assistance. Date initiated: 2/15/25 and revised on: 2/17/25. On 3/17/25 at 10:05 AM, an observation was made of resident 81. Resident 81 was observed ambulating in his room without a walker. His pant legs were under his shoes, and he repeatedly tried to pull up his pants while walking. No staff were observed in the hallway at the time. Resident 81 had purplish-yellow discolorations under both eyes. There was no signage indicating that the resident should use his call light for assistance. On 3/18/25 at 7:50 AM, an observation was made of resident 81 in the dining area of the unit. Resident 81 was observed to stand up out of his wheelchair and ambulate to a dining room chair without assistance. There were no staff present in the dining room. On 3/18/25 at 1:08 PM, an observation was made of resident 81 ambulating in his room without a walker. Resident 81 was observed to be wearing pants with the pant legs under his shoes. No staff were observed to be in the hallway. There was no signage indicating that the resident should use his call light for assistance. A review of the facility's incident reports revealed the following: a. On 2/15/25, an incident report documented, . Patient was in room with CNA [Certified Nursing Assistant]. CNA reports trying to organize room and prepare resident for cares. Patient's son was outside of room and prompted to keep door shut for cares. CNA reports resident was in room and wheeled over to door and tried to open the door. Resident reached to open the door and fell out of wheelchair. Patient suffered swelling and abrasion to left eyebrow and orbital area. Patient has abrasion to nose and medial part of forehead. Patient has abrasion to right tibia. Interventions put in place after the fall: Place sign reminding resident to use call light and ask for assistance. b. On 3/2/25, an incident report documented, . Resident in bedroom & [and] while standing next to his w/c [wheelchair] he reached to get the tissue box that was on the w/c seat & then lost his footing & fell down on his buttock first then on his left side and arm as went backwards to then being in laying position. No injuries noted & V/S [vital signs] stable & Neuro [neurological] check WNL [within normal limits] of baseline. Assisted by staff onto recliner chair in bedroom. States that Lt [left] lateral upper arm sore. Interventions put in place after the fall: Intervention was to keep resident in common areas while awake as able. c. On 3/12/25 an incident report documented, . Resident was found on the floor on his left side between the bed and his bedside table. He stated that he was going to turn down the temperature in his room, when he lost balance and he slipped. He complained of pain in his left forearm, it is red, but no other obvious injury. He hit his left ear, it is red and has a tear around the base of the outer ear next to the scalp. Nurse tried to clean it and apply bacitracin but he refused. VS within his normal range. Nurse was able to assist him up and back into his chair. He refused to come to the day, but the nurse then asked PT [physical therapy] to help and got him back into his chair so we can watch him better. He is not happy about staying in the dayroom. Interventions put in place after the fall: Educate the resident to use wheelchair instead of ambulating by himself. d. On 3/15/25 an incident report documented, . CNA was assisting resident getting ready for the day. Resident slid out of bed and landed on buttocks. Bed was in the lowest position possible. Patient has a small abrasion to right lower extremity by knee and hip. First aide [sic] was applied. Patient did not hit head or back. Patient rates pain 0/10 post fall. Patient's vitals were WNL. Interventions put in place after the fall: Ensure the resident was not sitting on the edge of the bed prior to transfers. On 3/19/25 at 8:55 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that resident 81 was a fall risk and needed to be checked on often. RN 2 stated that resident 81 needed to stay in the common area, but was independent and preferred to be in his room. RN 2 stated that resident 81 walked with a shuffling gait and required assistance when he was ambulating. RN 2 stated she often walked behind resident 81 when he used his walker to ensure that he did not fall down. On 3/19/25 at 9:46 AM, an interview was conducted with CNA 2. CNA 2 stated that staff were expected to remain in the hallway to monitor resident 81 and watch for his call light. CNA 2 stated resident 81 needed checks every 5 to 10 minutes due to his high fall risk. CNA 2 stated resident 81 was unsteady and did not use his walker and had fallen multiple times. CNA 2 stated staff tried to keep resident 81 in the common area for closer supervision, but he often returned to his room on his own. On 3/20/25 at 8:13 AM, an interview was conducted with RN 3. RN 3 stated that resident 81 walked with a shuffle or like his feet overlapped. RN 3 stated that resident 81 was supposed to use a walker when walking, but liked to walk around his room without it. RN 3 stated that resident 81 should be in the common area during the day. On 3/20/25 at 11:21 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 81 had fallen since arriving at the facility. The DON stated he was unsteady and required a walker. The DON stated a sign in his room reminded him to use the call light for assistance. The DON stated staff encouraged resident 81 to stay in the common area during the day. The DON stated there were two CNAs on the unit but planned to increase to three due to a rise in resident falls. On 3/20/25 at 11:27 AM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated that she had educated the CNA's on the need to monitor residents in their rooms and round frequently. ADON 1 stated that the facility had added a shift for an extra CNA for the day due to increased falls from resident 81. It should be noted that the nursing administration staff did not know that resident 81 did not have a sign hanging in his room to use his call light.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that the resident's drug regimen was free of unnecessary drugs without adequate monitoring. Specifically, for 1 out of 38 sampled residents, nursing staff administered blood pressure lowering medications to the resident when the resident's blood pressure was outside of the parameters specified by a physician's order. Resident identifier: 40. Findings Included: Resident 40 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but not limited to, essential primary hypertension, type 2 diabetes mellitus with hyperglycemia, mixed hyperlipidemia, and severe morbid obesity due to excess calories. Resident 40's medical record was reviewed on 3/17/25 through 3/20/25. A physician's order with a start date of 11/26/24, stated, HydroCHLOROthiazide Oral Tablet 25 MG [milligrams] (Hydrochlorothiazide) Give 100 mg by mouth one time a day for HTN [hypertension] Hold for SBP [systolic blood pressure] < [less than ]110 or HR [heart rate] < 60. A physician's order with a start date of 1/3/25, stated, Metoprolol Succinate Oral Capsule ER [extended release] 24 Hour Sprinkle 25 MG (Metoprolol Succinate) Give 50 mg by mouth two times a day for HTN Hold for SBP <110 or HR <60. The Medication Administration Record was reviewed for March 2025. a. On 3/1/25 at 8:00 PM, the SBP was measured as 90. Resident 40 received the 50 mg dose of metoprolol succinate. b. On 3/16/25 at 8:00 PM, the SBP was measured as 101. Resident 40 received the 50 mg dose of metoprolol succinate c. On 3/16/25, the SBP was measured as 101. Resident 40 received the 100 mg dose of hydrochlorothiazide. On 3/20/25 at 8:51 AM, an interview was conducted with Registered Nurse (RN) 4 and RN 5. RN 4 and RN 5 stated that they would not administer a blood pressure lowering medication if a resident's blood pressure was below the number specified in a physician's order. RN 4 and RN 5 stated that if a resident's blood pressure was outside the parameters specified by a physician's order, they would hold the medication and notify the physician. On 3/20/25 at 2:42 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that if a resident's blood pressure was outside of the parameters established by a physician's order for blood pressure lowering medications, then she would expect the nurses to hold the medication and notify the physician of the blood pressure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure the residents were free of any significant medication errors. Specifically, for 1 out of 38 sampled residents, a resident's physician order for oxycodone was transcribed to the wrong resident's Medication Administration Record (MAR) and that resident received five doses of the medication. Resident identifier: 60. Findings included: Resident 60 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, osteomyelitis of vertebra, cauda equina syndrome, stimulant abuse, and discitis. On 3/17/25 at 2:45 PM, an interview was conducted with resident 60. Resident 60 stated that she had not had her pain medications since 3/4/25, because her pain medications were not available. Resident 60's medical record was reviewed on 3/18/25 through 3/20/25. The March 2025 MAR was reviewed. The following documentation was related to pain. a. A physician's order dated 3/4/25 at 4:00 PM, documented oxyCODONE HCl [hydrochloride] Oral Tablet 5 MG [milligrams] (Oxycodone HCl) Give 1 tablet by mouth every 4 hours for aching pneumonia for 5 Days. Resident 60 received four doses prior to the physician's order being discontinued on 3/5/25 at 9:13 AM. b. A physician's order dated 3/5/25 at 1200 PM, documented oxyCODONE HCl Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth every 4 hours for aching pneumonia for 5 Days Crush Narcotics and verify they are swallowed. Resident 60 received one dose prior to the physician's order being discontinued on 3/5/25 at 12:42 PM. On 3/20/25 at 8:20 AM, an interview was conducted with Assistant Director of Nursing (ADON) 2. ADON 2 stated the Nurse Practitioner would email the facility the physician orders. ADON 2 stated the initial oxycodone physician order on 3/4/25, was the wrong order. ADON 2 stated she spoke with the Medical Director (MD) on 3/5/25, and the physician order was discontinued. ADON 2 stated the nurse on the night of 3/4/25, called her and was worried that resident 60 was not taking the oxycodone and might be diverting the medication. ADON 2 stated that was why a crush physician order was put in place on 3/5/25. ADON 2 stated she spoke to the MD on 3/5/25, regarding changing the physician order from every four hours to three times daily (TID). ADON 2 stated the TID order was never implemented because she realized the physician orders got mixed up with another resident's physician orders. ADON 2 stated resident 60 was not supposed to be on oxycodone. ADON 2 stated that she spoke to resident 60 about the mistake when it happened. ADON 2 stated when the physician orders were emailed to the facility, herself and the other ADON would split the physician orders and enter them into the resident's MAR but now only one of them would input the physician orders to prevent mistakes. ADON 2 stated when the physician orders were emailed on the day of the mistake there were three pages and page two and three got out of order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not provide or obtain outside resources for routine or emergency dental services to meet the needs of the resident. Specifically, for 1 out of 38 sampled residents, a resident was not provided dental services for missing teeth. Resident identifier: 2. Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses which included, chronic obstructive pulmonary disease, heart failure, dysphagia, and cognitive communication deficit. On 3/17/25 at 10:37 AM, an interview was conducted with resident 2. Resident 2 stated she had not received a vision assessment, new glasses, hearing aid evaluation, or dental care during her stay at the facility. On 1/15/25 at 12:21 PM, a Minimum Data Set Note documented, Resident assessed today for functional abilities. Resident reports she has difficulty hearing with background noise and would like hearing aids. Resident reports she has lost her glasses and would like new ones to be able to read. Social services notifiedof [sic] resident's request for hearing aids and glasses. On 3/20/25 at 8:53 AM, an interview was conducted with the Resident Advocate (RA). The RA stated that a different social worker handled referrals when resident 2 was admitted . The RA stated she was unaware of the request and had not submitted a referral for services. The RA stated that dental services visited monthly, based on resident needs, and optometry and hearing services visit quarterly. The RA stated she would look to see if resident 2 had the referrals sent in. On 3/20/25 at 9:41 AM a follow-up interview was conducted with the RA. The RA stated resident 2 had not yet been referred. The RA stated she typically submitted referrals immediately once informed but noted the previous social worker was responsible to do this at the time. The RA stated she would now follow through to ensure resident 2 was referred for services.

Based on observation and interview, the facility did not provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Specifically, surveyors observed two meals that were served late, multiple residents complained of late meals during the initial pool, and there were grievances filed by residents about late meals. Resident identifier: 2 and 44. Findings Included: The posted facility meal times posted outside of the main dining room were as follows: Breakfast: 7:30 to 8:30 AM Lunch: 11:30 AM to 12:30 PM Dinner: 4:30 to 5:30 PM The facility serves residents who eat in their rooms first and then serves residents who choose to eat in the dining room after. On 3/17/25, an observation was made of the breakfast meal service at the facility. The facility did not finish serving residents in the dining room until 8:52 AM. The last breakfast tray for the Colonial hall was not served until 8:48 AM. On 3/18/25, an observation was made of the dinner meal service at the facility. The facility did not begin plating and loading meal trays onto the delivery carts until 4:52 PM. The facility did not finish serving residents in the dining room until 5:53 PM. The last dinner dray for the Cambridge hall was not served until 5:40 PM. The last dinner tray for the Colonial hall was not served until 5:57 PM. On 3/13/25 at 8:25 AM, an interview was conducted with the Ombudsman. The Ombudsman stated there had been some continuing concerns at the facility including the quality of food and dining times. The Ombudsman stated that residents had complaints about the food quality, not enough food, and the food tasting bad. The Ombudsman stated that several residents have reported that the meals were served late, especially dinner. The Ombudsman stated that she had been told that dinner was not served to some residents until 7:00 PM. On 3/17/25 at 10:37 AM, an interview was conducted with resident 2. Resident 2 stated that the kitchen was understaffed and she had to wait until after 5:30 PM, to receive dinner. On 3/17/25 at 12:45 PM, an interview was conducted with resident 44. Resident 44 stated that she had no concerns about the food served at the facility other than the food timing. Resident 44 stated the facility was pressed to get the food out and there was not enough workers. On 9/30/24, a resident at the facility filed a Grievance/Complaint Report. The report stated, [Resident name redacted] expressed that he received a bagged lunch (sandwich and chips) for lunch on the weekend instead of a hot lunch. He was told it was due to kitchen being short handed. On 2/10/25, two residents at the facility filed a Grievance/Complaint Report. The report stated, Residents feel that dinner has been served late and the food was cold. On 2/18/25, a resident at the facility filed a Grievance/Complaint Report. The report stated, Dinner is coming out late impacting ability to attend family home evening. On 3/19/25 at 7:31 AM, an interview was conducted with the Administrator. The Administrator stated that the facility used to have three staff members working in the kitchen at night, but the facility census dropped and the extra staff had nothing to do. The Administrator stated that the facility was trying to staff the kitchen higher. The Administrator stated the facility should start plating meals 15 minutes prior to a meals starting time. On 3/19/25 at 9:35 AM, an interview was conducted with the Dietary Manager (DM). The DM stated when dietary staff at the facility were hired, they completed a three day training program with another dietary staff member. The DM stated that after the three day training was completed, the new dietary staff member completed a post training checklist. The DM explained the process the kitchen used to ensure meals that were served on time at the facility. The DM stated that the cook was responsible for following the spreadsheet on the tray table to ensure that meals were served timely. The DM stated that the facility recently lost two kitchen staff members, including one who had worked at the facility for over 20 years. The DM stated that staff in the kitchen had been stretched thin due to an increase in the facility census. The DM stated that after recently hiring additional evening kitchen staff, she felt that the facility had enough dietary staff. The DM stated that the facility has had difficulties with potential employees accepting job offers, but then not showing up on their start date. The DM stated that meals were served late because steps were missed in the training program for new kitchen staff. The DM stated that there was usually one cook and two dietary aides working in the kitchen in the evening. The DM stated that timeliness was the missing piece of the puzzle to ensuring that meals were served on time. On 3/20/25 at 7:29 AM, an additional interview was conducted with the Administrator. The Administrator stated that breakfast was served late on 3/17/25 because the cook scheduled to work the shift did not show up.

Based on observation and interview, the facility did not ensure that each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, surveyors sampled a test tray and found it to not be palatable, there were concerns about the palatability of the food served at the facility identified during the initial pool interviews, and there were grievances filed by residents about the food served at the facility. Resident identifiers: 2, 26, 40, 63, and 72. Findings Included: On 3/17/25 at 10:41 AM, an interview was conducted with resident 2. Resident 2 stated that most of the time the food served at the facility tasted bad. On 3/17/25 at 11:01 AM, an interview was conducted with resident 40. Resident 40 stated that sometimes the food was not so bad, but other times it was so bad he would rather not eat. Resident 40 stated that the food served at the facility was worse on the weekends. On 3/17/25 at 11:08 AM, an interview was conducted with resident 63. Resident 63 stated the food was normally good but every once in awhile it was on the yuck. On 3/17/25 at 1:20 PM, an interview was conducted with resident 26. Resident 26 stated the food served at the facility was not the best. Resident 26 stated on Christmas day she was served cold cheese pizza. Resident 26 stated that all of the soups served at the facility were watered down. On 3/18/25 at 8:38 AM, an interview was conducted with resident 72. Resident 72 stated that the potato soup served at the facility tasted like potato and water. On 11/4/24, a resident at the facility filed a Grievance/Complaint Report. The report stated, [Resident name redacted] expressed that colonial [name of unit at facility] often does not get full menu item [sic], english muffins are hard, kitchen freq. [frequently] out of coffee. On 2/10/25, two residents at the facility filed a Grievance/Complaint Report. The report stated, Residents feel that dinner has been served late and the food was cold. On 3/18/25 at 5:53 PM, surveyors sampled a test tray of the dinner served at the facility. The meal consisted of chicken tenders, onion rings, pickled beets, and a fruit cup. The onion rings were soggy. The beets were not pickled as described on the menu. The beets were very wet and beet juice had dripped onto the onion rings. On 3/19/25 at 9:35 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that food complaints were addressed in the facility food council and that she provided frequent training to the kitchen staff. The DM stated that kitchen staff should follow the instructions left on a spreadsheet to prepare meals. The DM stated that each resident had a tray card that listed their diet order, diet texture, and any other pertinent information.

**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 to prevent the development and transmission of communicable diseases. Specifically, for 1 out of 38 sampled residents, a resident's feeding tube was observed to be on the floor and not capped while not in use. Additionally, facility staff did not wear Personal Protective Equipment (PPE) while providing high contact care on Enhanced Barrier Precautions (EBP). Resident identifier: 238. Findings included: Resident 238 was admitted to the facility on [DATE] with diagnoses which included, encephalopathy, acute kidney failure, and adult failure to thrive. On 3/17/25 at 8:47 AM, an observation was made of resident 238's room. There was an EBP sign posted on the door. On 3/18/25 at 10:36 AM, an observation was made of Certified Nursing Assistant (CNA) 1 coming out of resident 238's room with a used brief in a disposable trash bag. On 3/18/25 at 10:57 AM, an observation was made of resident 238. Resident 238's tube feed was disconnected and the tubing was laying on the floor with no cap. On 3/18/25 at 5:54 PM, an observation was made of resident 238's feeding tube uncapped and hanging on an Intravenous (IV) pole. On 03/20/25 at 8:01 AM, an observation was made of resident 238's tube feed that was not running and the end of the tubing was not capped and was hanging from an IV pole. A physician's order with a start date of 3/16/25, documented that resident 238 was on EBP related to the feeding tube. On 3/18/25 at 11:04 AM, an interview was conducted with CNA 1. CNA 1 stated she had recently changed resident 238's brief before the resident went to physical therapy. CNA 1 stated she was unsure if resident 238 had EBP precautions, as she was new to the facility. CNA 1 stated the EBP sign on the door may have been for the previous resident in the room. On 3/18/25 at 11:14 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated night shift changed the tubing for tube feeds. RN 1 stated physical therapy requested that resident 238 be disconnected from her tube feed. RN 1 stated that she wore gloves when caring for the tube feed. RN 1 stated when the feeing tube was not in use she would leave the tubing with the feed because it was good for 24 hours. RN 1 stated she had not capped the feeding tube when it was disconnected. On 3/20/25 at 11:32 AM, an interview was conducted with the Director of Nursing (DON). The DON stated if a feeding tube needed to be unhooked for any reason the tube should be capped and hung up on an IV pole. The DON stated staff should be wearing PPE when providing care for feeding tubes or when changing the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 1 of 45 sampled residents, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice. Specifically, a resident was complaining that food was getting caught in a tooth that had been extracted. There was no monitoring documented after the resident had the tooth extraction. Resident identifier: 50. Findings include: Resident 50 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included hemiplegia and hemiparesis, type 2 diabetes mellitus, alcoholic cirrhosis of liver without ascites, chronic respiratory failure, dysphagia, repeated falls, pain in right shoulder, and anxiety. On 9/16/24 at 11:04 AM, an interview was conducted with resident 50. Resident 50 stated food was getting caught where her tooth was. Resident 50 stated she made sure to sweep her mouth out at night before bed. Resident 50 stated she had to brush her teeth a lot. Resident 50 stated she had not told staff that she was having trouble food being stuck in the side of her mouth. Resident 50's medical record was reviewed 9/9/24 through 9/16/24. A dental form revealed a tooth extracted was completed on 7/24/24 for the tooth #31. The form revealed patient tolerated well. A physician's order dated 7/24/24 with a discontinue date of 7/31/24 revealed Norco Oral tablet 5-325 mg (milligrams). Give 1 tablet by mouth every 4 hours as needed for pain due to tooth extraction for 5 days. Resident 50 was administered Norco 16 times during that period of time. Resident 50's nursing progress notes were reviewed. There were no notes located in resident 50's medical record regarding monitoring after a tooth extraction. On 9/16/24 at 12:25 PM, an interview was conducted with the Director of Nursing (DON). The DON stated if a resident had a tooth extracted the nurse should monitor if the resident was able to eat. The DON stated if the resident was not able to eat or had trouble chewing, then a diet change or alternative foods needed to be provided. The DON stated nursing staff needed to monitor for signs and symptoms of infection and pain control. The DON stated resident 50 usually had high pain scores so the pain scores were not higher after the tooth extraction. The DON stated she thought that the tooth extraction was care planned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 1 of 45 sampled residents, that the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents. Specifically, a resident that was assessed as requiring supervision while smoking was observed to be smoking unsupervised. Resident identifier: 50. Findings include: Resident 50 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included hemiplegia and hemiparesis, type 2 diabetes mellitus, chronic obstructive pulmonary disease, alcoholic cirrhosis of liver without ascites, chronic respiratory failure, dysphagia, repeated falls, pain in right shoulder, and anxiety. On 9/9/24 at 12:06 PM, an observation was made of resident 50 asking Registered Nurse (RN) 2 if she could go smoke and RN 2 stated not until 1:30 PM. At 12:22 PM, an observation was made of Certified Nursing Assistant (CNA) 2 reporting to Registered Nurse (RN) 2 that resident 50 got a cigarette from someone else and was smoking. RN 2 was observed to tell CNA 2 okay and continued passing medications. At 12:29 PM, CNA 4 asked RN 2 if resident 50 was outside smoking. RN 2 was observed to say resident 50 was 100% non-compliant. On 9/10/24 at 1:27 PM, an observation was made of resident 50. Resident 50 was observed in the main dining room. At 1:36 PM, an observation was made of resident 50 going to the smoking area. Resident 50 was observed to get a cigarette from resident 8. Resident 50 was observed to put the cigarette in her mouth and leaned to resident 8 and lit the cigarette from resident 8's lit cigarette. On 9/10/24 at 2:15 PM, an interview was conducted with resident 15. Resident 15 stated if a resident asked for a cigarette she was able to share one with the resident. On 9/10/24 at 2:15 PM, an interview was conducted with resident 66. Resident 66 stated he used to give cigarettes to other residents but did not anymore because he did not have enough money. On 9/10/24 at 2:20 PM, an interview was conducted with resident 8. Resident 8 stated he was able to keep his cigarettes and lighter. Resident 8 stated he should not share his cigarettes with anyone because it can cause fights from others not him paying back. Resident 8 stated he gave people cigarettes to others here and there. Resident 8 stated resident 50 was unable to smoke with out supervision. Resident 8 stated he should not give resident 50 cigarettes without staff there. Resident 8 stated resident 50 snuck out to smoke. Resident 8 stated resident 50 paid back any cigarettes she borrowed so he was okay with giving her cigarettes. Resident 8 stated he had not seen any residents smoke with oxygen on and if someone came out with oxygen other residents would tell them to not smoke and would get staff. A list provided upon entrance to the facility revealed resident 50 required full supervision when smoking and the form was updated September 2024. Resident 50's medical record was reviewed 9/9/24 through 9/16/24. A care plan dated 7/13/23 and revised on 9/13/23 revealed [Resident 50] uses tobacco [Cigarettes] I know to take off my oxygen before going to designated smoking area. I may choose to not smoke with specific individuals d/t personal conflict. The goal was The resident will not suffer injury from unsafe smoking practices through the review date. The interventions included Ensure O2 tank is not on and removed from wchr [wheelchair] when smoking; I may wait to smoke so I can be with the company that I choose to be with when smoking. I will notify staff if I have concerns; Instruct resident about the facility policy on smoking/vaping locations, times, and safety concerns; Notify charge nurse immediately if it is suspected resident has violated smoking policy; and Smoking: I am a supervised Smoker. I can smoke SUPERVISED which was revised on 8/14/24; and The resident should keep smoking paraphernalia secured in the nurse's cart. A Safety Smoking Evaluation dated 8/28/24 revealed resident had a diagnosis of neuropathy or other neurological impairment, history of unsafe smoking practices, non-compliance with smoking policy, and a condition or diagnosis that impairs ability to call for assistance if needed. In addition, resident demonstrated one or more of the following cognitive impairments: poor safety awareness, impaired short-term memory, impulsiveness. Pt [patient] will ask others for cigarettes. Pt sometimes will have the cherry/ash fall onto her lap while smoking. IDT [interdisciplinary team] has reviewed and has deemed that resident requires full supervision with smoking. Resident requires staff to hold onto smoking paraphernalia and requires assistance to and from the smoking area, and supervision while in the smoking area. Attendees: DON [Director of Nursing], ADDON [Assistant Director of Nursing], SSW [Social Service Worker], RA [Resident Advocate]. A Smoking Safety Evaluation dated 9/10/24 and locked on 9/11/24 revealed none of the above checked from the safety evaluation on 8/28/24. The additional documentation revealed Resia [sic] is able to access and exit smoking area with powerchair. She has been deemed safe to smoke independently. A social service progress note dated 9/13/24 at 1:58 PM revealed, The resident has been happy throughout the day, socializing with peers and engaging in activities. Staff reported that she vaped in her room; Admin & ADON notified. No other concerns noted. A nursing progress note dated 9/15/24 revealed Resident alert and oriented to self. Has been on [sic] calm mood since she woke up this morning. Goes out for smoke with constant supervision. On 9/16/24 at 10:55 AM, an interview was conducted with CNA 2. CNA 2 stated there was a CNA handbook that had information regarding residents who needed to be supervised when smoking and what times there was supervised smoking. CNA 2 stated resident 50 required supervision when smoking. CNA 2 stated resident 50 was supervised because she she might forget to ash her cigarette on her blanket or clothing. CNA 2 stated resident 50 had not had any burns on her skin. CNA 2 stated there was never a time that resident 50 could go out smoking unsupervised. CNA 2 stated resident 50 needed to tell staff when she wanted to go out and then staff were to remind her of the scheduled times. CNA 2 stated resident 50 would tell staff she was going to therapy and then would sneak out to smoke. CNA 2 stated last week resident 50 told staff she was going to therapy and when CNA 2 walked by the smoking area resident 50 was outside smoking. CNA 2 stated another resident gave her a cigarette. CNA 2 stated resident 50 had not had any burns on her skin or clothing. CNA 2 stated she reported it to RN 2. RN 2 stated to CNA 2 that she would speak to resident 50. On 9/16/24 at 10:59 AM, an interview was conducted with CNA 4. CNA 4 stated there was a clip board at the nurses station with the supervised smoking times. CNA 2 stated management went out with the supervised smokers. CNA 4 stated if a resident had to be supervised, then staff had to be outside with the resident. CNA 4 stated resident 50 was recently changed to unsupervised smoking about a week or 2 ago. CNA 4 stated resident 50 was on supervised smoking because she was a fall risk but since getting a new motorized wheelchair she was able to smoke unsupervised. CNA 4 stated nursing staff did an evaluation to make sure resident 50 was able to motorize herself to the smoking area. CNA 4 stated resident 50 was not able to keep her smoking material and they were stored in the nurses cart locked up. CNA 4 stated all residents had to get a lighter from the nurse and were unable to keep their lighters. On 09/16/24 at 11:11 AM, an interview was conducted with resident 50. Resident 50 stated she was able to go smoke by herself. Resident 50 stated that she recently was able to smoke independently. Resident 50 stated she got a new wheelchair that she was able to use to take herself out to smoke. Resident 50 stated she needed supervision because she did not have a wheelchair that she was able to use to get out to the smoking area. On 9/16/24 at 11:31 AM, an interview was conducted with RN 2. RN 2 stated that resident 50 used to be supervision for smoking but currently did not require supervision. RN 2 stated resident 50 required supervision before because she had a fall and staff were worried about resident 50 being outside with out staff. RN 2 stated resident 50 fell before she was admitted and that was why resident 50 had supervision when smoking. RN 2 stated resident 50 was not on supervised smoking for very long. RN 2 stated resident 50 had not had burn holes. RN 2 stated resident 50 was only supervised for about 2 to 3 weeks. On 9/16/24 at 9:59 AM, an interview was conducted with the Administrator (ADM). The ADM stated when a resident who smoked was admitted , an smoking safety assessment and IDT note was completed. The ADM stated if a resident required particle assistance, then staff needed to assist the resident to and from the smoking area. The ADM stated for residents that required supervision, then a staff member needed to be outside in the smoking area with the residents. The ADM stated staff should be watching residents the whole time. The ADM stated there were cameras outside, so she was able to monitor the smoking area from her computer. The ADM stated she was able to watch the cameras if she was sitting at her desk. The ADM stated there was a schedule for residents that required supervision and staff took residents outside to the smoking area to smoke. The ADM stated if staff were available between smoking break time, then staff could take residents out between the smoking breaks. On 9/16/24 at 11:20 AM, an interview was conducted with the ADM. The ADM stated resident 50 was re-assessed last week to determine if the resident was able to smoke independently. The ADM stated resident 50 was to be supervised because she was unable to transport herself to and from the smoking area. The ADM stated now that resident 50 had a power wheelchair she was able to take herself to and from the smoking area. The ADM stated she was not aware the previous smoking assessment was supervised because resident ashed in her lap. The ADM stated resident 50 was caught vaping in her room this weekend, so she would be going back to supervised smoking. On 9/16/24 at 11:57 AM, an interview was conducted with the ADM. The ADM stated resident 50 was ashing on herself so she was placed on supervised smoking. The ADM stated there was an adjustment to pain medications, so resident 50 was placed on supervised smoking. The ADM stated resident 50 came to her last week to re-evaluate her smoking because resident 50 wanted to smoke independently. The ADM stated the DON, ADON, and CNA coordinator monitored resident 50 at different times to determine if she was safe to smoke independently. The ADM stated the IDT met and after assessments were complete resident 50 was taken off of supervised smoking. The ADM stated that resident 50 had an electric wheelchair and was able to transport herself in and out from smoking. A form titled Smoking Monitor Duties provided upon entrance to the facility revealed a section titled Residents Requiring Supervision Smoking. The form revealed the following: The residents requiring assistance will have smoking materials secured in a locked container stored at the nurse's station. Monitor will bring to the designated smoking area. The smoking assistance form will be reviewed and validated necessary adaptive equipment is in use e.g. smoking apron, cigarette extender. Check the smoking assistance form to see if the resident needs assistance or any adaptive equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 of 45 sampled resident, the facility did not ensure that a resident who was fed by enteral means received the appropriate treatment. Specifically, a resident's tube feeding was not infusing at the prescribed infusion rate. Resident identifier: 51. Findings include: Resident 51 was admitted to the facility on [DATE] with diagnoses which included dysphagia following cerebral infarction, acute respiratory failure with hypoxia, gastrostomy malfunction, permanent atrial fibrillation, dependence on supplemental oxygen, hemiplegia and hemipareses affecting right dominant side, and primary hypertension. The following observations were made of the tube feeding for resident 51: a. On 9/9/24 at 11:45 AM, tube feeding of Jevity 1.2 was infusing at a rate of 90 ml (milliliter)/hr (hour) resident 51 was sitting in the dining room. b. On 9/10/24 at 11:00 AM, tube feeding of Jevity 1.2 was infusing at a rate of 90 ml/hr resident 51 was sitting in the common area by the nurse's station. c. On 9/11/24 at 10:30 AM, tube feeding Jevity 1.2 was infusing at a rate of 90 ml/hr resident 51 was sitting in the common area by the nurse's station. d. On 9/12/24 at 2:26 PM, tube feeding Jevity 1.2 was infusing at a rate of 90 ml/hr resident 51 was in bed in his room. e. On 9/16/24 at 1:10 PM, an observation was made of resident 51. Resident 51 was observed to be in the hallway by the rehab nurses station in a gerichair. Resident 51 was observed to have had Jevity 1.2 infused 1070 mls of formula. Resident 51 had Jevity 1.2 infusing at 90 mls/hr with 100 mls every 4 hours of water. Resident 51's medical record was reviewed 9/9/24 through 9/12/24. A quarterly Minimum Data Set (MDS) dated [DATE] revealed resident 51 had loss of liquids/solids from mouth when eating or drinking, holding food in mouth, cheeks or residual food in mouth after meals and coughing or choking during meals or when swallowing medications. Resident 51 received tubefeeding and mechanically altered diet while a resident at the facility. A care plan dated 2/1/24 and revised on 2/19/24 revealed [Resident 51] requires tube feeding PEG tube r/t [related to] dysphagia s/p [status post] CVA [cerebral vascular accident]. The goal was Will maintain adequate nutritional and hydration status aeb [as evidenced by] weight stable, no s/sx [signs and symptoms] of malnutrition or dehydration through review date. Interventions included Will remain free of side effects or complications r/t tube feeding through review date; HOB [head of bed] elevated 30-45 degrees during and thirty minutes after tube feed; RD [Registered Dietitian] to evaluate quarterly and PRN [as needed]. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed; and The resident is dependent with tube feeding and water flushes. See MD [medical doctor] orders for current feeding orders. A physician's order dated 8/21/24 which revealed Start Feeding Tube via Jtube [jejunostomy] tube @ [at] 2000 [8:00 PM]. Turn off at 1300 [1:00 PM]. Run Jevity 1.2 @ 90ml/hr, with a water flush @ 100 mL Q [every] 4 hrs [hours]. Provide 4 hours of gut rest. A physician's order dated 6/5/24 revealed regular diet, pureed texture, regular consistency. A nutrition dietary note dated 8/27/24 at 7:37 PM revealed, Resident BMI [body mass index] =24.3 gradually increasing. Weight 159.6 recommend trending weight maintenance. Po [oral] intake has increased the past 2 weeks to 50-100% 2-3 meals per day. Recommend decrease tubefeeding to Jevity 1.2 @90ml/hr x18 hour with 100ml water flush Q4 hours. Monitor po intake, weight and Tube feeding. A nutrition/dietary note dated 9/3/24 at 6:27 PM revealed, Resident eating 50-100% of pureed diet. Has been gaining weight with TF and po intake. Recommend change TF to Jevity 1.2 @ 90ml/hr with 100ml water flush Q 4 hours Start TF @ 2000. Turn off TF at 0600. This should provide 1080 kcal, 50g protein, 726ml water flush 600 water flush for 1326ml total water. Monitor intake, weight and TF. Adjust as needed. On 9/12/24 at 4:08 PM, a telephone interview was conducted with the Registered Dietician (RD). The RD stated she was aware of resident 51 as he was the only resident in the facility on a tube feeding. The RD stated there were weight meetings to review the residents but she did not attend those meetings. The RD stated she input her data into the medical record before the meeting so they could refer to it during the meeting. The RD stated the Certified Dietary Manager (CDM) was at the meetings and they would communicate by phone or text if needed. The RD stated she checked the resident's status every week and only went to the facility every other week. The RD stated she would only put new information into the skin and weight note in the medical record if there was a change. The RD stated if she recommended a change it would also be in a progress note and the CDM would relay the changed information to the nursing staff to implement. The RD stated resident 51's most current feeding tube recommendation was Jevity 1.2 to be started at 8:00 PM and turned off at 6:00 AM starting on 9/3/24. The RD stated they had cut it back and turned it off at 6:00 AM to facilitate his oral intake and decrease excessive weight gain. On 9/16/24 at 1:07 PM, an interview was conducted with the Director of Nursing (DON). The DON stated when the RD made a recommendation, the recommendations were emailed to the DON. The DON stated nurse managers inputted the orders into the medical record after talking with the physician. On 9/16/24 at 1:15 PM, an interview was conducted with Assistant Director of Nursing (ADON) 2. ADON 2 stated the RD sent nurse managers a form with dietary recommendations for residents weekly. ADON 2 stated those recommendations were taken to the physician to approve or not. ADON 2 stated the nurse managers verify the orders and inputted them into the electronic medical record. ADON 2 stated the RD recommended tubefeeding orders to be changed on 9/3/24 for resident 51. ADON 2 stated the orders were Jevity 1.2 90 mls/hr with 100 mls water every 4 hours and to start at 8:00 PM and turn off at 6:00 AM. ADON 2 stated the recommendations should have been put in as physician's orders. ADON 2 stated the Nurse Practitioner had signed for the orders to be implemented. ADON 2 stated the recommendations from the RD on 8/20/24 was for 19 hours from 8:00 PM to 1:00 PM at 90 mls/hr with 100 ml every 4 hours water flushes. ADON 2 stated the order on 8/20/24 the order from 8:00 PM until 1:00 PM was for 17 hours and not 18 hours. ADON 2 stated the physician's order should have been clarified and implemented. ADON 2 stated on 8/6/24 the RD wanted to continue current tube feeding of Jevity 1.2 at 90 mls/hr for 20 hr with 100 ml water flush every 4 hours. A review of the facility Enteral Nutrition policy which was revised August 2024 revealed the policy statement as, Adequate nutritional support through enteral nutrition is provided to residents as ordered. Under the section labeled Policy Interpretation and Implementation the policy documented the following: The interdisciplinruy team, including the dietitian, conducts a full nutritional assessment within current initial assessment timeframes to determine the clinical necessity of enteral feedings. The assessment includes: Evaluation of the resident's current clinical and nutritional status. The dietitian, with input from the provider and nurse: estimates calorie, protein, nutrient and fluid needs; determines whether the resident's current intake is adequate to meet his or her nutritional needs; recommends special food formulations; and calculates fluids to be provided (beyond free fluids in formula). Enteral nutrition is ordered by the provider based on the recommendations of the dietitian. If a feeding tube is ordered, the provider and interdisciplinary team document why enteral nutrition is medically necessary. The dietitian monitors residents who are receiving enteral nutrition, and makes appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings. Enteral feedings are scheduled to try to optimize resident independence whenever possible (e.g., at night or during hours that do not interfere with the resident's ability to participate in facility activities). The Nurse confirms that orders for enteral nutrition are complete. Complete orders include: The enteral nutrition product; delivery site (tip placement); the specific enteral access device (nasogastric, gastric, jejunostomy tube, etc.; administration method (continuous, bolus, intermittent); volume and rate of administration; the volume/rate goals and recommendations for advancement toward these; and instructions for flushing (solution, volume, frequency, timing and 24-hour volume). Residents receiving enteral nutrition are periodically reassessed for the continued appropriateness and necessity of the feeding tube. Results of these assessments are documented and any changes are made to the care plan. Input from the resident or legal representative is included in the assessment. The facility policy and procedure form Enteral Nutrition was reviewed and revealed the following: Policy Statement Adequate nutritional support through enteral nutrition is provided to residents as ordered. Policy Interpretation and Implementation 1. The inderdisciplinary team, including teh dietitian, conducts a full nutritional assessment within current initial assessment timeframes to determine the clinical necessity of enteral feedings. The assessment includes: a. Evaluation of the resident's current clinical and nutritional status; b. Relevant functional and psychosocial factors; and c. A review of interventions to maintain oral intake prior to the use of a feeding tube and the resident's response to them. 2. The recommendation to initiate teh use of enteral nutrition is based on the results of the comprehensive nutritional assessment, and is consistent with current standards of practice, the resident's advance directives, treatment goals and facility policies. 3. The dietitian, with input from the provider and nurse: a. Estimates calorie, protein, nutrient and fluid needs; b. Determines whether the resident's curre

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, for 1 of 45 sampled residents, the facility did not ensure that residents were free from significant medication errors. Specifically, an order for Furosemide 40 mg (milligrams) was not discontinued when the physician reduced the dose to 20 mg, resulting the resident receiving 60 mg on two separate days. Resident identifier: 39. Findings include: Resident 39 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, congestive heart failure (CHF), morbid obesity, pulmonary hypertension, asthma, and chronic kidney disease. On 9/9/24 at 2:05 PM, an interview was conducted with resident 39 who had been told by the nurse that her Furosemide dose was doubled and she was going to hold it until she spoke with the doctor. Resident 39 stated she had not been notified about the medication change in advance. Resident 39's medical record was reviewed between 9/9/24 and 9/16/24. Physician orders included: a. Furosemide Oral Tablet 40 mg; Give 40 mg by mouth one time a day for heart failure. Start date: 8/2/24, discontinue date: 9/9/24. b. Furosemide Oral Table 20 mg: Give 1 tablet by mouth one time a day for CHF. Start date: 9/6/24. The September 2024 MAR (Medication Administration Record) was reviewed. Per documentation, on 9/6/24, resident 39 received 40 mg and 20 mg of Furosemide. On 9/7/24, resident 39 refused both doses of Furosemide. On 9/8/24, resident 39 received 40 mg and 20 mg of Furosemide. On 9/9/24, resident 39 received 40 mg of Furosemide and refused the 20 mg of Furosemide. Progress notes revealed: a. 9/4/24 at 6:44 PM, Edema checks added following providers written order d/t [due to] pt [patient] being on diuretics. b. 9/5/24 at 5:40 PM, New orders to increase Spironolactone to 100 mg po [by mouth] d [sic] day. and to start lasix 20 mg po q [every] day for chf and to check bmp [basic metabolic panel] on Monday for chf and to monitor electrolytes. Needs a cardiology consult and that order given to scheduler. c. 9/7/24 at 10:37 AM, Administration note: Furosemide Tablet 20 mg Give 1 tablet by mouth one time a day for chf. ref [refused]. d. 9/7/24 at 10:38 AM, Administration note: Furosemide Tablet 40 mg Give 40 mg by mouth one time a day for Heart Failure. ref. e. 9/9/24 at 8:58 AM, Administration note: Furosemide Tablet 20 mg Give 1 tablet by mouth one time a day for chf. refused. f. 9/9/24 at 4:12 PM, Discontinue lasix 40 mg. Duplicate dosing. Continue to give 20 mg. On 9/16/24 at 10:43 AM, an interview was conducted with Registered Nurse (RN) 2 who stated resident 39's Furosemide dose was 40 mg for a while. RN 2 stated resident 39 was getting Spironolactone also. RN 2 stated she was concerned about resident 39's blood pressure. RN 2 resident 39's Spironolactone dose was bumped up on 9/5/24 from 50 mg to 100 mg. RN 2 stated resident 39 did not like the Furosemide. RN 2 stated the change to 20 mg of Furosemide was due to resident 39's kidney laboratory results. On 9/16/24 at 11:28 AM, an additional interview was conducted with RN 2 who stated she did not know if both doses of Furosemide were given during the weekend. RN 2 stated she did not know if the 40 mg was intended to be discontinued when the 20 mg order was given until she spoke with the provider. On 9/16/24 at 11:38 AM, an interview was conducted with the Director of Nursing (DON) who stated depending on what the physician ordered, the old order would discontinue when the new order was given. The DON stated the order to discontinue the 40 mg of Furosemide was not given until 9/9/24. The DON stated ideally the nurse should clarify if the old order should be discontinued when a new order is given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 of 45 sampled resident, that the facility did not ensure each resident received and the facility provided food prepared in a form designed to meet individual needs. Specifically, a resident was observed to be coughing after drinking liquids during two different meal times. Resident identifier: 46 Findings include: Resident 46 was admitted to the facility on [DATE] with diagnoses which included bilateral primary osteoarthritis of knee, chronic respiratory failure with hypoxia, adult failure to thrive, Alzheimer's disease, essential hypertension, cognitive communication deficit and hypertensive heart disease with heart failure. On 9/9/24 at 11:54 AM, an observation was made of resident 46 during lunch meal service. Resident 46 was observed to cough after drinking juice. At 12:11 PM, resident 46 was observed to finished glass of juice and continued coughing. At 12:17 PM, resident 46 was observed coughing and drinking juice. At 12:19 PM, an observation was made of resident 46 coughing while drinking juice. On 9/10/24 at 12:22 PM, an observation was made of resident 46 during lunch meal service. Resident 46 was given a glass of water, a glass of juice, and a cup of coffee. Resident 46 was observed to immediately begin coughing after she took a sip of her water and continued to cough throughout the meal service. A review of resident 46's care plan initiated on 1/26/23, shows that the resident is at risk for altered nutritional status/dehydration. Interventions include: a. Monitor/record/report to MD [medical doctor] PRN [as needed] s/sx [signs/symptoms] of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs [pounds] in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Date Initiated: 02/02/23 b. Provide and serve diet, supplements as ordered Date initiated: 1/26/23 c. Provide, serve diet as ordered. Monitor intake and record q [every] meal. Date initiated: 1/26/23 d. Resident is in hospice and weight loss is expected. Date initiated: 8/25/23 A review of resident 46's progress notes revealed the following: On 7/30/24 at 2:55 PM, a hospice order documented, CHANGE DIET TO MECHANICAL SOFT DIET On 8/1/24 at 9:13 AM, a hospice order documented, CHANGE DIET TO PUREED CRUSH PILLS On 8/1/24 at 12:11 PM, a nurses note documented, New order for puree regular diet, thin liquids per hospice. CNA's [certified nursing assistants] reporting resident is pocketing mechanical soft consistency regular diet. On 8/4/24 at 7:23 PM, a therapy note documented, Resident had trouble swallowing during meal times. Resident consistently coughed while eating breakfast. During lunch resident vomited, then continued to eat the remainder of her meal. Requesting resident be evaluated by speech therapist to change residents meals to mechanically soft diet. On 8/6/24 a doctors order documented, Regular diet, Pureed texture, Regular consistency. On 9/10/24 at 12:28 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that the resident sounded like she was aspirating when she ate. RN 1 stated she believed the coughing had to do with the resident eating and that the resident was on the soft puree diet. RN 1 stated that resident 46 had to eat and she was unsure what to do about the coughing. On 9/10/24 at 1:09 PM, an interview was conducted with CNA 3. CNA 3 stated that she had not noticed resident 46 coughing before today. CNA 3 stated she was unsure what the resident was coughing about. On 9/12/24 at 9:40 AM, a telephone interview was conducted with the Registered Dietitian (RD). The RD stated that residents were not able to get speech therapy evaluations of swallowing if they were on hospice. The RD stated that she would only get involved with the diet order if a speech therapist was involved and a resident was not on hospice. On 9/12/24 at 10:20 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that a swallow evaluation could be done for residents that were on hospice. The DON stated that a swallow evaluation could not be done on 9/12/24 for resident 46, but it would be done to see if she needed her liquids to be changed to thickened. The DON stated that resident 46 was currently on a pureed diet. On 9/13/24 a dysphagia evaluation was performed on resident 46. The dysphagia evaluation documented, Clinician performed a dysphagia evaluation via telehealth to assess patient's risk of aspiration and severity of dysphagia. Patient was sitting upright in the dining room and was accompanied by an OT [occupational therapist] in person. Patient presents with a moderately severe pharyngeal dysphagia when consuming liquids. Patient presents with a cough on thin, mildly thickened and moderately thickened lqiuids [sic] demonstrating clinical s/sx [signs and symptoms] of aspiration .Patient qualifies for skilled dysphagia therapy to analyze her PO [oral] intake to determine the safest level of liquid intake to reduce her risk of aspiration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, adult failure to thrive, need for assistance with personal cares, hypertensive heart, chronic kidney disease stage 3, diastolic congestive heart failure, pulmonary hypertension, chronic pain, major depressive disorder, and generalized anxiety disorder. On 9/11/24 at 10:21 AM, an observation was made of the oxygen concentrator in resident 6's room. The humidifier bottle on the oxygen concentrator was empty and labeled with the date of 8/28. The nasal cannula and bag that held the nasal cannula were both labeled with the date of 8/28. Resident 6 was not in the room to interview. The Certified Nursing Assistant Coordinator was observed to enter the room and change the oxygen tubing. A new date of 9/11 was written on the oxygen tubing and the humidifier bottle. Resident 6's medical record was reviewed 9/9/24 through 9/12/24. No Physician order for changing the oxygen tubing or equipment could be located in resident 6's medical record. No documentation could be located in the medical record of the oxygen tubing being changed and dated. A care plan focus of oxygen therapy r/t CHF [congestive heart failure], COPD . was initiated on 3/6/2020, with a goal for resident 6 to have no s/sx of poor oxygen absorption through the review date. No interventions for changing the oxygen tubing were noted. 3. Resident 51 was admitted to the facility on [DATE] with diagnoses which included dysphagia following cerebral infarction, acute respiratory failure with hypoxia, gastrostomy malfunction, permanent atrial fibrillation, dependence on supplemental oxygen, hemiplegia and hemipareses affecting right dominant side, and primary hypertension. On 9/11/24 at 10:31 AM, an observation was made of resident 51's oxygen tubing and humidifier. Both were labeled with the date of 8/28. The CNAC was observed to enter the room and change the oxygen tubing. A new date of 9/11 was written on the oxygen tubing and the humidifier bottle. Resident 51's medical record was reviewed 9/9/24 through 9/12/24. Physician order dated 5/16/24 documented, O2 per nc at 1-6 L [liter]/min [minute] PRN. Check O2 sat q [every] shift. Goal to maintain O2 sats > [greater than] 90% [percent]. one time a day every Thu [Thursday]. Change nasal cannula & O2 filters on concentrator Q week and PRN; Check humidifier weekly and change humidifier when consumed. THURSDAY The September 2024 Medication Administration Record (MAR) revealed the oxygen tubing had been changed on Thursday 9/12/24 by staff. The documentation of the oxygen tubing being changed that was observed on 9/11/24 was not found in the medical record. A care plan focus of [resident 51] has altered respiratory status/difficulty breathing DX [diagnoses] chronic respiratory failure w [with]/hypoxia. was initiated on 2/12/24 with a goal for resident 51 to have no complications r/t SOB (shortness of breath) through the review date. No interventions for changing the oxygen tubing were noted. 4. Resident 69 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, severe sepsis, pneumonia, thrombocytopenia, dependence on supplemental oxygen, hyperkalemia and shortness of breath. On 9/9/24 at 10:45 AM, an observation was made of the oxygen concentrator in resident 69's room. The nasal cannula, humidifier bottle and bag that held the nasal cannula were all labeled with the date of 8/28. The CNAC was observed to enter the room and change the oxygen tubing. A new date of 9/11 was written on the oxygen tubing, bag and the humidifier bottle. Resident 69's medical record was reviewed 9/9/24 through 9/12/24. No Physician order of Change oxygen tubing weekly had a revision date of 8/27/24. The order did not have a start date. No documentation could be located in the medical record of the oxygen tubing being changed and dated. A care plan focus of [Resident 69] has altered respiratory status and requires O2 rt COPD, Pneumonia, respiratory failure, SOB, tobacco use was initiated on 8/26/24 with a goal for resident 69 to have no complications related to SOB through the review date. No interventions for changing the oxygen tubing were noted. On 9/9/24 at 11:00 AM, an interview was conducted with the CNAC. The CNAC stated she was changing out the oxygen tubing, humidifiers and bags on all the residents in the facility who were on oxygen. The CNAC stated she was the only one who changed the oxygen supplies and that she did it weekly. The CNAC stated the oxygen tubing should be changed weekly to decrease the risk of the residents getting sick from dirty oxygen supplies. On 9/12/24 at 10:03 AM, a follow up interview was conducted with the CNAC. The CNAC stated she did change all of the oxygen supplies for the residents on Monday. The CNAC stated she did not chart it anywhere, she usually just keeps track of it. The CNAC stated the nurses keep track of the resident's oxygen levels but that did not reflect when she changed the oxygen supplies. The CNAC stated the CNA's at night could change it if she was not there. The CNAC stated there was no record for CNA's to reference to know if oxygen supples needed to be changed unless they just went around to each resident and checked the date on the oxygen supplies in the rooms. The CNAC stated the CNAs had a list of responsibilities they were supposed to look at each shift to make sure things were getting done. The CNAC stated they were aware this was an issue and were working on the process with the staff to ensure oxygen tubing was changed weekly. On 9/16/24 at 2:36 PM, an interview was conducted with the Administrator and DON. The DON stated oxygen supplies were changed out weekly. The DON stated the supplies included the nasal cannula, humidifier and tubing. The DON stated all the oxygen supplies should be dated and labeled. The DON stated there should be physician's orders for oxygen to know how much the resident needed. Based on observation, interview and record review, for 4 of 45 residents, the facility did not ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a resident did not have a physician order for the use of oxygen, and residents did not have properly labeled oxygen tubing. Resident identifiers: 6, 39, 51, and 69. Findings include: 1. Resident 39 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, morbid obesity, pulmonary hypertension, asthma, and chronic kidney disease. On 9/9/24 at 2:10 PM, an interview was conducted with resident 39 who stated she was supposed to be on oxygen 24 hours a day. Resident 39 stated that staff were not checking her oxygen levels. Resident 39's oxygen concentrator was observed to be running, while her oxygen tubing and cannula were hanging over her wheel chair. Resident 39's medical records were reviewed between 9/9/24 and 9/16/24. An admission MDS (Minimum Data Set) assessment dated [DATE] revealed that resident 39 had a BIMS (Brief Interview for Mental Status) score of 15 indicating the resident was cognitively intact. The MDS assessment also revealed that resident 39 was not using oxygen. A baseline care plan dated 7/31/24 included, Reasons for Nursing Services .Oxygen therapy, pain management, ADL [activities of daily living] assistance, skilled nursing assessment, skilled wound care, anxiety, and depression management. An admission review dated 7/31/24 revealed, .Admitting diagnosis: COPD, Heart failure; Reason for admission: Wound care, medication management, oxygen management. Lifestyle: current smoker, 20 years. A Care Conference report dated 8/1/24 revealed a care conference at 8:25 AM. The form stated resident 39 and the IDT (interdisciplinary team) were present at the meeting. Members who participated in development of resident 39's care plan were the attending physician, physician extenders, licensed nurse, certified nursing assistant (CNA), dietary manager, social services, activities director, and the administrator. Additional care areas noted were, She wears oxygen and needs some assistance with her ADL's. Resident 39's orders were reviewed. There were no orders for use of oxygen found. Resident 39's care plan revealed, [Resident 39] has altered respiratory status rt [related to] COPD, chronic respiratory failure, pulmonary HTN [hypertension], morbid obesity. The goal was, [resident 39] will have no s/sx [signs or symptoms] of poor oxygen absorption through the review date. Interventions included, Elevate the head of bed as tolerated for ease of breathing. Resident cannot tolerate lying flat due to SOB [shortness of breath]; Monitor for s/sx of respiratory distress and report to MD [medical doctor] PRN [as needed]: Increased respirations, decreased pulse oximetry, increased heart rate (tachycardia); Restlessness; Diaphoresis; Headaches; Lethargy; Confusion; Hemoptysis; cough; Pleuritic pain; Assessory muscle usage; skin color changes to blue/gray. On 9/11/24 at 9:22 AM, an observation was made of resident 39's oxygen concentrator. The concentrator was running and the cannula was noted to be on the floor next to the resident's bed. On 9/11/24 at 9:35 AM, an interview was conducted with CNA 5 who stated that resident 39 used her oxygen during the night and not during the day. CNA 5 stated the oxygen tubing was changed every Tuesday night. On 9/11/24 at 9:36 AM, an interview was conducted with Registered Nurse (RN) 3 who stated he thought resident 39 was on 2 liters of oxygen. RN 3 stated most residents were on 2 to 3 liters. RN 3 began to check resident 39's orders but was unable to find an order. RN 3 stated resident 39 had COPD and chronic respiratory failure with hypoxia. On 9/11/24 at 9:38 AM, an interview was conducted with the Director of Nursing (DON) who was also unable to find an oxygen order for resident 39. The DON stated it was necessary to have a physician order for oxygen use. On 9/11/24 at 10:17 AM, a physician order for oxygen revealed, Titrate oxygen as needed to maintain SPO2 [oxygen saturation] equal or greater than 90%. On 9/11/24, an additional intervention was added to resident 39's care plan stating, Oxygen Settings: Oxygen as ordered, wean as able, check 02 sats [saturations] as ordered. On 9/16/24 at 11:47 AM, a follow-up interview was conducted with the DON who stated resident 39 was originally admitted to the facility on hospice, but hospice was retracted because resident 39 was not appropriate for hospice. The DON stated that when a resident was admitted , the floor nurse was the first to do an assessment on the resident. The DON stated the assessment that went to the MDS coordinator who completed the comprehensive admission assessment. The DON stated resident 39 must not have been on oxygen when she was admitted and then she must have been put back on oxygen but there was no physician's order. On 9/16/24 at 11:57 AM, an observation was made of resident 39's oxygen concentrator which was set at 3 Liters.

Based on observation and interview, it was determined the facility did not ensure that all drugs and biologicals were stored and secured in locked compartments. Specifically, medication was left unattended in a medication cup on top of an unlocked medication cart within reach of other residents and a blue pill was observed to be on the floor during medication pass. Findings include: On 9/10/24 at 8:04 AM, an observation was made of the medication cart in the Cambridge Unit. It was observed that there were medications in a medication cup on top of the cart, the medication cart was not locked and left unattended by Registered Nurse (RN) 1. It was observed that several residents were passing by the medication cart on their way into the dining room. RN 1 was observed to be in the dining room and returned to the medication cart at 8:06 AM. On 9/11/24 at 7:17 AM, an observation was made of a blue pill on the floor near the nurses station and the south hall. It was observed that there were multiple residents in the area. On 9/11/24 at 7:30 AM, an observation was made of housekeeping picking the blue pill up off the floor and handing the pill to RN 4. RN 4 was observed to dispose of pill in the sharps container. On 9/11/24 at 9:42 AM, an interview was conducted with RN 1. RN 1 stated that when she passed medications to residents she tried not to leave the medications on top of the medication cart and if she did it was usually an emergency. RN 1 stated that she should not leave medications unattended and the medication cart should always be locked. On 9/16/24 at 10:38 AM, an interview was conducted with Assistant Director of Nursing (ADON) 2. ADON 2 stated that all medications should be stored inside of the medication cart and never left out unattended and the cart should be locked when not in use. ADON 2 stated that if a medication fell on the floor, she would verify what the medication was and what resident did not get their medication. ADON 2 stated that after she verified the medication she would waste the medication appropriately if it was on the floor. On 9/16/24 at 12:36 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that medications found on the floor should be identified and investigated to see where they came from. The DON stated that the medication should then be disposed of. The DON stated that medications should never be left on top of a medication cart unattended. The DON stated the medication cart should always be locked when a nurse left the cart.

Food council notes were obtained and revealed: a. On 5/29/24: Concerns- condiments were not sent with meals and too much fish was being served. b. On 6/27/24: Concerns- residents requested more snacks at night. c. On 7/24/24: Concerns- potatoes were too hard, carrots were not cooked, soups had no flavor, the corn dogs were not hot, no condiments were sent on the trays and sugar free juices were not being offered. Residents also added that they disliked Brussels sprouts and the enchilada casserole. d. On 8/28/24: Concerns- residents wanted more pancake and french toast days, and resident requested real eggs. Based on observation, interview, and record review, the facility did not provide food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, for 9 out of 45 sampled resident, residents complained of food quality and a test tray not attractive or palatable. Resident identifiers: 8, 15, 28, 31, 34, 39, 47, 55 and 66. Findings include: 1. On 9/9/24 at 9:29 AM, an interview was conducted with resident 15 who stated the food was terrible. Resident 15 stated there was too much rice served and what they pass off as meat went right through her. Resident 15 stated she continued to be served food she had put on her dislikes list. On 9/10/24 at 1:42 PM, an interview was conducted with resident 15. Resident 15 stated the food was not good. Resident 15 stated she was sick of rice and they put rice on everything. Resident 15 stated that there was rice on sandwiches. Resident 15 stated the last sandwich she was served had cheese, chicken, rice, tomato and bread with no sauce. Resident 15 stated she needed wheat bread and was only served white bread 2. On 9/9/24 at 10:06 AM, an interview was conducted with resident 28. Resident 28 stated the food had too many carbohydrates. Resident 28 stated the vegetables were under cooked or over cooked and not palatable. Resident 28 stated when vegetables were over cooked there were no vitamins in them. Resident 28 stated the portions at dinner were not big enough and if he asked for seconds, sometimes he was able to get them. Resident 28 stated the meal tray had salt and pepper packets but most of the time the milk or water spilled onto the packets. Resident 28 stated many times the food was left at his bedside because he was sleeping and staff did not wake him up. Resident 28 stated when he woke up the food was always cold. Resident 28 stated he tried to eat in the dining room because the food was not cold in the dining room. 3. On 9/9/24 at 10:23 AM, an interview was conducted with resident 55. Resident 55 stated the food was bad. Resident 55 stated that when he cut the eggs, powder would fall out of them. 4. On 9/9/24 at 2:03 PM, an interview was conducted with resident 39. Resident 39 stated the kitchen did not serve salads. Resident 39 stated the menu had been revamped to cut down on costs and the food quality had decreased. 5. On 9/9/24 at 2:44 PM, an interview was conducted with resident 34. Resident 34 stated since getting a new Dietary Manager, the food had gone down hill. Resident 34 stated she was not able to get coffee when she wanted it at night. Resident 34 stated she was served an English muffin and 1 sausage patty for breakfast and nothing else. 6. On 9/10/24 at 7:57 AM, an interview was conducted with resident 47. Resident 47 stated some days the food was good and some days the food was bad. Resident 47 stated the egg salad sandwiches were soggy with no flavor. 7. On 9/10/24 at 10:12 AM, an interview was conducted with resident 31 who stated the food was terrible and he was not getting enough to eat. Resident 31 stated he wished he could ask for something else to eat. 8. On 9/10/24 at 1:46 PM, an interview was conducted with resident 66. Resident 66 stated the food was not good. Resident 66 stated that he was served a Krabbycake and thought it was a chicken patty. Resident 66 stated he had to have Benadryl because he had a food allergy to shell fish. 9. On 9/10/24 at 1:46 PM, an interview was conducted with resident 8. Resident 8 stated the food was horrible. Resident 8 stated fries were not cooked and were still frozen in the middle. Resident 8 stated the facility did not have a fryer. Resident 8 stated the facility was buying cheap bread. Resident 8 stated he did not usually eat the food. Resident 8 stated that he ate a lot of oatmeal. Resident 8 stated that usually he took the lid off the meal and put the lid right back on because it was not appetizing. On 9/12/24 at 12:13 PM, an observation was made of the lunch trayline. There was pork, scalloped potatoes, California vegetable blend and cookie. The last meal was plated at 12:22 PM for the main dining room. A test tray was requested at 12:22 PM. The test tray was placed in the meal cart. The first tray was served at 12:26 PM and the last try was served at 12:31 PM. The test tray was observed to have shredded pork, scalloped potatoes, dull colored California blend veggies and a cookie in a plastic bag. The vegetables were warm, mushy and bland to the taste. The shredded pork was warm, had a dry consistency, chewy and bland to the taste. The ground pork for mechanical soft diet had a dark brown gravy on it. The pork was chewy and the gravy was thick. The scalloped potatoes had a glue and grain consistency. The California blend was dull in color and mushy with excess moisture. On 9/16/24 at 10:49 AM, an interview was conducted with the Certified Dietary Manager (CDM). The CDM stated food concerns were discussed during food council each month. The CDM stated she talked to residents individually between food council.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 9/9/24 at 12:03 PM, an observation was made of Business Office Manager (BOM) not performing hand hygiene after delivering a meal tray in the dining room to resident 62. The Director of Nursing (DON) delivered a meal tray in the dining room to resident 67 and no hand hygiene was observed. At 12:05 PM, the BOM was then observed to open a bag of potato chips for resident 35 and place her fingers inside the bag of potato chips without performing hand hygiene before or after. At 12:11 PM, the DON was observed to deliver a meal tray to resident 58 and did not perform hand hygiene before or after delivering the tray. CNA 3 was observed in the dining room at 12:21 PM to not perform hand hygiene before she began to feed resident 124. On 9/10/24 in the north rehab hall at 7:46 AM, it was observed that the Certified Dietary Manager (CDM) not perform hand hygiene before picking up a meal tray and delivering the tray to resident 68. No hand hygiene was performed by the CDM when she exited the room. The CDM then picked up another tray from the meal cart and delivered the tray to resident 33. No hand hygiene was observed afte the CDM exited the room. On 9/10/24 at 8:12 AM, an observation was made of CNA 3 assisting resident 9 in the dining room with eating and not performing hand hygiene prior. CNA 3 was observed to be resting her hands on the table in between feeding resident 9. CNA 3 was observed to pick a napkin up from the table and wipe resident 9's face. CNA 3 was observed to adjust resident 9's wheelchair after wiping resident 9's face and then began to feed resident 9 another bite of food. Based on observation, interview and record review it was determined, for 14 out of 45 sampled residents, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, hand hygiene was not performed between residents who were being assisted with eating or performed after delivering lunch trays between multiple resident rooms. In addition, after a staff member tested positive for COVID-19 and source control was not implemented. Resident identifiers: 3, 7, 9, 17, 22, 33, 35, 47, 51, 58, 62, 67, 68 and 124. Findings include: 1. Infection Control during dining: On 9/9/24 at 12:19 PM, a dining observation of lunch in the main dining room was started. At 12:29 PM, Certified Nursing Assistant (CNA) 2 was sitting on a rolling stool at a table with resident 22. CNA 2 was observed to stay seated on the stool and roll to another table to feed resident 51 a bite of food with a spoon, no hand hygiene was observed. CNA 2 was observed to roll to another table where resident 17 was sitting and helped feed him, no hand hygiene was observed. CNA 2 rolled to resident 3 at another table and fed her watermelon and opened a bag of chips onto her lunch plate, no hand hygiene was observed. CNA 2 rolled back to the table where resident 22 was sitting and proceeded to assist him in drinking some water and fed him a bite of hot dog, no hand hygiene was observed. CNA 2 rolled to the table with resident 51 who had a feeding pump connected to him that was beeping. CNA 2 was observed to push buttons on the feeding tube pump and the beeping stopped, no hand hygiene was observed. CNA 2 was then observed to feed resident 51 a bite of pureed hot dog and mashed potatoes and wiped his face with a napkin, no hand hygiene was observed. CNA 2 rolled over to an adjacent table where resident 17 was sitting and fed him three bites of mashed potatoes and assisted him with drinking water, no hand hygiene was observed. CNA 2 went back to the table that resident 51 was at and assisted him with opening and placing a straw in his cup, no hand hygiene was observed. At 12:47 PM, CNA 2 was observed to push buttons on resident 51's feeding tube pump, the beeping stopped, no hand hygiene was observed. CNA 2 was observed to touch her face, hair, ears, and face mask, no hand hygiene was observed. CNA 2 was then observed to feed resident 51 with a spoon, no hand hygiene was observed. On 9/9/24 at 12:59 PM, an interview was conducted with CNA 1. CNA 1 stated she assisted with dining and there were usually three staff to help residents eat. CNA 1 stated hand hygiene needed to be performed between each resident. On 9/9/24 at 1:07 PM, an interview was conducted with CNA 2. CNA 2 stated she usually had more help to assist residents in eating and that she would usually sit between two residents and assist two residents with eating at a time. CNA 2 stated she should have used hand sanitizer in between assisting residents but she did not have any hand sanitizer. On 9/16/24 at 1:51 PM, an interview was conducted with the CNA Coordinator (CNAC). The CNAC stated that staff should hand sanitize their hands after every meal tray was delivered and after every third tray that was delivered, staff should wash their hands. The CNAC stated staff should have used hand sanitizer between every resident when assisting residents with eating. On 9/16/24 at 2:29 PM, an interview was conducted with the Director of Nursing (DON). The DON stated when passing food trays in the hallways, one should have hand sanitized with every tray pass. The DON stated staff should have hand sanitized between each resident when assisting residents to eat in the dining room. 2. COVID-19 Infection Control: On 9/9/24 at 10:10 PM, an observation was made of the Cambridge unit. Licensed Practical Nurse (LPN) 1 was observed in the Cambridge dining room wearing a surgical mask. CNA 3 was observed in the hallway wearing a surgical mask. CNA 6 was observed in the hallway wearing a mask. At 10:16 AM, the DON was observed without a mask in the Cambridge hallway. LPN 1 was interviewed and stated she was wearing a mask because management told her to wear one. CNA 6 was interviewed and stated she was told to wear a mask by a the Certified Nursing Assistant Coordinator. CNA 6 stated she did not know why she was told to wear a mask. On 9/9/24 at 10:16 AM, an interview was conducted the DON. The DON stated staff on the Colonial hallway staff needed to wear masks because a CNA tested positive on 9/6/24. The DON stated the CNA worked on 9/5/24 on the Colonial hallway. The DON stated contact tracing was done to determine if residents had a high risk exposure. The DON stated resident 7 and resident 47 were considered a high risk exposure. The DON stated the CNA was able to determine those were the only 2 residents she spent more than 15 minutes and were considered close contact. The DON stated the CNA tested on [DATE] and then was planning to test on 9/10/24. The DON stated if the test was negative on 9/10/24 then the CNA could return to work on day 7. The DON stated resident 7 and resident 47 tested negative on 9/8/24. On 9/9/24 at 10:20 AM, an interview was conducted with the Administrator. The Administrator stated there was a staff member that tested positive for COVID-19. The Administrator stated contact tracing was done to determine resident 7 and resident 47 were high risk exposures. The Administrator stated both residents tested negative on 9/8/24. On 9/9/24 at 11:04 AM, a follow-up interview was conducted with the DON. The DON stated contact tracing was determine based on exposure. The DON stated if staff were in the Colonial or Cambridge unit for over 15 minutes then a mask needed to be worn. The DON stated she called the county health department and was told there was no reason to call anymore. On 9/9/24 at 11:41 AM, an observation was made of Medical Doctor (MD) 1 walking down the hall and entering room [ROOM NUMBER] with a mask below his nose. At 12:02 AM, an observation was made of MD 1 leaving room [ROOM NUMBER] with his mask under his chin. On 9/10/24 at 1:12 PM, a follow-up interview was conducted with the DON. The DON stated the contact tracking was based on anyone the CNA spent over 15 minutes in close contact with. The DON stated it was 15 minutes at a time and accumulative. The DON stated masks were implemented on the Colonial unit on 9/5/24. The DON stated the Cambridge unit had masks implemented since they were in the same area of the building. The DON stated resident 7 and 47 were tested day 1, 3 and 5. The DON stated the tests were negative. The DON stated the facility will remain in outbreak for 10 days. The DON stated no residents had symptoms of COVID-19. The DON stated signage on the front door was put there by the Administrator. The DON stated she would have done things differently if she was aware of the exposure being accumulative over a 24 hour period of time. On 9/10/24 at 1:20 PM, an interview was conducted with Regional Nurse Consultant (RNC). The RNC stated exposure was based on the accumulative time over the 24 hours periods. On 9/16/24 at 11:10 AM, an observation was made of Registered Nurse (RN) 2. RN 2 was observed to be at the Colonial nurses station with her mask below her nose. CNA 4 was observed at the nurses station with her mask below her nose. The Infection Prevention and Control Program Policy and Procedure revised February 2024 revealed the following: Policy Statement An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy Interpretation and Implementation 1. The infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary. 2. The program is based on accepted national infection prevention and control standards. 3. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. 4. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. 5. Coordination and Oversight a. The infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist). b. The qualifications and job responsibilities of the Infection Preventionist are outlined in the Infection Preventionist Job Description. c. The infection prevention and control committee is responsible for reviewing and providing feedback on the overall program. Surveillance data and reporting information is used to inform the committee of potential issues and trends. Some examples of committee reviews may include: (1) documented IPCP incidents and corrective actions taken; (2) whether physician management of infections is optimal; (3) whether antibiotic usage patterns need to be changed because of the development of resistant strains; (4) whether information about culture results or antibiotic resistance is transmitted accurately and in a timely fashion; and (5) whether there is appropriate follow-up of acute infections. d. The committee meets regularly, at least quarterly, and consists of team members from across disci-plines, including the Medical Director. 6. Policies and Procedures a. Policies and procedures are utilized as the standards of the infection prevention and control program. b. Policies and procedures reflect the current infection prevention and control standards of practice. c. The infection prevention and control committee, Medical Director, Director of Nursing Services, and other key clinical and administrative staff review the infection control policies at least annually. The review will include: (1) Updating or supplementing policies and procedures as needed; (2) Assessment of staff compliance with existing policies and regulations; and (3) Any trends or significant problems since the previous review. 7. Surveillance a. Process surveillance (adherence to infection prevention and control practices) and outcome surveil-lance (incidence and prevalence of healthcare acquired infections) are used as measures of the IPCP effectiveness. b. Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications. c. The information obtained from infection control surveillance activities is compared with that from other facilities and with acknowledged standards (for example, acceptable rates of new infections), and used to assess the effectiveness of established infection prevention and control practices. d. Standard criteria are used to distinguish community-acquired from facility-acquired infections. 8. 9. Data Analysis a. Data gathered during surveillance is used to oversee infections and spot trends. b. One method of data analysis is by manually calculating number of infections per 1000 resident days as follows: (1) The infection preventionist collects data from the nursing units, categorizes each infection by body site (these can also be categorized by organism or according to whether they are facility- or community-acquired), and records the absolute number of infections; (2) To adjust for differences in bed capacity or occupancy on each unit, and to provide a uniform basis for comparison, infection rates can be calculated as the number of infections per 1000 patient days (a patient day refers to one patient in one bed for one day), both for each unit and for the entire facility; (3) Monthly rates can then be plotted graphically or otherwise compared side-by-side to allow for trend comparison; and (4) Finally, calculating means and standard deviations (using computer software) allows for screening of potentially clinically significant rates of infections (greater than two standard deviations above the mean). c. The Medical Director will help design data collection instruments, such as infection reports and anti-biotic usage surveillance forms, used by the Infection Preventionist. 10. Outbreak Management a. Outbreak management is a process that consists of: (1) determining the presence of an outbreak; (2) managing the affected residents; (3) preventing the spread to other residents; (4) documenting information about the outbreak; (5) reporting the information to appropriate public health authorities; (6) educating the staff and the public; (7) monitoring for recurrences; (8) reviewing the care after the outbreak has subsided; and (9) recommending new or revised policies to handle similar events in the future. b. Specific criteria will be used to help differentiate sporadic cases from true outbreaks or epidemics. c. The medical staff will help the facility comply with pertinent state and local regulations concerning the reporting and management of those with reportable communicable diseases. 11. Prevention of Infection a. Important facets of infection prevention include: (1) identifying possible infections or potential complications of existing infections; (2) instituting measures to avoid complications or dissemination; (3) educating staff and ensuring that they adhere to proper techniques and procedures; (4) communicating the importance of standard precautions and cough etiquette to visitors and family members; (5) enhancing screening for possible significant pathogens; (6) immunizing residents and staff to try to prevent illness; (7) implementing appropriate isolation precautions when necessary; and (8) following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). 12 . 13. Monitoring Employee Health and Safety a. The facility has established policies and procedures regarding infection control among employees, contractors, vendors, visitors, and volunteers, including: (1) situations when these individuals should report their infections or avoid the facility (for example, draining skin wounds, active respiratory infections with considerable coughing and sneezing, or frequent diarrheal stools); (2) pre-employment screening for infections required by law or regulation (such as TB); (3) any limitations (such as visiting restrictions) when there are infectious out breaks in the facility; and (4) precautions to prevent these individuals from contracting infections such as hepatitis and the HIV virus from residents or others. b. Testing for medical conditions is done in compliance with other laws (such as the Americans with Disabilities Act), and regulations protecting individual confidentiality and/or prohibiting discrimina-tion against those with certain disabilities or conditions. c. Those with potential direct exposure to blood or body fluids are trained in and required to use appro-priate precautions and personal protective equipment. (1) The facility provides personal protective equipment, checks for its proper use, and provides ap-propriate means for needle disposal. (2) A protocol is in place for managing those who stick themselves with a needle that was possibly or actually in contact with blood or body fluids.

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, the dish machine was not meeting the required temperature to sanitize the dishes and there were no chemical strips in the kitchen to monitor the sanitizer in the dish machine or the sanitation buckets. Additionally, food items in the freezer and dry storage room were open to air. Findings include: On 9/9/24 at 9:41 AM, an initial walk through was conducted in the kitchen. The Assistant Dietary Manager was asked to check the sanitation buckets. The Assistant Dietary Manager obtained a bottle of sanitizer strips and attempted to check the chlorine content of the water, but was unable to get a reading on the strip. The Assistant Dietary Manager checked the expiration date on the strips and stated they were expired. The Assistant Dietary Manager was unable to locate additional strips to test the sanitizer. On 9/9/24 at 9:50 AM, an observation was made of the dish machine as it was running after the breakfast meal. An attempt to check the sanitizer content was made, but again, the strips would not produce a reading. The temperature was monitored for a wash and rinse cycle for the low temperature machine. The wash temperature was 115 degrees Fahrenheit and the rinse temperature was 120 degrees Fahrenheit. An observation was made of the temperature log just outside of the dish machine area. The temperatures on the log were 120 and higher, and all chemical readings were 100 ppm [parts per million] on the log. An observation of the Assistant Dietary Manager was made putting the dish covers on the rack. At 9:52 AM, an interview was conducted with the Certified Dietary Manager (CDM). The surveyor reviewed the temperature log with the CDM and observed the chemical content was marked at 100 ppm for all entries. The CDM stated she would have to provide education to the kitchen staff tomorrow. The CDM stated the [servicing company] came every 3 months, but had come twice in the past 3 months. The CDM stated the dish machine had not been suctioning enough sanitizer up during the cycle. The CDM stated she had ordered some new chemical strips to test the machine. The CDM stated if the temperatures were not correct on the machine she would call the repair man. The CDM stated temperatures were always checked while doing the dishes for each meal. On 9/9/24 at 10:01 AM, a second temperature reading was conducted. The wash temperature was observed to be 113 degrees Fahrenheit and the rinse temperature was observed to be 118 degrees Fahrenheit. On 9/9/24 at 10:04 AM, an observation was made of the dry food storage area. A container of cold cereal was found to be open to air. At 10:08 AM, an observation of the walk-in freezer was made. Beef pattie fritters were open to air, and patties of Salisbury steak were open to air. On 9/9/24 at 10:13 AM, an observation was made of 2 packages of hot dogs sitting in a container in the sink. The hot dogs were sitting in water, and there was no running water being used to thaw them. On 9/10/24 at 8:16 AM, an observation was made of the dish machine log. The entries were as follows with the date, wash temperature and chemical reading for each meal: a. 9/9/24- B: 127 130 --- L: 127 131 --- D: 120 130 --- b. 9/10/24- No entries had been made. On 9/16/24 at 2:22 PM, a second walk through of the kitchen was conducted. In the walk-in freezer, patties for Salisbury steak was open to air, and cinnamon roll dough was open to air. On 9/16/24 at 2:30 PM, an observation was made of the dish machine. The washing temperature was 117 degrees Fahrenheit and 120 degrees Fahrenheit for the rinse cycle. At 2:46 PM, the CDM was asked to check the chlorine content in the dish machine. Several attempts were made to obtain a reading with the strips that she had. The CDM was observed to push the switch regulating the sanitizer several times while the dish cycles were running. After approximately 7 attempts, the CDM was able to obtain a reading of 200 ppm on the strip. The temperature log was reviewed. Additional entries were as follows: a. 9/12/24- B: 128 132 100 L: 132 131 50 D: 138 130 55 b. 9/13/24- B: 127 132 100 L: 130 132 100 D: No temperature logged c. 9/14/24- B: 127 132 100 L: 130 129 55 D: No temperature logged d. 9/15/24- B: 120 132 200 L: 122 123 200 D: No temperature logged e. 9/16/24- B: No temp logged L: No temp logged D: No temp logged On 9/12/24 at 9:46 AM, an interview was conducted with the Registered Dietitian (RD) who stated she completed monthly inspections in the kitchen. The RD stated her inspections consisted of going through every area of the kitchen, looking at cleanliness, making sure food items were closed and off of the floor, and that the freezer and refrigerator were running at proper temperatures. The RD stated she always looked at counter tops, in the drawers and microwave. The RD stated she would check to see if the mixer was clean, if the stove, ovens and walls were clean. The RD stated she did not check the temperature on the dish machine, she would just check the temperature log. The RD stated she asked the staff to test the chemicals and temperature and/or tell her how it is done. The RD stated if the dish machine was running she would check it. The RD stated she found it was best to let the dish machine run through a couple of cycles before testing to ensure the temperatures and chemicals were correct. On 9/16/24 at 2:53 PM, an interview was conducted with the CDM who stated the [service company] service man came on 9/10/24 and said everything was working and the tubing from the sanitizer was sitting on top of a metal bar instead of going into the dish machine. The CDM stated temperatures were being checked and the staff were required to check during the breakfast, lunch and dinner dish cycles. The CDM stated the kitchen staff were supposed to be writing down the temperatures as they take them. The CDM stated if there was a problem with the dish machine temperatures the kitchen staff should be telling her so she could call to have the machine serviced. The CDM stated if the dish machine was not working the staff should be doing the dishes in the 3 sink compartment to ensure they were clean and sanitized. The CDM stated if staff were using frozen foods to prepare a meal, they usually took it out a couple of days in advance and let it thaw in the refrigerator. The CDM stated if that did not happen, the frozen food should be thawed under cold running water. The CDM stated for items in the freezer and refrigerator, the staff should be making sure an open date was on the item, that food items were wrapped up or closed tightly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility did not provide a safe, clean, comfortable, and homelike environment. Specifically, resident bathrooms in the memory care unit did not have paper towel dispensers that worked. Findings included: On 3/11/24 at 2:33 PM, an observation was made of the bathroom in room [ROOM NUMBER]. The paper towel dispenser did not work. On 3/11/24 at 2:35 PM, an observation was made of the bathroom in room [ROOM NUMBER]. The paper towel dispenser did not work. On 3/11/24 at 2:39 PM, an observation was made of the bathroom in room [ROOM NUMBER]. The paper towel dispenser did not work. On 3/21/24 at 10:08 AM, an observation was made of the bathroom in room [ROOM NUMBER]. The paper towel dispenser did not work. On 3/21/24 at 10:13 AM, an observation was made of the bathroom in room [ROOM NUMBER]. The paper towel dispenser did not work. On 3/21/24 at 10:18 AM, an observation was made of the bathroom in room [ROOM NUMBER]. The paper towel dispenser did not work. On 3/21/24 at 10:26 AM, an interview was conducted with Housekeeper (HK) 2. HK 2 stated housekeeping refilled the paper towel dispensers. HK 2 stated the maintenance department replaced the batteries in the paper towel dispensers. HK 2 stated maintenance staff provided batteries for housekeeping to replace also. HK 2 was observed to try the paper towel dispenser in room [ROOM NUMBER]'s bathroom. The paper towel dispenser did not work. HK 2 stated the dispenser was not working and she needed batteries from the maintenance staff. On 3/21/24 at 10:28 AM, an interview was conducted with Certified Nursing Assistant (CNA) 8. CNA 8 stated that housekeeping refilled and made sure the paper towel dispensers were working in resident bathrooms. CNA 8 stated if she noticed a paper towel dispenser was not working, she notified maintenance staff. CNA 8 stated the paper towel dispenser was not working in room [ROOM NUMBER] and the bathroom in 203. On 3/21/24 at 10:36 AM, an interview was conducted with the Maintenance Director (MD). The MD stated staff verbally notified him of things that needed to be fixed and there was an application use. The MD stated there was a laminated form at the nurses station to show agency staff how to use the application system. The MD stated the paper towel dispensers were usually the HK because they replaced the paper towels. The MD stated he provided housekeepers with batteries. The MD stated he had not been notified the paper towel dispensers were not working. On 3/21/24 at 10:40 AM, an interview was conducted with the HK Supervisor. The HK Supervisor stated housekeepers changed paper towels when they were low. The HK Supervisor stated there were batteries in the maintenance office. The HK Supervisor stated sometimes the paper towel dispensers needed to be rest. The HK Supervisor stated HK staff checked the paper towel dispensers daily to see if they were working.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not provide necessary services to maintain good nutrition for a resident who was unable to carry out activities of daily living. Specifically, for 1 out of 45 sampled residents, a resident that required assistance with eating waited 35 minutes to get assistance by staff after the meal was served to the resident. Resident identifier: 29. Findings included: Resident 29 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included myasthenia gravis without (acute) exacerbation, displaced fracture of surgical neck of right humerus, moderate dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and type 2 diabetes mellitus with diabetic neuropathy. On 3/14/24 at 11:44 AM, an observation was made of resident 29. Resident 29 was observed to be served their lunch tray. The plate was observed to be placed on the bedside table located to the right side of resident 29 with a dome over plate. At 3/14/24 at 12:04 PM, an observation was made of the Certified Nursing Assistant (CNA) Coordinator and CNA 3 entering resident room [ROOM NUMBER] and asked resident 29, how he was doing, then exited the room. At 3/14/24 at 12:17 PM, an observation was made of the Dietary Manager (DM) entering resident room [ROOM NUMBER]. At 3/14/24 at 12:19 PM, an observation was made of the DM talking to resident 29 stating, I came down here to talk with you and noticed you haven't started eating, so I can talk to you and help you. On 3/14/24 at 12:29 PM, an observation was made of resident 29 stating to the DM, This isn't the first time I have been bypassed for lunch. Resident 29's medical record was reviewed on 3/11/24 through 3/22/24. An Optional State Minimum Data Set (MDS) assessment dated [DATE], revealed that resident 29 had a Brief Interview of Mental Status score of 10 which indicated moderately impaired cognition. The MDS revealed resident 29 needed extensive assistance with one person physical assistance for eating. A care plan initiated on 7/31/22 and revised on 1/3/24, revealed a Focus of [Resident 29] has an ADL [Activities of Daily Living] self -care performance deficit r/t [related to] weakness, impaired mobility, pain, cognitive impairment DX [diagnoses]: Myasthenia Gravis, OA [osteoarthritis], Fx [fracture] R [Right] humerus, Dementia, Carpal tunnel The goal was [Resident 29] will maintain current level of function in ADLS through the review date. One of the interventions revealed EATING: The resident requires supervision to physical 1 staff assistance. On 03/14/24 at 12:51 PM, an interview with the DM was conducted. The DM stated that she came to visit resident 29 and noticed he had not been fed and took the opportunity. The DM stated she was unsure how the CNAs handle the order of the four residents on North and South Rehab halls that require feeding assistance. On 3/14/24 at 12:57 PM, an interview with resident 29 was conducted. Resident 29 stated, He is the outlier for the feeders. Resident 29 also stated He often waits for them to find someone to come feed him. On 3/20/24 at 10:45 AM, an interview was conducted with CNA 4. CNA 4 stated that the CNA assigned to the floor was designated to assist residents with feeding. CNA 4 stated he would wait until the end of the hall's meal pass to serve those requiring assistance with feeding. CNA 4 stated once the tray was taken into a resident's room, he would set up the meal and assist the resident with feeding. If a hall does not have any assisted feedings, the CNA was to help any other residents needing assistance. On 3/20/24 at 12:26 PM, an interview was conducted with the CNA Coordinator. The CNA Coordinator stated that she expected immediate feeding of residents after being serviced their food tray. The CNA Coordinator stated she had trained the CNAs to pass out food trays then go to the rooms to do any assisted feeding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice. Specifically, for 1 out of 45 sampled residents, a resident was admitted to the facility on hospice and was not assessed upon admission, provided the appropriate medications, and was not transferred until the following day to the memory care unit after family requested. Resident identifier: 119. Findings included: Resident 119 was admitted to the facility on [DATE] with diagnoses which included sarcopenia, blindness, hypertension, and cardiovascular disease. On 3/11/24 at 11:18 AM, an interview was conducted with resident 119's family member. Resident 119's family member stated resident 119 did not receive her blood pressure medications because there was some confusion about them when she was admitted . Resident 119's family member stated she asked to have resident 119 moved to the memory care unit and she was not moved till the following day. Resident 119's medical record was reviewed on 3/11/24 through 3/21/24. A form titled Medication Profile dated 2/12/24 through 5/11/24, revealed current medications: a. Abilify Oral Tablet 2 mg (milligram) once daily. b. Promethazine Hydrochloride (HCL) oral tablet 25 mg every 6 hours as needed. c. Acetaminophen Rectal Suppository 650 mg every 6 hours as needed d. Bisacodyl Rectal Suppository 10 mg daily as needed e. Hyoscyamine Sulfate sublingual tablet 0.125 mg every 4 hours as needed f. Lorazepam oral concentrate 2 mg/ml (milliliter) every 2 hours as needed g. Morphine Sulfate 20 mg/ml. Give 1 syringe orally every hour as needed. It should be noted there was no blood pressure medication listed. A form from resident 119's hospice titled Physician telephone order dated 3/1/24, revealed the following medications: a. Losartan Potassium 50 mg once daily b. Metoprolol 100 mg once daily at 7:00 PM c. Calcium 1000 mg once daily at 7:00 PM d. Lorazepam 2 mg/ml (.05 ml) four times a day e. Crush medications as needed It should be noted the Metoprolol did not have the form needed. Resident 119's physician's ordered medications in the medical record were: a. On 3/1/24, Acetaminophen Rectal Suppository 650 mg every 6 hours as needed b. On 3/1/24, Bisacodyl Rectal Suppository 10 mg every 24 hours as needed c. On 3/1/24, Hyoscyamine Sulfate 0.125 mg every 4 hours as needed d. On 3/1/24, Morphine Sulfate 20 mg/ml .25 ml every hours as needed e. On 3/1/24, Promethazine HCL 25 mg every 6 hours as needed. f. On 3/3/24, Metoprolol Tartrate 100 mg at bedtime g. On 3/3/24, Cozaar (Losartan Potassium) 50 mg at bedtime. Nursing progress notes revealed the following: a. On 3/1/24 at 10:25 PM, I received nurse to nurse on [resident 119]. [Resident 119] is a 97 yof [year old female] with vascular dementia confused and delirious. She is DNR [Do Not Resuscitate] with comfort cares. She is minimally responsive and only responds to noxious stimuli she is not eating or drinking. normally she is independent however She had a change in condition today. No recent falls. They have ordered a cxr [chest x-ray], ua [urine analysis] c/s [culture and sensitivity]. Her diet is advance as tolerated. No foley not continent. Normally she walks with a walker but was super weak today, new onset. She does not have any wounds. She is extremely hard of hearing and legally blind. Daughter will bring her meds [medications] and meet her at the facility. b. On 3/3/24 at 6:44 PM, This order is outside of the recommended dose or frequency. Metoprolol Tartrate Oral Tablet 100 MG Give 1 tablet by mouth at bedtime for HTN [hypertension] - The frequency of daily is below the usual frequency of 2 to 4 times per day. c. On 3/3/24 at 6:45 PM, New order received from hospice. 1. Metoprolol 100 mg 1 tablet po [orally] every evening. 2. Losartan 50 mg 1 tablet po every evening. 3. Calcium 600 with Vitamin D po 1 tablet every evening. Resident's daughter brought in medications. d. On 3/4/24 at 6:04 PM, Received order from Hospice for Lorazepam to be PRN [as needed] rather than scheduled. e. On 3/5/24 at 3:17 AM, . Focused Assessment: Resident takes meds whole, incontinent of bowel and bladder, requires extensive 1 person assist with ADLs [activities of daily living] and transfers. Adjustment to admission: Resident appears to be adjusting well Pain Management: No c/o [complaints of] pain Mental Status/Behavior: Alert and oriented to self, restless at times, especially when brief is wet, staff checks on resident frequently. Improvement/Decline: Stable. f. On 3/8/24 at 2:47 PM, Ra [Resident Advocate], Admission, and Admin [Administrator] met with family to discuss concerns. Family is concerned about the level of care family member requires and the level of care rt [resident] is receiving. After discussing and resolving concerns it was decided that rt may be a good candidate for the specialized unit to provide more structure and support for resident. Daughter was able to tour the unit and expressed that she does believe that it will be a good fit for her loved one. g. On 3/9/24 at 10:30 PM, Resident transferred to Rm. [room] 217-2 'Cambridge' Wing with all personal belongings (Dtr. [daughter] aware) & report given to Nurse on Duty. h. On 3/11/24 at 2:33 AM, Patients medications are not on hand, only medications on hand are pain medications. The March 2024 Medication Administration Record (MAR) was reviewed. Resident 119 was not administered medication on 3/1/24 or 3/2/24. The following was revealed: a. Lorazepam 2 mg/ml, give 0.5 ml by mouth three times a day was refused by resident on 3/2/24, 3/3/24, and 3/4/24, twice daily and was administered once daily those days. b. Metoprolol Tartrate 100 mg by mouth at bedtime was administered 3/3/24, 3/4/24, 3/5/24, 3/7/24, 3/8/24, 3/9/24, and was refused on 3/6/24 and 3/10/24. c. There was no Abilify listed d. Cozaar (Losartan Potassium) 50 mg by mouth at bedtime was administered 3/3/24, 3/4/24, 3/5/24, 3/7/24, 3/8/24, 3/9/24, and was refused on 3/6/24 and 3/10/24. The admission Assessments were unlocked on 3/5/24, and were blank. On 3/12/24 at 10:26 AM, an interview was conducted with the hospice Registered Nurse (RN). The hospice RN stated when she visited a resident she talked to the facility nurse. The hospice RN stated that she had not provided the facility any paperwork except for a form titled physician's telephone order. The hospice RN stated resident 119's family stated that she brought bottles of Metoprolol and Losartan to the facility nurse. On 3/12/24 at 2:12 PM, an interview was conducted with the Director of Nursing (DON). The DON stated when a resident was admitted , the DON, Assistant Director of Nursing (ADON), or the Regional Nurse Consultant (RNC) received the nurse to nurse report and admission orders. The DON stated the floor nurse completed the admission process. The DON stated the nurse completed an admission note, assessments, and admitting vital signs. The DON stated the nurse managers completed a 48 hour admission check list to make sure it was all done. The DON stated resident 119 was an after hours admission from an Assisted Living Facility. The DON stated she received the nurse to nurse report from the hospice nurse. The DON stated the medications were sent in an e-mail. The DON stated she entered the medications into the resident's medical record on 3/1/24. The DON stated the next day there were medications that were entered and home meds that they wanted her to have later. The DON stated she did not know what the medications were that the family wanted. The DON stated the floor nurse informed her that there were more medications. The DON stated she instructed the floor nurse to call the hospice company and get order clarification. The DON stated I believe I got a hold of the hospice company regarding medications. The DON stated the family wanted to bring in a pill box and the floor nurse told family she needed actual orders from hospice for the medications. On 3/20/24 at 11:48 AM, a follow-up interview was conducted with the DON. The DON stated the telephone orders on 3/1/24, were different from the ones put into the computer and emailed to the facility. The DON stated an email provided on 3/1/24 at 10:15 PM, from the hospice company revealed different physician's orders than were in the medical record. The DON stated if the hospice nurse was onsite, then verbal order could be entered and then orders could be send to the facility. The DON stated facility nurses could call the hospice nurse. The DON stated if a resident did not receive the correct blood pressure medications, then a resident blood pressure could increase. On 3/20/24 at 11:58 AM, an interview was conducted with ADON 1. ADON 1 stated she was e-mailed a medication list. ADON 1 stated the medication was Metoprolol Succinate. On 3/20/24 at 12:04 PM, an interview was conducted with the RNC. The RNC stated she did not know the difference between Metoprolol Tartrate verses Metoprolol Succinate because she was not a physician or pharmacist. The RNC stated after googling the medications the Tartrate was an immediate release or short acting. The RNC stated the Succinate was an extended release. A notice of room change was completed on 3/8/24. Resident with impaired cognition alert and oriented to self. Behaviors identified were nursing services and social services. Resident is a good candidate for resident on special care unit. There was no information regarding a hospice plan of care or what services resident 119 had received from hospice in resident 119's medical record. On 3/12/24 at 10:26 AM, an interview was conducted with the hospice RN. The hospice RN stated there was no orientation when she entered the facility. The hospice RN stated she was not aware that resident 119 had moved and was looking throughout the facility for her. The hospice RN stated the on-call nurse was notified the facility did not have medications for her in stock. The hospice RN stated hospice nurses left a form titled physician's orders when there was a change to orders. The hospice RN stated she was unable to get Ativan scheduled at specific times because the nurse told her the facility would administer it at 6:00 AM, 10:00 AM, and 8:00 PM. The hospice RN stated she wanted Ativan scheduled at 10:00 PM, 4:00 AM, and 12:00 PM, so resident 119 would not be to tired during meal times if she wanted to eat. The hospice RN stated she usually talked to the nurses but has not provided any paperwork. The hospice RN stated at other facilities there was a book that she was able to sign and put any information regarding the resident when she visited. The hospice RN stated she was not sure if there was a coordination of care completed. On 3/12/24 at 2:48 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated when a resident received hospice services she had a phone number for the nurse. LPN 2 stated the hospice nurse would usually tell the nurse they were at the facility. LPN 2 stated the hospice nurse could leave signed or faxed physician's orders. LPN 2 stated usually hospice would let staff know what days they would provide showers. LPN 2 stated hospice provided the emergency kits and physician's orders. LPN 2 stated she was not aware if hospice staff left paperwork. On 3/20/24 at 10:01 AM, an interview was conducted with the RA. The RA stated resident 119's family member approached the RA because she was concerned about resident 119's level of care. The RA stated resident 119's family member felt there was not enough care and structure. The RA stated she discussed the memory care unit and let her tour it. The RA stated the memory care unit was more structured for residents with dementia. The RA stated resident 119 was upset that resident 119 was in someone else's clothing. The RA stated there was not a grievance completed for resident 119. The RA stated the situation could have been a grievance and should have followed the grievance procedure. On 3/20/24 at 10:10 AM, an interview was conducted with the Administrator. The Administrator stated that resident 119's family member wanted more structure in her day and making sure she was up for every meal and attending activities. The Administrator stated that staff were able to get resident's up for meals better in the memory care unit. The Administrator stated when resident 119 was admitted , she discussed the struggles resident 119 was having with the family member. The Administrator stated resident 119's family member stated that resident 119 was in the wrong clothing and her chest was exposed. The Administrator stated resident 119 was covered with a blanket when she saw her. The Administrator stated there were a few buttons that were buttoned and some that were not under the blanket. The Administrator stated she could not recall if she asked the RA to write a grievance. The Administrator stated it would have been good to have a grievance for a situation like this. The Administrator stated the Social Services came into the facility to move resident 119 to the memory care unit. The Administrator stated that resident 119 was not moved till the following day because they like to give 24 hour notice before moving. The Administrator stated usually when a resident was admitted with hospice services, the hospice staff communicate with the nursing staff. The Administrator stated the hospice company was to provide notes for the residents medical record. On 3/20/24 at 11:48 AM, an interview was conducted with the DON. The DON stated the hospice company faxed or emailed notes to the facility. The DON stated she was not sure how often notes should be sent to the facility. The DON stated hospice staff verbally communicate with the staff. The DON stated the telephone order on 3/1/24, were different from the ones put into resident 119's medical record. The DON stated the physician's orders matched her comfort medications. The DON stated if the hospice nurse was onsite, verbal physician's orders were entered into the medical record and then orders could be send over. The DON stated nursing staff can call the hospice with concerns. The DON stated if there were newer employees that have not worked with us before. On 3/20/24 at 12:31 PM, a follow-up interview was conducted with the DON. The DON stated that the admission assessments for resident 119 were blank but she remembered completing them on 3/5/24, with the floor nurse. The DON stated she was not sure why they were blank. The DON stated the admission assessments should have been completed on 3/1/24, when resident 119 was admitted but she was admitted after 10:00 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents goals, and preferences. Specifically, for 1 out of 45 sampled residents, a resident that required continuous oxygen therapy was observed without their oxygen nasal cannula on and out of reach. Staff were observed to not apply the oxygen nasal cannula for the resident. Resident identifier: 59. Findings included: Resident 59 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, severe protein-calorie malnutrition, chronic respiratory failure with hypoxia, convulsions, hypertension, and chronic atrial fibrillation. On 3/11/24 at 1:16 PM, an observation was conducted of resident 59's room. Resident 59 was observed in bed and the oxygen nasal cannula was not placed properly on resident 59. The oxygen nasal cannula was observed near resident 59's mouth but the oxygen nasal cannula was not in resident 59's mouth. Resident 59 did not appear to be short of breath. Resident 59's medical record was reviewed on 3/19/24. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 59 did not have a Brief Interview for Mental Status score due to resident was rarely or never understood. The MDS further documented that resident 59 was dependent with all cares and had functional limitation in range of motion with upper and lower extremities. A care plan Focus initiated on 2/12/24, documented [Resident 59] has altered respiratory status/difficulty breathing DX [diagnoses]: Chronic respiratory failure w/ [with] hypoxia Requires O2 [oxygen] therapy and nebulizers PRN [as needed] for management. Interventions initiated on 2/12/24, included a. OXYGEN SETTINGS: Oxygen as ordered, wean as able, Check O2 sats [saturations] as ordered. b. Position resident with proper body alignment for optimal breathing pattern. The February and March 2024 Treatment Administration Record (TAR) were reviewed. The following physician orders were documented: a. On 1/19/24, CHECK O2 SATS EVERY SHIFT every shift. i. On 2/28/24 at Night, O2 sats were documented at 85%. ii. On 2/29/24 at Night, O2 sats were documented at 89%. b. On 1/29/24, Monitor SOB [shortness of breath] or Difficulty Breathing: (1) SOB with Exertion (2) Sitting at Rest (3) Laying Flat every shift. The March 2024 TAR documented that resident 59 had SOB with exertion on one occasion. c. On 1/29/24, O2 per nc [nasal cannula] at 1-6 L/min [liters per minute] continuous. Check O2 sat [saturation] qshift [every shift]. Goal to maintain O2 sats > [greater than] 90%. every shift. The physician's order was discontinued on 3/1/24. i. 2 L/min of O2 was administered on 17 occasions in February. ii. 3 L/min of O2 was administered on 38 occasions in February. d. On 3/1/24, O2 per nc at 1-6 L/min continuous. Check O2 sat qshift. Goal to maintain O2 sats >90%. every shift. i. 2 L/min of O2 was administered on two occasions in March. ii. 3 L/min of O2 was administered on 27 occasions in March. iii. 4 L/min of O2 was administered on six occasions in March. On 2/27/24 at 6:51 PM, a Nurse Practitioner Note documented Note Text: Resident is residing in a skilled nursing facility due to a recent stroke and inability to care for himself. He is unable to walk or eat independently and can not leave the facility without oxygen and assistance. Resident is unable to serve on a jury due to physical limitations. On 3/19/24 at 1:34 PM, an observation was conducted with Registered Nurse (RN) 1. RN 1 performed a dressing change on resident 59's left hip. Resident 59's oxygen nasal cannula was observed on the floor near the head of the bed. Resident 59 was unable to reach the oxygen nasal cannula. RN 1 completed the dressing change and exited resident 59's room without applying the oxygen nasal cannula for resident 59. A continuous observation was initiated. On 3/19/24 at 2:46 PM, resident 59's oxygen concentrator was observed to be set at 2 L/min. On 3/19/24 at 3:20 PM, an observation was conducted with RN 1. RN 1 obtained an O2 sat on resident 59 at 91% and the heart rate was 113. [Note: The continuous observation was concluded and resident 59 was observed without oxygen for two hours and 46 minutes.] On 3/20/24 at 8:29 AM, an observation was conducted of resident 59. Resident 59 was observed in bed with the oxygen nasal cannula positioned near his cheek. A continuous observation was initiated. On 3/20/24 at 8:41 AM, an observation was conducted of Certified Nursing Assistant (CNA) 11 entering resident 59's room. CNA 11 exited resident 59's room without applying the oxygen nasal cannula for resident 59. Resident 59's oxygen nasal cannula was observed on the floor near the head of the bed. Resident 59 was unable to reach the oxygen nasal cannula. On 3/20/24 at 9:26 AM, an interview was conducted with RN 1. RN 1 stated that resident 59 would remove the oxygen nasal cannula frequently. RN 1 stated she was not sure how often the CNAs would check on the residents but she was in resident 59's room around 7:30 AM, and RN 1 stated she had to put the oxygen back on resident 59. RN 1 stated that resident 59 would usually sat around 90% with the oxygen off. RN 1 was observed to obtain an O2 sat on resident 59. Resident 59's O2 sat was 95% and the heart rate was 91. An observation of resident 59's back wound was observed with RN 1. RN 1 completed the dressing change and exited resident 59's room without applying the oxygen nasal cannula for resident 59. On 3/20/24 at 9:43 AM, an observation was conducted of the Administrator entering resident 59's room. The Administrator exited resident 59's room and did not apply the oxygen nasal cannula for resident 59. On 3/20/24 at 9:46 AM, an observation was conducted of CNA 4 entering resident 59's room. CNA 4 exited resident 59's room and did not apply the oxygen nasal cannula for resident 59. On 3/20/24 at 10:08 AM, an interview was conducted with CNA 4. CNA 4 stated that he would check on all the residents every two hours as required. CNA 4 stated he liked to check on the residents more frequent like every 30 to 40 minutes. CNA 4 stated if he was in a room cleaning he would check on the residents when he finished. CNA 4 stated the staff had to check on resident 59 often. CNA 4 stated that often meant more frequent than every two hours. CNA 4 stated that resident 59 had to be checked on because he was a fall risk and had a tube feed. CNA 4 stated that he would make sure that resident 59 was not tugging on the tube feed and would ensure that everything was on. CNA 4 stated that resident 59 liked to pull on things so he would check the call light because it would get moved. CNA 4 stated that he would ensure resident 59 was not trying to get out of bed and would wedge him to keep him off of his back. CNA 4 stated that resident 59 would tend to lean a certain way and needed to be readjusted. On 3/20/24 at 10:19 AM, a staff member was observed to enter resident 59's room. The staff member exited resident 59's room with a bag of garbage and did not apply the oxygen nasal cannula for resident 59. On 3/20/24 at 10:26 AM, resident 59 activated the call light. At 10:33 AM, a staff member responded to resident 59's call light. The staff member did not apply the oxygen nasal cannula for resident 59. On 3/20/24 at 11:04 AM, an interview was conducted with RN 1. The State Survey Agency asked RN 1 to obtain an O2 sat on resident 59. RN 1 stated that resident 59's oxygen probably was not on yet and she could guarantee it. Resident 59's O2 sat was 87% and the heart rate was 94. At 11:06 AM, two minutes later resident 59's O2 sat was 93%. [Note: The continuous observation was concluded and resident 59 was observed without oxygen for three hours and 35 minutes.] On 3/20/24 at 12:54 PM, an interview was conducted with the Director of Nursing (DON). The DON stated if a resident required oxygen the nurse would apply the oxygen and call the physician to obtain a physician's order. The DON stated that staff should be checking on the residents every two hours. The DON stated that she had been in resident 59's room when resident 59 had refused oxygen therapy. The facility policy for Oxygen Administration was reviewed and documented, Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed. General Guidelines 1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter. a. The oxygen mask is a device that fits over the resident's nose and mouth. It is held in place by an elastic band placed around the resident's head. b. The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band placed around the resident's head. c. The nasal catheter is a piece of tubing inserted through the resident's nostrils into the back of his/her mouth. It is held in place by a piece of skin tape attached to the resident's forehead and/or cheek. Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure. 1. Portable oxygen cylinder (strapped to the stand); 2. Nasal cannula, nasal catheter, mask (as ordered); 3. Humidifier bottle; 4. 'No Smoking/Oxygen in Use' signs; 5. Regulator; and 6. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed). Assessment Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 1. Signs or symptoms of cyanosis (i.e., blue tone to the skin and mucous membranes); 2. Signs or symptoms of hypoxia (i.e., rapid breathing, rapid pulse rate, restlessness, confusion); 3. Signs or symptoms of oxygen toxicity (i.e., tracheal irritation, difficulty breathing, or slow, shallow rate of breathing); 4. Vital signs; 5. Lung sounds; 6. Arterial blood gases and oxygen saturation, if applicable; and 7. Other laboratory results (hemoglobin, hematocrit, and complete blood count), if applicable. Steps in the Procedure 1. Wash and dry your hands thoroughly. 2. Place an 'Oxygen in Use' sign on the outside of the room entrance door. Close the door. 3. Place an 'Oxygen in Use' sign in a designated place on or over the resident's bed. 4. Remove all potentially flammable items (e.g., lotions, oils, alcohol, smoking articles, etc.) from the immediate area where the oxygen is to be administered. 5. Unless otherwise instructed, unplug and/or relocate all electrical devices (e.g., radios, televisions, electric shavers, etc.) in the immediate area where oxygen is to be administered. 6. Remove any [NAME] blankets, nylon and/or [NAME] clothing, etc., from the immediate area where oxygen is to be administered. 7. Check the tubing connected to the oxygen cylinder to assure that it is free of kinks. 8. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. 9. Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal catheter). 10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. 11. Securely anchor the tubing so that it does not rub or irritate the resident's nose, behind the resident's ears, etc. 12. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. 13. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated (see 'Assessment'). 14. Periodically re-check water level in humidifying jar. 15. Discard used supplies into designated containers. 16. Discard personal protective equipment in designated receptacles. Wash and dry your hands thoroughly. 17. Reposition the bed covers. Make the resident comfortable. 18. Place the call light within easy reach of the resident. 19. If the resident desires, return the curtains to the open position and if visitors are waiting, tell them that they may now enter the room. 20. Instruct the resident, his/her family, visitors and roommate (if any) of the oxygen safety precautions. Provide the resident with a written copy of the Oxygen Safety handout. 21. Wash and dry your hands thoroughly. Documentation After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed. 2. The name and title of the individual who performed the procedure. 3. The rate of oxygen flow, route, and rationale. 4. The frequency and duration of the treatment. 5. The reason for p.r.n. administration. 6. All assessment data obtained before, during, and after the procedure. 7. How the resident tolerated the procedure. 8. If the resident refused the procedure, the reason(s) why and the intervention taken. 9. The signature and title of the person recording the data. Reporting 1. Notify the supervisor if the resident refuses the procedure. 2. Report other information in accordance with facility policy and professional standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that residents did not receive psychotropic drugs pursuant to an as needed (PRN) order unless the PRN order for psychotropic drugs were limited to 14 days. If the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, they should document their rationale in the resident's medical record and indicate the duration for the PRN order. In addition, PRN orders for anti-psychotic drugs were limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. Specifically, for 1 out of 45 sampled residents, a resident had a PRN order for a cream that included Haldol, Benadryl, and Ativan. The cream was not limited to 14 days, and the physician or prescribing practitioner had not evaluated the resident for the appropriateness of the medication. Resident identifier: 2. Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, type 2 diabetes mellitus, chronic kidney disease stage 2, dementia with other behavioral disturbance, bipolar disorder, major depressive disorder, and anxiety disorder. Resident 2's medical record was reviewed on 3/12/24. A care plan Focus initiated on 1/30/24, documented [Resident 2] has Bipolar Disorder Requires the use of psychotropic medications. The interventions initiated on 1/30/24, included: a. Administer PSYCHOTROPIC medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT [every shift]. b. Consult with pharmacy, MD [Medical Director] to consider dosage reduction when clinically appropriate at least quarterly. c. Monitor/document/report PRN any adverse reactions of PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia, EPS [extrapyramidal side effects] (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. On 1/16/24, a physician's order documented ABH- Ativan-Benadryl-Haldol Apply to WRIST topically every 12 hours as needed for BIPOLAR WITH AGITATION for 30 Days 1ML [milliliter] TO WRIST. The physician's order was discontinued on 2/7/24. On 2/7/24 at 12:45 PM, a Nurses Note documented Note Text: Daughter met with ADON [Assistant Director of Nursing] and requested that his ABH cream is to be PRN instead of scheduled. Order approved by in house MD. On 2/7/24, a physician's order documented ABH- Ativan-Benadryl-Haldol Apply to WRIST topically every 12 hours as needed for BIPOLAR WITH AGITATION for 30 Days 1ML TO WRIST- PRN BID [twice daily]. Max [maximum] dose of 3 syringes given a day. The physician's order was discontinued on 2/11/24. On 2/8/24 at 3:22 PM, a Nurses Note documented Note Text: MD spoke with resident's daughter about medication changes. New orders to discontinue sertraline and aripiprazole. Change tramadol to BID. DC [discontinue] PRN clonazepam and maintain current scheduled clonazepam order. ABH cream is PRN and only to be given if anxious/agitated per daughter's request. Orders have been updated accordingly. On 2/11/24 at 4:52 PM, an Event/Alert Charting documented Type of Event: Verbal and physical aggression Assessment /Observation: Rt. [resident] combative and verbally aggressive toward staff when assisting with ambulation, transfers, ADLs [activities of daily living], and toileting. Observed Rt. punch and scratch staff during transfers and while assisting with ambulation. Interventions: Notified ADON, family and physician. Physician ordered prn ABH cream to be applied QID [four times a day]. Applied cream with effective results. Family notified about frequency change. Resident Reaction to Interventions:Cooperative. Pain Management: No c/o [complaints of] pain or discomfort Improvement/Decline: Stable Notifications: On 2/11/24, a physician's order documented ABH- Ativan-Benadryl-Haldol Apply to Wrist topically every 6 hours as needed for Bipolar and Agitation. The physician's order was discontinued on 2/16/24. On 2/11/24 at 11:37 PM, an Event/Alert Charting documented Type of Event: Verbal and physical aggression Assessment /Observation: Resident combative and verbally aggressive with staff during cares. Attempting to kick and punch staff. Med [medication] pass nurse reported resident punched her in the face. Interventions: Redirection, calm environment, PRN ABH cream, scheduled meds. Resident Reaction to Interventions: Resident was able to be redirected and calmed down after a while. Pain Management: Scheduled Tramadol Improvement/Decline: No changes. Notifications: ADON, MD and daughter were notified. On 2/15/24 at 6:43 PM, a Physician Progress Notes documented Note Text: Visit type: Reg [regular] . Reason for visit: Regulatory visit Subjective: Reviewed plan of care with patient and daughter (via phone). Addressed all concerns. Reviewed full list of medications. Trying to minimize medications. Discussed difficult situation of over medicating him but keeping him safe. Patient to see psychiatrist at outpatient clinic for further evaluation/management of his psychiatric medications. On 2/16/24, a physician's order documented ABH- Ativan Benadryl-Haldol Apply to Wrist topically every 6 hours as needed for Bipolar and Agitation NOTIFY ON CALL NURSE MANAGEMENT IF ABH MUST BE GIVEN. The January, February, and March 2024 Medication Administration Record was reviewed. a. ABH was administered two times in January. One dose was documented as ineffective. b. ABH was administered 23 times in February. One dose was documented as ineffective and on one dose the effectiveness was documented undetermined. c. ABH was administered one time in March and the dose effectiveness was documented as undetermined. On 2/28/24 at 4:52 PM, a Behavioral Health Clinic Note documented Chief Complaint Client presents to follow-up with his dementia with behavioral disturbance and bipolar disorder. He suffers from dementia and is on a memory unit. She relates that he was given a notice to vacate after going to the hospital ER [Emergency Room] for behavioral issues felt to be secondary to his dementia. [Doctor name redacted] at that time switched him over to Haldol [to] help minimize exposure from multiple antipsychotics since he was already getting a compounded cream with a combination of Haldol, Benadryl and Ativan in it. Daughter relates that she did not want her dad on Haldol and he was not functioning on it, could not walk, so the oral form has been discontinued. He continues to take Seroquel 25 mg [milligrams] at night and his clonazepam has been reduced now he is on 0.5 mg in the morning and milligram at night. Reportedly he get [sic] agitated at times, sometimes thinks people are stealing things from his room. Daughter still wanting client to be off Haldol completely, but reportedly he has gotten this compounded cream a few times for agitation. Today, client continues to not seem depressed or manic, his bipolar does seem to be well-controlled. He does have episodic issues with behavioral outburst from his dementia. I do agree with going down on his clonazepam, hopefully that will decrease his chances of falls and also help hopefully with less confusion. Discussed that we should not have 2 different providers prescribing for the same condition. Daughter wants to talk it over with her brother on exactly what to do, since the provider at the facility seems to like the compounded cream. Perhaps they could take the Haldol out of the compounded cream. PLAN: Plan was made with regards to the psychiatric medications to continue the medications unchanged. It was felt the potential benefits of changing the medications did not outweigh the potential risk and side effects of changing the medication at this time. FOLLOW UP: It was recommended the patient follow up in 1 or 2 months or she can transfer care to the facility provider. [Note: The PRN ABH physician's order was not limited to 14 days and an evaluation every 14 days by the attending physician or prescribing practitioner to evaluate resident 2 for the appropriateness of the medication was unable to be located in the medical record.] On 3/19/24 at 1:03 PM, an interview was conducted with the Director of Nursing (DON). The DON stated an evaluation would depend on the medication. The DON stated the facility had behavior tracking for the psychotropic medications. The DON stated that during the psychotropic meetings the team would pull the behavior tracking and review how much the resident expressed behaviors. The DON stated the team would also review the PRN medication usage and review if the resident still needed the medication. The DON stated the team tried not to use as many PRN antipsychotics. The DON stated the facility MD did not like to use PRN Seroquel. The DON stated that resident 2 was seen by an out patient psychologist doctor and that doctor recommended not changing any medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure each resident was free of any significant medication errors. Specifically, for 1 out of 45 sampled residents, a resident was not administered the correct blood pressure medication. Resident identifiers: 119. Findings included: Resident 119 was admitted to the facility on [DATE] with diagnoses which included sarcopenia, blindness, hypertension, and cardiovascular disease. On 3/11/24 at 11:18 AM, an interview was conducted with resident 119's family member. Resident 119's family member stated resident 119 did not receive her blood pressure medications because there was some confusion about them when she was admitted . Resident 119's medical record was reviewed on 3/11/24 through 3/21/24. A form titled Medication Profile dated 2/12/24 through 5/11/24 revealed current medications: a. Abilify Oral Tablet 2 mg (milligram) once daily. b. Promethazine Hydrochloride (HCL) oral tablet 25 mg every 6 hours as needed. c. Acetaminophen Rectal Suppository 650 mg every 6 hours as needed d. Bisacodyl Rectal Suppository 10 mg daily as needed e. Hyoscyamine Sulfate sublingual tablet 0.125 mg every 4 hours as needed f. Lorazepam oral concentrate 2 mg/ml (milliliter) every 2 hours as needed g. Morphine Sulfate 20 mg/ml. Give 1 syringe orally every hour as needed. It should be noted there was no order for blood pressure medication. A form from resident 119's hospice titled Physician telephone order dated 3/1/24, revealed the following medications: a. Losartan Potassium 50 mg once daily for hypertension b. Metoprolol 100 mg once daily at 7:00 PM, for hypertension c. Calcium 1000 mg once daily at 7:00 PM d. Lorazepam 2mg/ml (.05 ml) four times a day e. Crush medications as needed It should be noted there was no specification on what type of Metoprolol was to be administered. Resident 119's physician ordered medications entered into the medical record at the facility were: a. On 3/1/24, Acetaminophen Rectal Suppository 650 mg every 6 hours as needed b. On 3/1/24, Bisacodyl Rectal Suppository 10 mg every 24 hours as needed c. On 3/1/24, Hyoscyamine Sulfate 0.125 mg every 4 hours as needed d. On 3/1/24, Morphine Sulfate 20 mg/ml .25 ml every hours as needed e. On 3/1/24, Promethazine HCL 25 mg every 6 hours as needed. f. On 3/3/24, Metoprolol Tartrate 100 mg at bedtime g. On 3/3/24, Cozaar (Losartan Potassium) 50 mg at bedtime. Nursing progress notes revealed the following: a. On 3/1/24 at 10:25 PM, I received nurse to nurse on [resident 119]. [Resident 119] is a 97 yof [year old female] with vascular dementia confused and delirious. She is minimally responsive and only responds to noxious stimuli she is not eating or drinking. Normally she is independent however She had a change in condition today. No recent falls. They have ordered a cxr [chest x-ray], ua [urine analysis] c/s [culture and sensitivity] Her diet is advance as tolerated. No foley not continent. Normally she walks with a walker but was super weak today, new onset. She does not have any wounds. She is extremely hard of hearing and legally blind. Daughter will bring her meds [medications] and meet her at the facility. b. On 3/3/24 at 6:45 PM, New order received from hospice. 1. Metoprolol 100 mg 1 tablet po [by mouth] every evening. 2. Losartan 50 mg 1 tablet po every evening. 3. Calcium 600 with Vitamin D po 1 tablet every evening. Resident's daughter brought in medications. c. On 3/3/24 at 6:44 PM, This order is outside of the recommended dose or frequency. Metoprolol Tartrate Oral Tablet 100 MG Give 1 tablet by mouth at bedtime for HTN [hypertension]- The frequency of daily is below the usual frequency of 2 to 4 times per day. The March 2024 Medication Administration Record (MAR) was reviewed. Resident 119 was not administered medication on 3/1/24 or 3/2/24. The following was revealed: a. Lorazepam 2 mg/ml, give 0.5 ml by mouth three times a day was refused by resident on 3/2/24, 3/3/24, and 3/4/24, twice daily and was administered once daily on those days. b. Metoprolol Tartrate 100 mg by mouth at bedtime was administered 3/3/24, 3/4/24, 3/5/24, 3/7/24, 3/8/24, 3/9/24, and was refused on 3/6/24 and 3/10/24. On 3/12/24 at 10:26 AM, an interview was conducted with the hospice Registered Nurse (RN). The hospice RN stated when she visited a resident she talked to the facility nurse. The hospice RN stated that she had not provided the facility any paperwork except for a form titled physician's telephone order. The hospice RN stated resident 119's family stated that she brought bottles of Metoprolol and Losartan to the facility nurse. The hospice RN stated there was a mix up regarding resident 119's blood pressure medication and it was not administered for a few days after admission. On 3/12/24 at 2:12 PM, an interview was conducted with the Director of Nursing (DON). The DON stated when a resident was admitted , the DON, Assistant Director of Nursing (ADON) or the Regional Nurse Consultant (RNC) received the nurse to nurse report and admission orders. The DON stated the floor nurse completed the admission process. The DON stated the nurse completed an admission note, assessments, and admitting vital signs. The DON stated the nurse managers completed a 48 hour admission check list to make sure it was all done. The DON stated resident 119 was an after hours admission from an Assisted Living Faintly. The DON stated she received the nurse to nurse report from the hospice nurse. The DON stated the ordered medications were sent in an e-mail. The DON stated she entered the medications into the resident's medical record on 3/1/24. The DON stated the next day the family had home medications that they wanted resident 119 to have later. The DON stated she did not know what the medications were that the family wanted. The DON stated the floor nurse informed her that there were more medications. The DON stated she instructed the floor nurse to call the hospice company and get order clarification. The DON stated I believe I got a hold of the hospice company regarding medications. The DON stated the family wanted to bring in a pill box and the floor nurse told the family she needed actual orders from hospice for the medications. On 3/20/24 at 11:48 AM, a follow-up interview was conducted with the DON. The DON stated the telephone orders on 3/1/24, were different from the ones entered into resident 119's medical record and they were different from the list emailed to the facility. The DON stated an email provided on 3/1/24 at 10:15 PM, from the hospice company revealed different physician orders than were in the medical record. The DON stated if the hospice nurse was onsite, then verbal orders could be entered and then orders could be sent to the facility. The DON stated facility nurses could call the hospice nurse. The DON stated if a resident did not receive the correct blood pressure medications, then a resident blood pressure could increase. On 3/20/24 at 11:58 AM, an interview was conducted with ADON 1. ADON 1 stated she was e-mailed a medication list for resident 119. ADON 1 stated the medication was Metoprolol Succinate. On 3/20/24 at 12:04 PM, an interview was conducted with the RNC. The RNC stated she did not know the difference between Metoprolol Tartrate verses Metoprolol Succinate because she was not a physician or pharmacist. The RNC stated after googling the medications the Tartrate was an immediate release or short acting. The RNC stated the Succinate was and extended release.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that a feeding assistant had completed a state-approved training course before providing feeding assistance to residents. Specifically, for 1 out of 45 sampled residents, the Dietary Manager (DM) was providing feeding assistance to a resident without having completed a state-approved training course. Resident identifier: 29. Findings included: Resident 29 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included myasthenia gravis without (acute) exacerbation, displaced fracture of surgical neck of right humerus, moderate dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and type 2 diabetes mellitus with diabetic neuropathy. On 3/14/24 at 12:19 PM, an observation of resident 29 was made. Resident 29 was observed to be assisted with feeding by the DM. The DM was observed talking to resident 29 stating, I came down here to talk with you and noticed you haven't started eating, so I can talk to you and help you. Resident 29's medical record was reviewed on 3/11/24 through 3/22/24. An Optional State Minimum Data Set (MDS) assessment dated [DATE], revealed resident 29 had a Brief Interview of Mental Status score of 10 which indicated moderately impaired cognition. The MDS revealed resident 29 needed extensive assistance with 1 person physical assistance for eating. A care plan initiated on 7/31/22 and revised on 1/3/24, revealed a focus of [Resident 29] has an ADL [Activities of Daily Living] self -care performance deficit r/t [related to] weakness, impaired mobility, pain, cognitive impairment DX [diagnose]: Myasthenia Gravis, OA [osteoarthritis], Fx [fracture] R [Right] humerus, Dementia, Carpal tunnel The goal was [Resident 29] will maintain current level of function in ADLS through the review date. One of the interventions revealed EATING: The resident requires supervision to physical 1 staff assistance. On 3/20/24 at 12:26 PM, an interview was conducted with the Certified Nursing Assistant (CNA) Coordinator. The CNA Coordinator stated only the nurses and CNAs were qualified to assist with resident feeding. On 3/20/24 at 12:28 PM, an interview was conducted with the DM. The DM stated that as far as she was aware the facility did not have extra paid feeding assistants. The DM stated that feeding assistants must have a certification and the CNAs were certified to help with resident feeding assistance. The DM stated that she previously had training in that regard, but she did not hold a CNA certificate, her current certifications were in the kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not maintain medical records on each resident that were accurately documented. Specifically, for 2 out of 45 sampled residents, a resident's medical record contained another resident's fall report and a resident's care plan was found in another resident's medical record. Resident identifiers: 17 and 56. Findings included: 1. Resident 56 was admitted to the facility initially on 3/3/23 and was readmitted on [DATE] with diagnoses that included hereditary and idiopathic neuropathy, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, bipolar disorder, major depressive disorder, and anxiety disorder. Resident 56's medical record was reviewed between 3/11/24 and 3/21/24. A review of resident 56's medical record revealed an unwitnessed fall documentation belonging to resident 2. 2. Resident 17 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia with other behavioral disturbance, cognitive communication deficit, unsteadiness on feet, abnormal postures, adult failure to thrive, major depressive disorder, and insomnia. Resident 17's medical record was reviewed on 3/11/24 through 3/21/24. A care plan dated 2/23/24, revealed [Resident 48] has expressed a need for physical affection . On 3/20/24 at 12:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that residents information should be in the correct medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that the hospice services met professional standards and principles that applied to individuals providing services in the facility, and to the timeliness of those services. Specifically, for 1 out of 45 sampled residents, the facility did not obtain from the hospice provider the nursing notes, coordination of care notes, and the correct physician's orders. Resident identifier: 119. Findings included: Resident 119 was admitted to the facility on [DATE] with diagnoses which included sarcopenia, blindness, hypertension (HTN), and cardiovascular disease. On 3/11/24 at 10:55 AM, a phone interview was conducted with resident 119's family member. Resident 119's family member stated that the facility lost resident 119's medications that were provided to the nurse. Resident 119's family member stated the facility offered to move resident to the memory care unit to provide her more care but resident 119 was not moved until the following day. Resident 119's family member stated the communication with hospice and the facility was not good. Resident 119's medical record was reviewed on 3/11/24 through 3/21/24. Progress notes revealed the following entries: a. On 3/1/24 at 10:25 PM, I received nurse to nurse on [resident 119]. [Resident 119] is a 97 yof [year old female] with vascular dementia confused and delirious. She is DNR [Do Not Resuscitate] with comfort cares. She is minimally responsive and only responds to noxious stimuli she is not eating or drinking. normally she is independent however She had a change in condition today. No recent falls. They have ordered a cxr [chest x-ray], ua [urine analysis] c/s [culture and sensitivity]. Her diet is advance as tolerated. No foley not continent. Normally she walks with a walker but was super weak today, new onset. She does not have any wounds. She is extremely hard of hearing and legally blind. Daughter will bring her meds [medications] and meet her at the facility. b. On 3/3/24 at 6:44 PM, This order is outside of the recommended dose or frequency. Metoprolol Tartrate Oral Tablet 100 MG [milligrams] Give 1 tablet by mouth at bedtime for HTN - The frequency of daily is below the usual frequency of 2 to 4 times per day. c. On 3/3/24 at 6:45 PM, New order received from hospice. 1. Metoprolol 100 mg 1 tablet po [by mouth] every evening. 2. Losartan 50 mg 1 tablet po every evening. 3. Calcium 600 with Vitamin D po 1 tablet every evening. Resident's daughter brought in medications. d. On 3/4/24 at 6:04 PM, Received order from Hospice for Lorazepam to be PRN [as needed] rather than scheduled. e. On 3/5/24 at 3:17 AM, . Focused Assessment: Resident takes meds whole, incontinent of bowel and bladder, requires extensive 1 person assist with ADLs [activities of daily living] and transfers. Adjustment to admission: Resident appears to be adjusting well Pain Management: No c/o [complaints of] pain Mental Status/Behavior: Alert and oriented to self, restless at times, especially when brief is wet, staff checks on resident frequently. Improvement/Decline: Stable. f. On 3/8/24 at 2:47 PM, Ra [Resident Advocate], Admission, and Admin [Administrator] met with family to discuss concerns. Family is concerned about the level of care family member requires and the level of care rt [resident] is receiving. After discussing and resolving concerns it was decided that rt may be a good candidate for the specialized unit to provide more structure and support for resident. Daughter was able to tour the unit and expressed that she does believe that it will be a good fit for her loved one. g. On 3/9/24 at 10:30 PM, Resident transferred to Rm. [room] 217-2 'Cambridge' Wing with all personal belongings (Dtr. [daughter] aware) & report given to Nurse on Duty. h. On 3/11/24 at 2:33 AM, Patients medications are not on hand, only medications on hand are pain medications. A form titled Medication Profile dated 2/12/24 through 5/11/24, revealed current medications: a. Abilify Oral Tablet 2 mg once daily. b. Promethazine Hydrochloride (HCL) oral tablet 25 mg every 6 hours as needed. c. Acetaminophen Rectal Suppository 650 mg every 6 hours as needed. d. Bisacodyl Rectal Suppository 10 mg daily as needed. e. Hyoscyamine Sulfate sublingual tablet 0.125 mg every 4 hours as needed. f. Lorazepam oral concentrate 2 mg/ml (milliliter) every 2 hours as needed. g. Morphine Sulfate 20 mg/ml. Give 1 syringe orally every hour as needed. It should be noted there were no orders for blood pressure medication. A form from resident 119's hospice titled Physician telephone order dated 3/1/24, revealed the following medications: a. Losartan Potassium 50 mg once daily for hypertension b. Metoprolol 100 mg once daily at 7:00 PM, for hypertension c. Calcium 1000 mg once daily at 7:00 PM d. Lorazepam 2mg/ml (.05 ml) four times a day e. Crush medications as needed Resident 119's physician ordered medications entered into the medical record at the facility were: a. On 3/1/24, Acetaminophen Rectal Suppository 650 mg every 6 hours as needed b. On 3/1/24, Bisacodyl Rectal Suppository 10 mg every 24 hours as needed c. On 3/1/24, Hyoscyamine Sulfate 0.125 mg every 4 hours as needed d. On 3/1/24, Morphine Sulfate 20 mg/ml .25 ml every hours as needed e. On 3/1/24, Promethazine HCL 25 mg every 6 hours as needed. f. On 3/3/24, Metoprolol Tartrate 100 mg at bedtime g. On 3/3/24, Cozaar (Losartan Potassium) 50 mg at bedtime. The March 2024 Medication Administration Record (MAR) was reviewed. Resident 119 was not administered medication on 3/1/24 or 3/2/24. The following was revealed: a. Lorazepam 2 mg/ml, give 0.5 ml by mouth three times a day was refused by resident on 3/2/24, 3/3/24 and 3/4/24, twice daily and was administered once daily on those days. b. Metoprolol Tartrate 100 mg by mouth at bedtime was administered 3/3/24, 3/4/24, 3/5/24, 3/7/24, 3/8/24, 3/9/24, and was refused on 3/6/24 and 3/10/24. c. Cozaar (Losartan Potassium) 50 mg by mouth at bed time was administered on 3/3/24, 3/4/24, 3/5/24, 3/7/24, 3/8/24, 3/9/24, and refused on 3/6/24 and 3/10/24. d. Abilify was not on the MAR. A notice of room change was completed on 3/8/24. Resident with impaired cognition alert and oriented to self. Behaviors identified were nursing services and social services. Resident was a good candidate for resident on special care unit. There was no information regarding a hospice plan of care or what services resident 119 had received from hospice in resident 119's medical record. On 3/12/24 at 10:26 AM, an interview was conducted with the Hospice Registered Nurse (RN). The Hospice RN stated there was no orientation when she entered the facility. The Hospice RN stated she was not aware that resident 119 had moved and was looking throughout the facility for her. The Hospice RN stated the on-call nurse was notified by the facility and did not have medications for her in stock. The Hospice RN stated hospice nurses left a form titled physician's orders when there was a change to orders. The Hospice RN stated she was unable to get Ativan scheduled at specific times because the nurse told her the facility would administer it at 6:00 AM, 10:00 AM, and 8:00 PM. The hospice RN stated she wanted Ativan scheduled at 10:00 PM, 4:00 AM, and 12:00 PM, so resident 119 would not be to tired during meal times if she wanted to eat. The Hospice RN stated she usually talked to the nurses but had not provided any paperwork. The Hospice RN stated at other facilities there was a book that she was able to sign and put any information regarding the resident when she visited. The Hospice RN stated she was not sure if there was a coordination of care completed. On 3/12/24 at 2:48 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated when a resident received hospice services she had a phone number for the nurse. LPN 2 stated the hospice nurse would usually tell the nurse when they were at the facility. LPN 2 stated the hospice nurse could leave signed or fax physician orders. LPN 2 stated usually hospice would let staff know what days they would provide showers. LPN 2 stated hospice provided the emergency kit and physician's orders. LPN 2 stated she was not aware if hospice staff left paperwork. On 3/20/24 at 10:01 AM, an interview was conducted with the RA. The RA stated resident 119's family member approached the RA because she was concerned about resident 119's level of care. The RA stated resident 119's family member felt there was not enough care and structure. The RA stated she discussed the memory care unit and let her tour it. The RA stated the memory care unit was more structured for residents with dementia. The RA stated resident 119's family member was upset that resident 119 was in someone else's clothing. The RA stated there was not a grievance completed for resident 119. The RA stated the situation could have been a grievance and should have followed the grievance procedure. On 3/20/24 at 10:10 AM, an interview was conducted with the Administrator. The Administrator stated that resident 119's family member wanted more structure in her day and making sure she was up for every meal and attending activities. The Administrator stated that staff were able to get resident's up for meals better in the memory care unit. The Administrator stated when resident 119 was admitted , she discussed the struggles resident 119 was having with the family member. The Administrator stated resident 119's family member stated that resident 119 was in the wrong clothing and her chest was exposed. The Administrator stated resident 119 was covered with a blanket when she saw her. The Administrator stated there were a few buttons that were buttoned and some that were not under the blanket. The Administrator stated she could not recall if she asked the RA to write a grievance. The Administrator stated it would have been good to have a grievance for a situation like this. The Administrator stated the Social Services came into the facility to move resident 119 to the memory care unit. The Administrator stated that resident 119 was not moved till the following day because they like to give a 24 hour notice before moving. The Administrator stated usually when a resident was admitted with hospice services, the hospice staff communicate with the nursing staff. The Administrator stated the hospice company was to provide notes for the residents medical record. On 3/20/24 at 11:48 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the hospice company faxed or emailed notes to the facility. The DON stated she was not sure how often notes should be sent to the facility. The DON stated hospice staff verbally communicate with the staff. The DON stated the telephone order on 3/1/24, was different from the ones put into resident 119's medical record. The DON stated the physician orders matched her comfort medications. The DON stated if the hospice nurse was onsite, verbal physician orders were entered into the medical record and then orders could be send over. The DON stated nursing staff could call the hospice with concerns. The DON stated there were newer employees that had not worked with us before. On 3/20/24 at 12:31 PM, a follow-up interview was conducted with the DON. The DON stated that the admission assessments for resident 119 were blank but she remembered completing them on 3/5/24, with the floor nurse. The DON stated she was not sure why they were blank. The DON stated the admission assessments should have been completed on 3/1/24, when resident 119 was admitted but she was admitted after 10:00 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 21 was admitted to the facility initially on 8/2/19, and re-admitted on [DATE] with diagnoses that included type 2 diabetes with neuropathy, morbid obesity, dementia with behavioral disturbance, and depressive disorder. Resident 21's medical record was reviewed between 3/11/24 and 3/21/24. A quarterly MDS assessment dated [DATE], revealed resident 21 had a BIMS score of 8, indicating moderate cognitive impairment. Resident 21's care plan focus area, initiated on 2/16/24, revealed, [resident's name redacted] has expressed a need for physical intimacy, such as kissing other residents. He has a dx [diagnosis] of dementia and does not have the capacity to consent to physical intimacy. The goal was, Residents psychosocial need for physical touch/intimacy will be met safely through review date. Interventions included, Assess resident for unmet needs .Provide resident with physical touch PRN [as needed] from staff by providing gentle hand massage .Involve resident in activities of choice (gather personalized suggestions, items, activities, IDT input .Redirect resident when resident is seeking intimacy/affection from other residents (exercise, pet therapy, hand massage, identify possible unmet need). A physician's order initiated on 2/21/24, included, Behavior monitoring: physical intimacy. Notify Management. On 2/21/24, an IDT: Behavioral Health Review was conducted and revealed that in the past three months resident had been Socially Objectionable by kissing multiple female residents in the unit. The review was marked no to resident 21 having sexually inappropriate behavior. The review is marked yes for resident 21 having a change to medications for behavior health reasons. Additional information included, 1:1 [one on one] with the resident due to abuse allegation. Resident has been taking this well. New interventions included, Meeting with SSW and nurse regarding kissing; 1:1 monitoring; Monitoring on sexually inappropriate behaviors; Med [medication] review; and update care plan on his kissing behavior. Resident 21's progress notes were reviewed and revealed the following: a. On 12/12/23 at 4:43 PM, a physician progress note revealed, Reason for visit: acute; Subjective: Asked to evaluate patient as he has been noted to be mutually kissing another resident recently.Provider action: I have spoken with the patient to assess his cognition of the situation. He does have some mild to moderate dementia but is able to answer questions appropriately and appears to have moral aptitude with the situation. He has been friends with the other female resident and it appears she may have a mutual interest. Cognitively he is able to give consent at this time. Will monitor for any change in condition. b. On 12/13/23 at 3:32 PM, a social service progress note revealed, Note text: IDT Note; In attendance: MD, DON, ADON, LCSW [Licensed Clinical Social Worker], WCRN, SWW [sic], RA . MD has assessed this resident. Rt [resident] is cognitively able to consent at this time. Care plan updated. Will continue to monitor for any changes in condition. c, On 1/26/24 at 5:46 PM, an IDT review note revealed, IDT met to review allegation of sexually inappropriate behavior that occurred on 1/15/24. Other resident was immediately redirected. Resident received frequent visits from social services throughout the investigation. Per the alert charting there were no changes from psychosocial baseline and no lasting effects. Attendees: Administrator, ADON, RA, SSW. [It should be noted that there was no documentation of an event of inappropriate sexual behavior in resident 21's progress notes on 1/15/24.] d. On 2/16/24 at 4:37 PM, an IDT review note revealed, IDT to reviewed concern related to Rt and another female resident sharing a peck kiss related to dementia and impaired cognition with inability to safely consent. MD to review medication and adjust appropriately, 1:1 implemented during wake hours. Attendees: ADM, Regional Nurse Consultant, ADON, RA. e. On 2/16/24 at 5:04 PM, a Nurses note revealed, MD ordered to start Depo Provera IM [intramuscular] Q [every] 14 days to help decrease intimate feelings. Family has been notified and approves of the new order. f. On 2/17/24 at 3:32 PM, an Orders-Administration note revealed, Event/alert charting following event, Document every shift until resolved: 1:1 6am-10pm. If resident wakes up during night, staff provide line of site to ensure resident is not seeking physical intimacy, every shift; Resident kissed another resident on the lips. On 3/14/24 at 2:25 PM, an interview was conducted with CNA 8. CNA 8 stated resident 17 was actually the resident who was initiating interactions with resident 21 and he did not reciprocate. CNA 8 stated it was more like a friendship between the two residents and resident 21 was being a gentleman. CNA 8 stated she had not been instructed to keep an eye on any residents or keep any residents apart. On 3/18/24 at 1:00 PM, an interview was conducted with CNA 19. CNA 19 stated resident 17 liked to kiss resident 21 on the lips. CNA 9 stated staff were to do a 1:1 so resident 17 would not kiss resident 21. CNA 19 stated resident 17 was chasing resident 21 and wanted resident 21 to kiss her. CNA 19 stated at first staff thought it was okay. CNA 19 stated since both residents were confused with dementia they were not able to kiss. CNA 19 stated resident 21 and resident 17 had a relationship for about three months. CNA 19 stated she found the residents making out. CNA 19 stated resident 17 and resident 21 kissed on the lips one to two times during her shift. CNA 19 stated resident 17 watched television in resident 21's room. CNA 19 stated resident 21 tried to kiss resident 48 but she refused. CNA 19 stated she tried to re-direct the residents. CNA 19 stated resident 21 had one on one supervision for a couple weeks before resident 17 was discharged . CNA 19 stated resident 41 tried to kiss resident 21. CNA 19 stated resident 41 asked for a kiss from resident 21 and resident 21 would kiss resident 41. CNA 19 stated she re-directed resident 41 when she asked resident 21 to Give me a kiss. CNA 19 stated she re-directed by trying to get the residents minds on other things. CNA 19 stated she saw resident 41 give resident 21 a kiss on the lips a few times. 4. Resident 48 was admitted to the facility initially on 12/21/23, and re-admitted on [DATE] with diagnoses that included dementia with agitation, cognitive communication deficit, chronic kidney disease, anxiety disorder, major depressive disorder, Psychotic disorder with delusions, and insomnia. Resident 48's medical record was reviewed between 3/11/24 and 3/21/24. An admission MDS assessment dated [DATE], revealed that resident 48 had a BIMS score of 4, indicating severe cognitive impairment. Resident 48's care plan included a focus area, initiated on 2/23/24, [resident's name redacted] has expressed a need for physical affection. She has been deemed by the IDT without the capacity to consent to sexual intimacy/expressions r/t [related to] dementia. The goal stated, Residents psychosocial need for physical touch/intimacy will be met safely through review date. Interventions included, Monitor resident's intimacy seeking behaviors to determine a trend, increase or decrease in behavior; Provide resident with physical touch PRN from staff by providing gentle hand massage; Redirect [resident's name redacted] when she is seeking intimacy/affection from other residents (exercise, pet therapy, hand massage, identify possible unmet need). A review of resident 48's progress notes revealed: a. On 1/16/24 at 3:00 PM a physician progress note revealed, Pt was seen by staff kissing another resident. I was asked to evaluate both patients to assess their capacity for safety and awareness, and capacity for such a relationship. While both patients are in our memory care suite, they both appear to understand relationships and have a mutual respect for each other. They do feel safe in their relationship with each other and understand limitations in their relationship at this time. They have the capacity at this time for self determining who they want to be friends with. Both do not feel intimidated or threatened by this relationship and it appears to be a mutual interest. They also understand if they feel any change or feel threatened by the other resident, they can let the staff know for their own safety. Staff will also monitor for any changes and try to maintain safety for each resident. b. On 1/31/24 at 7:08 AM, a Physician Progress Note revealed, Reason for visit: facility requested evaluation .I have spoken with the patient to assess her cognition of the situation. She has poor short term memory due to dementia but is able to answer questions appropriately and appears to have the moral aptitude with the situation. She has been friends with the other male resident. We discussed situations regarding friends and signs of affection. Cognitively she is able to consent at this time. Will monitor for any change in condition. c. On 2/5/24 at 8:48 AM, a Social Service Note revealed, IDT note, in attendance: ADON, WCRN, SSW, RA. MD has assessed this resident on her cognition to be able to consent to kiss another resident. Rt is cognitively able to consent at this time. Care plan updated. Will continue to monitor for any changes. d. On 2/16/24 at 5:41 PM, an IDT event review note revealed, IDT to reviewed concern related to Rt and another male resident sharing a peck kiss related to dementia and impaired cognition with inability to safely consent. Intervention implemented to prevent re-occurrence. Attendees: Admin, Regional nurse consultant, ADON, RA. On 3/13/24 at 12:34 PM, an interview was conducted with RN 3. RN 3 stated she was not aware that there had been any inappropriate interaction between resident 48 and resident 21. RN 3 stated resident 48's behavior was very unpredictable. On 3/14/24 at 1:23 PM, an interview was conducted with MD 2. MD 2 stated his process to determine capacity to consent was to talk with the residents. MD 2 stated he tried to gauge the residents orientation and ability to consent using the resident's history and medical background. MD 2 stated his understanding was that the relationship was consensual for both residents. MD 2 stated he did not recall if he asked the nurses if there had been any distressing interactions on the part of either resident. Regarding resident 48, MD 2 stated she had short term memory issues, but was able to talk about having friends and partners, and was able to discuss hypothetical's for the ability to say yes or no. MD 2 stated if the facility staff were made aware of relationships starting, that included touching or signs of affection, he would be contacted to assess the capacity of the residents. MD 2 stated kissing on the lips meant different things to different people. MD 2 stated that capacity also depended on what might be going on with a resident at the time, such as having a urinary tract infection or other medical issues that may affect cognition. MD 2 stated his instructions for staff would be given verbally while at the facility, or an order would be put into the system. On 3/14/24 at 2:30 PM, an interview was conducted with the SSW. The SSW stated the process for determining the ability to consent was that if there were two residents showing affection toward each other, the staff would notify the physician and both residents were assessed. The SSW stated after the MD assessed the residents, the IDT would meet to review the physician assessment and discuss based on staff observation and knowledge. The SSW stated other factors taken into consideration were the resident's cognitive assessment and BIMS score. The SSW stated the physician deemed that resident 17 was able to have the capacity to consent to a sexual relationship. The SSW stated cognitive assessments and BIMS scores were reviewed. The SSW stated resident 17's BIMS score was a 7, which indicated severe cognitive impairment. The SSW stated she did not remember if the IDT reviewed resident 17 and resident 21's capacity to consent to a sexual relationship and was not sure if the residents had the capacity. On 3/14/24 at 3:23 PM, an interview was conducted with the DON and the Regional Nurse Consultant (RNC). The RNC stated capacity to consent was evaluated through assessments and using the BIMS score. The RNC stated that the physician determined if the a resident was able to have the capacity to consent to a sexual relationship. The RNC stated resident 17 was a cute lady and she went up to resident 21 and would give him a peck on the lips. The RNC stated resident 17 gave resident 21 a peck on the cheek like you would give your mom but it was on the lips. The RNC stated neither resident expressed they wanted to be boyfriend and girlfriend. The DON stated that they had talked about the relationship with the previous DON and the physician was going to assess the relationship. The RNC stated the physician approved the capacity to consent, but after talking with the SSA, there was guidance from the regulations that it was not appropriate. The RNC stated initially the facility did what the physician told them to but then re-evaluated the situation and decided to change care plans and manage it differently. The RNC stated resident 17 was from Hawaii and that was part of her culture to kiss on the lips. The RNC stated the IDT felt resident 17 and resident 21 were able to consent to a friendship relation without inappropriate touching or sexual touching. The RNC stated when resident 17 asked for a kiss from resident 21, resident 48 wanted one also. The RNC stated initially the staff thought that resident 21 was the person initiating the interaction, however, after putting resident 21 on 1:1 monitoring, staff found out that he was not the resident initiating, so they swapped the 1:1 monitoring to the female resident. The RNC stated staff would report what was happening. The RNC stated interventions that were put into place included 1:1 monitoring, education with staff as to what was and was not appropriate, education that interactions that were sexual in nature could be considered abuse among residents that have dementia, and encouraging the activities staff to include more meaningful activities that include touch. The DON stated care planning was completed during the IDT meetings. The DON stated during the meeting staff would also brainstorm as to other ways the needs of the residents could be met. On 3/19/24 at 8:39 AM, an interview was conducted with the Administrator. The Administrator stated she was not the Administrator when resident 17 and resident 21's relationship started. The Administrator stated the RNC was with the Administrator when she found the note that residents had kissed. The Administrator stated she provided training about inappropriate behaviors and about how if resident's did not have the capacity to consent it could be abuse. The Administrator stated the clinical team was in charge of determining capacity to consent to a sexual relationship. The Administrator stated the physician was also involved in determining capacity. The Administrator stated if staff were unable to track psychosocial baseline, unable to determine if they could be effected by it then We can't say they have that capacity. On 3/19/24 at 10:10 AM, an interview was conducted with MD 1. MD 1 stated he obtained information about the ability to consent by chatting with the resident to get an idea of what their cognition was like. MD 1 stated he was told there was an issue with residents on the memory care unit kissing other residents. MD 1 stated he wanted to make sure the residents had the ability to consent for something like that. MD 1 stated he was not asked about giving directions if the relationship progressed. MD 1 stated that he asked resident 21 if he felt he was being taken advantage of and resident 21 stated that he did not. MD 1 stated he did not go as far as asking who was initiating the relationship. MD 1 stated he did not feel hallucinations were involved and the residents had no intention of going further than kissing. MD 1 stated he was unaware of any cultural norms that were held by any of the residents regarding kissing. MD 1 stated he did not inquire about time limitation issues from the residents. MD 1 stated he did not have any concerns about resident 48's history of aggression or level of cognition. The facility policy and procedure for Identifying Sexual Abuse and Capacity to Consent dated September 2023 revealed the following: Policy Statement A resident's consent to sexual activity is not valid if obtained from a resident who lacks the capacity to consent, or if consent was obtained through intimidation, fear or coercion. Policy Interpretation and Implementation 1. 'Sexual abuse' is non-consensual sexual contact of any type with a resident, as defined at 42 CFR §483.5. Sexual abuse includes, but is not limited to: a. unwanted intimate touching of any kind especially of breasts or perineal area; b. all types of sexual assault or battery, such as rape, sodomy, and coerced nudity; c. forced observation of masturbation and/or pornography; and d. taking sexually explicit photographs and/or audio/video recordings of a resident(s) and maintaining and/or distributing them (e.g. posting on social media). This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident. 2. Generally, sexual contact is non-consensual if the resident either: a. appears to want the contact to occur, but lacks the cognitive ability to consent; or b. does not want the contact to occur. 3. Other examples of nonconsensual sexual contact may include, but are not limited to, situations where a resident is sedated, is temporarily unconscious, or is in a coma. 4. Any forced, coerced or extorted sexual activity with a resident, regardless of the existence of a pre -existing or current sexual relationship, is considered to be sexual abuse. 5. The facility will conduct an investigation and protect a resident from non-consensual sexual relations anytime there is reason to suspect that the resident does not wish to engage in sexual activity or may not have the capacity to consent. 6. Not all physical contact involving a resident is considered sexual abuse. Residents have the right to engage in consensual sexual activity and to receive non-sexual physical contact consistent with their preferences. 7. Sexual abuse may occur as: a. staff-to-resident sexual abuse; b. resident-to-resident sexual abuse; c. spouse-to-resident sexual abuse; or d. visitor-to-resident abuse. 8. Except in the rare situation in which an employee and a resident had a pre -existing sexual relationship (i.e., spouse or partner) prior to the resident's admission, engaging in a sexual relationship with a resident, (even an apparently willingly engaged and consensual relationship) is not consistent with the staff member's role as a caregiver and is prohibited. 9. Any sexual relationship between a staff member and a resident with or without diminished capacity may constitute sexual abuse in the absence of a sexual relationship that existed before the resident was admitted to the facility, such as a spouse or partner, and will be thoroughly investigated. Indicators of Potential Sexual Abuse 1. Physical indicators of sexual abuse that would prompt an investigation include (but are not limited to): a. bruises around the breasts, genital area, or inner thighs; b. unexplained sexually transmitted disease or genital infections; c. unexplained vaginal or anal bleeding; and/or d. torn, stained, or bloody underclothing. 2. Psychosocial indicators of sexual abuse may include: a. depression; b. anxiety; c. post-traumatic stress disorder; d. sudden or unexplained changes in behaviors and/or activities, such as: (1) fear or avoidance of a person or place; (2) fear of being left alone; (3) fear of the dark; (4) nightmares; and/or (5) disturbed sleep. Investigating an Allegation of Suspicion of Sexual Abuse 1. For any alleged violation or suspicion of sexual abuse, protective measures and an investigation (pursuant to 42 CFR §483.12 (c)(1)-(4), F609-Reporting of Alleged Violations and F610-Response to Alleged Violations) will begin immediately. These include: a. immediately implementing safeguards to prevent further potential abuse; b. immediately reporting the allegation to appropriate authorities; c. conducting a thorough investigation of the allegation, including the resident's capacity to consent; and d. thoroughly documenting and reporting the result of the investigation of the allegation. 2. During the investigation evidence will be preserved and not tampered with. Examples of tampering include, but are not limited to: a. washing linens or clothing; b. destroying documentation; c. bathing or cleaning the resident until the resident has been examined (including a rape kit, if appropriate); or d. otherwise impeding a law enforcement investigation. 3. The director of nursing services (or designee), in conjunction with the administrator and the QAPI [Quality Assurance and Performance Improvement] committee will determine the facts specific to the case, including: a. whether the resident consented to the sexual activity; and b. whether the resident had the capacity to consent. (1) Determination of capacity is not based on a diagnosis alone. It is evaluated within the context of the situation. (2) Capacity on its most basic level means that a resident has the ability to understand potential consequences and choose a course of action for a given situation. (3) Decisions of capacity to consent to sexual activity balance considerations of safety and resident autonomy, and capacity determinations must be consistent with State law, if applicable. Resident Representatives' Scope of Authority 1. While a legal representative may have been empowered to make some decisions for a resident, it does not mean that the representative is empowered to make all decisions for the resident. a. The individual arrangements for legal representative will be reviewed to determine the scope of authority. b. Any decision-making power that is not legally granted to a representative under state law is retained by the resident. 2. When a resident with capacity to consent to sexual activity and his/her representative disagree about the resident engaging in sexual activity, the facility will honor the resident's wishes irrespective of that disagreement if the representative's legal authority does not address that type of decision -making for sexual activity. 3. If the resident representative's legal authority addresses decision -making for sexual activity, then the facility will honor the resident representative's decision consistent with 42 CFR §483.10(b). 4. If the facility has reason to believe that a resident representative is making decisions or taking actions that are not in the best interests of a resident, the facility shall report such concerns in the manner required under State law. Based on interview and record review, the facility did not develop and implement written policies and procedures that; prohibit and prevent abuse, neglect, and exploitation of residents. In addition, the facility did not established polices and procedures to investigate any such allegations. Specifically, for 4 out of 45 sampled residents, there were residents in the memory care unit that were kissing and did not have a full capacity to consent evaluated. Resident identifiers: 17, 21, 41, and 48. Findings included: The facility provided a form 358 on 2/16/24 at 4:15 PM, to the State Survey Agency (SSA). The form revealed an allegation of sexual abuse. Resident 21 was expressing intimacy with resident 48 with a peck on the lips. The immediate measures were implementing one on one for resident 21 and the physician to assess resident 21 for medication adjustment. The interdisciplinary team (IDT) would establish a new baseline for resident 48 and frequent monitoring from social services. In addition, alert monitoring was implemented for changes in psychosocial baseline. The form 359 was provided to the SSA on 2/23/24 at 10:30 PM. The form revealed the Summary of interviews section that staff concluded resident 21 did not usually approach females in the unit to kiss them. However, resident 17 went up to resident 21 and asked for a kiss. Resident 21 gave her a peck. Resident 41 had sometimes seen this and had requested a kiss from resident 21 as well. Resident 21 had kissed resident 48 occasionally. Staff were able to redirect residents easily. Resident 17 believed that resident 21 was her boyfriend. The allegation was inconclusive Facility is unable to verify or refute the allegation. Throughout the investigation facility did not identify any further physical contact that would raise to the level of inappropriate contact or sexual abuse. Contact between residents consisted of light pecks and very brief contact that did not include sexual activities where one resident indicates that the activity is unwanted through verbal or non-verbal cues. Facility investigation notes no sexual activity, fondling or touching of a persons sexual organs. Facility has intervened as we recognize that this behavior could lead to sexual expression. 1. Resident 17 was admitted to the facility on [DATE] and discharged on 3/1/24 with diagnoses which included unspecified dementia with other behavioral disturbance, cognitive communication deficit, unsteadiness on feet, abnormal postures, adult failure to thrive, major depressive disorder, and insomnia. Resident 17's medical record was reviewed on 3/11/24 through 3/21/24. A Minimum Data Set (MDS) assessment titled Other Payment assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. A care plan dated 12/13/23, revealed [Resident 17] and a male resident are in a companionship (not married)(hold hands, share a kiss). [Resident 17] has a diagnosis of dementia and been assessed by the MD [Medical Doctor] and IDT to have capacity to consent to holding hands and kissing. The goal was [Resident 17's] psychosocial needs in relation to companionship/holding hands/ kissing will be met safely though review date. Interventions included Reassess resident's capacity for consent to companionship/holding hands/kissing quarterly; Resident at increased risk for potential Abuse related to decreased cognition; Resident will not have unaddressed signs and symptoms of Abuse; Follow Abuse Protocol if Allegations are made; Frequent visits from social services; and Monitor for Behavior Changes. On 12/11/23 at 3:28 PM, Late entry Social Service Note revealed missing part of prog [progress] note MD to assess residents for the ability to consent. Activities informed and requested to provide activities that include meaningful touch. On 12/11/23 at 9:40 AM, a Social Service Note revealed IDT Note In attendance: Admin [Administrator], DON [Director of of Nursing], AIT [Administrator in Training], ADON [Assistant Director of Nursing], WCRN [Wound Care Registered Nurse], RA [Resident Advocate], SSW [Social Service Worker], Activities. IDT met to discuss this resident and another resident kissing. Neither residents were in distress, both residents appeared to engage in the kiss. A Physician's progress note dated 12/12/23 at 4:44 PM, documented Visit type: Acute Visit - . [resident 17] is a [AGE] year old female at [name of facility] . Subjective: Asked to evaluate patient as she has been noted to be mutually kissing another resident recently . Assessment/Plan Disability Weakness Risk of malnutrition Poor memory Wandering . Dementia/Alzheimer's disease with behaviors, . h/o [history of] encephalopathy, PSYCH, Auditory hallucinations, Insomnia .Provider action: I have spoken with the patient to assess her cognition of the situation. He [sic] does have moderate dementia but is able to answer questions appropriately and appears to have a grasp on the situation. She has been friends with the other male resident and it appears he may have a mutual interest. She understands her own moral standards and what she is willing to do. Cognitively she is able to give consent at this time. Will monitor for any change in condition. On 3/13/24 at 10:03 AM, an interview was conducted with Certified Nursing Assistant (CNA) 8. CNA 8 stated resident 17 was independent when she was admitted to the memory care unit. CNA 8 stated weeks later resident 17 needed assistance with cleaning herself. CNA 8 stated resident 17 was a hoard[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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, food and drinks were observed to be uncovered when being delivered to resident rooms. Findings included: 1. On 3/11/24 at 11:45 AM, an observation was made of the lunch meal cart on the North Rehab hallway. The lunch meal cart was parked next to resident room [ROOM NUMBER]. a. At 11:47 AM, a meal tray was delivered to room [ROOM NUMBER]. The dessert was uncovered. b. At 11:47 AM, a meal tray was delivered to room [ROOM NUMBER]. The dessert was uncovered. c. At 11:48 AM, a meal tray was delivered to room [ROOM NUMBER]. The dessert was uncovered. d. At 11:49 AM, a meal tray was delivered to room [ROOM NUMBER]. The drinks were uncovered. e. At 11:50 AM, a meal tray was delivered to room [ROOM NUMBER]. The dessert was uncovered. 2. On 3/11/24 at 12:07 PM, an observation was made of the lunch meal cart on the South Rehab hallway. The lunch meal cart was parked next between resident room [ROOM NUMBER] and 152. a. At 12:08 PM, a meal tray was delivered to room [ROOM NUMBER]. The dessert was uncovered. b. At 12:08 PM, a meal tray was delivered to room [ROOM NUMBER]. The dessert and drink were uncovered. c. At 12:09 PM, a meal tray was delivered to room [ROOM NUMBER]. The dessert and drink were uncovered. d. At 12:10 PM, a meal tray was delivered to room [ROOM NUMBER]. The dessert and drinks were uncovered. e. At 12:11 PM, a meal tray was delivered to room [ROOM NUMBER]. The dessert and drinks were uncovered. f. At 12:12 PM, a meal tray was delivered to room [ROOM NUMBER]. The dessert and drink were uncovered. 3. On 3/11/24 at 12:15 PM, an observation was made of the lunch meal cart on the [NAME] Rehab hallway. The lunch meal cart was parked next to resident room [ROOM NUMBER]. a. At 12:17 PM, a meal tray was delivered to room [ROOM NUMBER]. The dessert and drink were uncovered. 4. On 3/12/24 at 11:50 AM, an observation was made of Certified Nursing Assistant (CNA) 12 passing trays on the South Rehab hallway. a. At 11:50 AM, a meal tray was delivered to room [ROOM NUMBER]. The drink was uncovered. b. At 12:12 PM, a meal tray was delivered to room [ROOM NUMBER]. The dessert was uncovered. c. At 12:13 PM, a meal tray was delivered to room [ROOM NUMBER]. The dessert was uncovered. d. At 12:15 PM, a meal tray was delivered to room [ROOM NUMBER]. The dessert was uncovered. e. At 12:21 PM, an observation was made of CNA 15. CNA 15 was observed transporting a meal tray through the nursing station the full length of the South Rehab hallway with the dessert uncovered and delivered to room [ROOM NUMBER]. f. At 12:22 PM, an observation was made of CNA 16. CNA 16 was observed transporting a meal tray through the nursing station the full length of South Rehab hallway with the dessert uncovered and delivered to room [ROOM NUMBER]. 5. On 3/12/24 at 12:14 PM, an observation was made of CNA 1 passing trays on the Colonial hallway during the lunch meal. The meal cart was parked between resident room [ROOM NUMBER] and 249. a. At 12:14 PM, a meal tray was delivered to room [ROOM NUMBER]. The dessert was uncovered. b. At 12:15 PM, a meal tray was delivered to room [ROOM NUMBER]. The dessert was uncovered. c. At 12:16 PM, a meal tray was delivered to room [ROOM NUMBER]. The dessert was uncovered. d. At 12:17 PM, a drink was delivered to room [ROOM NUMBER] uncovered. e. At 12:19 PM, a meal tray was delivered to room [ROOM NUMBER]. The dessert was uncovered. f. At 12:21 PM, a meal tray was delivered to room [ROOM NUMBER]. The dessert was uncovered. 6. On 3/13/24 at 7:43 AM, an observation was made of CNA 12 passing trays during the breakfast meal. The meal cart was parked next to resident room [ROOM NUMBER]. a. At 7:44 AM, a meal tray was delivered to room [ROOM NUMBER]. The drink was uncovered. b. At 7:46 AM, a meal tray was delivered to room [ROOM NUMBER]. The drink was uncovered. c. At 7:47 AM, a meal tray was delivered to room [ROOM NUMBER]. The drink was uncovered. d. At 7:49 AM, a meal tray was delivered to room [ROOM NUMBER], which was in a different hallway from where the meal cart was parked. The drink was uncovered. 7. On 3/13/23 at 8:03 AM, an observation was made the breakfast meal cart on the Colonial hallway. The meal cart was parked between resident room [ROOM NUMBER] and 243. a. At 8:16 AM, a meal tray was delivered to room [ROOM NUMBER]. The fruit cup on the tray was uncovered On 3/20/24 at 12:28, an interview with the Dietary Manager (DM) was conducted. The DM stated that her expectation for delivering food to resident rooms was to have all the food covered. The DM stated that the main meal was covered with a heavy-duty cover, and all desserts and fruits should be covered. The DM stated there was a drink cart where staff should either be pouring drinks right outside a resident's room and then delivered to that room, or, have the drinks covered if staff were walking throughout the hallway with the drinks. The DM stated that if condiments were not already in a prepared packet, then the condiments must be in a contained lid.

**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 SARS-COV-2, also referred to as COVID-19. Specifically, two facility staff members developed symptoms of COVID-19 and did not report the symptoms to the facility. One of the staff members tested positive for COVID-19 and did not report the positive test result to the facility, and one of the staff members continued to work after developing symptoms and did not utilize source control. Resident 58, who had contact with the symptomatic staff member. subsequently tested positive for COVID-19. Additionally, a staff member was observed transporting dirty linens in the facility without ensuring the linens were covered. Resident identifier: 58. Findings included: 1. On 3/19/24 at 2:49 PM, an interview was conducted with Certified Nursing Assistant (CNA) 12. CNA 12 stated that the CNA Coordinator went home sick with COVID-19. On 3/19/24 at 6:31 PM, the State Survey Agency received a phone call from the Administrator (Admin). The Admin stated a resident had tested positive in the facility. Resident 58 was admitted on [DATE] and again on 10/8/23 with diagnoses which include displaced fracture of surgical neck of right humerus, type 2 diabetes mellitus, alcoholic cirrhosis of liver, chronic respiratory failure, infection and inflammatory reaction due to internal left knee prosthesis, pain, hemiplegia and hemiparesis, dysphagia, difficulty in walking, pain in left hip, muscle weakness, unsteadiness on feet, repeated falls, low back pain, essential hypertension, sleep related hypoventilation, glaucoma, hemorrhoids, hyperlipidemia, anxiety disorder, and depression. Resident 58's medical record was reviewed on 3/11/24 through 3/22/24. On 3/19/24 at 6:14 PM, a Nurses Progress Note for resident 58 revealed the following: Due to resident possible exposure to Covid, she was tested. Result was positive. Resident placed in isolation. On 3/20/24 at 7:55 AM, an observation was made of the facility entrance. There was no signage informing the public that COVID-19 was in the facility. There was no PPE available for the public when entering the facility. At 10:00 AM, an observation was made of the facility entrance. There was a sign that revealed there was a COVID-19 positive case in the facility. On 3/20/24 at 1:18 PM, an interview was conducted with the CNA Coordinator. The CNA Coordinator stated she started getting a runny nose on 3/17/24. The CNA Coordinator stated she was not worried about a runny nose, thinking it was allergies, and came to work at the facility. The CNA Coordinator stated she did not wear a mask while in the facility. The CNA Coordinator stated she did not believe she needed to test for COVID-19 it was the Admin that instructed the need for COVID-19 testing. The CNA Coordinator stated she shared an office with the Minimum Data Set (MDS) Coordinator, and the Admin informed her that the MDS Coordinator tested positive for COVID-19. The CNA Coordinator stated she tested positive for COVID-19 on 3/19/24 at approximately 10:00 AM. The CNA Coordinator stated that she was in contact with the Admin providing a list of residents she had contact with for more than 15 minutes. On 3/20/24 at 1:56 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated she was working in the facility on 3/14/24, after she had left for the day she started experiencing symptoms of illness. The MDS Coordinator stated on 3/15/24 at approximately 9:00 AM, she self-tested positive for COVID-19. The MDS Coordinator stated that she was not scheduled to work on 3/15/24, and did not come into the facility after experiencing symptoms of COVID-19. On 3/20/24 at 2:08 PM, an observation was made of room [ROOM NUMBER] assigned to resident 58. room [ROOM NUMBER] was observed to have PPE outside of the room with a Droplet Precautions sign posted on the door. On 3/21/24 at 07:56 AM, an observation was made of the facility entrance. A sign was posted on the outside informing the public that COVID-19 was in the facility. Another observation was made that PPE was not available at the main door or at the reception desk. At 1:55 PM, an observation was made of the reception area. There was a box of surgical masks located on the front desk. On 3/21/24 at 8:38 AM, an interview was conducted with RN 7. RN 7 stated that the facility did make her aware of an outbreak of COVID-19 in the facility. RN 7 stated that resident 58 was assigned to her, resident 58 was COVID-19 positive, and was instructed to don PPE prior to entering the room. On 3/21/24 at 10:31 AM, an interview with the AD and TRT was conducted. Both the AD and TRT stated that they received a group text on the evening of 3/19/24, from the facility letting them know they would need to be tested for COVID-19. The AD and TRT stated on 3/20/24 at 7:46 AM, they received another text message informing them a resident test COVID-19 positive in the facility. The AD stated, that resident 58 was the resident that tested positive for COVID-19. The AD stated, resident 58 was in attendance of activities on 3/19/24, with 17 other residents. The AD stated, that she had heard of two staff members who also tested positive for COVID-19. The AD and TRT stated the only instructions given regarding COVID-19 by the facility was full PPE was needed to go into resident 58's room. On 3/21/24 at 10:44 AM, an interview was conducted with RN 2. RN 2 stated the facility policy for residents exposed to COVID-19, start with precautions and testing. RN 2 stated until further results from exposed residents, N95 masks should be worn when residents were out of their room or until the DON cleared the resident. RN 2 stated he would notify the DON or Administrator regarding COVID-19 status and the DON would contact the provider to determine the length of precautions. RN 2 stated if a resident tested positive for COVID-19, the facility would put the resident in isolation. RN 2 stated if a staff member was exposed to COVID-19, the staff member would inform the DON of possible exposer. RN 2 stated the DON would want to know the status of COVID-19 testing, a positive test staff member should stay away from the facility for 7 to 10 days. If staff tested negative but was still exposed, the management might tell the staff to wear a mask for a determined number of days. On 3/21/24 at 12:58 PM, an interview was conducted with the Infection Preventionist (IP). The IP stated she was assigned to the facility to be the IP and was overseen by the DON, who has completed the IP certification. The IP stated when the CNA Coordinator tested positive for COVID-19 on 3/17/24, it was determined that anyone she had close contact with would get tested for COVID-19. The IP stated close contact was defined as, within six feet and spent 15 minutes or longer with a person who tested positive for COVID-19. The IP stated resident 58 was identified to have had close contact with the CNA Coordinator, resident 58 tested positive for COVID-19. The IP stated resident 58 was placed in isolation, placed signs on her door, placed PPE outside of the room for staff, and the physician was contacted. The IP stated the facility had been following their policy and the most recent guidelines from the Center of Disease Control (CDC) regarding COVID-19. The IP stated the regional nurses follow any updates from the CDC and would forward the information to the facilities. The IP stated the protocol for anyone exposed to COVID-19 would be tested on the first, third, and fifth day of exposure. The IP stated currently only those that had close contact with COVID-19 positive staff or residents would be tested not the whole facility. The IP stated any staff exposed to COVID-19 that tested negative or was asymptomatic would not need to wear a mask. The IP stated the Admin would be the one to contact the County Health Department when an outbreak of COVID-19 occurred. The IP stated the Admin had not contacted the County Health Department at that moment. The IP stated COVID-19 acknowledgment was not placed on the facility's entrance until the morning of 3/20/24, and reaffirmed resident 58 tested positive the evening of 3/19/24. On 3/21/24 at approximately 2:00 PM a follow-up interview was conducted with the IP. The IP stated the Admin was contacting the local Health Department right now. The IP stated when discussing with management it was determined any COVID-19 outbreak should be reported within 24 hours. A review of the Infection Prevention and Control Program revised February 2024 revealed the following: Outbreak management is a process that consists of: Determining the presence of an outbreak; Managing the affected residents; Preventing the spread to other residents; Documenting information about the outbreak; Reporting the information to appropriate public health authorities; Educating the staff and the public; Monitoring for recurrences; Reviewing the care after the outbreak has subsided; Recommending new or revised policies to handle similar events in the future. Important facets of infection prevention include: Identifying possible infections or potential complications of existing infections; Instituting measures to avoid complications or dissemination; Educating staff and ensuring that they adhere to proper techniques and procedures; Communicating the importance of standard precautions and cough etiquette to visitors and family members; Enhancing screening for possible significant pathogens; Immunizing residents and staff to try to prevent illness; Implementing appropriate isolation precautions when necessary; Following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). According to the Center for Disease Control updated 9/23/22, the Return to Work Criteria for HCP [Healthcare Professional] Who Were Exposed to Individuals with Confirmed SARS-CoV-2 [COVID-19] Infection. Higher-risk exposures are classified as HCP who had prolonged close contact with a patient, visitor, or HCP with confirmed COVID-19 infection and: HCP was not wearing a respirator (or if wearing a facemask, the person with SARS-CoV-2 infection was not wearing a cloth mask or facemask) HCP was not wearing eye protection if the person with SARS-CoV-2 infection was not wearing a cloth mask or facemask HCP was not wearing all recommended PPE (i.e., gown, gloves, eye protection, respirator) while present in the room for an aerosol-generating procedure Following a higher-risk exposure, HCP should: Have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Follow all recommended infection prevention and control practices, including wearing well-fitting source control, monitoring themselves for fever or symptoms consistent with COVID-19, and not reporting to work when ill or if testing positive for SARS-CoV-2 infection. Any HCP who develop fever or symptoms consistent with COVID-19 should immediately contact their established point of contact (e.g., occupational health program) to arrange for medical evaluation and testing. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html 2. On 3/21/24 at 9:43 AM an observation was made of CNA 3. CNA 3 was observed walking the North Rehab hallway through the common area near the television to the soiled linen closet with linens that wear uncovered. On 3/21/24 at 10:03 AM an interview was conducted with the HKS. The HKS stated when transporting any type of laundry, the laundry needed to be covered or bagged. The HKS stated for example if a CNA came down to the laundry area and requested sheets the laundry staff would put the sheets in a bag for the CNA and hand them to the CNA. On 3/21/24 at 10:10 AM, an interview was conducted with CNA 3. CNA 3 stated the policy for transporting linens throughout the facility was to have all laundry bagged for clean and dirty linens. CNA 3 stated with dirty laundry you want to make sure it was bagged as not to containment and not to have other residents to see the dirty laundry as it was transported.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 52 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included intracranial injury, dementia, diabetes mellitus type II, and depression. Resident 52's medical record was reviewed 9/11/23 through 9/18/23. A nurse's note dated 8/30/23 at 2:11 AM, indicated at approximately 7:40 PM on 8/29/23 .this nurse was at the med cart by the nurses station when I heard a commotion. I turned and saw other resident [resident 43] with his right hand raised in a fist swinging it in an attempt to hit [resident 52]. I did not actually see the other resident strike [resident 52]. This nurse and other med pass nurse immediately ran towards residents and the other resident [resident 43] was immediately moved away from [resident 52]. [resident 52] then stated he hit me and pointed to his left forearm. [resident 52] was assessed and no visible marks were noted tohis [sic] arm, he denied pain to area and when asked if he was ok he stated I'm ok. Both resident's were sitting next to each other in the common area watching t.v at the time with no previous exchanges between residents leading up to the incident. [Resident 52] stayed in the common area by nurses station watching t.v where staff continued to monitor him and making sure he was ok until he decided he was ready for bed. DON, father [name omitted] and MD were notified. An Interdisciplinary Team (IDT) Review dated 8/30/23 at 9:37 AM indicated, IDT event review for resident to resident incident 8/29 at 19:40. RA (resident advocate) and SSW (Social Services Worker) to assess resident. Least restrictive interventions in place. Will continue to monitor. Continue with plan of care. An Incident Report dated 8/29/23 indicated that resident 52 was alert and oriented to person and situation. The report further indicated that no injuries were observed, no predisposing environmental factors were identified, no predisposing physiological factors were identified, no predisposing situation factors were identified, and that there were no witnesses of the incident. The report further indicated that the DON was notified on 8/29/23 at 7:45 PM. Resident 52's care plan indicated, [resident 52] is at increased risk for potential abuse/ unwanted attention. [resident 52] will not receive any unwanted attention or verbal or physical aggression from other residents q day. On 9/13/23 at 2:47 PM, an interview was conducted with the DON. The DON stated that allegations of abuse included if a resident stated they were hit by another resident. The DON stated she reviewed the nurse's note from 8/30/23 at 2:11 AM and interviewed the author of the nurse's note, RN 5. The DON stated the investigation conducted by the facility was completed and reviewed by the interdisciplinary team and it was concluded that the incident was not reportable. The DON stated resident 52 was alert and oriented and does not have a history of making false allegations. The DON stated abuse allegations, witnessed or not, should be reported and investigated. On 9/14/23 at 12:38 PM, a telephone interview was conducted with RN 5. RN 5 stated she heard an individual yell, hey, and that she ran over and separated resident 52 and resident 43. RN 5 stated she saw resident 43 with his hand up, but she did not witness resident 52 being hit. RN 5 further stated that resident 52 alleged resident 43 hit him. RN 5 stated resident 52 is alert and oriented. On 9/14/23 at 1:06 PM, an interview was conducted with the RA. The RA stated the resident-to-resident altercation was discussed at the interdisciplinary team meeting. The RA stated she interviewed resident 52 and that he has a hard time forming sentences. The RA stated resident 52 stated it did not hurt and that resident tapped his arm to show her what resident 43 did to him. The RA further stated that resident 52 indicated that resident 43 was trying to get his attention. The RA stated that resident 43 had the ability to remember things. The facility's policy on Coordinating/Implementing Abuse, Neglect and Exploitation Policies and Procedures documented that the policy was in place to prohibit and prevent resident abuse, neglect, exploitation and misappropriation of resident property, to establish processes to investigate allegations, to implement staff training, and to coordinate with the Quality Assurance and Performance Improvement (QAPI) committee. The policy stated that the administrator had the overall responsibility for the coordination and implementation of the facility policy and procedures. It should be noted that the policy did not state the process to investigate allegations of abuse, neglect or misappropriation of resident property, or when and who to notify of those allegations. The policy was last revised in April 2021. Based on observation, interview, and record review, it was identified that the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency. Specifically, an entity report for 3 separate allegations of abuse were not submitted to the State Survey Agency within 2 hours after the allegations were identified. Resident identifiers: 11, 43, and 52. Findings include: 1. Resident 11 was admitted to the facility on [DATE] with diagnoses which included right and left hand contractures, moderate malnutrition, hypothyroidism, dementia, paranoid schizophrenia, panic disorder, major depressive disorder and chronic pain syndrome. The exhibit 358 revealed that staff became aware of the incident on 9/4/23 at an unknown time. The exhibit revealed that resident 11 alleged, The hospice nurse is mean and hurt her fingers. Immediate action to protect resident was documented as, Alleged perpetrator has been blocked from the facility. On 9/11/23 at 11:23 AM, an interview was conducted with resident 11. Resident 11 stated the hospice nurse does come in to see her and take care of her. Resident 11 stated, she just did not want to remember it, then stated the hospice nurse still comes in to see her. Resident 11 stated the hospice nurse did hurt her but she did not want to remember where she hurt her. Resident 11 was observed to get agitated with the interview and closed her eyes and would not answer any more questions. Resident 11's medical record was reviewed 9/11/23 through 9/18/23. A progress note dated 9/6/23 at 15:45 (3:45 PM) revealed, IDT (Interdisciplinary Team) Review: IDT event review for alleged abuse on 9/4. Incident was reported to mgmt (management) on 9/6. Resident stated that hospice nurse was mean and hurt her fingers. Alert charting initiated for psychosocial changes from baseline. Hospice contacted and alternate nursing team will be sent in pending investigation. Floor nurse did assessment for pain or injury. None noted at this time. Will continue to monitor. On 9/14/23 at 11:59 PM, a telephone interview was conducted with Hospice Registered Nurse (RN) 4. RN 4 stated she had taken care of resident 11 for the past 6 months. RN 4 stated she was not in the facility and did not provide cares to resident 11 on the day of the incident. RN 4 stated she had been in the facility to care for resident 11 on 9/8/23 (time unknown) and 9/13/23 at 11:00 AM and had not provided nail care during these visits to resident 11. RN 4 stated she was informed of the incident by her supervisor but she was never asked to not provide care to resident 11 or to not enter the facility. On 9/14/23 at 12:18 PM, a telephone interview was conducted with Hospice Certified Nursing Assistant (CNA) 5. CNA 5 stated she cared for resident 11. CNA 5 stated she would always have another facility aide in the room with her to assist with moving resident 11. CNA 5 stated she took care of resident 11 on 9/4/23 and stated that she asked resident 11 if she could file her nails but resident 11 refused. CNA 5 stated she did remember that someone from the facility had called her and asked if something had happened to resident 11's hands but they never asked her to not enter the building or to not take care of resident 11. CNA 5 stated she had been in the facility and cared for resident 11 on 9/12/23.2. Resident 43 was admitted to the facility on [DATE] with diagnoses which consisted of intracranial injury with loss of consciousness, hemiplegia, Alzheimer's disease, osteoarthritis, major depressive disorder, insomnia, benign prostatic hypertrophy, and history of malignant neoplasm of the skin. Resident 43's medical record was reviewed 9/11/23 through 9/18/23. On 8/23/23, the Quarterly Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 00, which would indicate severe cognitive impairment. The assessment documented that resident 43 was an extensive 1 person assist for bed mobility, transfer, locomotion on and off the unit, dressing, toilet use, and personal hygiene. Review of the resident 43's progress notes revealed the following: a. On 8/26/2023 at 5:31 AM, the progress note documented, Before resident went to sleep on 8/25/23, he was touching one of the female resident's thighs and trying to fight another resident. No one was hurt during the encounter. Resident was separated from other residents and went to bed and fell asleep for the night. Will continue to monitor. It should be noted that the progress note did not document who the licensed nurse was that authored the note. b. On 8/30/2023 at 1:36 AM, the nurse note documented, At around 1940 [7:40 PM] this evening this nurse was at the med cart at the nurses station when I heard a commotion, I turned and saw [resident 43] with his right hand raised in a fist and swinging it in an attempt to hit another resident. I did not see [resident 43] actually strike the other resident, but the other resident did report that [resident 43] did in fact hit his left forearm. Both resident's were sitting in the common area at the time sitting next to each other watching t.v. [television] PT [patient] had just sat [resident 43] next to resident a few minutes prior and there were no other exchanges between residents leading up to the incident. This nurse and other med pass nurse immediately ran towards both residents and intervened. [Resident 43] was immediately removed from next to the other resident. When asked why he hit the other resident, [resident 43] stated ' I didn't hit ' . [Resident 43] was then taken down to activities room by CNA where CNA reported they played basketball and did other activities before [resident 43] was then brought back to his room and put to bed. [Resident 43] continued on Q [every]15 minute checks. DON, POA [Power of Attorney's name omitted], and MD [Medical Director] were notified. Review of the facility abuse investigations revealed no documentation of an investigation for the incident on 8/25/23 between resident 43 and an unknown female resident or the incident on 8/30/23. No documentation could be found that the SSA or Adult Protective Services (APS)were notified of either incidents. On 9/14/23 at 9:26 AM, a follow-up interview was conducted with the DON. The DON stated that the incident on 8/25/23 with resident 43 and an unknown female resident should have been reported to her and she was not aware of the incident prior to the SSA bringing it to her attention. On 9/14/23 at 9:58 AM, the Administrator (ADM) stated that he was never informed of the incident on 8/25/23 between resident 43 and an unknown female resident and he was starting the abuse investigation today.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 52 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included intracranial injury, dementia, diabetes mellitus type II, and depression. Resident 52's medical record was reviewed 9/11/23 through 9/18/23. A nurse's note dated 8/30/23 at 2:11 AM indicated at approximately 7:40 PM on 8/29/23 .this nurse was at the med cart by the nurses station when I heard a commotion. I turned and saw other resident [resident 43] with his right hand raised in a fist swinging it in an attempt to hit [resident 52]. I did not actually see the other resident strike [resident 52]. This nurse and other med pass nurse immediately ran towards residents and the other resident [resident 43] was immediately moved away from [resident 52]. [Resident 52] then stated he hit me and pointed to his left forearm. [resident 52] was assessed and no visible marks were noted tohis [sic] arm, he denied pain to area and when asked if he was ok he stated I'm ok. Both resident's were sitting next to each other in the common area watching t.v at the time with no previous exchanges between residents leading up to the incident. [Resident 52] stayed in the common area by nurses station watching t.v where staff continued to monitor him and making sure he was ok until he decided he was ready for bed. DON, father [name omitted] and MD were notified. An IDT Review dated 8/30/23 at 9:37 AM indicated, IDT event review for resident to resident incident 8/29 at 19:40. RA and SSW (Social Services Worker) to assess resident. Least restrictive interventions in place. Will continue to monitor. Continue with plan of care. An Incident Report dated 8/29/23 indicated that resident 52 was alert and oriented to person and situation. The report further indicated that no injuries were observed, no predisposing environmental factors were identified, no predisposing physiological factors were identified, no predisposing situation factors were identified, and that there were no witnesses of the incident. The report further indicated that the DON was notified on 8/29/23 at 7:45 PM. No further investigative documentation regarding resident 52's allegation of abuse on 8/29/23 was provided. Resident 52's care plan indicated, [Resident 52] is at increased risk for potential abuse/ unwanted attention. [resident 52] will not receive any unwanted attention or verbal or physical aggression from other residents q day. On 9/13/23 at 2:47 PM, an interview was conducted with the DON. The DON stated that allegations of abuse included if a resident stated they were hit by another resident. The DON stated she did not notify the Administrator when she was first notified, the night of the incident, because RN 5 did not relay the correct information to her. The DON stated she reviewed RN 5's nurse's note when she arrived at the facility, the morning after the incident occurred, and then notified the Administrator. The DON stated that she did not know if the date or time the notification to the Administrator was documented. The DON stated she interviewed the author of the nurse's note, RN 5. The DON stated the interview with RN 5 should have been documented. The DON stated the investigation conducted by the facility was completed and reviewed by the interdisciplinary team and it was concluded that the incident was not reportable. The DON stated resident 52 was alert and oriented and does not have a history of making false allegations. The DON stated abuse allegations, witnessed or not, should be reported and investigated. On 9/14/23 at 12:38 PM, a telephone interview was conducted with RN 5. RN 5 stated she heard an individual yell, hey, and that she ran over and separated resident 52 and resident 43. RN 5 stated she saw resident 43 with his hand up, but she did not witness resident 52 being hit. RN 5 further stated that resident 52 alleged resident 43 hit him. RN 5 stated resident 52 is alert and oriented. On 9/14/23 at 1:06 PM, an interview was conducted with the RA. The RA stated the resident-to-resident altercation was discussed at the interdisciplinary team meeting. The RA stated she interviewed resident 52 and that he has a hard time forming sentences. The RA stated resident 52 stated it did not hurt and that resident tapped his arm to show her what resident 43 did to him. The RA further stated that resident 52 indicated that resident 43 was trying to get his attention. The RA stated that resident 52 had the ability to remember things. The facility's policy on Coordinating/Implementing Abuse, Neglect and Exploitation Policies and Procedures documented that the policy was in place to prohibit and prevent resident abuse, neglect, exploitation and misappropriation of resident property, to establish processes to investigate allegations, to implement staff training, and to coordinate with the Quality Assurance and Performance Improvement (QAPI) committee. The policy stated that the administrator had the overall responsibility for the coordination and implementation of the facility policy and procedures. It should be noted that the policy did not state the process to investigate allegations of abuse, neglect or misappropriation of resident property, or when and who to notify of those allegations. The policy was last revised in April 2021. Based on interview and record review it was determined, for 3 of 33 sampled residents, that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility did not have evidence that all alleged violations were thoroughly investigated. Specifically, alleged perpetrators were allowed access to a victimized resident during an ongoing investigation. Additionally, allegations of physical, sexual, and verbal abuse were not thoroughly investigated to determine if abuse occurred. Resident identifiers: 11, 43 and 52. Findings include: 1. Resident 11 was admitted to the facility on [DATE] with diagnoses which included right and left hand contractures, moderate malnutrition, hypothyroidism, dementia, paranoid schizophrenia, panic disorder, major depressive disorder and chronic pain syndrome. The exhibit 358 revealed that staff became aware of the incident on 9/4/23 at an unknown time. The exhibit revealed that resident 11 alleged, The hospice nurse is mean and hurt her fingers. Immediate action to protect resident was documented as, Alleged perpetrator has been blocked from the facility. The exhibit 359 revealed that Per interview [resident 11] stated that hospice was mean to her and bent her fingers back and does not know when this took place. Resident [11] stated that she feels safe staying at the facility and the staff takes (sic) good care of her. A summary on interviews of the staff revealed, Hospice nurse stated she was not present during the time of question. She reported that [resident 11] does not like her nails to be trimmed, as well as not liking other cares at times, which can result in her being tearful at the times she doesn't like the cares. Nurse had nothing concerning brought to her attention concerning [resident 11]. Resident 11's Brief Interview of Mental Status (BIMS) revealed moderately impaired cognition with diagnoses of dementia, schizophrenia and mood disturbance. The allegation was not verified, Facility is unable to verify abuse. There was no intent to harm resident, hospice nurse uses wash cloths to protect her hands from contractures. No residual s/s (signs/symptoms) of psychosocial distress noted in resident. On 9/11/23 at 11:23 AM, an interview was conducted with resident 11. Resident 11 stated the hospice nurse comes in to see her and take care of her. Resident 11 stated she just did not want to remember it, then stated the hospice nurse still comes in to see her. Resident 11 stated the hospice nurse did hurt her but she did not want to remember where she hurt her. Resident 11 was observed to get agitated with the interview and closed her eyes and would not answer any more questions. Resident 11's medical record was reviewed 9/11/23 through 9/18/23. Progress note on 9/6/2023 at 15:45 (3:45 PM) revealed, IDT (Interdisciplinary Team) Review: IDT event review for alleged abuse on 9/4. Incident was reported to mgmt (management) on 9/6. Resident stated that hospice nurse was mean and hurt her fingers. Alert charting initiated for psychosocial changes from baseline. Hospice contacted and alternate nursing team will be sent in pending investigation. Floor nurse did assessment for pain or injury. None noted at this time. Will continue to monitor. On 9/14/23 at 11:59 PM, a telephone interview was conducted with Registered Nurse (RN) 4. RN 4 stated she had taken care of resident 11 for the past 6 months. RN 4 stated she was not in the facility or did not provide cares to resident 11 on the day of the incident. RN 4 stated she had been in the facility to care for resident 11 on 9/8/23 (unknown time) and 9/13/23 at 11:00 AM and had not provided nail care during these visits to resident 11. RN 4 stated she was informed of the incident by her supervisor but she was never asked to not provide care to resident 11 or to not enter the facility. On 9/14/23 at 12:18 PM, a telephone interview was conducted with Certified Nursing Assistant (CNA) 5. CNA 5 stated she cared for resident 11. CNA 5 stated she would always have another aide in the room with her to assist with moving resident 11. CNA 5 stated she took care of resident 11 on 9/4/23 and stated that she asked resident 11 if she could file her nails but she refused. CNA 5 stated she did remember someone from the facility called her to ask if something happened to resident 11's hands but they never asked her to not enter the building or to not take care of resident 11. CNA 5 stated she had been in the facility and cared for resident 11 on 9/12/23. Hospice notes were reviewed and revealed that on 9/6/23 CNA 5 was in the facility and provided cares for resident 11. [Note: The investigation for resident 11 was not completed or submitted until 9/13/23 at 2:48 PM. This was after both hospice employees had been in the facility two times since the alleged incident.] On 9/14/23 at 10:16 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the hospice nurses were supposed to sign in at the front desk when they entered the building. On 9/18/23 at 1:33 PM, a follow up interview was conducted with the DON. The DON stated the Administrator in Training (AIT) contacted someone at the corporate office of the hospice company and asked them not to send the alleged perpetrators into the facility. The DON stated they ensured that the hospice employees did not enter the building by asking them not to come. The DON stated the hospice company did not use the facilities charting system and that they do not need a badge to enter the building. The DON stated the alleged perpetrators should not have been in the building during the investigation and that she would talk with the hospice company about this. The DON stated they kept the residents safe by telling the hospice company not to allow the alleged perpetrators into the building while the investigation was ongoing. The DON stated they determined the abuse was not verified because resident 11 told multiple people, accused the hospice nurse (who was not in building during the allegations), then she accused the hospice aide, then she accused the facility staff. The DON stated the only problem was resident 11 holds her hand with her fingers curled in and digs into the skin on the palms of her hands. Hospice will cut her nails really short to help prevent skin breakdown. Resident 11 does not like this. If she was made to do something she does not want to do, she will get upset and decide that she hated the staff. Sometimes they put washcloths in her hands to prevent skin damage. Resident 11 has had contractures since admit. The DON stated that PT (Physical Therapy) should assess this upon admit. 2. Resident 43 was admitted to the facility on [DATE] with diagnoses which consisted of intracranial injury with loss of consciousness, hemiplegia, Alzheimer's disease, osteoarthritis, major depressive disorder, insomnia, benign prostatic hypertrophy, and history of malignant neoplasm of the skin. Resident 43's medical record was reviewed 9/11/23 through 9/18/23. On 8/23/23, the Quarterly Minimum Data Set (MDS) Assessment documented a BIMS score of 00, which would indicate a severe cognitive impairment. The assessment documented that resident 43 was an extensive 1 person assist for bed mobility, transfer, locomotion on and off the unit, dressing, toilet use, and personal hygiene. Review of the resident 43's progress notes revealed the following: a. On 8/26/2023 at 05:31 AM, the progress note documented, Before resident went to sleep on 8/25/23, he was touching one of the female resident's thighs and trying to fight another resident. No one was hurt during the encounter. Resident was separated from other residents and went to bed and fell asleep for the night. Will continue to monitor. It should be noted that the progress note did not document who the licensed nurse was that authored the note. b. On 8/30/2023 at 01:36 AM, the nurse note documented, At around 1940 [7:40 PM] this evening this nurse was at the med cart at the nurses station when I heard a commotion, I turned and saw [resident 43] with his right hand raised in a fist and swinging it in an attempt to hit another resident. I did not see [resident 43] actually strike the other resident, but the other resident did report that [resident 43] did in fact hit his left forearm. Both resident's were sitting in the common area at the time sitting next to each other watching t.v. (television) PT [patient] had just sat [resident 43] next to resident a few minutes prior and there were no other exchanges between residents leading up to the incident. This nurse and other med pass nurse immediately ran towards both residents and intervened. [Resident 43] was immediately removed from next to the other resident. When asked why he hit the other resident, [resident 43] stated 'I didn't hit'. [Resident 43] was then taken down to activities room by CNA where CNA reported they played basketball and did other activities before [resident 43] was then brought back to his room and put to bed. [Resident 43] continued on Q [every]15 minute checks. DON, POA [Power of Attorney's name omitted], and MD [Medical Director] were notified. Review of the facility abuse investigations revealed no documentation of an investigation for the incident on 8/25/23 between resident 43 and an unknown female resident or the incident on 8/30/23. No documentation could be found that the State Survey Agency (SSA) or Adult Protective Services was notified of either the incident. On 9/13/23 at 2:34 PM, an interview was conducted with the DON. The DON stated that if she had a resident to resident altercation she would investigate to determine if it was a reportable incident to the SSA based on a flowsheet that was provided by the state agency. The DON stated that the flowsheet helped them identify which incidents needed to be reported and investigated. The DON stated that staff were to notify either her or the Administrator of any incident of resident to resident altercations that were physical in nature. The DON stated that if it was just an accusation and not witnessed it still needed to be reported to management. The DON stated that once she was notified she would inform the ADM, they would conduct a quick IDT meeting, and assign staff to go down the flowsheet and conduct an investigation. The DON stated that the Resident Advocate (RA) went and spoke to resident 52 about the altercation between him and resident 43 on 8/30/23. The DON stated that the RA reported that resident 52 had said that resident 43 just touched him to gain his attention. The DON stated that when she spoke to the licensed nurse who reported the incident to her, the nurse had said that she heard resident 52 say owe and that resident 43 was sitting next to him. The DON stated that the next morning when she read the nurse's progress note was the first time that she was made aware of resident 52 alleging that resident 43 had hit him. The DON stated that she informed the ADM of the incident then. The DON stated that they conducted an IDT meeting to address the issue and they gathered more information to determine if it was a reportable incident. The DON stated that resident 52 was alert and oriented times 3-4 to person, place, situation, and maybe time was a little off. The DON stated that resident 52 did not have a history of making false allegations and was a reliable source. The DON agreed that with the inconsistencies in the events of the incident they should have errored on the side of caution and reported the incident and investigated it. The DON stated that they did not report the incident to the SSA based off the the information provided to the RA by resident 52. On 9/14/23 at 9:26 AM, an interview was conducted with the DON. The DON stated that the incident on 8/25/23 with resident 43 and an unknown female resident should have been reported to her. At 9:43 AM, the interview with the DON continued. The DON stated that it was an agency nurse on shift that documented the progress note on 8/26/23. The DON stated that she was not the nurse manager on call the weekend the incident occurred. The DON stated that sometimes allegations of abuse were reported to the Administrator (ADM) because he was the abuse coordinator. The DON stated that at some point she should have been made aware of the incident. The DON stated that she was not aware of the incident prior to the SSA bringing it to her attention. On 9/14/23 at 9:58 AM, the ADM stated that he was never informed of the incident on 8/25/23 between resident 43 and an unknown female resident and he was starting the abuse investigation today. On 9/14/23 at 10:12 AM, a follow-up interview was conducted with the DON. The DON stated that it was a night shift agency nurse that documented the incident on 8/26/23. The DON stated that the agency staff had to read the plan of correction on the facility abuse process and it stipulated who staff must call and notify in the event of an abuse incident. The DON stated that she was not sure if the education went over the types of abuse. The DON stated that they had so many in-services on abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 80 sample residents, that the facility did not provide the resident the right to manage his or her financial affairs. Specifically, residents who had authorized the facility to manage any personal funds did not have reasonable access to those funds. Resident identifiers: 9. Findings include: Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included complications of internal left hip prosthesis, Cerebrovascular disease, type 2 diabetes, infection and inflammatory reaction to internal left hip prosthesis, cognitive communication deficit, and adjustment disorder with mixed anxiety and depressed mood. Resident 9's medical record was reviewed from 3/28/23 through 4/25/23. A quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 9 had a Brief Interview of Mental Status (BIMS) score of 13 which was considered cognitively intact. On 3/29/23 at 9:39 AM, an interview with resident 9 was conducted. Resident 9 stated that he had requested funds from his account that was managed by the facility and explained that it had taken about a month for him to get the $300 he was requesting. Resident 9 further explained due to staff turnover this created an additional delay. On 4/24/23, the facility Business Office Manager (BOM) 1 provided a copy of a form entitled Patient Trust Cash Request Acknowledgement for resident 9. The form indicated that on 3/8/23 resident 9 requested a withdrawal of $300 from his account at the facility. The bottom portion of the form was incomplete, indicating that there was no acknowledgment of the resident receiving the requested funds. On 4/24/23, the BOM 1 also provided a transaction receipt from a local bank. The receipt was dated 3/15/23 at 2:42 PM, and indicated that $300 was withdrawn from the local bank. The receipt had resident 9's initials handwritten on it, indicating that this withdrawal was on resident 9's behalf. This was a total of five business days from resident 9's request of funds to receipt of funds. On 4/10/23 at 1:26 PM, an interview was conducted with the Front Desk Employee (FD) 1 regarding the process on how residents requested money. FD 1 stated that when a resident came to the front desk and requested funds, she would refer to the printout provided to her bi-monthly showing residents' available funds. FD 1 stated that she would inform the business office manager or designated back up staff for approval. FD 1 stated that funds then were paid out to residents from petty cash. FD 1 stated that if there were not enough funds available in petty cash, there would be a delay until the next banking day. FD 1 stated that if the request was over $100, this needed to be sent to the corporate office; the corporate office would then issue and mail a check to the facility. FD 1 explained that once the check was received at the facility it was then taken to the bank to be cashed. FD 1 stated that the resident would receive the requested funds shortly after that. On 4/24/23 at 1:29 PM, an interview with the BOM 1 was conducted. The BOM 1 stated when a resident requested cash in a large amount, this could typically take up to 10 days. The BOM 1 stated when residents requested cash it was dependent on the availability of funds in petty cash as to when they received the money. The BOM 1 stated that a larger amount could be accommodated at the time of the request, but it would need to allow for additional requests from other residents. The BOM 1 stated that if the funds from petty cash were unavailable, the facility would need to request a check from the corporate office, who would send the check to the facility. BOM 1 stated they tried to get the requested funds to the residents as quickly as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 80 sampled residents, that the facility did not include provisions to inform and provide written information concerning the right to accept or refuse medical or surgical treatment, and the resident's option to formulate an advance directive. Specifically, one resident was not provided the opportunity to document their life-saving preferences. Resident identifier: 357. Findings included: Resident 357 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, type 2 diabetes mellitus, alcoholic cirrhosis, hemiplegia and hemiparesis following a cerebral infarction, dysphagia, concussion, repeated falls, chronic kidney disease stage 3, hypertensive heart and chronic kidney disease, and hypomagnesemia. On 3/29/23, resident 357's medical records were reviewed. Resident 357's electronic medical records revealed no documentation of a Physician Orders for Life-Sustaining Treatment [POLST] form or advanced directives. Review of the POLST binder revealed no documentation of a POLST form for resident 357. On 4/24/23 at 8:11 AM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated that there should be a POLST binder located at the nurse's station with a copy of all the resident's POLST forms. On 4/24/23 at 9:18 AM, a follow-up interview was conducted with RN 5. RN 5 stated she would look in the electronic medical records for a POLST form. RN 5 stated if the form was not available she would talk to management to get one signed, or obtain one from the resident or Power of Attorney (POA). RN 5 stated that in an emergency, she has not had to address this prior and would not know what she should do. On 4/24/23 at 11:35 AM, an interview was conducted with Director of Nursing (DON) 3 and the Chief Nursing Officer (CNO). DON 3 stated that she located the resident POLST binder in medical records and would like to see them at the nurse's station. DON 3 stated that the nurse's had access to the POLST in the resident's electronic medical records, and it would be located under the miscellaneous documents. DON 3 stated that a POLST form should be completed upon admission, and the admitting nurse was responsible for initiating the POLST form. DON 3 stated that if an advanced directive or POLST was not obtained or was not in the resident's medical records the staff were to assume the resident was a full code in an emergency. If a DNR [Do Not Resuscitate] is not established then they are a full code until one is in place or established. DON 3 stated that was the facility policy and that she would provide a copy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not notify the resident's representative of the resident's discharge and the reasons for the move in writing. Specifically, 1 of 80 sampled residents was transferred to a different skilled nursing facility, without the knowledge of the resident or the resident's power of attorney. Resident identifier: 409. Findings include: Resident 409 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, altered mental status, muscle weakness and cognitive communication deficit. Resident 409 was discharged on 1/24/23. Resident 409's medical record was reviewed from 3/28/23 through 4/25/23. On 8/24/22, resident 409's admission Minimum Data Set (MDS) Assessment indicated that the resident's Brief Interview for Mental Status (BIMS) score was 4, indicating severe cognitive impairment. On 8/18/22, a care plan was developed for resident 409 indicating that she required long term care services. A discharge care plan was not developed. On 1/24/23, resident 409's physician documented that they had evaluated the resident that day, but did not indicate that resident 409 would be discharged soon. On 1/24/23, a nurses note indicated that resident 409 was being discharged due to Altercations with other residents. On 2/2/23, a nurses note indicated that resident 409's daughter, who was also the resident's Power of Attorney (POA), contacted the facility. The note stated Family claims that they did not receive a voice mail or call from the facility indicating why [resident 409] was moved. AIT (Administrator in Training) claims that he did leave a voice mail informing family. SSA (Social Services) did let family know location, and why resident was moved. Family was not upset, but did express concerns about [resident 409] being under the impression that we told [resident 409] it was her daughters fault that she moved. No notes prior to this date indicated that the resident had a discharge plan, that the family had been involved regarding the discharge and other possible placement options, or that the facility Interdisciplinary Team had been involved in the discharge. On 4/5/23, an interview was conducted with resident 409's POA. The POA stated that she and her family were unaware of the resident's transfer to another facility. The POA stated that she did not know where her mother, resident 409, was for several days during January 2023. The POA stated that she called the facility to check on her mother, but they told her the resident was no longer at the facility, but would not tell her where the resident had gone because it was protected information. The FM stated that she only found out where her mother had been transferred to because the new facility called to ask her some questions about her mother. The POA stated that the new facility told her that resident 409 had been sexually acting out at South [NAME] Post Acute. The POA stated that no one gave me any information with who or what was going on. I'm her POA. I was very frustrated and angry about it. they (the facility staff) were not forthcoming about things. The POA also stated that resident 409 didn't know what was happening . She hasn't been doing well since this happened (the resident was transferred). She doesn't understand why she was moved. She had gotten more comfortable there, and her friends lived in [NAME]. The POA stated that resident 409's friends would visit the resident at least once a week, but they could not visit anymore because resident 409 had been transferred to a facility in Salt Lake, which was too far for the friends to travel. The POA stated that since being transferred to the new facility, resident 409 has been physically acting out, tried to escape . it exacerbated her dementia. It has gotten bad. She now doesn't recognize my brother. She is very angry because I won't take her out of there. She doesn't have the support system that she had before. Its been a nightmare that (they transferred the resident). It was so hard on her. On 4/13/23 at 2:28 PM, an interview was conducted with Administrator (ADM) 1. ADM 1 stated he did not recall being involved in resident 409's discharge planning. On 4/12/23 at 1:12 PM, an interview was conducted with the Resident Advocate (RA). The RA stated that it was the clinical team who decided who should be discharged , and where to. The RA stated that the clinical team consisted of the Medical Director, Director of Nursing and Assistant Director of Nursing. With regard to coordinating the resident's discharge with family members, the RA stated I would prefer to notify the families first if possible. When asked about resident 409's discharge, the RA stated that it was the previous AIT who had initiated the discharge. The RA stated that the AIT had notified the family of the discharge via telephone, but had misdialed one of the numbers, so the family member did not receive the voicemail. The RA stated that both the family members and resident 409 were upset about the discharge. Neither the AIT or Director of Nursing who were present during resident 409's discharge were still employed at the facility, and therefore, not interviewed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 80 sampled residents, that the facility did not plan a safe discharge that met a resident's health and safety needs, as well as their preferences and goals and did not effectively transition them to post-discharge care. Specifically, a homeless resident was discharge to the streets and without adequate follow-up care. Resident Identifier: 102. Findings Included: Resident 102 was admitted to the facility on [DATE] and discharged from the facility on 3/29/23 with diagnoses that included complete traumatic amputation of left great toe, superficial frost bite, difficulty in walking, unsteadiness, personality disorder, manic episode, traumatic stress disorder, and major depressive disorder. On 3/28/23 at 2:03 PM, an interview was conducted with resident 102. Resident 102 stated she was going to be discharged from the facility and had no way to get back to [name of previous home city and state]. Resident 102 stated she was concerned about where she was going to stay after she had been discharged since she was homeless. Resident 102 stated her concern that once she got discharged back to the streets, she would be in the same situation she was in before. Resident 102 stated she wanted to go to a rehab facility in [name of previous home state]. Resident 102 stated she was concerned about discharge without a place to go. Resident 102 stated the hospital doctor in [name of previous home state] had told her she could come back to [name of previous home state] and be placed in a rehab facility. Resident 102 stated the doctors name and the name of the local hospital and said to call for verification purposes. Resident 102 stated she had given the social worker at the facility the doctor's information in hopes that she called the rehab facility for placement in [name of previous home city]. Resident 102's medical records were reviewed on 4/10/23. On 3/18/23, an admission Minimum Data Set (MDS) revealed resident 102 had a Brief Interview Mental Status (BIMS) score of 15 which indicated resident 102 was cognitively intact. On 2/19/23, [name of local hospital] history and physical documented, Resident 102 was homeless and living in a homeless tent city without adequate shelter for cold weather. Resident 102's progress notes reviewed and documented as followed: a. On 3/11/23, an MDS note documented, Pt [patient] admitted to skilled on waiver after wounds not healing and living in hotel with increased need for assistance with ADL's [activities of daily living], increased weakness, and recent hospital admission. Pt admitted with waiver from hotel room to prevent rehospitalization and hospital burden. b. On 3/13/23, an MDS note documented, Pt is a 73 YOF [year old female] admitted from hotel room on waiver for decline in cognition/ADLs, and uncertain if wounds to feet are healed. MD [medical director] going to assess dx [diagnoses], orders, and wounds this afternoon. Pt c/o [complaining of] pain to back and feet 7/10. Pt is missing most teeth. Has no dentures. No glasses, denies impaired vision. Denies HOH [hard of hearing] or hearing aids. C/O wounds to feet. Needs assessed. C/O SOB [shortness of breath] with activity only. States it was worse when she had pneumonia. Pt states she is continent of B [bowel] and B [bladder]. Pt somewhat confused and not able to answer all questions. Denies flu/pneumonia vaccine. Wants to work with therapy and wants wounds to heal. Wants to maybe go home to [previous location]. Previously homeless. c. On 3/13/23 at 5:41 PM, an MDS note documented, Clarified dx [diagnosis] codes with MD. Resolved Osteomyelitis, Cellulitis, and frost bite to toes per MD. Pt had recent amputation to left great toe and has surgical incision. Per MD mark as primary DX. Updated pt status. d. On 3/16/23, a skin/wound note documented, slight toe amputations to left first and second toes. eschar present to right toe; Surgical site to right shin. All affected areas are dressed with border gauze dressings and are clean, dry and intact. e. On 3/29/23, a social service note documented, pt to discharge today back to [name of previous home city and state] by train. Pt does not have a place to live and will be staying in a motel in [name of previous home city]. Pt said that she does not want or need home health. f. On 3/29/23, a discharge summary note stated resident 102 was admitted for 20 days at the facility while she healed form a toe amputation due to frostbite. It stated resident 102 had met the goals and was discharged from the facility on 3/29/23 at 6pm. It stated resident 102 was transported by facility staff to the bus station. [Note: Resident 102 was admitted to the facility due to a toe amputation cause by exposure to inclement weather due to her previous living situation. Resident 102 was then discharge back to her previous living arrangements. The facility ensured resident had a way to get back to her previous location but did not ensure resident 102 had a safe place to be discharged to.] A [name of wound care company] progress note dated 3/9/23 documented, [Resident 102] was wanting to go home to [name of previous home city] when possible, hoping to get into an assisted living environment eventually. She is currently on a waiting list and is in need of a living arrangement that can assist with strengthening, wound care as needed. A psychosocial review assessment dated [DATE] documented resident 102 wanted to return to [name of previous home city and state] and was on a waiting list for an assisted living facility. It also stated, staff will talk to [resident 102] about the discharge options and services available to help keep [resident 102] safe. A signed discharge order dated 3/29/23 documented, resident 102's plan for discharge was to be discharge back to the community with orders and medication. A discharge packet dated 3/29/23 documented that resident 102 was admitted to the hospital on [DATE] for bilateral foot osteomyelitis with frostbite was homeless and living in tent city in [name of previous home city and state]. On 4/11/23 at 12:31 PM, an interview was conducted with Discharge Planner (DP). The DP stated they started the discharge process once the resident was admitted . The DP stated the challenged she faced with homeless residents was getting them back to their desired location. The DP stated resident 102 wanted to go back to her previous home town. The DP stated resident 102 received state assistance from her previous state and stated resident 102 was not comfortable disclosing how much money she got. The DP stated resident 102 had money saved up to pay for a motel. The DP stated resident 102 decided to discharge from the facility early because she did not want to pay the co-pay. The DP stated they offered to get resident Medicaid changed to in-state but stated resident 102 was not comfortable changing her address. The DP stated resident 102 did not want to be in a facility. The DP stated they offered to find resident 102 a place locally but stated the resident did not want to stay here. The DP stated resident 102 had contacted multiple housing places close to her former location and had it all in place. On 4/11/23 at 12:50 PM, an interview was conducted with the Resident Advocate (RA). The RA stated she and resident 102 purchased the train ticket together. The RA stated resident 102 had expressed some concern about her discharge. The RA stated resident 102 was able to find a temporary room at a motel due to weather concerns after she was discharged . On 4/12/23 at 11:11 AM, a follow up interview was conducted with the RA. The RA stated resident 102 was concerned about being discharged back to her home base. The RA stated resident 102 planned on booking a motel room for a month. The RA stated she was aware resident 102 had her toes amputated due to frostbite from being homeless. The RA stated resident 102 was concerned about the weather and storms rolling through when she was discharged . The RA stated resident 102 booked her train ticket by looking at the arrival time in her home state and making sure she had enough time to get to a shelter or a motel room. The RA stated they were not aware of any service that had been arranged for resident 102 prior to her discharge. 04/13/23 02:27 PM, an interview was conducted with the Administrator (ADMIN) 1. ADMIN 1 stated resident 102 wanted to get a back to a town in Nevada. ADMIN 1 stated they had made arrangements for resident 102 to take a train back to her previous state. ADMIN 1 stated resident 102 had a plan but was unable to given specifics about resident 102 plan once in her previous state. ADMIN 1 stated they were unsure of resident 102 final destination but stated resident 102 was glad to go back to her home state. ADMIN 1 stated they were the one to drive resident 102 to the train station and stated they watched her board the train. ADMIN 1 was asked if they needed to be notified if a resident's discharge plan was not safe and they stated yes. On 04/17/23 at 3:50 PM, a follow up interview was conducted with the Discharge Planner (DP). The DP stated the discharge process and discharge location was based on resident preference. The DP stated resident 102 freaked out when she was nearing her copay days and stated she did not have money to pay. The DP stated resident 102 cried once she was told about her co-pay cost because she was unable to afford to pay it. The DP stated resident 102 wanted to be discharged from the facility before she needed to pay and wanted to go back to her previous location because she was concerned about her cats. The DP stated resident 102 had told them she was at the top of the line for an apartment back in her previous city. The DP stated from her understanding, resident 102 wanted to take a bus to get back to her previous location and figure things out from there. The DP stated she was unaware how resident 102 made it to the bus station.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not coordinate assessments with the pre-admission screening and resident review (PASARR) program for 1 of 80 sampled residents. Specifically, the facility did not incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. Resident identifier: 15. Findings include: Resident 15 was admitted to the facility on [DATE] with diagnoses included diffuse sclerosis of the central nervous system, acute and subacute infective endocarditis, mild protein calorie malnutrition, psychoactive substance abuse, paroxysmal atrial fibrillation, acute systolic congestive heart failure, presence of cardiac pacemaker, and generalized anxiety disorder. Resident 15's medical record was reviewed from 3/28/23 through 4/25/23. On 4/29/22, a level II PASARR assessment was completed for resident 15. The assessment indicated that the evaluator's diagnostic impression was that resident 15 had major depressive disorder, recurrent, moderate; and generalized anxiety disorder. The assessment also indicated that [Resident 15] has had a long history of chaos and disruption in his life. His single mother was not very present in his life, he was partly raised by his aunt and grandparents, and he turned to drugs and alcohol during high school. [Resident 15] was unable to work consistently, had failed relationships, was made to leave his last apartment, and when health and other issues hit he became homeless. [Resident 15] has resisted mental health treatment and has consistently turned to illegal drugs instead. He is seriously mentally ill for purposes of PASARR. The assessment listed the following: Recommendation for Specialized Services for mental illness treatment: It is recommended that [Resident 15] is encouraged to access mental health and substance abuse treatment as needed. Resident 15's medical record contained a psychosocial review dated 4/20/22, but no other social work notes. No indication of mental health and substance abuse treatment referrals could be located in resident 15's medical record. The Licensed Clinical Social Worker (LCSW) consultant notes for March 2023 were reviewed. The consultant notes indicated the following: Resident 15 needs a social history, quarterly note that is past due for January, and social service care plans. Resident's progress notes from October indicating a decline in mood and difficulty coping with past trauma, a referral was made for counseling. There should be follow up documentation in place regarding the outcome of the referral, the support resident is receiving, and how resident is currently doing. This has been consistently called out in reports and no follow up documentation has been completed. On 4/19/23 at 2:08 PM, an interview was conducted with a local county mental health LCSW. The local county mental health LCSW stated that she had not received a referral for services for resident 15. On 4/19/23 at 2:00 PM, an interview was conducted with the Resident Advocate (RA). The RA stated that the LCSW consultant notes were sent by the LCSW to the Administrator and the RA, so she was aware of the LCSW recommendations, as well as what needed to be followed up on in the PASARR. The RA did not state why she had not followed up on the LCSW or PASARR recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined for 1 of 80 sampled residents that the facility failed to ensure that residents who require colostomy, urostomy, or ileostomy services, received such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a resident who returned from the hospital with a new ileostomy placement did not have new orders for ileostomy care. Resident identifiers: 7 Findings Include: 1. Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cerebral palsy, asthma, type 2 diabetes mellitus, systemic lupus, chronic respiratory failure, muscle weakness, cognitive communication deficit, hypertensive heart and chronic kidney disease without heart failure, open wound of abdominal wall, major depressive disorder, polyneuropathy, chronic kidney disease, ileostomy status, low back pain, hyperlipidemia, sleep apnea, and neuromuscular dysfunction of bladder. Resident 7's medical record was reviewed 3/28/23 through 4/25/23. According to progress notes, resident 7 was sent to the hospital on [DATE] and was diagnosed with a small bowel obstruction at the hospital. Resident 7 returned from the hospital on [DATE] with a moved ileostomy, staple on midline, and a peripherally inserted central catheter (PICC) line still in place. On 4/11/23 at 11:51 AM, an interview with resident 7 and resident 7's Power of Attorney (POA) was conducted. Resident 7's POA stated that when resident 7 returned from the hospital on [DATE], the staff were not completing any wound care or ileostomy care for resident 7's surgical site and new ileostomy. Resident 7's POA stated that the CNA's covered the surgical site with bandages. When resident 7's POA asked to see the orders for surgical site and ileostomy, the staff were unable to show resident 7's POA any orders. A review of the December 2022 Treatment Administration Report (TAR) revealed that resident 7 did have an order for colostomy care that was started on 7/5/22 and discontinued on 12/13/22. The order stated, Change monthly and as needed for leaking or dislodgement. One time a day starting on the 5th and ending on the 5th every month for colostomy . The December 2022 Treatment Administration Record (TAR) revealed that the order for colostomy care was completed once, on December 5th, 2022. On 12/13/22 a document from resident 7's general surgery appointment stated, Bandage unchanged, ostomy leaking [plus] appears not sealed to skin. Skin breakdown along incision appears severely neglected. A Nurses Note from 12/13/22 at 5:48 PM stated, Resident turned from her general surgery appt [appointment] . with the following note: 'Bandage unchanged, ostomy leaking and appears not sealed to skin. Skin breakdown along incision appears severely neglects. I replaced her _ and bag today. Stoma was cleansed and dried. ½ staples removed. No future dressing required. May shower as usual. Change ostomy bad and wafer Q [every] 2 days with Cavilon skin barrier .' Called office, spoke with [Doctor's name redacted]. Spoke with him regarding his concerns. The bandage he was referring to, this nurse changed this morning. She currently has a lot of drainage that the bandage needs changed multiple times a day upon occasion. Herileostomy [sic] wafer and bag was changed 2 days ago due to it leaking, it leaks frequently. Resident has a history of picking at her wafers and causing leakage. We have been giving her bed baths, and gently cleansing the skin around her incisions. I informedhim [sic] that we did not receive different orders regarding her ileostomy changes, wound care, or shower instructions from the hospital. I apologized that we were not following his instructions that were suppose to come with the DC [discharge] orders. We reviewed her DC orders from the hospital, and the provider was upset that there were no new ileostomy care instructions, no surgical wound instructions. New instructions received : change ileostomy wafer and bad every 2 days, use Cavilon skin barrier between wafer and skin. He stated the ileostomy secretions are more irritating on the skin, so we need to change it and wash it frequently to help protect the skin. The Cavilon skin prep will also help. He informed that shower like normal is OK now, theincision [sic] has healed enough that it will not cause any issues. He instructed to leave the sutures open to air, dry and clean until follow up appt . A review of the December 2022 TAR revealed that resident 7 had an order which started on 12/14/22 for Ileostomy Care and stated, Check ileostomy appliance each shift. Monitor and empty PRN [as needed]. Change Q2 [every two] days and as needed for leaking or dislodgement. One time a day every 2 day(s) for ileostomy care to apply new ileostomy appliance: clean site, gently pat dry, apply skin prep barrier wipe to periileostomy skin, then apply the appliance. It should be noted that resident 7 went 11 days without having the new ileostomy cares after she returned from the hospital on [DATE]. On 4/13/23 at 2:31 PM, an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated that nurses should have called the hospital to receive the orders for new ileostomy care when resident 7 returned from the hospital on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 3 out of 80 sampled residents, that the facility did not ensure that each resident received and the facility provided the necessary behavior health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, the physician orders for a behavioral health evaluation to obtain a court ordered guardianship for a resident was not completed and mental health services were not provided for a resident. Resident identifiers: 15 and 51. Findings included: 1. Resident 51 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included unspecified dementia, type 2 diabetes mellitus, cervicalgia, major depressive disorder, dysthymic disorder, hypertension, gastro-esophageal reflux disease, anxiety disorder, insomnia, and post-traumatic stress disorder. On 3/29/23, resident 51's medical records were reviewed. On 2/10/23, resident 51's Quarterly Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 00, which would indicate that resident 51 was severely cognitively impaired. The assessment documented that resident 51 did not hallucinate but did have delusions. On 10/24/19, resident 51's Preadmission Screening Resident Review (PASRR) Level II documented that resident 51's Transient Ischemic Attack (TIA) from 8/31/19 and cognitive impairments were most likely contributing to mental health issues. The current psychiatric functioning documented that resident 51 was feeling depressed and anxious. The assessment recommended that the nursing facility refer the resident for a neuropsychological exam to rule out other possible treatable causes of dementia symptoms. The recommendations for specialized services were for an antidepressant and urine drug tests. On 10/5/22, resident 51's provider documented that resident 51 had multiple interactions and aggressions towards residents. In evaluation of resident 51's behaviors, she was on Depakote but frequently refused medications along with her antipsychotic medication. The provider's assessment documented, Elderly female resident in memory care past history of homelessness psychological conditions not being adequately treated as patient refuses medications. Patient needs a POA [Power of Attorney] or guardian of the state as she has no family she has significant mental status changes she's not competent to make decisions on her own. The provider recommended a referral to a psychiatrist and started the process to evaluate if resident 51 needed court ordered medications. On 4/11/23 at 10:45 AM, a follow-up interview was conducted with the RA. The RA stated that she and the clinical team evaluated and deemed if a resident needed guardianship. The RA stated that she would work with the physician, have them document a progress note addressing the resident's guardianship need and then she would submit this to the Office of Public Guardianship (OPG). The RA stated that once the documents were submitted, she would have to follow-up with OPG. The RA stated that this process had been initiated for resident 51. The RA stated that resident 51 was on the list and waiting for a note from the current physician because the recommendation transferred from the old physician. The RA stated that in October 2022 the physician had recommended guardianship. The RA stated that it was her responsibility to submit the documentation to the OPG and to follow-up on that process. The RA stated that she normally documented this in a progress note, but she does not see that she documented on the guardianship for resident 51 in October. The RA stated that the progress note from the physician on 10/5/22 was sufficient documentation, but it did not get sent off the OPG at that time. The RA stated she did not recall why it was not completed in October. The RA stated that she would also make referrals to behavior health services and coordinate that care. The RA stated that she did not make a referral to behavioral health services in October to initiate the guardianship process. The RA stated she should get an update from the provider somehow, but currently only if she requested it. The RA stated that in October 2022 there was not a process in place for the provider information/documentation to be sent to her to make the appropriate referrals. The RA stated that once they have guardianship, they have someone to communicate with and work with them in resident care. The RA stated that guardianship would ensure that someone was advocating for the resident outside of the facility. The RA stated that currently resident 51 did not have a guardian, and she was not capable of making medical decisions. On 4/12/23 at 1:02 PM, an interview was conducted with the local mental health Licensed Clinical Social Worker (LCSW). The LCSW stated that she was at the facility at least two times a month and after each visit she gave the Resident Advocate (RA) a list of residents seen and any issues they may have. The LCSW stated that the facility could request copies of her evaluations or visit notes if they wanted them. The LCSW stated that the RA would contact her for any new referrals. The LCSW stated that she had not completed an assessment on resident 51. The LCSW stated that for any resident who needed a court ordered guardianship she would conduct a mini mental status exam and would screen for dementia. The LCSW stated that she never received a request for a mini mental status exam for resident 51. The LCSW stated that she would evaluate any resident with behaviors of physical aggression, sexual aggression, verbal aggression with dementia or those who were not capable of making medical decisions themselves. [Cross-refer to F600] 2. Resident 15 was admitted to the facility on [DATE] with diagnoses included diffuse sclerosis of the central nervous system, acute and subacute infective endocarditis, mild protein calorie malnutrition, psychoactive substance abuse, paroxysmal atrial fibrillation, acute systolic congestive heart failure, presence of cardiac pacemaker, and generalized anxiety disorder. Resident 15's medical record was reviewed from 3/28/23 through 4/25/23. On 4/29/22, a level II PASARR assessment was completed for resident 15. The assessment indicated that the evaluator's diagnostic impression was that resident 15 had major depressive disorder, recurrent, moderate; and generalized anxiety disorder. The assessment also indicated that [Resident 15] has had a long history of chaos and disruption in his life. His single mother was not very present in his life, he was partly raised by his aunt and grandparents, and he turned to drugs and alcohol during high school. [Resident 15] was unable to work consistently, had failed relationships, was made to leave his last apartment, and when health and other issues hit he became homeless. [Resident 15] has resisted mental health treatment and has consistently turned to illegal drugs instead. He is seriously mentally ill for purposes of PASARR. The assessment listed the following: Recommendation for Specialized Services for mental illness treatment: It is recommended that [Resident 15] is encouraged to access mental health and substance abuse treatment as needed. Resident 15's medical record contained a psychosocial review dated 4/20/22, but no other social work notes. No indication of mental health and substance abuse treatment referrals could be located in resident 15's medical record. The Licensed Clinical Social Worker (LCSW) consultant notes for March 2023 were reviewed. The consultant notes indicated the following: Resident 15 needs a social history, quarterly note that is past due for January, and social service care plans. Resident's progress notes from October indicating a decline in mood and difficulty coping with past trauma, a referral was made for counseling. There should be follow up documentation in place regarding the outcome of the referral, the support resident is receiving, and how resident is currently doing. This has been consistently called out in reports and no follow up documentation has been completed. On 4/19/23 at 2:08 PM, an interview was conducted with a local county mental health LCSW. The local county mental health LCSW stated that she had not received a referral for services for resident 15. On 4/19/23 at 2:00 PM, an interview was conducted with the Resident Advocate (RA). The RA stated that the LCSW consultant notes were sent by the LCSW to the Administrator and the RA, so she was aware of the LCSW recommendations, as well as what needed to be followed up on in the PASARR. The RA did not state why she had not followed up on the LCSW or PASARR recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 80 sampled residents, that the facility did not ensure that each resident's drug regimen was reviewed once a month by the licensed pharmacist and any irregularities were reported to the physician and were acted upon. Specifically, residents did not have monthly pharmacy reviews completed and the physician did not document in the resident's medical record that the identified irregularities had been reviewed and what action had been taken to address the irregularity. Resident identifiers: 51 and 79. Findings included: 1. Resident 51 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included unspecified dementia, type 2 diabetes mellitus, cervicalgia, major depressive disorder, dysthymic disorder, hypertension, gastro-esophageal reflux disease, anxiety disorder, insomnia, and post-traumatic stress disorder. On 3/29/23, resident 51's medical records were reviewed. Review of resident 51's monthly drug regimen review revealed no documentation that a monthly review was conducted by the licensed pharmacist for October and December 2022. On 4/6/23 at 12:27 PM, an interview was conducted with the Director of Nursing (DON) 1. The DON 1 stated that the previous DON 2 was terminated, but allowed to come back into the building afterwards to clean out her office. The DON 1 stated that after DON 2 cleaned out her office the pharmacy book, fall book, and psychotropic book were missing. On 4/13/23 at 11:14 AM, the Chief Nursing Officer (CNO) stated that if they did not have the documentation then it did not exist. 2. Resident 79 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included major depressive disorder, anxiety disorder, altered mental status, history of traumatic brain injury (TBI) and intertrochanteric fracture of right femur. Resident 79's medical record was reviewed 3/28/23 through 4/25/23. Resident 79's pharmacy review from January 2023 revealed on 1/30/23,[Resident 79] has been taking Sertraline 100 mg daily for depression since September 2022. Escitalpram was added in December, then increased to 20 mg [milligrams] daily 1/4/23, which appears to be unnecessary duplication of SSRIs [selective serotonin reuptake inhibitors]. He also takes trazodone 50 mg daily for insomnia. We should avoid combining two antidepressants from the same pharmacological class due to risk of serotonin toxicity. This fits criteria for a preapproved recommendation for the following: 1. Discontinue Sertraline. The response from the physician was OK to DC sertraline. Resident 79's physician's order dated 9/26/22 revealed Sertraline HCL tablet 100 MG. Give 100 mg by mouth one time a day related to major depressive disorder. The order was discontinued on 4/3/23. Resident 79's pharmacy review from April 2023 revealed on 4/7/23, This resident has an order for Eliquis 5 mg BID [twice daily]. This was started at a previous facility on August 31 for an acute, provoked DVT [deep vein thrombosis], with no prior history of DVT noted. It was documented that only six months of treatment was needed, and this treatment duration has been met. However, the patient also suffered a femur fracture recently, and is at risk of VTE [Venous thromboembolism], so the preventive dose is indicated until the functional status returns, and the risk of VTE is resolved. This fits criteria for a pre approved recommendation for the following: 1. Decrease Elliquis to 2.5 mg BID. A current physician's order dated 12/14/22 revealed Eliquis tablet 5 mg. Give 1 tablet by mouth two times a day for DVT. On 4/13/23 at 11:14 AM, an interview was conducted with the CNO and Regional Nurse (RN). The CNO stated if the information was not in the medical record, then the facility did not have it. The RN stated that the pharmacy book had to be recreated. The RN stated not all of the recommendations had been followed up on.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 7 of 80 sampled residents, that the facility did ensure the residents' right to a dignified existence. In addition, the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, residents had clothing with another residents names visible on the clothing and residents were not provided clothing that fit properly. Resident identifiers: 9, 37, 44, 47, 68, 83 and 86. Findings include: 1. Resident 37 was admitted to the facility on [DATE] with diagnoses which included dementia with anxiety, morbid obesity, mood disorder, radial styloid tenosynovitis, and palliative care. Resident 37 resided in the secured unit at the facility. On 3/28/23 at 12:34 PM, an observation was made of resident 37. Resident 37 was in the secured unit dining room sitting across from resident 83, a male resident. Resident 37 was observed to stand up and her shirt was see-through. Resident 37 was not wearing a bra and helped resident 83 with his food. On 3/28/23 at 1:19 PM, an observation was made of resident 37. Resident 37 was observed in the hallway walking with no bra and a see-through shirt. Resident 37's medical record was reviewed 3/28/23 through 4/25/23. A quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 37 had short and long term memory problems. The MDS further revealed that resident 37's cognitive skills for decision making were moderately impaired. Resident 37 had an altered level of consciousness, disorganized thinking and inattention were continuously present, and behaviors and did not fluctuate. Resident 37 required extensive 1 person physical assistance with dressing. A care plan dated 5/4/22 and updated on 4/5/23 revealed resident 37 had an Activities of Daily Living (ADL) self-care performance deficit/decreased in function related to dementia. The goal was that resident 37 would maintain current level of function in cares through the review date. Interventions included Dressing: Allow sufficient time for dressing and undressing;Dressing: Assist the resident to choose simple comfortable clothing that enhances the resident's ability to dress self; and Dressing: The resident requires extensive assist by 1 staff to dress. On 4/25/23 at 10:19 AM, an interview was conducted with Certified Nursing Assistant (CNA) 9. CNA 9 stated resident 37 required 2 person assistance with dressing. CNA 9 stated resident 37 had not seen resident 37 wear a bra since the CNA began employment in February of 2023. CNA 9 stated a resident should not be dressed in a see-through shirt with no bra to go to the dining room. CNA 9 stated some residents have spaghetti strap shirt tank tops to put underneath shirts if they did not want to wear a bra. CNA 9 stated she noticed resident 37 in see-through shirts without a bra and told the nurse a few weeks ago about it. CNA 9 stated that resident 47, another male resident had said to the CNAs things like it's chilly or frosty after resident 37 walked by with her see-through shirt with no bra. CNA 9 stated that resident clothing in the secured unit was all mixed up. CNA 9 stated that there was a place in laundry with donated clothing and the CNA had to go down to the donations to get clothing for residents. CNA 9 stated there was some clothing on certain residents and then another resident had the same clothes on a few days later. CNA 9 stated that resident 86 had a name on her white socks in black sharpie that was not her name. CNA 9 stated there was a lot of agency staff who did not know the residents and put any clothing on residents. 2. Resident 68 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, history of traumatic brain injury, hemiplegia affecting left non-dominant side and major depressive disorder. Resident 68 resided in the secured unit from 12/22/22 until 3/31/23 when he was transferred from the secured unit. On 3/28/23 at 1:28 PM, an observation was made of resident 68 in the secured unit. Resident 68 was observed to have food on the front on his clothing. Resident 68 was observed in white socks with his first name and last initial written with black sharpie on them. On 3/31/23 at 9:40 PM, an observation was made of resident 68 in the rehab unit hallway. Resident 68 was observed to have white substance on his black pants. Resident 68 had his first name and last initial written on white socks with a black sharpie. On 4/1/23 at 5:16 PM, an observation was made of resident 68 sitting in the hallway near the rehab nurses station. Resident 68 was observed to have a typed label with resident 9's name on the left shoulder. Resident 68's medical record was reviewed 3/28/23 through 4/25/23. A quarterly MDS dated [DATE] revealed resident 68 had a Brief Interview of Mental Status (BIMS) score of 5 which indicated severe cognitive impairment. The MDS revealed resident 68 required 1 person extensive assistance with dressing. A care plan dated 12/30/22 revealed that resident 68 had an ADL self-care performance deficit related to Alzheimer's and impaired balance. The goal was resident 68 would improve current level of function in ADLs through the review date. Interventions included encourage the resident to participate to the fullest extent possible with each interaction; encourage the resident to use bell to call for assistance; praise all efforts at self care; and therapy evaluation and treatment as per physician's orders. 3. Resident 86 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, anxiety disorder and depression. Resident 86 resided in the secured unit. On 3/28/23 at 9:30 AM, an observation was made of resident 86. Resident 86 was observed wearing white socks with a name of another resident written in black sharpie. On 3/28/23 at 3:00 PM, an observation was made of resident 86. Resident 86 was observed with a white sock with a name of another resident written in black sharpie. Resident 86's medical record was reviewed from 3/28/23 through 4/25/23. A quarterly MDS dated [DATE] revealed that resident 86 had a BIMS score of 1 which indicated severe cognitive impairment. The MDS revealed resident required 1 person extensive assistance with dressing. A care plan dated 8/17/22 and revised on 10/27/22 revealed resident 86 had an ADL self-care performance deficit related to metabolic encephalopathy, diagnoses of dementia and anxiety. The goal was resident 86 would maintain current level of function in ADLs through the review date. An intervention for dressing revealed to Allow sufficient time for dressing and undressing. 4. Resident 44 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, chronic obstructive pulmonary disease (COPD), dementia, major depressive disorder (MDD) and anxiety disorder. On 3/28/23 at 11:59 AM, an observation was made of resident 44. Resident 44 was observed to have the letters HC written on the back of the residents shirt with a black sharpie. Resident 44's initials were not HC. Resident 44's medical record was reviewed from 3/28/23 through 4/25/23. A quarterly MDS dated [DATE] revealed resident 44 had a BIMS score of 5 which indicated severe cognitive impairment. The MDS further revealed resident 44 required 1 person limited assistance with dressing. A care plan dated 10/18/22 and updated on 4/18/23 revealed resident 44 had limited mobility/ADL performance deficit related to cognitive deficit, advanced age, impaired mobility. Diagnoses included dementia and Alzheimer's disease, COPD, and MDD. The goal was resident 44 would maintain current level of function in ADLs through the review date. Interventions for dressing included Allow sufficient time for dressing and undressing and The resident requires (limited assistance) by (1) staff to dress. On 4/24/23 at 1:11 PM, an interview was conducted with CNA 11. CNA 11 stated when a resident was admitted , a form should be completed with all the resident's personal items. CNA 11 stated staff did not complete the forms upon admission. CNA 11 stated the residents have each other's clothing all the time everyday. CNA 11 stated CNAs should take the residents' clothing from their closet, but they put the wrong clothing in the wrong dresser. CNA 11 stated CNAs were unable to find the right clothing or the right size for residents, so CNAs had to go and look through the lost and found for residents' clothing. CNA 11 stated CNAs did not have another option so CNAs had to use clothing with other residents' names on them. On 4/24/23 at 11:13 AM, an interview was conducted with CNA 10. CNA 10 stated that clothing was labeled with a press in the laundry department. CNA 10 stated sometimes the labeler did not work, so CNAs used sharpies to label resident clothing with their names. On 4/20/23 at 12:20 PM, an interview was conducted with Director of Nursing (DON) 3. DON 3 stated clothing labeling was an ongoing process. DON 3 stated residents' clothing should be tagged using a label on the inside of the resident clothing. DON 3 stated staff should not use black sharpie on resident clothing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 66 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, chronic kidney disease stage 3, hypertensive heart and chronic kidney disease, atherosclerosis, gastro-esophageal reflux disease without esophagitis, major depressive disorder, fibromyalgia, anxiety disorder, mononeuropathy, hypothyroidism, hyperlipidemia, nicotine dependence, restless legs syndrome, migraine without aura, chronic pain, xerosis cutis, osteoarthritis, muscle wasting and atrophy, difficulty in walking, limitation of activities due to disability, and need for assistance with personal care. On 4/11/2023, an interview with resident 66 was conducted. Resident 66 stated that 3 weeks prior to the interview that she had been outside smoking with another resident sometime around 8:30 PM. Resident 66 stated that Admin 1, who had been spending the night at the facility, came out and told resident 66 that she couldn't smoke as it was past the scheduled smoking times. Resident 66 stated that the other resident who was present at the time, left the area. Resident 66 stated that she leaned forward to put out her cigarette. Resident 66 stated that Admin 1 then grabbed her by the arm and forcefully pulled her and her wheelchair back into the building. On 4/11/2023, an interview was conducted with Staff Member (SM) 10. SM 10 stated that another staff member had told her about this incident between Admin 1 and resident 66. SM 10 stated she was told by this staff member that the incident was reported to the Resident Advocate (RA). SM 10 stated that resident 66 reported that and the RA followed up by saying the resident just has to follow the rules. On 4/11/2023, an interview was conducted with SM 5. SM 5 stated that she had been told about the previous incident by resident 66. SM 5 reported the incident to the RA. SM 5 stated the RA told her she would look into it. SM 5 stated that the RA told resident 66 that she had been breaking the new smoking policy rules. On 4/11/2023, an interview was conducted with the RA. The RA stated that she had not received any reports of abuse from resident 66. The RA stated that she was familiar with residents being upset about the facility's new smoking policy. The RA stated that the issue involving resident 66 had been brought to her attention before in a conversational way. The RA stated that the facility administrator had excused residents from the patio due to the new smoking policy. On 4/13/2023, a follow-up interview was conducted with SM 5. SM 5 stated that the facility had taken away resident 66's cigarettes due to resident 66 allegedly smoking inside her room. SM 5 stated that resident 66 has never smoked inside the building. SM 5 stated that resident 66 had been crying since her cigarettes had been taken away. SM 5 stated I feel like it's retaliation. On 4/12/2023, the following progress note was documented in resident 66's medical record at 3:22 PM: Resident spoke with DON about smoking policy being unfair she did state she understands it. 3. Resident 11 was admitted to the facility on [DATE] with diagnoses which included Wernicke's encephalopathy, chronic pain, anxiety disorder, delusional disorders, nicotine dependence, alcoholic polyneuropathy, chronic kidney disease, encounter for palliative care, and insomnia. Resident 11's medical record was reviewed from 3/28/23 through 4/25/23. On 3/10/23 the Quarterly MDS revealed that resident 11 had a BIMS score of 11, indicating his cognition was considered moderately impaired. On 3/28/23 at 12:25 PM, an interview was conducted with resident 11. Resident 11 stated with the new management they were going to be enforcing smoking times and he was not happy with having structured times to go out and smoke. On 4/5/23 at 12:39 PM, a follow-up interview was conducted with resident 11. Resident 11 stated he was actively looking to be relocated to a facility that will allow him to smoke. Resident 11 further stated that if facility staff took his cigarettes away, I will fight and hit if I have to. 4. Resident 9 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included complications of internal left hip prosthesis, Cerebrovascular disease, type 2 diabetes, infection and inflammatory reaction to internal left hip prosthesis, cognitive communication deficit, and adjustment disorder with mixed anxiety and depressed mood. Resident 9's medical record was reviewed from 3/28/23 through 4/25/23. A quarterly MDS dated [DATE] revealed that resident 9 had a BIMS score of 13 which was considered cognitively intact. On 3/29/23 at 10:15 AM, an interview with resident 9 was conducted. Resident 9 stated he came to this facility on the impression that this was a smoking facility and he had the freedom to go out and smoke when he wanted. Resident 9 stated now there were structured smoking times and doors would be locked. Resident 9 stated that staff were now required to supervise him when he wanted to smoke. Resident 9's medical record included a Resident Smoking Behavior Contract. The contract was signed by resident 9 on 2/17/23. The contract indicated, I ACKNOWLEDGE THAT SMOKING IS A PRIVILEGE AND NOT A RIGHT AND THE FACILITY MAY SUSPEND MY PRIVILEGE AT ANY TIME. On 4/13/23 at 2:28 PM an interview with Administrator (Admin) 1 was conducted. Admin 1 stated a change in the smoking policy took place about a month ago. Admin 1 stated that the smoking policy included scheduled smoking times five times a day at 6:30 AM, 9:30 AM, 1:00 PM, 4:00 PM and 8:30 PM with no exceptions. Admin 1 stated that this policy change made independent smokers supervised because it was really cold outside, and staff wanted to make sure everyone was safe. Admin 1 stated he started noticing residents that have been smoking for twenty plus years would have ashes on their clothing and blankets. Admin 1 stated he was unaware where the policy came from, and that maybe got it from Director of Nursing (DON) 1. Admin 1 stated due to a combination of events they recently changed the policy to include that those residents that were deemed substantially competent could smoke independently, any others would be supervised. Admin 1 stated that upon admission, residents were assessed by the DON, social services, or floor nurse to determine competency. Admin 1 stated that this assessment would be located in each of the residents' medical records. Admin 1 further stated that the facility currently did not have a re-assessment tool in place, but that they were focusing on launching a program. Admin 1 stated that before he was employed at the facility, there was no structure to the smoking schedule, and that he was trying to create a structure and safety for the residents. Admin 1 then stated he wanted to put a lock on the door to the smoking area. Based on observation, interview and record review it was determined, for 4 of 80 sampled residents, that the facility did not ensure that the resident had the right to, and the facility did not promote and facilitate, the resident self-determination through support of the resident choice. Specifically, a facility wide smoking policy which only allowed residents to smoke 5 predetermined times of the day, did not accommodate residents' abilities and rights. Resident identifiers: 9, 11, 43, and 66. Findings included: 1. Resident 43 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, type 2 diabetes mellitus, bipolar disorder, borderline personality disorder, and anxiety disorder. On 3/28/23 at 3:19 PM, an interview was conducted with resident 43. Resident 43 stated it was bull crap the smoking policy was changing. Resident 43 stated it was ridiculous they were limited to 5 smoking times a day. Resident 43 stated they were unsure why the facility was enforcing the new smoking policy. Resident 43 stated they were being locked up like prisoners since they won't be able to go outside to get fresh air due to the doors being locked. Resident 43 stated other residents have talked about going out the front and smoking in the street since it would be 25 feet away from the building. Resident 43 stated the rule was to have their smoking supplies taken away and locked up by the nurses. Resident 43 stated she was concerned she would never get her supplies when she requested them since the nurses were always busy and would not have time to get them. Resident 43 stated they were strict about the smoking times and if you missed it, you were shit out of luck and had to wait until the next posted time. Resident 43's medical records were reviewed 3/28/23 through 4/25/23. A Quarterly Minimum Data Set (MDS) dated [DATE], documented resident 43 had a Brief Interview of Mental Status (BIMS) score of 9. This indicated that resident 43 was moderately cognitively impaired. On 2/20/23 and 4/13/23, a smoking safety evaluation documented that resident 43 was an independent smoker and she was allowed to have her smoking supplies with her. On 3/29/23, a nursing progress note documented, .she wanted to go AMA [against medical advice] because the facility has now implemented smoking times. Pt [patient] is a chain smoker and is struggling with the new rule. An admission agreement packet dated 10/5/22 documented the facility's smoking policy was to ensure smoking policies and procedures have not been established to restrict any residents' right to smoke. Resident 43 signed the smoking policy upon admission. [Note: No admission smoking contract was located in resident 43's medical record.] On 2/20/23, resident 43 signed a smoking contract that listed all the terms smoking residents were obliged to follow and were documented as followed: [Note: The document stated if a resident/POA (power of attorney) disagreed and refused to initial any of the following statements, the facility did not allow smoking to occur. It also stated the smoking contract was developed with the resident's input and it reflects the resident's best interest.] a. I understand that I must follow each and every rule governing smoking and should I violate even one rule, even one time, I am aware that the facility may temporarily suspend, revoke, and/or initiate discharge proceedings and I will not be allowed to live in this building. I ACKNOWLEDGE THAT SMOKING IS A PRIVILEGE AND NOT A RIGHT AND THE FACILITY MAY SUSPEND MY PRIVILEGE AT ANY TIME. b. I have been informed that if I wish to quit smoking, my physician can prescribe medication to assist me. c. I agree to only smoke in the designated area, at the designated times. d. I agree that I am not allowed to have in my possession and must turn over all smoking materials (i.e., cigarettes, tobacco, rolling papers, lighters, matches) to a staff person. e. I will not give cigarettes away to any other person. I will not beg or panhandle for cigarettes or money. Again, I recognize that there will be a serious consequence for noncompliance. f. I will discard my cigarette ashes in an appropriate receptacle. I will not drop/throw cigarette butts or matches on the floor or ground. g. I will smoke carefully and make sure I do not burn my clothes or fingers (or any other person). I KNOW THAT CARELESS SMOKING WILL CAUSE MY PRIVILEGES TO BE SUSPENDED. h. I agree to allow staff to check/search my room for contraband (i.e., such as hidden cigarettes, lighters, matches) at staff discretion. i. If I require oxygen, I understand that I am not allowed to smoke with my oxygen in use or to have my oxygen in the Designated Smoking Area. j. If the facility has determined that a ______ be used/worn for my safety, I must follow this recommendation k. I understand in cases of unsafe weather conditions that staff may suspend smoking privileges for all residents. [Note: The smoking contract stated for the 1st/2nd offense, resident smoking privileges were suspended and or revoked, as well as an involuntary discharge was pursued at the administrator's discretion. Actions taken for the 3rd/multiple smoking offenses included revoked smoking privileges or involuntary discharge was pursued at the administrator's discretion.] Facility smoking times were posted in resident 43's room with the following smoking times: 0630 (6:30) AM, 0930 (9:30) AM, 1 PM, 4 PM, and 8:30 PM. The documented stated, Door will remain locked for all times except those above. Please be on time so that you don't miss out.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 4/12/2023, the facility hosted a resident council meeting. Residents brought up concerns about the new smoking policy, meal trays being delivered so late that the food was cold, lack of adequate staffing to provide cares and meet resident needs, and untrained agency staff. Many of these concerns had been voiced during previous resident council meetings, as indicated by the resident council notes. During the meeting, resident 357 stated, Do we have rights here? It doesn't feel like it. On paper maybe, but do we really? [Cross refer to F584, F585, F676 and F923] Based on interview, observation and record review, the facility did not act promptly upon the grievances and recommendations of the resident council regarding issues of care and life in the facility. Resident identifiers: 357 and 407. Findings include: 1. Resident council notes were reviewed and included the following entries as concerns voiced by the residents: a. 4/29/22: . Residents want shower schedules because they are only getting 2 showers if they are lucky, some none at all . [Nurse] never is on time with pain mediation [sic] by request . W/C [wheelchair] Still not getting wasled [sic] . Clothes so wrinckled [sic] so they send back for rewash. Rooms not getting vaccumed [sic] . Dusty rooms. Showrooms [sic] filthy . b. 5/27/22: . Van, residents want to know whats going on with van getting fixed or getting a new van. Call light wait times . Rooms not getting vacummed [sic] . Some clothes still missing . food is bland . c. 6/24/22: . Talked about fixing boiler rooms [and] heat/AC [air conditoning] . Getting van fixed. Shower rooms need heat . CNAs [Certified Nursing Assistants] will come in and turn off call lights, say they will be back but do not come back . Bad agency nurse on AM shift - 6/23 Mean . d. 7/29/22: . Its been hard getting money out of Res [resident] trust. Someone will take a lot out money. Wonder when the van will be fixed . CNA/Nurses are not knocking before entering rooms, or waiting for response before ending . Bad call light response on Heritage [and] Colonial morning. water not getting hot for showers . e. 8/25/22: . CNAs are still entering [without] waiting/knock or they will say they will be back and turn off light and not come back . Laundry not getting clothes back. Not enough chucks, towels or washcloths . Could RNA [Restorative Nursing Aid] have a washig [sic] machine replaced . f. 9/22/22: . Van, when will they get a new van . Washer being put in RNA room . No knocking when coming into rooms . W/C not being washe [sic] at all, or ever . Flys [sic] in rooms [and] everywhere . g. 10/27/22: . No over [night] guests . CNAs still knocking [and] walking right in room [without] waiting for reply . Hall trays are being passed late, Res getting meals cold. The presentation of meals is bad . Food delivered cold . h. 11/30/22: . Visiting hours [and] visitors. Washing machine . Van . No turning or emptying caths [catheters] . No knocking beofre going . Meals being put on bed .Meals not hot . i. 12/26/22: . Want to know update on van, if its getting fixed or getting new one. Washer machine in RNA room update on that . Trays . Main dining . Snacks . CNA staffing . Getting residents up in the AM . Pressure sore concerns . Overmedicating . Nurses making residents wait to be last . Vital signs . Wheelchairs not being cleaned . Hydration . Cath cares . Showers . Better way to do maintenace [sic] requests for staff [and] residents (residents ask staff, doesn't get put into TELS (?) or gets forgoten [sic]) . Residents rooms are not getting cleaned unless they ask them personally. Residents shouldn't have to beg to get rooms vaccumed [sic] or swept. Per residents on all halls. Residents not being heard (by social [NAME]). Finding easy way out of all situations rather than helping. Asking Res what would you like me to do then [and] doing it to 'shut them up' . Noodles not cooked . Potatotes too hard . Staff willingness to help in kitchen when asking for an alternative meal or snacks . Finding a solution for cold meals, staff not passing trays out when kitchen staff deliver carts . j: 1/23/23: . Trays, CNAS or staff not helping cut foods or open drinks . Showers not getting offered [and] residents not getting showered for days . Hydration, residents don't get water offered unless they get it theirselves [sic] . Call light waiting times . Better way to do mainenace [sic] request, for staff [and] residents. (residents ask staff, doesn't get put into TELS (?) or gets forgotten) . Rooms not being cleaned frequently. Access for staff to be able to get cleaning supplies if needed after hours.following up with residents after they fill out a grievance.milk is sour sometimes . ice cream is melted by the time it gets to residents .meals are cold . They want more variety of foods. k. 2/22/23: . CNAs not helping residents open containers or cut up food .Showers not getting offered to residents . Hydration . Other CNA willingness to help when the other CNAs are busy . l. 3/22/23: . Showers not getting offered . Hydration . All nursing staff (CNAs [and] Nurses) not helping residents that aint [sic] 'Their resident' . Cath's [catheters] not being emptied for multiple shifts or till [sic] completely full . w/c never getting cleaned . Lifts never being cleaned. clothing protectors not getting offered [and] residents getting dirty every meal . Residents feel they have to bug to get information from you (referring to the social services worker), That you say 'we will look into it' [and] never follow up . Meats not being cooked in the middle . The resident council notes documented that the residents repeatedly had the same concerns with things such as lack of assistance with Activities of Daily Living (ADLs) such as showers and repositioning, medications not being passed timely, the overall cleanliness of the building and equipment, equipment not functioning and no system in place to address it, missing laundry, call light response times, not responding to grievances or resident complaints, staff treatment of residents, quality of care issues such as pressure sores and catheter care, food quality, providing residents with water, and call light response times. The resident council notes did not indicate what interventions and/or solutions were put into place after the resident council meeting. On 4/6/23 an interview was conducted with Staff Member (SM) 11. SM 11 stated that they had been present during several resident council meetings. SM 11 stated that in one of the most recent meetings, residents stated that they felt they were being treated like herded cattle; and that the facility only cared about the money the residents brought in, but that no one actually cares about them. SM 11 stated that resident 407 told SM 11 that she had brought up her concerns repeatedly to management but that there was never any follow up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. Resident 209 was admitted on [DATE] with diagnoses that included cognitive communication deficit, paroxysmal atrial fibrillation, need for assistance with personal care, adjustment disorder with mixed anxiety and depressed mood, abnormal coagulation profile, and chronic kidney disease. On 3/28/23 at 10:12 AM, an interview with resident 209 was conducted. Resident 209 stated that she sustained a left foot injury when a staff member hit her foot into the door frame while being transferred into the room. Resident 209 stated her foot was sore. An observation of resident 209's left foot was immediately made. Resident 209's left foot had a baseball size hematoma on the dorsal and lateral side. On 4/5/23 at 12:26 PM, an interview was conducted with resident 209. Resident 209 was asked if the physician had assessed her foot regarding the injury on 3/24/23. Resident 209 stated, No, no one has. Resident 209's medical record was reviewed from 3/28/23 through 4/25/23. On 3/27/23 at 12:01 PM, facility staff documented in a Minimum Data Set (MDS) Progress Note as follows: Pt [patient] complains of pain all over but says her left foot hurts mostly. Left foot is bruised top and bottom. The progress note indicated that the facility Nurse Practitioner had been notified. However, no notes or orders were documented by the Nurse Practioner. On 3/28/23, the facility Medical Director (MD) assessed resident 209 as part of the admission assessment. The MD did not document that he had evaluated or been notified of resident 209's bruised and painful foot. A Nurses Progress Note on 4/13/2023 at 7:17 PM documented, this nurse was informed by another staff member that [resident 209's] left foot was accidentally hit into something during transport over a week ago. The incident was not reported at the time. This nurse assessed resident's foot; resident stated it was her inner left foot. No swelling noted, denied pain, bruising to inner and outer aspects of foot noted. Medical doctor (MD) was notified and ordered x-ray of foot. [Name of x ray company] called and placed order for x-ray. Stated they will be coming tomorrow. A review of resident 209's medical records revealed on 4/14/23 an x-ray of left foot was performed, and results of radiology findings were given at 2:45 PM. [Note: The xray of resident 209's foot was completed approximately 22 days after the injury occurred.] An interview on 4/20/23 at 2:59 PM, was conducted with DON 3. DON 3 stated that if a resident was to get hurt, for sure the physician and family needs to be notified. DON 3 stated that the event would also need to be documented in a progress note. DON 3 stated an incident report also needed to be initiated and it should be brought to the Interdisciplinary Team (IDT) meeting. DON 3 stated she would also expect further orders from the physician and an x-ray should have been done much sooner. 7. Resident 257 was admitted to the facility on [DATE] and discharged on 4/2/23 with the following diagnoses but not limited to a traumatic brain compression without herniation, type 2 diabetes mellitus (DM II), end stage renal disease, gastroparesis, post traumatic seizures. On 3/28/23 at 10:23 AM, an interview was conducted with resident 257. Resident 257 stated, in the six days he had been at the facility, he had noticed it took the nurses awhile to give him his medications even after he had asked for them. Resident 257 stated he had to remind the nurses to check his blood sugar and administer his insulin. Resident 257 stated on his first night here, the nurses did not check his blood sugar timely. Resident 257 stated he remember feeling weird and then the nurses finally checked his blood sugar and saw that it was high. Resident 257 stated the nurses had to chase his blood sugar down until it was finally back down in the 200's. Resident 257's medical records were reviewed on 4/11/23. Resident 257's care plan was reviewed and revealed a care area that stated resident 257 had DM II and was managed with insulin. The documented goal was resident 257 would not have any complications related to diabetes. An intervention was identified and included as followed: Monitor/document/report PRN [as needed] compliance with diet and documented any problems. The care plan was initiated on 3/23/23 A physician's order dated 3/22/23, documented as followed: Blood glucose test ac [before meals] & has [sic] [at bedtime]. Notify MD if bs [blood sugar] above 350 or below 60 before meals and at bedtime. A review of the daily blood sugar summary for the months of March 2023 and April 2023 revealed the following blood sugars: a. On 3/25/23, BS 368 and 400 b. On 3/26/23, BS 359 and 380 c. On 3/27/23, BS 399 d. On 3/31/23, BS 365 e. On 4/1/23, BS 377 f. On 4/2/23, BS 458 No documentation could be located indicating that the provider had been notified when the BS was above the parameters set by the provider. On 4/19/23 at 1:36 PM, an interview was conducted with Director of Nursing (DON) 3. DON 3 stated a resident's blood sugars were checked by the registered nurse as ordered by the provider. DON 3 stated if the blood sugar was over a certain number as set by the physician parameters, they expected the nurse to notify the provider. DON 3 stated a progress note should be made to document that provider was notified and if any new orders were received. On 4/24/23 at 1:44 PM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated blood sugars were checked by the nurses and they were checked before meals and at bedtime. RN 5 stated a resident's blood sugars were found in the weight/vitals tab and it showed when the blood sugars were obtained. RN 5 stated a provider was notified about a resident's blood sugars, if it was outside of the ordered parameters. RN 5 stated normally a progress note was made to document the provider was notified and what new orders were received. Based on interview, observation and record review it was determined for, for 8 of 80 sampled residents, that the facility did not immediately consult with the residents' physician or the residents' representative when there was a change in the residents' status. Specifically, the physician was not notified when a resident had a worsening wound, the physician was not notified when a resident had high blood sugar levels, and the physician was not notified when multiple residents had a fall or injuries. Resident identifiers: 7, 51, 76, 86, 96, 209, 257, and 357. Findings Include: 1. Resident 7 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included cerebral palsy, asthma, type 2 diabetes mellitus, systemic lupus, chronic respiratory failure, muscle weakness, cognitive communication deficit, hypertensive heart and chronic kidney disease without heart failure, open wound of abdominal wall, major depressive disorder, polyneuropathy, chronic kidney disease, ileostomy status, low back pain, hyperlipidemia, sleep apnea, and neuromuscular dysfunction of bladder. According to progress notes, resident 7 was sent to the hospital on [DATE] and was diagnosed with a small bowel obstruction at the hospital. Resident 7 returned from the hospital on [DATE] with a moved ileostomy, staple on midline, and a PICC line still in place. A Nurses Note from 12/10/22 at 2:20 PM stated, Wound dressing changed. Small amount of drainage and redness. A review of resident 7's medical record revealed that the physician was not notified of the drainage and redness. On 4/13/23 at 9:42 AM, an interview with Certified Nursing Assistant (CNA) 5 was conducted. CNA 5 recalled the time when resident 7 returned from the hospital from her surgery on 12/3/22. CNA 5 stated that she remembered one day that the surgical wound appeared to be more red than normal. CNA 5 stated that the nurse she was working with stated the wound was not supposed to look like that, and CNA 5 and the nurse noted that they did not know how long the current band aide was on because there was no date. CNA 5 stated she was not sure if the nurse reported the change in the wound to the doctor. On 4/13/23 at 2:25 an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated that the nurse should have notified the doctor if there was drainage and redness because those were signs of an infection with a wound. On 12/13/22 a document from resident 7's general surgery appointment stated, Bandage unchanged, ostomy leaking + appears not sealed to skin. Skin breakdown along incision appears severely neglected. 3. Resident 51 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included unspecified dementia, type 2 diabetes mellitus, cervicalgia, major depressive disorder, dysthymic disorder, hypertension, gastro-esophageal reflux disease, anxiety disorder, insomnia, and post-traumatic stress disorder. On 3/29/23, resident 51's medical records were reviewed. Review of resident 51's incident reports and progress notes revealed the following: a. On 11/24/22 at 12:23 PM, the incident report documented, Resident sitting by nurses' station and fell asleep in chair. Resident fell out of chair, to floor, onto buttocks. No contact of head to floor. Fall was witnessed by nurse. No apparent injuries observed. The report did not document that the physician was notified. b. On 2/3/23 at 4:45 PM, the incident report documented, Resident slid to floor while holding handrail. Landed on buttocks. No injuries. The report did not document that the physician was notified of the fall. On 2/3/23 at 4:00 PM, neuro checks were initiated and continued through 2/6/23. The form documented that resident 51's left pupil was not round, but was sluggish and that this was resident 51's baseline. It should be noted that resident 51's level of consciousness was only documented 7 times out of 20 observations with 2 episodes of drowsiness documented. The assessment pupil response did not utilize the legend responses, and documentation was indiscernible. The assessment documented abnormal blood pressure readings of 179/108 on 2/4/23 at 3:45 PM, 168/72 on 2/4/23 at 11:45 PM, and 164/94 on 2/5/23 at 11:45. It should be noted that no documentation could be found to show that the physician was notified of the abnormal blood pressure readings or resident 51's drowsiness. c. On 3/22/23 at 3:38 PM, the progress note documented, Pt. had an unwitnessed fall. Neuro checks started. vital sign stable: 133/74 [blood pressure], p [pulse] :80, RR [respiratory rate]-18. Pupils reactive. It should be noted that no documentation could be found to indicate that the physician was notified of the fall. 4. Resident 76 was admitted to the facility on [DATE] with diagnoses which included esophageal obstruction, chronic obstructive pulmonary disease, emphysema, esophagitis, essential (hemorrhagic) thrombocythemia, Barrett's esophagus, gastritis, major depressive disorder, anxiety disorder, post-traumatic stress disorder, gastrostomy status, and opoid dependence. On 3/28/23, resident 76 medical records were reviewed. On 12/23/22 at 7:06 PM, resident 76's progress note documented, Resident had a loose, dark bowel movement today. He stated this is the first BM [bowel movement] he has had since his EGD [Esophagogastroduodenoscopy] on Tuesday. It did appear to possibly have blood in it but I was unable to test it. Will continue to monitor. It should be noted that no documentation could be found to show that the physician was notified of the possible bloody stool. On 4/24/23 at 11:35 AM, an interview was conducted with Director of Nursing (DON) 3 and the Chief Nursing Officer (CNO). DON 3 stated that nurses should notify the MD if they suspect a resident had blood in their stool. DON 3 stated that the nurse should document in the progress notes that the physician was informed and any orders that were obtained. DON 3 stated that the facility did not have Guaiac tests available in the facility. 5. Resident 96 was admitted to the facility on [DATE] with diagnoses which consisted of osteomyelitis, type 2 diabetes mellitus, sepsis, hypertension, retention of urine, major depressive disorder, personality disorder, insomnia, anxiety disorder, and acquired absence of right leg below the knee. On 4/24/23, resident 96's medical records were reviewed. Resident 96's Progress notes revealed revealed the following: a. On 4/22/23 at 1:08 AM, the progress note documented, Pt stated abd [abdominal] pain beginning early in day, decreased appetite, denies N/V [nausea and vomiting], noted to have 1 episode of tarry stool by CNA [Certified Nurse Assistant]. It should be noted that no documentation could be found to show that the physician was notified of the tarry stool. b. On 4/22/23 at 6:30 PM, the note documented, Patient called the 911 asking for an ambulance because he was worried about his black tarry stool. This nurse did not see his stool and was unaware that he was going to call EMS [Emergency Medical Services]. It should be noted that no documentation could be found to show that the physician was notified of the tarry stool or the resident transfer the the hospital. On 4/25/23 at 9:49 AM, an interview was conducted with the CNO. The CNO stated that the licensed nurse should obtain vital signs and conduct an assessment for a change in condition. The CNO stated that the staff should communicate with the physician to obtain further orders. The CNO stated that they were in the process of obtaining guaiac tests to increase the speed of treatment. The CNO stated that the nurse should document a progress note or an assessment, and the assessment would be located in the e-interact form. 6. Resident 357 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, type 2 diabetes mellitus, alcoholic cirrhosis, hemiplegia and hemiparesis following a cerebral infarction, dysphagia, concussion, repeated falls, chronic kidney disease stage 3, hypertensive heart and chronic kidney disease, and hypomagnesemia. On 3/29/23, resident 357's medical records were reviewed. On 3/28/23 at 10:15 AM, an observation was made of resident 357 with bruising to the face, bilateral orbits and bridge of the nose. The bruising was dark purple in coloring. At 12:34 PM, an interview was conducted with resident 357. Resident 357 stated that last night when she was exiting the door to smoke the part holding the door open fell and landed on top on her head. Resident 357 stated that the door hinge broke and when it struck her it caused her to fall out of her wheelchair. Resident 357 complained of a headache and the resident thought her nose may be broken from the hinge striking her on the head. Resident 357 stated that her nose hurt and all she had for pain control was Tylenol. Resident 357 stated that after the fall all they did was take her vitals, and she did not go to the hospital. Resident 357 stated that they did not obtain an x-ray of her nose after the incident. On 3/27/23 at 11:25 AM, the incident report documented, Resident began yelling and was found at the front door. Resident had fallen backwards after opening the door. Resident had no new injuries noted. Resident has a red bump to their R [right] forehead from a previous fall, and bruising under their eyes. Resident has no new bruising noted. Resident states that they were trying to go outside to smoke, and the door hinge of the front door hit them on the right side of their head, causing them to fall backwards. Resident has no c/o pain or discomfort. The immediate action taken was Resident had vital signs and neurological assessments completed. Resident had a head to toe assessment done to assess for any further injuries. Resident has no current c/o pain or discomfort. Res was assisted back into their bed in their room. The MD was notified on 3/28/23 at 7:14 AM. It should be noted that the physician notification was approximately 20 hours after the incident occurred. It should be noted that no documentation could be found that the neurological assessments forms were initiated after the fall at 11:25 AM. On 3/27/23 at 10:39 PM, the progress note documented, Resident had an unwitnessed fall in her room at approximately 2220 [10:20 PM]. Resident states she was transferring self from her bed to W/C [wheelchair] and slipped as breaks were not on. Resident initially told Aid [sic] she did not hit head but then told nurse she hit the back of her head. No redness or obvious injury to head or other parts of body. Resident was assisted to feet and W/C and vitals obtained. Resident was agitated that we were assessing her and obtaining vitals. Resident initially hesitant for me to call family at this time and wanted us to call them in the morning then decided for me to call now. It should be noted that no documentation could be found to show that the physician was notified of the fall. On 4/6/23 at 12:06 PM, an interview was conducted with Director of Nursing (DON) 1. DON 1 stated that the physician should be notified immediately after a fall, even if the resident did not sustain an injury. DON 1 stated that the resident representative should also be notified if the resident had a power of attorney. DON 1 stated that the incident report and progress note would document all the parties that were informed of the fall. 2. Resident 86 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, mild protein-calorie malnutrition, anxiety disorder, depression, and history of falling. On 4/5/23 the Social Service Worker (SSW) provided the following recommendations to the Chief Nursing Officer (CNO) via email: Patient (resident 86) is diagnosed with unspecified dementia with psychotic behaviors.Recommended interventions for patient are an increase to quetiapine furmate (sic) or introduce Trazadone (sic), Cognitive Behavioral Therapy to help manage behaviors, modify environment to reduce triggers. Resident 86's medical record was reviewed on 3/28/23 through 4/25/23. A physician's order dated 4/8/23 revealed Quetiapine Fumarate Oral tablet 50 mg. Give 50 milligrams by mouth one time a day related to unspecified dementia, psychotic disturbance, mood disturbance, anxiety and depression. A physician's order dated 4/7/23 revealed Trazodone HCl oral tablet 50 milligrams. Give 50 milligrams by mouth at bedtime related to insomnia. The orders were entered by DON 3. On 4/20/23 10:50 AM, an interview was conducted with Hospice Registered Nurse (RN) 1. Hospice RN 1 stated there had not been any changes to resident 86's medications for over a month. Hospice RN 1 stated all medications changes should be through the hospice physician. Hospice RN 1 stated medication changes without Hospice being notified had happened before. Hospice RN 1 stated that resident 86 had been extra drowsy recently. Hospice RN 1 stated that the family had asked the hospice nurse about resident 86 being extra drowsy. Hospice RN 1 stated that she had asked the nurse on 4/11/23 about why resident 86 was drowsy. Hospice RN 1 stated that the nurse reported to Hospice RN 1 that there had not been any medication changes. Hospice RN 1 stated she was unable to see a list of medication through the electronic medical record. Hospice RN 1 stated that hospice should be managing resident 86's medications. Hospice RN 1 stated if there was a medication change, it needed to go through the hospice physician. Hospice RN 1 stated Hospice pays for medications, so not sure why medication orders were not through Hospice. Hospice RN 1 stated that resident 86's Trazodone was discontinued in December 2022 right before she was admitted to hospice. Hospice RN 1 stated resident 86's family member were concerned the facility was sedating her. Hospice RN 1 stated hospice evaluated resident 86's medications and resident 86 was able to walk, eat and the family was happy. Hospice RN 1 stated the facility should contact hospice prior to any medication changes. On 4/20/23 12:07 PM, an interview was conducted with DON 3. DON 3 stated nurses should be calling hospice nurse or on call hospice agency with medication changes. DON 3 stated the hospice contact information was in the resident's care plan. DON 3 stated that the facility physician was unable to make medication changes for residents receiving hospice services. DON 3 stated the hospice agency physician should be changing medications. DON 3 stated anything going on with the resident, staff should notify the hospice company. DON 3 stated Hospice RN 1 had just brought up to her there were medication changes that hospice RN 1 had not been notified of. DON 3 stated she asked Hospice RN 1 to go through resident 86's medications so they could discuss what medications were changed. DON 3 stated on 4/7/23, the Medical Director gave her a list of orders that she input into the electronic medical record. DON 3 stated she was not sure why the Medical Director had her change medications. On 4/20/23 at 12:49 PM, a follow-up interview was conducted with DON 3. DON 3 stated that the house physician was able to provide orders, but the new orders should be discussed with hospice regarding orders prior to being ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** [Cross refer to F565] Based on observation, interview, and record review it was determined the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, resident rooms were not clean, common areas were not clean, equipment was not kept clean, wheelchairs were in disrepair, there were large brown stains on a mattress and there was mold in a resident room. Resident identifiers: 12, 37, 38 and 84. Findings include: 1. On 3/28/23 at 11:18 AM, an observation was made of the Cambridge Unit. The Living Room in the unit was noted to have food crumbs all over the floor and all over one of the chairs. On 3/28/23 at 2:55 PM, an observation was made of hand rails in the Cambridge unit. There was debris and food in the hand rails. On 3/30/23 at 12:50 PM, an observation was made of the Colonial Hallway. The walls of the hallway were noted to be covered in dirt, hand prints, and paint chips. There was a brown stain on the wall outside of room [ROOM NUMBER]. The floor was noted to be covered in dirt, scratches, and tire marks. The floor between room [ROOM NUMBER] and 249 was sticky enough that the surveyor's shoes stuck to the floor. There were dust balls hanging from the ceiling tiles. The overhead speakers in the hallway ceiling were observed to be crackling. On 3/31/23 at 8:12 PM, an observation was made of overhead speakers outside the main dining room and in the Cambridge hallway outside room [ROOM NUMBER]. The speakers were crackling. On 4/1/23 at 5:32 PM, an observation was made of South Rehab hallway. There was a meal tray outside room [ROOM NUMBER] on the Personal Protective Equipment cart with a full drum stick on it uncovered. room [ROOM NUMBER] had pink debris on floor, other items on floor and food tray at bedside and there was no resident in the room. There was a trash can lid on floor in the hallway outside room [ROOM NUMBER]. On 4/11/23 at 10:31 AM, an observation was made in the Cambridge dining room of residents painting. The table that the residents were painting had a missing foot and was tipping when residents touched the table. On 4/11/23 at 10:40 AM, an observation was made in the Cambridge hallway outside room [ROOM NUMBER] and 224. The carpet was wet. On 4/13/23 12:27 PM, an observation was made of torn wallpaper and dark scruff marks along the wall in room [ROOM NUMBER]. On 4/17/23 at 2:44 PM, an observation was made of wallpaper lifting near room [ROOM NUMBER]. On 4/17/23 at 2:44 PM, an observation was made of stains in the hall carpet in front of rooms 124, 125, 131 and 132. On 4/17/23 at 2:44 PM, an observation of a purple substance dripping on wall near room [ROOM NUMBER]. On 4/17/23 at 2:44 PM, an observation was made of the white Hoyer Lift with a blackish brown substance on it in the Heritage unit. On 4/17/23 at 2:46 PM, an observation was made of room [ROOM NUMBER]. There was trash on the floor. There was brown splatter on the wall outside room [ROOM NUMBER]. On 4/17/23 at 2:54 PM, an observation was made of a stain in the carpet in the hall in front of the main dining room. On 4/17/23 at 2:55 PM, an observation was made of the overhead light fixture full of dead bugs and debris at the kitchen entrance. On 4/17/23 at 2:55 PM, an observation was made of torn wallpaper and a hole in the wall at the kitchen entrance. On 4/17/23 at 2:59 PM, an observation was made of grimy windows and black marks on doors and door frames going to the outside smoking area. On 4/17/23 at 2:59 PM, an observation was made of tiles outside the ancillary storage. On 4/17/23 at 3:00 PM, an observation was made of the floors in the Colonial hallway. The floors were sticky. Rooms in the hallway were observed to be sticky. room [ROOM NUMBER] had scraps on wall and next to the heating and cooling unit. There was popcorn and debris under bed A. The beadboard was pulling away from the wall between rooms [ROOM NUMBERS] in the Colonial hallway. The wall was soiled between rooms [ROOM NUMBERS]. There was a sit to stand lift with handles that were soiled with white substance and the handles were blue colored. The foot rest soiled with debris. On 4/17/23 at 3:01 PM, an observation was made of dust on the ceiling air duct near the nursing station in the Colonial. On 4/17/23 at 3:03 PM, an observation was made of missing caulking around toilet in the Colonial unit shower room. On 4/17/23 at 3:06 PM, an observation was made of stained flooring at the entry of room [ROOM NUMBER]. On 4/17/23 at 3:10 PM, an observation was made of doors being chipped of paint for rooms [ROOM NUMBERS]. On 4/17/23 at 3:11 PM, an observation was made of grimy hand grips and dirt and debris on the footrest for a Hoyer lift in Colonial hallway. On 4/17/23 at 3:15 PM, there was debris and gloves under the nursing carts in the Colonial hallway. On 4/17/23 at 3:34 PM, an observation was made of food crumbs and debris on the floor and tables in the Cambridge unit dining room. On 4/19/23 at 11:07 AM, an observation was made of the shower head on the floor in the Cambridge unit shower room. On 4/18/23 at 9:46 AM, an observation was made of a light brown colored splatter on the ceiling above the nurse station in Cambridge unit. On 4/19/23 at 11:14 AM, an observation was made of a broken kick plate on the janitorial door in the Cambridge unit. On 4/19/23 at 11:16 AM, an observation was made of missing tile under the temperature valve in the shower stall in the Cambridge unit. On 4/19/23 at 11:20 AM, an observation was made of grime on handles and foot plates of the Hoyer lift in the Cambridge unit shower room. On 4/19/23 at 11:30 AM, an observation was made of the Cambridge dining room. There was white substance on the table leg. On 4/19/23 at 11:34 AM, an observation was made of low lighting, every other light panel was absent of light down both halls, in the Cambridge unit. On 4/24/23 at 9:16 AM, an additional observation was made of the Colonial Hallway. The walls of the hallway were noted to be dirty, scuffed, stained, and covered in hand prints. On 4/24/23 at 1:27 PM, an observation was made of a brief on the floor in room [ROOM NUMBER]. 04/24/23 01:37 PM, an observation was made of the Cambridge unit. There were stains on the ceiling tiles. On 4/25/23 10:04 AM, an observation was made of the Cambridge hallway hand rails. There was debris in the hand rails. On 4/17/23 at 3:00 PM, an interview was conducted with Staff Member (SM) 5. SM 5 stated the floors were sticky in the Colonial hallway. SM 5 stated every room and the hallway were sticky after housekeeping mopped them. SM 5 stated a maintenance staff member told the resident the floors were sticky because We were squeaky clean. On 4/19/23 at 11:16 AM, an interview was conducted with Certified Nursing Assistant (CNA) 14. CNA 14 stated the tile in the shower stall in the Cambridge unit had been missing for about 2 weeks. On 4/19/23 at 11:27 AM, an interview with CNA 14 was conducted. CNA 14 stated that a full cleaning of any of the lifts was done after each use. CNA 14 stated she would report any cleaning issues to housekeeping. On 4/19/23 an interview was conducted with SM 19. SM 19 stated CNA's were to clean lifts after each use. SM 19 stated the remote control, sling area and food rests were cleaned after each use. On 4/19/23 an interview was conducted with SM 18. SM 18 stated a lift was cleaned after every use. SM 18 stated the lift handles and anything the resident touched were cleaned. SM 18 stated the lift in the shower room was cleaned last week. SM 18 stated that inside the handrails in the hallway were cleaned daily. 4. On 3/28/23 at 12:25 PM, an observation was made of a large black area of what appeared to be mold on the wall adjacent to resident 38's bed and restroom wall. On 3/28/23 at 12:26 PM, an interview was conducted with resident 38. Resident 38 stated the Administrator (ADMIN) 1 was aware of the mold in the room and was going to move her to a new room because of it. Resident 38 stated the mold was present before they moved her to the room. On 4/24/23 at 12:17 PM, an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated resident 38 should have been moved out of the room as soon as they were aware that mold was present. The CNO stated it was not safe to be in a room with mold present because of the multiple risks it presented to a resident's health. [Note: According to the resident census, resident 38 was moved into the room on 3/23/23 and was relocated to another room on 4/6/23. Resident 38 was exposed to mold for 15 days.] 5. On 4/20/23 at 2:10 PM, an observation was made of stained mattress in room [ROOM NUMBER]. The mattress appeared to have a large brown spot in the middle. There were cracks in the mattress. On 4/20/23 at 2:30 PM, an interview was conducted with Licensed Practical Nurse (LPN) 5. LPN 5 stated What do you think it is? LPN 5 stated a large brown stain on the mattress was fecal matter. LPN 5 stated there were more mattresses in the facility with large brown stains. LPN 5 stated it was not a special order mattress and the resident should have a different mattress. On 4/20/23 at 2:19 PM, an interview was conducted with CNA 18. CNA 18 stated she had seen multiple mattresses stained the same way throughout the facility. CNA 18 stated the stain was caused because of poop and not changing a resident timely enough. On 4/20/23 at 2:49 PM, an interview was conducted with the ADMIN 2. The ADMIN 2 stated they were going to look for a replacement mattress or order the resident a new mattress, if a bariatric bed was not available. The ADMIN 2 stated he was concerned how well the mattress was sterilized since there were a couple of cracks on it. The ADMIN 2 stated it was not a fun mattress to look at. The ADMIN 2 stated the stain was caused by a mixture of sweat and bowel movements. On 4/19/23 at 10:17 AM, an interview was conducted with Assistant Director of Maintenance (ADOM). The ADOM stated the facility just implemented a maintenance list last Friday (4/14/23). The ADOM stated he had been employed at the facility for about 3 months and had not kept a record of any of the repairs. When asked about the phone app, the ADOM stated he had not been told to do things on the app. The ADOM stated that he was told about some mold in a room about a month ago. The ADOM stated that he had not addressed the mold in the resident's room, because the resident needed to be moved out of the room prior to him cutting out the mold and repairing the wall. The ADOM stated that there was so much to do around this place it is hard to catch up. On 4/19/23 at 11:38 AM, an interview with Housekeeping Supervisor (HKS) 2 was conducted. HKS 2 stated she had been in this position for two days. HKS 2 stated that each housekeeping staff had their own chart for which areas they were responsible for cleaning. HKS 2 stated that on each of the cleaning carts there was a list of cleaning tasks that needed to be done. HKS 2 stated there was a sign off sheet for each room that has been cleaned and this was turned in to the supervisor at the end of each shift. HKS 2 stated when housekeeping staff noticed a disrepair in a room, they were supposed to tell the housekeeping supervisor, who would go directly to maintenance and verbally inform them. HKS 2 stated beds were cleaned daily. 3. Resident 84 was admitted to the facility on [DATE] with diagnoses which included polyneuropathy, protein-calorie malnutrition, liver cell carcinoma, chronic viral hepatitis C, schizophrenia, anxiety disorder, fibromyalgia, hypertension, chronic pain syndrome, and hearing loss. On 3/28/23 at 9:31 AM, an interview with resident 84 was conducted. Resident 84 stated that the housekeeper rarely cleaned his room. Resident 84 stated that his roommate frequently urinated on the floor in the bathroom and resident 84 placed towels around the toilet on the bathroom floor as an attempt to keep the bathroom clean. Resident 84 stated that he was the only person who cleaned his bathroom. Resident 84 stated that he would put gloves on and use the towels to clean the bathroom. Resident 84 stated that he was upset by this and wanted a cleaner room and bathroom. On 3/28/23 at 10:03 AM, an observation of resident 84's room and bathroom was made. The trash can in resident 84's room was full and overflowing with trash. In the bathroom, there were two white towels around the base of the toilet with what appeared to be large urine stains on the towels. The bathroom had a strong urine odor. 2. On 4/19/23 at 11:22 AM, an observation was made of resident 12's wheelchair. The wheelchair had debris and appeared soiled. In addition, the left arm rest was cracked and worn. On 4/24/23 at 1:27 PM, an observation was made of resident 37's wheelchair. Resident 37's wheelchair was observed to have a white substance on the side of the cushion. On 4/19/23 at 11:22 AM an interview with CNA 8 was conducted. CNA 8 stated that she cleaned wheelchairs in the morning while she was getting the residents ready for the day. CNA 8 stated that she wiped down the chair and let it air dry. CNA 8 stated that if she noticed a wheelchair was in disrepair, she would let maintenance know through the phone app that facility staff used. CNA 8 stated the CNAs cleaned the lifts after each use including the controller. On 4/19/23 at 11:27 AM, an interview with CNA 14 was conducted. CNA 14 stated the night shift was supposed to clean the wheelchairs and there should be a cleaning schedule. CNA 14 stated that she would notify maintenance and therapy about any wheelchair repairs. On 4/19/23 an interview was conducted with SM 19. SM 19 stated the CNA's were in charge of cleaning wheelchairs. SM 19 stated wheelchairs were cleaned before a resident was transferred to their wheelchair. SM 19 stated staff used disinfectant wipes to wipe down the arm rests, seat and handles. SM 19 stated she was not sure who cleaned the rest of the wheelchair. On 4/19/23, an interview was conducted with SM 18. SM 18 stated the night shift CNA's cleaned the wheelchairs. SM 18 stated there was a schedule for night shift to know which wheelchairs to clean. SM 18 stated if a wheelchair was broken, it was reported to the nurse or maintenance staff member. On 4/20/23 at 12:27 PM, an interview was conducted with Director of Nursing (DON) 3. DON 3 stated she thought that the night shift cleaned wheelchairs. DON 3 stated the CNA coordinator did the training on how to clean the wheelchairs to the CNA's during night shift. On 4/20/23 at 11:36 AM, an interview was conducted with Occupational Therapist (OT) 1. OT 1 stated that therapy was not allowed to fix any wheelchairs and maintenance was in charge of fixing wheelchairs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. On 4/12/23 at 11:19 AM, an interview was conducted with Resident 66. Resident 66 stated that she had filed multiple grievances in the facility. Resident 66 stated that there was never any follow up on any of the grievances she submitted. On 4/19/23 at 12:20 PM, an interview was conducted with the Activity Assistant (AA) 1. AA 1 stated that if a resident was unable to file a grievance themselves, she did her best to help file the grievance form. AA 1 stated once the form was completed she turned it into the corresponding department head. AA 1 stated ff the grievance was related to her job responsibilities, she tried and resolve the grievance. The facility policy for Grievances/Complaints, Recording and Investigating was reviewed. The policy stated the following: . 1. The administrator has assigned the responsibility of investigating grievances and complaints to the grievance officer. 2. Upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations. 3. The department director(s) of any named employee(s) will be notified of the nature of the complaint and that an investigation is underway. 4. The investigation and report will include, as applicable: a. the date and time of the alleged incident; b. the circumstances surrounding the alleged incident; c. the location of the alleged incident; d. the names of any witnesses and their accounts of the alleged incident; e. the resident's account of the alleged incident; f. the employee's account of the alleged incident; g. accounts of any other individuals involved (i.e., employee's supervisor, etc.); and h. recommendations for corrective action. 5. The grievance officer will record and maintain all grievances and complaints on the Resident Grievance Complaint Log. The following information will be recorded and maintained in the log: a. The date the grievance/complaint was received; b. The name and room number of the resident filing the grievance/complaint (if available); c. The name and relationship of the person filing the grievance/complaint on behalf of the resident (if available); d. The date the alleged incident took place; e. The name of the person(s) investigating the incident; f. The date the resident, or interested party, was informed of the findings; and gather disposition of the grievance (i.e., resolved, dispute, etc.). 6. The 'Resident Grievance/Complaint Investigation Report Form' will be filed with the administrator within five (5) working days of the incident. 7. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within five working days of the filing of the grievance or complaint. 8. The grievance officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse and/or misappropriation of property will be reported and investigated under guidelines for reporting abuse, neglect and misappropriation of property, as per state law. 9. Copies of all reports must be signed and will be made available to the resident or person acting on behalf of the resident. [Cross refer to F565] 4. Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included complications of internal left hip prosthesis, cerebrovascular disease, type 2 diabetes, infection and inflammatory reaction to internal left hip prosthesis, cognitive communication deficit, and adjustment disorder with mixed anxiety and depressed mood. On 3/29/23 at 9:39 AM, an interview was conducted with resident 9. Resident 9 stated he had $20 stolen out of his wallet, and he thought it was agency staff that took his money. Resident 9 stated he put in a grievance. Resident 9 stated after he put in his grievance about the stolen money the facility made him sign a paper. Resident 9 stated the paper he signed indicated that if a resident had money on their person the facility was not responsible. Resident 9 stated he did not like that he needed to declare to management how much cash was on his person. Resident 9 stated the facility had not replaced the $20. The facility grievances were reviewed. There was a grievance filed on 3/20/23 by resident 9. The grievance indicated that Wallet was in his jacket pocket and says he had $20.00 in it. Later he went to get wallet and it wasn't in pocket anymore. Housekeeping. The actions taken to resolve the grievance by facility staff were Have Admin talk with [name of resident 9] about what facility will or will not do. The grievance indicated that facility staff had spoken with resident 9 and told him that any cash needed to be listed on the resident's inventory list, and that facility staff could lock up the resident's money in the safe. The grievance then stated the next time [resident 9] was given money we had his daughter take his money out of the facility. The grievance did not indicate if the facility replaced resident 9's cash or not. On 4/25/23 at 10:04 AM, an interview was conducted with Resident Advocate (RA) regarding grievances related to missing money. The RA stated any missing money grievances that were given to her were redirected to the administrator. The RA stated it was the administrator that would make any of the decisions related to money. The RA stated she would go to the resident's room and try and help look for any missing items including money. 5. Resident 26 was admitted on [DATE] with the following diagnoses other chronic pain, major depressive disorder, recurrent severe without psychotic features, anxiety disorder, unspecified dementia, unspecified severity, with anxiety, and polyosteoarthritis. On 3/23/23 at 11:51 AM, an interview was conducted with resident 26. Resident 26 stated that she had a pair of gray pants that went missing. Resident 26 stated she has told staff about her missing property and they told her she needed to talk to the laundry manager. Resident 26 stated no one has followed up with her about her missing property. On 4/10/23 at 2:40 PM an interview was conducted with Housekeeping (HSK) 1. HSK 1 was asked about the process for missing laundry. HSK 1 stated this was her third day and referred to her supervisor. On 4/10/23 at approximately 2:40 PM, an interview was conducted with the Temporary Housekeeping Supervisor (THKS). The THKS stated that if a resident mentioned they had missing clothing, HSK 1 would need to inform her supervisor, then the supervisor would fill out a grievance form. The THKS stated that the grievance form would be given to social services for follow-up. The THKS stated that a new missing clothing process was just implemented that week where the grievance forms regarding missing clothing would go directly to laundry. The THKS stated that laundry would have 24 hours to search all current laundry for the missing item. The THKS stated that if laundry was unable to locate the item, the grievance form would be forwarded to social services. On 4/19/23 at 11:38 AM, an interview with Housekeeping Supervisor (HKS) 2 was conducted. HKS 2 stated she has been in this position for two days. HKS 2 stated some property would come in without the resident's name. HKS 2 stated laundry would keep non-labeled clothing for several months to see if a grievance came in. HKS 2 stated when a grievance came to laundry she would go to the resident's room and do a thorough search by looking in the closets and around the bed. HKS 2 stated there was a board in the housekeeping supervisor's office where grievances were tacked up so laundry could be on the lookout for the missing items. HKS 2 stated whichever staff member the resident told an issue to, that staff member was supposed to help the resident with filling out and submitting a grievance form. On 4/24/23 at 12:21 PM, an interview with RA was conducted regarding missing clothing. The RA stated a missing clothing form was filled out first, and if that did not resolve the issue then a grievance form was filled out. The RA stated she would tell the resident she would talk with laundry and then get back to the resident. The RA stated that residents would not be able to go to the laundry area to check on the status of missing clothing, as it was in a restricted area which was locked and located in the back of the building. 2. Resident 79 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included major depressive disorder, anxiety disorder, altered mental status, history of a traumatic brain injury (TBI) and intertrochanteric fracture of right femur. Resident 79 resided in the secured unit. On 3/29/23 at 10:30 AM, an interview was conducted with resident 79's family member. Resident 79's family member stated that he had missing clothing. Resident 79's family member stated he was usually wearing other residents' clothing. Resident 79's medical record was reviewed. A quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 79 had a Brief Interview of Mental Status (BIMS) score of 3 out of 15. The BIMS revealed that resident 79 had severe cognitive impairment. The facility grievances were reviewed and there were no grievances for resident 79. On 4/24/23 an interview was conducted with Staff Member (SM) 16. SM 16 stated resident 79 stated to her that he was missing clothing. SM 16 stated that in the memory care unit, it was hard because residents took each others clothing. SM 16 stated resident 79 was always missing his clothes and was upset about it. SM 16 stated when resident 79 was admitted , there should have been a form with clothing listed on it, but staff did not usually complete the form. SM 16 stated the residents have each others clothing all the time. SM 16 stated CNA's should take the residents clothing from their closet, but the laundry staff put the wrong clothing in the wrong dresser. SM 16 stated CNA's were unable to find the right clothing or the right size for residents, so CNA's went and looked through the lost and found for residents' clothing. SM 16 stated CNA's did not have another option so CNA's had to use clothing with other residents names on them. 3. Resident 94 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dysphagia following infarction, diabetes mellitus, cognitive communication deficit, paroxysmal atrial fibrillation, metabolic encephalopathy, schizophrenia and sepsis. Resident 94 resided in the secured unit. On 3/28/23 at 2:41 PM, an observation was made of resident 94. Resident 94 stated she was missing 8 pairs of pants and 4 shirts to SM 17. SM 17 was observed to tell resident 94 that she needed to ask laundry about her missing clothing. SM 17 was observed to walk away. Resident 94's medical record was reviewed. An admission MDS dated [DATE] revealed a BIMS score of 11 which indicated resident 94 had mild cognitive impairment. There were no grievance forms for resident 94 located in the grievance binder. On 4/25/23 at 8:45 AM, an interview was conducted with Registered Nurse (RN) 6. RN 6 stated she was not aware of any resident missing clothing in the secured unit. On 4/25/23, an interview was conducted with SM 24. SM 24 stated that resident 94 complained that her socks, shoes, and sweatshirts were missing. SM 24 stated she had looked in the laundry to see if resident 94's things were there. SM 24 stated a lot of clothing was not labeled and was in the laundry. SM 24 stated there was donated clothing and then the clothing was sent to be laundered and back to the donation area. SM 24 stated when she started at the facility there was not much in the residents closets. SM 24 stated every morning she had to go to laundry to find donated clothing for residents to wear. SM 24 stated a lot of the residents did not have shoes or socks. Based on interview and record review it was determined, for 18 of 80 sampled residents, that there were not prompt efforts made by the facility to resolve resident grievances. In addition, the facility did not ensure that all written grievance decisions included the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusion regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. Specifically, resident grievances were not resolved. Resident identifiers: 4, 7, 8, 9, 12, 14, 22, 23, 26, 28, 66, 67, 79, 92, 94, 209, 357, and 461. Findings include: 1. The resident grievance binder was reviewed. The following grievances were filed and documented the following: a. On 12/7/22, resident 7 filed a grievance stating that she was without her teeth and hearing aids. There is only one CNA [Certified Nursing Assistant] here to take care of 20 pts [patients] all alone. Short staffed. Director of Nursing (DON) 2 listed the intervention as 1 CNA in Colonial is not outside of state standards. No other interventions or investigation were listed on the grievance form. b. On 12/8/22, resident 7 filed a grievance indicating that the facility was short-staffed on nursing care. DON 2 listed the intervention as Not short staffed. No other interventions or investigation were listed on the grievance form. c. On 1/6/23, an unknown person filed a grievance stating I was not informed that resident had ostemy [sic] bag at report hospic [sic] aide did not could not have changed the bag it exploded nurse refused to change .The resident was laying covered in fetuses [sic]. The intervention listed to Put the residents name on the report sheet that he has ostemy [sic] bag. Nurse needs correction action [sic]. The interventions did not include what systemic changes would be implemented to prevent this from occurring in the facility again. d. On 1/9/23, a grievance was filed on behalf of resident 67. The grievance indicated that resident 67's dentures were lost or stolen in September 2022, and had not been replaced yet. The form also indicated that Assured replacement. November 2022. I made appointments for her [resident 67] in [NAME] - November 2022. Mgmt [management] refused to take her - December 2022. No in house dental impressions taken yet as alternative plan was supposed to have her dentures by Christmas - was given someone else's top dentures only. IMPACT - cannot chew foods provided soft [and] small diet not being adhered to . Diabetic diet not being adhered to . Causes choking on food more often [and] that causes crushed pills that taste terrible instead of taking one at a time. Then she doesn't want to take them. Then she gets UTIs [urinary tract infections] [and] lack of changing often. Is not receiving physical therapy as stated she could start in January. The facility resolution indicated that an outside company has been working on dentures for [resident 67] . 12/9/23 upper dentures completed. 1/30/23 scheduled to start lower. No other interventions or investigation were listed. e. On 1/13/23, resident 7 filed a grievance stating that her top dentures are now broken too. Please call me and give me the number of the company that is to come fix them. They were contacted on [DATE] to fix them and they still are not fixed. The grievance form listed the resolution as First referral was made 1/9/23 not December 8 and that they had notified an external company about the concern. f. On 1/14/23, a family member filed a grievance on behalf of resident 461 stating that the resident was in bed fully dressed. I had to get him up to fix his bed [and] have him get a new brief on [and] change his clothes. I had a very difficult time waking him up. Once awake [Name of staff member] CNA from other side helped me get him out of bed. I don't know where his CNA was. [Name of staff member] took him into the bathroom to change. He was soaked through his brief [and] all his clothes. Also, his bedding was soaked. I supplied [resident 461] with 2 bags of Depend briefs [Thursday] night. 1 large bag for day and 1 smaller bag for nights. I explained to [resident 461] [and] the CNA and also put a note on the wall in the bathroom to make sure they only use the night was [sic] for night [and] day for day. So as of 6 PM Sat [Saturday] 14 not one day brief had been used. and 5 night ones were used. 2 things concern me. 1- Why can't instructions be followed! 2 - How is it he has only had 5 briefs used since [Thursday] night. With the amount he urinates each day, several of the day briefs should have been gone. And, his clothes should not be soiled. I was told by a CNA patients are to be checked every 2 [hours]. This tells me he's worn 2 briefs a day! Unless he is using the toilet - but his bedding [and] clothes have been wet the last 3 days! The intervention listed was We had an IDT [interdisciplinary team] to address [sic] these concerns as well as increased email comunication [sic] for addressing concerns. The grievance did not indicate what systemic changes would be implemented to prevent this from happening to this resident, and/or other residents residing in the facility. g. On 1/19/23 resident 14 explained he doesn't like [name of staff member] [and] 'fired' her last week after she was yelling [and] being mean regarding him asking for his brief to be changed everytime he goes to the bathroom. [Resident 14] stated she said it costs a lot of money [and] got rude [and] threw whatever she had in her hands down on the table. [Resident 14's roommate] . also stated he doesn't like her [and] she is really rough [and] aggressive. The intervention listed was We have had education with [name of staff member] about tone of voice [and] being kind. The grievance form indicated that only DON 2 had filled out and filed the form. No other interventions were listed to ensure that the residents felt safe, or that they were being protected while the investigation was completed. Review of the State Survey Agency system indicated that this grievance had not been submitted as a possible abuse investigation. [Note: It should be noted that another grievance regarding this staff member's behavior would be filed on 3/10/23 by another resident.] h. On 1/20/23 resident 28's daughter filed a grievance indicating that she was unsure if her mother was being repositioned in bed. The daughter indicated that her mother is mostly non-verbal. Her roommate [resident 22] observed that [resident 28] had a soiled brief all night that was not changed until 5:30 AM 1-20-23. That brief was soiled also for 'hours' and was not changed until 3:00 PM 1-20-23. The first change required a full bedding change as well because bedding was soaked, according to [resident 22]. We are unsure if repositioning to avoid bedsores occurred [sic] as ordered. So, it appears that [resident 28] has only received two brief changes in the past 16 hours, repositioning status is unknown. Resident 28's daughter recommended that the facility Hire more staff. Train all staff on frequency of brief changes and repositioning. Spot check staff to see if tasks are completed as charted. Alter the charting software to allow reporting of more than one brief change per shift. Currently my mom has preventable bedsores that are unlikely to heal before she passes away. The DON's response to the grievance was Room mate is involving herself in residents cares. Staff is having a hard time ensuring her privicy [sic] during cares to maintaine [sic] dignity. Hospice as well as staff provide cares [and] hospice reported that when they arrived 1/20 resident was dry. RN [Registered Nurse] noted progress note identifing [sic] roommate attempting to involve herself while cares are being provided. No other interventions or investigations were listed on the grievance form. The DON's response did not address the bedsores. The grievance form did not indicate that any other staff, including the Administrator had seen the form. i. On 1/23/23, a resident filed a grievance stating that she had a long haired male CNA who left her in BM [bowel movement] over an hour while he found another aide when he and the African American aide returned they were too rough, hurt her knee and was wiping rough. She is sore now. The intervention listed was The 2 aides described in this greivance [sic] are both [name of agency]. [Agency] out of the building starting 2/1/2023. The grievance form indicated that only DON 2 had filled out and filed the form. No other interventions were listed to ensure that the residents felt safe, or that they were being protected while the investigation was completed. Review of the State Survey Agency system indicated that this grievance had not been submitted as a possible abuse investigation. In addition, agency staff were still observed to be in the facility during the period of the recertification survey. j. On 1/27/23, a grievance was filed indicating that on 1/26/23, a staff member refused to give [resident 7] a shower. Also said aide refused to get her in chair and told [resident 7] they were short handed that there is only one aide today (1/27) and aide said she couldn't shower her in am. The follow up to the grievance indicated that the employee felt she did not have time to give shower. Educated aid [sic] to always ask for help from nurse, CNA coordinator, ADON [and] DON to help ensure resident cares are completed. k. On 2/17/23, resident 4 filed a grievance alleging that Cigaretts [sic] were stolen from [resident 4's] fridge. 6 packs are missing. there were 2 packs on the tray table that are also missing. 4 in the fridge, 2 on tray table 6 packs total missing. The resident indicated that she wishes for her smokes to be replaced. She said her plan of action is to find a hiding spot for the packs of cigaretts [sic]. Facility staff indicated that resident 4 had not listed the cigarettes on her inventory list, and that staff were unable to comfirm [sic] or deney [sic] if resident had cigarettes. [Note: It should be noted that resident 4 was admitted on [DATE], and there was no policy located for residents updating their inventory list after admission.] l. On 3/2/23, resident 14 expressed that his call light wait times have been long. The grievance included a witness statement indicating that Durring [sic] lunch tray pass i [sic] witnessed [resident 14] yelling for help [with] his bathroom call light on. There were aids passing trays ignoring him. The intervention listed was Reminded aids of the importance of rounds before meals so that we do not run into problems like this. The intervention did not address what steps would be taken if a resident needed to use the restroom during the passing of meal trays. m. On 3/3/23, resident 92 filed a grievance saying she feels like nurse on her hall was ignoring her. Reports that she only got 1 pain pill. The interventions listed were to Address [with] nurse. No other follow up was listed. n. On 3/3/23, resident 9 filed a grievance and said no one emptied his urinal all day and that his call light was on for over 45 min [minutes]. Also asked staff to call pain clinic for him and he hasn't heard anything. The actions for resolution of the grievance was Teach [resident 9] how to empty his own urinal since he is wanting to go to an ALF [assisted living facility]. The form indicated that the DON was informed of resident 9's concerns, but that they were unable to confirm if his light was on for that long. Nothing on the form indicated that resident 9's grievance regarding the pain clinic had been addressed. [Note: Resident 9 would file another grievance 5 days later for the pain clinic not being contacted as requested.] o. On 3/3/23, resident 12 reported to the RA that his call light wait times have been long. He is also having a problem [with] the nurses working his c-pap [continuous positive airway pressure] [at] night. The investigation portion of the form indicated that Talked [with] staff on how to use c-pap [and] assist resident to put it on. staff have been inserved on cpap use. The extended wait time for the call light response was not addressed. p. On 3/8/23 the RA reported that resident 8 was kicked out of pain clinic due to the facility perscribiling (sic) meds (medications) when clinic had perscribed (sic) enough. The resident requested that he would like to get back into pain clinic. Would like an audit [and] explination (sic) as to why he is running out of pills prior to two weeks. The intervention listed by staff was that staff has attempted to contact the clinic [and] is still trying to get ahold of them. No other information was listed on the form as to what the facility had done to resolve the resident's grievance. The Administrator signed the grievance form as reviewed on 3/25/23. q. On 3/10/23, the RA reported that a nurse, who was identified only by her first name, told resident 9 that she was glad the resident was leaving so she didn't have to deal [with] him. The RA documented that she spoke with the nurse regarding appropriate tone [and] verbage. The RA also documented that she spoke with resident 9 about being kind to floor staff. No other interventions were listed. The form indicated that the Administrator had signed the form on 3/18/23. Review of the State Survey Agency system indicated that this grievance had not been submitted as a possible abuse investigation by either the RA or the Administrator. r. On 3/23/23, resident 92 reported that resident 23 was harassing residents about their pain meds [medications] when they are being passed. [Resident 23] is even telling residents how to hide them from the nurse. The follow up by RA was listed as: Spoke [with] 2 other residents [and] they confirmed that she (resident 23) was asking them for their pain meds. spoke with [resident 23] [and] she agreed that she wouldn't do that anymore. s. On 3/27/23, resident 209 reported that on 3/25/23 she was left in feeces [sic] for 3 hours [and] has not gotten a shower or bed bath since admit. Facility staff indicated that they had educated staff on the importance of proper pericare and the importance of doing rounds. t. On 3/27/23, resident 357 reported that staff had left her in urine [and] after changing her tried put [sic] her back in a urine soaked bed. Told resident we did not have the staff to work slower [with] her. Facility staff indicated that they had educated the staff on the importance of time management and cleanliness. On 4/11/23 at 11:51 AM, an interview with resident 7 and resident 7's Power of Attorney (POA) was conducted. Resident 7's POA stated that she had submitted multiple grievances in the past. Resident 7's POA stated she had never received a phone call or update from any staff member regarding the grievances. Resident 7's POA stated she had since given up submitting grievances because nobody had ever followed up with her grievances. Resident 7's POA stated she believed nobody at the facility reviewed the grievances. On 4/13/23 at 2:30 PM, an interview was conducted with Administrator (ADM) 1. ADM 1 stated that both he and the Resident Advocate (RA) were assigned as the grievance officers, and were highly involved in the grievance process. ADM 1 stated that when a grievance was filed, both he and the RA would start looking at it, trying to find solutions. ADM 1 stated that before he signed off that a grievance was completed, he made sure the issue was fully resolved. ADM 1 stated that the investigation of the grievance was supposed to be documented on the grievance form. ADM 1 could not provide an explanation as to why the above listed grievances had not been investigated throughly or followed up on.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident 43 was admitted to the facility on [DATE] with the following diagnoses but not limited to chronic obstructive pulmonary disease, type 2 diabetes mellitus, bipolar disorder, borderline personality disorder, and anxiety disorder. On 3/28/23 at 3:19 PM, an interview was conducted with resident 43. Resident 43 stated it was bull crap the smoking policy was changing. Resident 43 stated it was ridiculous they were limited to 5 smokes a day. Resident 43 stated they were unsure why they were enforcing the new smoking policy. Resident 43 stated they were being locked up like prisoners since they won't be able to go outside to get fresh air due to them locking the doors. Resident 43 stated other residents have talked about going out the front and smoking in the street since it would be 25 feet away from the building. Resident 43 stated the rule was to have their smoking supplies taken away and locked up by the nurses. Resident 43 stated she was concerned she would never get her supplies when she requested them since the nurses were always busy and would not have time to get them. Resident 43 stated they were strict about the smoking times and if you missed it, you were shit out of luck and had to wait until the next posted time. Resident 43's medical records were reviewed on 4/11/23 A Quarterly MDS dated [DATE], documented resident 43 had a BIMS score of 9. This indicated that resident 43 was moderately impaired. On 2/20/23 and 4/13/23, a smoking safety evaluation documented that resident 43 was an independent smoker and she was allowed to have her smoking supplies with her. Resident 43 had 2 active care plans for smoking which were documented as followed: a. A care plan focus area documented, resident 43 uses tobacco: Cigarettes. I am a safe smoker, I am independent. I can smoke in designated smoking area. I purchase my own cigarettes through activities. I wear oxygen but not while smoking. I take off in order to smoke. This care plan was initiated on 2/10/23. b. A care plan focus area documented, resident 43 is a smoker. A documented goal was the resident will not smoke without supervision through the review date. Documented interventions included: 1. Instruct resident about the facility policy on smoking: locations, times, safety concerns. 2. Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. 3. The resident requires SUPERVISION while smoking. 4. The resident's smoking supplies are stored (SPECIFY). This care plan was initiated on 2/8/23. [Note: Resident 43 was considered an independent smoker and did not need to be supervised.] On 3/29/23, a nursing progress note documented, .she wanted to go AMA [against medical advice] because they facility has now implemented smoking times. Pt [patient] is a chain smoker and is struggling with the new rule. On 4/19/23 at 1:55 PM, an interview was conducted with the Chief Nursing Officer (CNO) and the Director of Nursing (DON) 3. The CNO stated resident 43 was considered an independent smoker based on the most current care plan and smoking evaluation. The CNO stated he was going to resolve the other care plan that stated resident 43 was a supervised smoker because that was not the case. The CNO stated nurses knew to follow the most up to date care plan in a resident's chart. Based on observation, interview, and record review it was determined, for 5 of 80 sampled residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident. Specifically, residents who sustained falls did not have an appropriate care plan, a resident did not have an appropriate care plan for dementia, and residents did not have appropriate care plans that addressed smoking. Resident identifiers: 1, 43, 51, 79, and 98. Findings Include: 1. Resident 1 was initially admitted to the facility on [DATE] and again on 1/2/23 with diagnoses which included chronic obstructive pulmonary disease, acute respiratory failure, unspecified asthma, acute kidney failure, history of falling, muscle weakness, systolic heart failure, adult failure to thrive, hypothyroidism, lactose intolerance, insomnia, adjustment disorder, personality disorder, anxiety disorder, and bipolar disorder. Resident 1's progress notes were reviewed and it was revealed that resident 1 had 17 falls (11 unwitnessed and 6 witnessed) since 5/18/22. Resident 1 was sent to the hospital after three of the falls. Resident 1 sustained a patellar fracture and a nasal bone fracture from a fall on 12/31/22. A review of the care plan revealed that the care plan was not updated after multiple falls, and it was revealed through staff interviews that the care plans were not implemented by the facility staff. On 5/14/22 at 9:54 PM a progress note revealed that resident 1 had a witnessed, assisted fall by a CNA in the resident's bathroom. The resident did not sustain any injuries stated. The care plan was updated on 5/18/22 and stated, educate resident and ask for the staff assistance with ADLs, transfers, ambulation r/t [related to] poor balance, weakness. On 6/23/22 at 11:27 PM a progress note revealed that resident 1 had a witnessed, assisted fall by a CNA in the resident's room. Resident 1 did not sustain any injuries. Staff educated the resident about safety and using bed pan when needing to go to the bathroom. The care plan was updated on 6/23/22 and stated, Labs as ordered and evaluated by MD r/t [related to] recent fall, weakness, c/o [complaints of] bladder spasms. On 9/17/22 at 10:32 PM a progress note revealed that resident 1 had an unwitnessed fall in her room and was found on the floor by a CNA. According to the progress note, the resident stated her bed was not locked. Resident 1 did not sustain any injuries. The care plan was updated on 9/23/22 and stated, ensure residents bed is locked at all times. On 10/1/22 at 6:59 AM a progress note revealed that resident 1 had a witnessed, assisted fall by a CNA in the residents room. Resident 1 did not sustain any injuries. The care plan revealed no new interventions. On 10/5/22 at 12:17 AM a progress note revealed that resident 1 was found on the floor in her room. Resident 1 stated that she crawled onto the floor from her chair. Resident 1 then waited on the floor until the Hoyer lift was available. The care plan revealed no new interventions. On 11/20/22 at 10:53 AM a progress note revealed that resident 1 had an witnessed, assisted fall by a CNA. The CNA stated the resident was, weak during transfer. Resident 1 did not sustain any injuries. The care plan was updated on 12/5/22 and stated, implement the Falling Star Program. On 11/22/22 at 4:38 AM a progress note revealed that resident 1 had an unwitnessed fall in her room. The resident did not sustain any injuries. The care plan was updated on 12/5/22 and stated, implement the Falling Star Program. On 12/2/22 at 7:48 PM a progress note revealed that resident 1 had an unwitnessed fall in her room. The resident had scratches and bruising on her left knee. The care plan was updated on 12/5/22 and stated, implement the Falling Star Program. On 12/31/22 at 4:04 PM a progress note revealed that resident 1 had an unwitnessed fall out of her wheelchair. Resident 1 had bruising above her right eye and a bloody nose. The progress note revealed that resident 1 began choking on blood and was sent to the hospital and returned 1/2/23. Resident 1 sustained a contusion to her head, a patellar fracture, and a nasal bone fracture. The care plan was updated on 1/2/23 and stated, low bed at all times when in bed, reeducated on asking staff for assistance and remind of recent fall with fracture. On 1/3/23 at 12:45 AM a progress note revealed that resident 1 was found on the floor in her room. Resident 1 was bleeding from her knee, a bump above her left eye, and complaints of pain to her head, left leg, ankle, and left and right knee. Resident 1 was sent to the hospital. The care plan revealed no new interventions. Resident 1 received a new order to discharge Ativan due to falls per resident's request. A 72 Hour Charting progress note on 1/5/23, related to the fall, reported resident 1 had increased confusion, refused neurological checks, and refused to go back to the hospital. On 2/5/23 at 7:14 PM a progress note revealed that resident 1 was found on the floor in her room. Resident 1 did not sustain any injuries. The care plan was updated on 2/6/23 and stated, continue interventions on the at-risk plan. On 2/15/23 at 11:51 PM a progress not revealed that resident 1 was found crawling on the floor in her room. The care plan revealed no new interventions. On 2/20/23 at 1:28 PM a progress note revealed that resident 1 fell during a transfer with a CNA in the shower room. Resident 1 did not sustain any injuries. The care plan revealed no new interventions. On 2/24/23 at 5:43 PM a progress note revealed that resident 1 had an unwitnessed fall and was bleeding from her nose. Resident 1 was unresponsible until paramedics arrived. The care plan was updated on 2/28/22 and stated, for no apparent acute injury, determine and address causative factors of the fall. On 3/3/23 at 4:35 AM a progress note revealed that resident 1 was found on the floor in her room. The care plan was updated on 3/3/23 and stated, offer and assist with frequent toileting as needed. On 3/4/23 at 12:01 AM a progress note revealed that resident 1 had an assisted fall by a CNA during a transfer. The resident then refused assistance off the floor for approximately 2 hours. The care plan revealed no new interventions. On 3/7/23 an incident report revealed that resident 1 fell out of her wheelchair. Resident 1 had and order for an x-ray for her left shoulder, left elbow, and left forearm. The x-ray findings revealed no fractures. The care plan was updated on 3/7/23 and stated to monitor, document, and report as needed for 72 hours to the medical director for signs and symptoms including pain, bruises, changes to mental status, confusion, sleepiness, inability to maintain posture, and agitation. On 4/6/2023 at 12:06 PM an interview with the Director of Nursing (DON) 1 was conducted. DON 1 stated that the Falling Star Program informed staff as to which residents were at a higher risk for falls. DON 1 stated that this program was never fully implemented in the facility. DON 1 stated that the At-Risk written on the care plans meant that staff were to answer call lights, ensure proper footwear, ensure no faulty equipment, and to keep the bed in the lowest position. DON 1 stated that these interventions were taught to staff during orientation. DON 1 stated that each time a resident fell, a new intervention should have been added to the residents' care plan and the morse fall scale should have been updated. DON 1 stated that educating residents who had cognitive deficits was not an appropriate intervention. DON 1 stated that she was responsible for updating resident care plans. 3. Resident 51 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included unspecified dementia, type 2 diabetes mellitus, cervicalgia, major depressive disorder, dysthymic disorder, hypertension, gastro-esophageal reflux disease, anxiety disorder, insomnia, and post-traumatic stress disorder. On 3/29/23, resident 51's medical records were reviewed. Review of resident 51's incident reports, progress notes, and care plans revealed the following: a. On 8/17/22 at 8:30 AM, the incident report documented that resident 51 was .found sitting on bathroom floor when cna [Certified Nurse Assistant] walked, no injuries noted from what pt [patient] had said, pt refused skin check, no pain, rom [Range of Motion] at baseline. Neurological (Neuro) assessments were started every 15 minutes. The report documented injuries observed at time of incident were to the top of the scalp, and the injury type documented Unable to determine. The report documented the predisposing factors were poor lighting, resident was confused, resident was incontinent, resident had a gait imbalance, resident had impaired memory, and resident was ambulating without assist. The physician was notified on 8/17/22 at 6:35 PM. On 6/22/22 and again on 6/23/22, a care plan for at risk for falls was initiated for resident 51. Interventions identified were anticipate and meet the resident's needs; ensure call light was within reach and encourage the resident to use it for assistance; respond promptly to the resident's requests for assistance; educate the resident/family/caregivers about safety reminders and what to do if a fall occurs; clean up spills immediately; encourage self-mobile residents to rise slowly an be sure of their steadiness prior to walking; and examine all footwear for proper fit. It should be noted that no new interventions were identified on the care plan after the fall on 8/17/22. b. On 8/26/22 at 11:55 AM, the incident report documented, Resident was found on floor at approx [approximately] 1155 [AM] by staff. Resident was sitting on her floor in the middle of her room. Resident has not c/o [complained of] pain or discomfort. The report documented that resident 51 was unable to give a description of the incident. Immediate action taken was VSS [vital signs stable] neuros started provider notified. Left message with [family member] to call back. No other problems noted at this time. The report documented no injuries were observed at the time of the incident. The report documented the predisposing factors were resident was confused and drowsy, resident was incontinent, resident had a gait imbalance, and resident had impaired memory. The physician was notified on 8/26/22 at 12:17 PM. On 8/22/22, a care plan for the resident had an actual fall with no injury was initiated for resident 51. Interventions identified were to continue interventions on the at-risk plan, frequent checks on rounds related to dementia with behaviors, implement the Falling Star Program, and offer and assist with frequent toileting as needed related to fall in bathroom. The care plan was resolved on 3/24/23. c. On 8/26/22 at 5:15 PM, the incident report documented, Resident was found on floor in her room at approx 1715 [5:15 PM]. She was laying on her right side when found by this nurse. Resident has a hematoma appox [sic] 2 cm [centimeters] in circ. [circumference] to the back of her head close to her neck and a 0.5 cm cut to her lip. She is alert and appropriate to self at this time. Resident provider notified and her [family representative] also called. Restarted neuros. The report documented injuries observed at the time of the incident were a hematoma to the back of the head and a small 0.5 cm cut to the lip. The report documented the predisposing factors were confusion and weakness/fainted. The physician was notified on 8/26/22 at 5:26 PM. d. On 9/4/22 at 12:37 PM, the incident report documented, Unwitnessed fall. Resident sitting in recliner is [sic] facility hallway, watching t.v. Resident slipped down and out of recliner to floor, landing on buttocks sitting position. No injuries observed. Notified MD [Medical Doctor]. No c/o [complaints of] pain. V/S [vital signs] 130/75 [blood pressure] 64 [heart rate] 14 [respiratory rate] 97.3 [temperature] O2 [oxygen] 92% The report documented that resident 51 was unable to give a description of the incident and resident 51 was returned to sitting in the recliner. The report documented no injuries were observed at the time of the incident. The report documented the predisposing factors were resident was confused and impaired memory. The physician was notified on 9/4/22 at 12:29 PM. It should be noted that no new interventions were identified on the care plan after the fall on 9/4/22. e. On 9/11/22 at 9:45 PM, the incident report documented, Resident was found on floor in rm [room] this night at 1920 [7:20 PM]. She was found by another resident. She was on her back at the end of her bed. She had items from her walker all over the floor near her. She had her R [right] shoe off her foot. She didn't want any help getting off the floor. She wanted every one to get out of her room. Resident stated she was not hurt and that she did hit her head on the floor. There are no injuries visible on her person. She states she was not in pain. Two CNA [Certified Nurse Assistants]were able to convince her to get off the floor and into bed at 1927 [7:27 PM]. We laid her down to bed and started Neuro charting. She is stable. She was not on the mat by her bed at all. I contacted the MD and DON at 2028 [8:28 PM] and at 2051 [8:51 PM] I tried to call her sister with no response. Resident Description: Resident stated she wanted to be on the floor and that was why she was there and to leave her alone, she would get up when she wants. The immediate action taken was MD, DON, notified. NEURO V/S started, resident put in bed, non grippy socks taken off, Head to toe assessment no visible injury. The report documented the predisposing factors were clutter, confusion, gait imbalance, impaired memory, and ambulating without assist. The MD was notified on 9/11/22 at 9:49 PM. It should be noted that no new interventions were identified on the care plan after the fall on 9/11/22. f. On 11/21/22 at 2: 55 PM, the incident report documented, CNA notified this nurse that during shower while whole resident was standing up, she lost her balance and fell to the floor. CNA told this nurse that resident did not hit her head. On assessment in the bathroom no apparent injuries noted. Resident denied pain. Resident refused vital signs on more than 3 attempts. MD notified by ADON [Assistant Director of Nursing]. The report documented the predisposing factors was a wet floor. The physician was notified on 11/21/22 at 3:31 PM. It should be noted that no new interventions were identified on the care plan after the fall on 11/21/22. g. On 11/24/22 at 12:23 PM, the incident report documented, Resident sitting by nurses' station and fell asleep in chair. Resident fell out of chair, to floor, onto buttocks. No contact of head to floor. Fall was witnessed by nurse. No apparent injuries observed. V/S 126/84 72 18 93.1 95. The report documented no predisposing factors to the fall. The report did not document that the physician was notified. It should be noted that no new interventions were identified on the care plan after the fall on 11/24/22. h. On 11/24/22 at 2:25 PM, the progress note documented, Resident ambulating with FWW [forward wheeled walker] in hall. Fell to right knee, supported by FWW. Redness to right knee observed. No c/o pain. v/s 132/78 [blood pressure] 88 [hear rate] 16 [respiratory rate] 98.1 [temperature] 96 [oxygen saturation] PEERL [sic] Equal grips. MD notified. It should be noted that no new interventions were identified on the care plan after the fall on 11/24/22. i. On 12/1/22 at 2:03 PM, the incident report documented, Resident found on floor, lying on right side. FWW was on its side, on the floor. Assessed resident for head injuries and for physical injuries. No injuries observed. PERRL [pupils equal, round and react to light] Equal grips. V/S 148/74 80 16 96.3. Resident has been placed on Neuro checks. MD notified. The physician was notified on 12/1/22 at 2:08 PM. It should be noted that no new interventions were identified on the care plan after the fall on 12/1/22. j. On 12/3/22 at 2:41 PM, the incident report documented, Resident found on floor, lying on right side. FWW was on its side, on the floor. Assessed resident for head injuries and for physical injuries. Skin tear to left forearm. PERRL [pupils equal round and reactive to light] Equal grips. V/S 148/74 80 16 96.3. Resident has been placed on Neuro checks. MD notified. The physician was notified on 12/3/22 at 9:46 AM. It should be noted that no new interventions were identified on the care plan after the fall on 12/3/22. k. On 12/5/22 at 5:15 PM, the incident report documented, pt called out for help and nurse found patient on floor near entrance of bedroom. nurse assisted pt into wheelchair. The immediate action taken was nurse assisted pt into wheelchair. Once in wheelchair nurse gained vital signs. Pt's vital signs were wnl [within normal limits]. Patient verbalized pain in back and buttock but would not allow nurse to assess skin. pt stated, 'that is enough'. Nurse unable to assess skin for injuries. pt is alert to baseline, pupils are not equal at baseline but are reactive to light, hand grasps equal, able to move all extremities. neuros started. provider notified. unable to reach family. The report documented resident 51's at a 4/10. The report documented the predisposing factors were gait imbalance, impaired memory and wanderer. The physician was notified on 12/5/22 at 8:04 PM. It should be noted that no new interventions were identified on the care plan after the fall on 12/5/22. l. On 12/18/22 at 2:30 PM, the incident report documented, CNA reported to the nurse that the resident was found in the hallway on the floor and leaning up against the wall because she had fallen. She reports the hallway was cluttered with other residents and there was not enough room for her to get by. She lost her balance and fell into the wall, hitting her R [right] cheek on the hand railing. She denies pain, unless the site is palpated, to which she states the pain is there but not bed [sic]. There were no other apparent injuries. The resident description documented, Resident states she lost her balance with all the other people around and ended up falling into the wall and hitting her R [right] cheek on the handrail. She reports being ok and denies pain. The immediate action taken was, Resident was assisted off the floor by two staff members, skin check and Neuro checks and vital sign checks were initiated per protocol. MD and family contact were called. Nurse and aides reminded the resident that she needs to use her walker at all times when ambulating and to avoid obstacles and people. She needs constant re-direction d/t [due to] dementia. Encouraged her to use her call light in her room. The physician was notified on 12/18/22 at 5:08 PM. It should be noted that no new interventions were identified on the care plan after the fall on 12/18/22. m. On 2/1/23 4:50 PM, the incident report documented, Aide notified nurse of being unable to find patient. Nurse found patient supine lying in wheelchair storage room. The immediate action taken documented, Pt was drowsy when initially found and was unable to give description. Nurse and aide assisted patient into sitting position and c/o of dizziness. Pt did not c/o of pain. Pt stated they were fearful but was reassured successfully by nurse. Pt did not have visible injuries other than light bleeding from posterior head hematoma. Pt was alert after transfer, hand grasps equal yet weak, and able to move all extremities. provider notified. neuros started. The report documented an injury of a hematoma to the Top of Scalp. The physician was notified on 2/1/23 at 7:34 PM. It should be noted that no new interventions were identified on the care plan after the fall on 2/1/23. n. On 2/7/23 at 2:31 PM, the progress note documented, [name omitted], resident, came to the nurse's station and alerted SN [skilled nurse] that a Resident had a fall. SN followed [name omitted] to the kitchen area where [resident 51] was found lying on her right side on the floor next to her rolling walker. She was [NAME] [sic], oriented x2, and complained of back pain. She stated that she hit her head and this was confirmed by [name omitted] who witnessed it. Resident stated that she went to sit on her rolling walker and it moved back away from her. She said she hit her head, back, and arms. Residen't [sic] head was examined and there was a soft raised area on her lower occipital lobe. Pt's arms and back were examined but there was no visible injury. Pt's legs were palpated and the pt stated that they did not hurt. Pt was lifted by SN into her rolling walker seat and wheeled back to the nurse's station and assessed further. Pt's right Pupil was slightly more dilated that [sic] her left. Right pupil was sluggish to respond to direct flashlight. Left pupil was smalll [sic] but not very reactive at all. Pt states that her Left eye is her good eye, and that she can't see very much at all out of her Right eye, as before. Pt's grip was weak and slightly unequal [left greater than right]. She was moving all extremities. She stayed alert and stated that she felt fine. Neuro checks was started as per facility policy. It was noted that her wheel locks on her walker were not capable of stopping the wheels from rolling when engaged in the locked position. Pt's MD and Family were contacted. SN will continue to monitor. It should be noted that no new interventions were identified on the care plan after the fall on 2/7/23. o. On 3/12/23 at 5:12 PM, the progress note documented, Resident was in a regular sitting chair, fell backward, and hit back of head on wall. No open areas observed to back of head. No hematoma observed. v/s 125/70 [blood pressure] 97.8 [temperature] 80 [heart rate] 16 [respiratory rate]. MD notified. Placed on Neuros. It should be noted that no new interventions were identified on the care plan after the fall on 3/12/23. p. On 3/22/23 at 3:38 PM, the progress note documented, Pt. had an unwitnessed fall. Neuro checks started. vital sign stable: 133/74 [blood pressure], p [pulse] :80, RR [respiratory rate]-18. Pupils reactive It should be noted that no new interventions were identified on the care plan after the fall on 3/22/23. On 4/6/23 at 12:06 PM, an interview was conducted with the Director of Nursing (DON) 1. The DON stated that the Falling Star Program informs the staff which residents are at higher risk for falls. The DON stated that there was supposed to be a star magnet on their door frame of those resident's room, but it's not there as it was never fully implemented. The DON stated that the At Risk Plan had standard fall interventions of answer the call light, ensure shoes were on, ensure no faulty equipment, and bed in the lowest position. The DON stated that staff were taught these interventions during orientation and during in-services about falls during orientation. The DON stated that she was going to put the At Risk Plan interventions into a book for the agency staff. The DON stated that every time a resident had a fall a new intervention should have been implemented on the resident care plan, and a Morse fall scale assessment should be completed. The DON stated that she had been busy updating the resident care plans. The DON stated that the unit managers were in charge of updating the care plans previously. The DON stated that the staff should be implementing fall interventions based on the fall scale. The DON stated that the Morse fall scale did not automatically link the interventions identified to the care plan. The DON stated that an intervention of education was not an appropriate intervention for residents with cognitive deficits. The DON stated that a new intervention to prevent falls should be identified after each fall and should not be an intervention that was previously identified. [Cross-refer F689] 4. Resident 98 was admitted to the facility on [DATE] with diagnoses which consisted of unspecified dementia, type 2 diabetes mellitus, cognitive communication deficit, adult failure to thrive, weakness, major depressive disorder, mixed hyperlipidemia, hypertension, osteoporosis, and tremor. On 3/30/23, resident 98's medical records were reviewed. Review of resident 98's incident reports, progress notes and care plans revealed the following: a. On 3/30/23 at 8:24 AM, the incident report documented, Resident has bruising to left eye and left elbow. The resident description was I fell in my room. The immediate action taken documented Assessed bruising injuries, checked pupils and hand grips, Pupils 2 and regular, Equal hand grips, V/S 130/87 [blood pressure] 131 [heart rate] 16 [respiratory rate] 97.4 [temperature] 02 [oxygen]93. Ice pack applied to left eye. The injuries documented were a bruise to the left elbow and face. The report documented predisposing factors as confusion, impaired memory, alone and unattended. The MD and family were notified on 3/30/23 at 8:29 AM. On 3/30/23, resident 98's care plan for at High Risk for Falls was initiated. Interventions identified included answer call lights promptly, clean up spills immediately, ensure adequate lighting in room, keep room free of clutter and ensure objects are within reach, and orient and reorient on an ongoing basis to room and unit. b. On 3/30/23 at 8:45 PM, the incident report documented, Resident was found on the floor, Resident has bruising on right knee and has redness near left knee. The report documented that the resident stated, I fell. The immediate action taken was Resident was assessed. Hand grip and pupils were assessed. Resident's pupils were 3 and regular and hand grip was equal. The report documented predisposing factors as confusion and alone and unattended. The MD and family were notified on 3/30/23 at 9:00 PM and 11:00 PM. On 3/30/23, resident 98's care plan for a fall with injury was initiated. The care plan documented that resident 98 reported she fell and a bruise to the left eye and cheek were noted. The interventions identified were to continue interventions on the at-risk plan, to determine and address causative factors of the fall, and frequent checks on rounds. c. On 3/31/2023 at 3:32 AM, the progress note documented, Pt had an unwitnessed fall. Pt was found on the floor. Resident was assessed. Hand grip and pupils were assessed. Resident's pupils were 3 and regular and hand grip was equal. Vital signs: Blood pressure was 127/81, T [temperature] : 98.2, P [pulse]: 100, RR [respiratory rate]:16, O2: 91%. Resident's sister and MD were notified. Pts bed was lowered, call light within reach, non-skid socks on, and fall mat placed next to bed. It should be noted that no new interventions were identified on the care plan after the fall on 3/31/23. d. On 3/31/23 at 8:25 PM, a State Survey Agency (SSA) surveyor observed resident 98 sitting on the floor next to her bed. The resident's room was dark and the resident requested that the surveyor turn a light[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 32 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right side dominant side, toxic encephalopathy, paroxysmal atrial fibrillation, paranoid schizophrenia, depression, anxiety, and cognitive communication deficit. On 3/28/23 at 1:08 PM, an interview was conducted with resident 32. Resident 32 stated staff had not discussed discharge with her and she wanted to discharge home. Resident 32's medical record was reviewed 3/28/23 until 4/25/23. A quarterly MDS dated [DATE] revealed that resident 32 had a BIMS score of 15 which indicated cognitively intact. A care plan dated 11/9/22 that revealed resident 32 met Pre-admission Screening/Resident Review (PASRR) level II related to Schizophrenia and major depressive disorder and needed long term care. The goal was that resident would be appropriately re-evaluated for specialized services as needed and quarterly psychotropic reviews. Interventions included to provide mental health follow up as needed, verbalizes delusions of discharging with family members, and arrange for PASRR re-evaluation if there was a change. An admission Psychosocial Review dated 7/19/22 revealed that resident 32's plan was to stay at the facility long term. A social services note on 1/20/23 at 5:29 PM, .Resident said that they do not have any concerns at this time, but would like to apply for NCW [New Choice Waiver] nextweek [sic]. A social services note dated 2/14/23 at 2:31 PM revealed, [Resident 32's] NCW has moved to the next stage. Case management team to reach out and eval [evaluate] [resident 32]. Discharge to ALF [assisted living facility] is currently planned for April. A social services note dated 4/10/23 at 1:42 PM revealed, Spoke with Guardian about transferring [resident 32] to facility with a wander guard vs keeping her in the memory care unit at [name facility]. PT [patient] is currently in Memory care unit for wander/ exit seeking behaviors. OPG [guardian] agreed that it may be better for PT to be around others with her level of cognition. OPG requested [local] area for placement, but would be fine with any placement ultimately. A social service note dated 4/11/23 at 9:32 AM revealed a referral was sent to another long term care facility. Resident 32's guardian wanted resident 32 to go somewhere that had a wander guard system because the memory care unit was not a good fit. Resident 32's guardian felt resident 32 was an elopement risk based on history prior to coming to the facility. On 4/25/23 at 8:41 AM, an interview was conducted with RN 6. RN 6 stated she was not aware of a discharge plan for resident 32. RN 6 stated she had read a note that the emergency contact was contacted regarding discharge and the emergency contact had given instruction to discharge anywhere. On 4/25/23 at 11:11 AM, an interview was conducted with the RA. The RA stated that the plan was for resident 32 to transfer to another facility with a wander guard system. The RA stated that a facility about an hour away had agreed to assess resident 32. The RA stated the guardian was fine with a transfer to a facility with a wander guard system. The RA stated that resident 32 had been approved by NCW but the guardian was not okay with the resident not going to a facility without a locked unit because she was not taking her medications and was exit seeking. The RA stated she had not tried a behavioral contract because typically she was unable to do those with a resident that has dementia. The RA stated since resident 32 was cognitively intact, behavioral contract maybe appropriate. It should be noted the RA had not contacted ALF's to determine if there were secured units. 3. Resident 86 was admitted to the facility on [DATE] with diagnoses which included dementia, mild protein-calorie malnutrition, anxiety, depression, and nicotine dependence. On 4/20/23 at 10:50 AM, an interview was conducted with Hospice RN 1. Hospice RN 1 stated resident 32's family had been trying to move her with the NCW and it takes about 3 months. Hospice RN 1 stated that the facility told the family they were working on the NCW. Hospice RN 1 stated the family found out that nothing had been done for the NCW. Hospice RN 1 stated the family worked on the NCW and got her approved. Resident 86's medical record was reviewed 3/28/23 through 4/25/23. A quarterly MDS dated [DATE] revealed that resident 32 had a BIMS score of 1 which revealed severe cognitive impairment. There was no care plan regarding discharge plans. An admission discharge planning review dated 8/18/22 revealed unknown for anticipated length of stay. An admission discharge planning review dated 11/12/22 revealed resident 32 long term for anticipated length of stay. On 4/20/23 at 1:41 PM, an interview was conducted with the RA. The RA stated the discharge planning started when resident's admitted . The RA stated that the discharge goals were discussed. The RA stated to apply for the NCW, medicaid required a 60 day waiting period prior to applying. The RA stated the resident had to be in the facility for 90 days. The RA stated the RA, DON and physician worked together to determine a safe discharge or the need for the NCW application. The RA stated there were forms on-line to be completed with the resident. The RA stated since starting the on-line system, she was not sure how long the process was. The RA stated previously it was a month or 3 to get approval. The RA stated resident 32's family initiated the NCW process on their own. The RA stated she provided paperwork that the family needed for the application. The RA stated if she remembered correctly, the MD or DON did not see an assisted living as a good fit. The RA stated it was still the residents right to do the NCW, even if the DON or physician did not think it was a good for the resident. The RA stated the discharge plan upon admission was in the social service admission progress notes. The RA stated resident 86's discharge plan was not documented in social service admission note. The RA stated she did not complete the NCW forms because the previous DON or physician said no. The previous DON was not available to interview. 4. Resident 79 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included major depressive disorder, anxiety disorder, altered mental status, history of traumatic brain injury (TBI) and intertrochanteric fracture of right femur. On 3/29/23 at 10:30 AM, a phone interview was conducted with resident 79's family member. Resident 79's family member stated that he wanted resident 79 discharged to a TBI speciality facility. Resident 79's family member stated that the facility was unable to care for resident 79's with a TBI. Resident 79's family member stated the facility was warehousing residents and unable to care for the residents. Resident 79's medical record was reviewed 3/28/23 through 4/25/23. A care plan dated 9/27/22 and updated on 12/28/22 revealed resident 79 required long term care services related to diagnoses of dementia, altered mental status and major depression. The goals were that resident would adjust to daily activities in the long term care facility and resident 79 would receive services as necessary to meet his individualized needs. Interventions were to engage assistance from ombudsman as need; monitor for adjustment to long term care; provide care conference for residents and family; and review plan of care quarterly and as needed. On 10/27/22 at 11:05 PM, a social services note revealed a referral was sent to another long term care facility. On 10/28/22 at 4:10 PM, a social service note revealed a referral was sent to another long term care facility. On 11/9/22 at 12:25 PM, a nursing progress note revealed resident 79 was aggressive toward staff, resident 79 was expressing frustration when he hit the lounge door and slammed door on nurse, nurse entered the lounge room and calmed resident down with the assistance of the administrator. On 11/9/22 at 1:06 PM, a social service note revealed a referral was sent to another long term care facility. On 12/2/22 at 11:52 AM, a Medical Director (MD) note revealed that resident 79 had dementia and had the ability to be aggressive. Resident 79 was his own power of attorney and needed a guardian. Resident 79's past medical history revealed a TBI from a car accident and communication deficits. Resident 79 had a psychiatric referral pending and needed TBI specialty follow up. On 1/9/23 at 8:09 PM, a physician's progress notes revealed resident 79 had been having increased episodes of aggression toward staff and others. Resident 79 has had increased agitation. On 1/10/23 at 4:30 PM, a nursing progress note revealed that admissions staff pulled nurse into the dining room who found resident supine grabbing onto another resident's arm and was covered in blood. On 1/10/23 at 5:32 PM, a social service note revealed a referral was sent to two long term care facilities. On 1/10/23 at 5:36 PM, a social service note revealed that resident 79 got in a physical altercation with another resident. On 1/13/23 at 11:21 AM, a physician's progress note revealed that resident 79 was involved in an altercation last night with another resident. On 1/17/23 at 5:39 PM, a social services note revealed there was a referral to be wait listed for a special program for TBI injuries. On 1/20/23 at 9:03 AM, a social services note revealed a referral was sent to another long term care facility for a transfer. On 2/10/23 at 11:19 AM, a social service progress note revealed Spoke to intake specialist at [local disability specialist] about application for this pt. received the application and will follow up with an additional paperwork that will be needed. It should be noted the physician documented resident 79 needed TBI specialty care follow on 12/2/22. On 2/24/23 at 12:58 PM, a social service progress note revealed a referral was sent to another long term care facility for transfer. On 2/27/23 at 11:32 AM, a social service progress note revealed the facility denied the referral. On 3/19/23 at 10:39 PM, a nursing progress note revealed Pt returned from [local] hospital ER at around 7:30 pm, blue sheet was cleared. Upon return pt was calm cooperative, took night medications. Pt came back with new orders. On 3/20/23 at 4:05 PM, a social service note revealed referrals were sent to multiple long term care facilities in the state. On 3/21/23 at 10:40 AM, a social service note revealed a quarterly note that resident 79 had several behavioral problems resulting in abuse allegations when he was first admitted . Staff were working with resident 79's and his behaviors had decreased significantly. Resident 79 seamed to get along better with other residents, and can be seen laughing a joking with others in the lobby area. The discharge planner was working with family to get resident 79 into a facility that specialized in TBI care. On 3/24/23 at 3:47 PM, a physician's progress note revealed a psychiatric (psych) IDT was the reason for the visit. The action was that it was inappropriate to have a gradual dose reduction due to active hallucinations. The physician ordered a psych consult for schizophrenia diagnosis confirmation when able. On 3/28/23 at 10:45 AM, a social service note revealed the Department of Health and Human Services came to complete an assessment with resident 79 for TBI disability. Resident 79 refused to participate. On 3/28/23 resident 79 fell and sustained a right femur fracture. Resident 79 re-admitted to the facility on [DATE]. Resident 79 was admitted to a room outside of the secured unit. On 4/3/23 at 4:57 PM, a nursing progress note revealed that resident 79's family member called. The nurse informed family member that resident 79 had declined since fall and hit his head when he fell. On 4/10/23 at 12:55 PM, a social service note revealed that there was a facility initiated transfer/IDT meeting due to facility not being able to meet the needs of the resident. Facility initiated transfer was arranged for resident to discharge to another facility in Price, Utah. Resident 79's family member was present at time of an IDT meeting.RA explained to the family that due to us not having a wander guard and [resident 79] being determined to not be a good candidate for memory care we are no longer able to meet the residents needs. Family and [resident 79] were understanding of reasoning for transfer. They did mention concern that the progress of getting [resident 79] into the specialized TBI center in [city] would stop. RA and discharged planner are going to coordinate with [name of facility] to ensure that the progress withcontinue [sic] as that is the end goal that family and [resident 79] given a copy of the paper work for facility transfer. On 4/11/23 at 1:22 PM, a physician discharge summary revealed that resident 79 would not be safe to go back to the memory care unit and he was a wander risk and would require a wander guard which the facility did not have. Resident 79 would benefit going to a wander guard equipped facility for his safety. A form titled Notice of Discharge dated 4/10/23 revealed that The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident. The discharge was to be effective 4/14/23. The discharge was necessary because the resident's welfare and the resident's need(s) could not be met, the facility attempted to meet the resident's needs, and the services available at the receiving facility to meet the resident's need(s). The form further revealed 2 signatures at the bottom of the form. On 4/13/23 at 1:03 PM, a social service note revealed that resident 79 was notified of facility initiated discharge being canceled. On 4/13/23 at 2:56 PM, an interview was conducted with Administrator (Admin) 1. Admin 1 stated he did not know about resident 79 discharging and had not been involved in discussing discharges for the previous 2 weeks. On 4/12/23 at 11:11 AM, an interview was conducted with the RA. The RA stated there were two different ways residents were transferred to another facility. The RA stated if the facility was unable to care for the resident, like if there was no wander guard system. The RA stated she had heard there was a system at the facility but it was broken or not working. The RA stated the Cambridge unit was the locked memory care unit in the facility. The RA stated there were residents that needed to be monitored but not in the memory care unit. The RA stated if the resident's cognition was not low enough to need a locked unit, then the staff looked at their cognitive ability to determine if they qualify for the locked unit. The RA stated if a resident needed a different setting then other facilities were contacted to determine who had a wander guard system. The RA stated the clinical team decided if the resident needed a wander guard. The RA stated she would rather notify families prior to calling other facilities. The RA stated when there was no guardianship and the resident was not cognitively intact, then she communicated with the resident. The RA stated she worked with the MD and the clinical team on what to do. The RA stated she Would prefer to get them [family members] involved as soon as possible. The RA stated resident 79's discharge was initiated by the facility. The RA stated resident 79 was in memory care unit and was on a higher cognitive function but had trouble expressing himself. The RA stated resident 79 was able to have full conversations. The RA stated Administrator 4 and the discharge planner were working on getting resident 79 into a specialized TBI center. The RA stated since the facility did not have a wander guard system, then the facility was unable to meet his needs. The RA stated the the decision was made by the physician, clinical team and herself. The RA stated a facility with a wander guard system would be more appropriate for resident 79. The RA stated resident 79 would be better off surrounded by people who can converse with him because memory care residents had very low cognition. The RA stated resident 79 needed to be in a facility with residents that had a higher cognitive status. The RA stated resident 79 also had behaviors. The RA stated the behaviors were physical and verbal aggression toward residents and sexual behaviors like groping other residents. The RA stated resident 79 was moved to the memory care unit because of his behaviors. The RA stated since he was abusing resident that were cognitively impaired, it was important to put him around residents that were cognitively intact. The RA stated she was not sure why he was not moved for 4 months after his abusive behaviors started. The RA stated he was moved off of the unit because of his hip fracture. The RA stated she was planning on calling the family regarding discharge to Price, Utah but the family came in so she did a quick IDT with the family and DON. The RA stated the family was okay with the temporary move until he was accepted into the TBI program. The RA stated they expressed a little concern about him going all the way down to Price but they lived in California. The RA stated that resident 79's family member said that the new facility was quite far away. The RA stated currently resident 79 was not ambulatory but he needed to discharge because he would be ambulatory soon and needed a wander guard system. The RA stated resident 79 had to work with a case management team to get him to TBI center. The RA stated resident 79 was not a threat right now because he was not mobile. The RA stated she talked to the medical director about her concerns about the resident. The RA stated the concern was not having a locked/non-memory care unit for him. The RA stated DON 1 expressed her concerns that resident 79 was abusive and would not go back to the secured unit when he was ambulatory again. The RA stated she had contacted multiple facilities in the area. On 4/12/23 at 10:50 AM, a phone interview was conducted with resident 79's family member. Resident 79's family member stated the moved to another facility created an additional hardship on the family. Resident 79's family member stated it was a long drive to the other facility. Resident 79's family member stated the facility was not able to handle him and the facility did not want the liability of having him in the secured unit. Resident 79's family member stated he had been informed that resident 79 had been aggressive, and that was why some of the people in the region would not take him. Resident 79's family member stated some of the aggression was caused by being in the memory care unit, and he was just being warehoused and not getting treatments. Resident 79's family member stated he was working with a staff member at the speciality center for TBI's and are waiting for state approval. Resident 79's family member stated the facility wanted to move him before he was able to be admitted to the TBI center. Resident 79's family member stated he feared that when he moved he would be more aggressive but he was docile. Resident 79's family member stated the facility said they tried all other facilities with wander guard and no one would take him close by. Resident 79's family member stated he received a stack of papers but did not sign anything. Resident 79's family member stated it would be less problematic if he stayed at the facility until he was moved to the TBI facility. Resident 79's family member stated it was a long drive and there was no family support in Price. Resident 79's family member stated I wouldn't have known that he was being transferred Friday except we stopped last night and the staff told me that he was discharging on Friday. Resident 79's family member stated resident 79 did not have a POA and he did not think he could sign a legal document with his mental state. Resident 79's family member stated I'm [AGE] years old and I don't want to be doing this in my golden years. On 4/13/23 at 7:43 AM, an interview was conducted with Chief Nursing Officer (CNO). The CNO stated that the company had been laterally transferring residents from one facility to the next. The CNO stated that he did not know about a transfer for resident 79 to another facility and did not know why he needed a wander guard. On 4/13/23 at 9:44 AM, an observation was made of resident 79. Resident 79 was observed in a wheelchair in his bathroom. Certified Nursing Assistant (CNA) 21 was observed to assist resident 79 to the bathroom. At 9:52 AM, an interview was conducted with CNA 21. CNA 21 stated resident 79 required verbal assistance with transfers because he took his time. CNA 21 stated resident 79's legs were wobbly and she sometimes needed to give him a boost during transfers. CNA 21 stated she assisting with stability. CNA 21 stated she was informed that resident 79 was combative but he had been fine with her. On 4/13/23 at 9:47 AM, an interview was conducted with Registered Nurse (RN) 10. RN 10 stated resident 79 required 1 person extensive assistance with transfers. RN 10 stated resident 79 had not been exit seeking since being transferred from the secured unit. On 4/13/23 10:00 AM, an interview was conducted with the Medical Director (MD). The MD stated he was contacted via phone call, text or verbally when he was in the facility regarding discharges. The MD stated he completed discharge orders and signed the ordered. The MD stated when a resident was transferring to another facility he completed paperwork for the transfer. The MD stated resident 79 was having issues with behaviors and wandering. The MD stated resident 79 had issues with other residents in the memory care unit and was constantly getting in fights despite him being redirected. The MD stated the other facility had a wander guard system and resident 79 was at risk for wandering with his mental issues. The MD stated he had not been informed of concerns from family regarding transfer to another facility. On 4/17/23 at 3:50 PM, an interview was conducted with the Discharge Planner (DP). The DP stated she had been with the Department of Health and Human Services to get resident 79 into a special TBI program facility. The DP stated resident 79 was assigned a case worker and needed the second part of his assessment completed. The DP stated she would try to be there and convince him to not refuse the assessment. The DP stated Administrator 1, the RA and herself talked about not sending resident 79 anywhere and see how he was doing outside the secured unit. The DP stated the team felt he was a risk to himself and other residents in Cambridge because he was wandering and he got irritated. The DP stated he was younger than a lot of the residents over there. The DP stated DON 1 wanted to transfer him out because of his behaviors. The DP stated DON 1 wanted to send him to any place that would take him. The DP stated she had talked to resident 79's family member a lot but did not think that DON 1 had reached out the family or anyone. The DP stated she was not involved in IDT meeting when resident 79's family member was informed of the discharge to Price. The DP stated she was not sure who made the decision. The DP stated stated the External Consultant said that the facility needed to make sure We were sending him to a situation where he got services he needed based on his needs and not to a place that offers the same services available here. Based on interview and record review, the facility did not develop and implement an effective discharge planning process for 4 of 80 sampled residents. Specifically, the facility did not ensure that the discharge needs were identified and used to develop a discharge plan for each resident; the Interdisciplinary Team was involved; involve the resident and/or resident representative in the discharge plan; did not allow the resident and/or resident representative to be involved in selecting a facility to be transferred to; or evaluate and document the residents' discharge needs and discharge plan. Specifically, residents' family members were not involved with the discharge process. Resident identifiers: 32, 79, 86 and 409. Findings include: 1. Resident 409 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, altered mental status, muscle weakness and cognitive communication deficit. Resident 409 was discharged on 1/24/23. Resident 409's medical record was reviewed from 3/28/23 through 4/25/23. On 8/24/22, resident 409's admission Minimum Data Set (MDS) Assessment indicated that the resident's Brief Interview for Mental Status (BIMS) score was 4, indicating severe cognitive impairment. On 8/18/22, a care plan was developed for resident 409 indicating that she required long term care services. A discharge care plan was not developed. On 1/24/23, resident 409's physician documented that they had evaluated the resident that day, but did not indicate that resident 409 would be discharged soon. On 1/24/23, a nurses note indicated that resident 409 was being discharged due to Altercations with other residents. On 2/2/23, a nurses note indicated that resident 409's daughter, who was also the resident's Power of Attorney (POA), contacted the facility. The note stated Family claims that they did not receive a voice mail or call from the facility indicating why [resident 409] was moved. AIT [Administrator in Training] claims that he did leave a voice mail informing family. SSA [Social Services] did let family know location, and why resident was moved. Family was not upset, but did express concerns about [resident 409] being under the impression that we told [resident 409] it was her daughters fault that she moved. No notes prior to this date indicated that the resident had a discharge plan, that the family had been involved regarding the discharge and other possible placement options, or that the facility Interdisciplinary Team had been involved in the discharge. On 4/5/23, an interview was conducted with resident 409's POA. The POA stated that she and her family were unaware of the resident's transfer to another facility. The POA stated that she did not know where her mother, resident 409, was for several days during January 2023. The POA stated that she called the facility to check on her mother, but they told her the resident was no longer at the facility, but would not tell her where the resident had gone because it was protected information. The POA stated that she only found out where her mother had been transferred to because the new facility called to ask her some questions about her mother. The POA stated that the new facility told her that resident 409 had been sexually acting out at South [NAME] Post Acute. The POA stated that no one gave me any information with who or what was going on. I'm her POA. I was very frustrated and angry about it. they (the facility staff) were not forthcoming about things. The POA also stated that resident 409 didn't know what was happening . She hasn't been doing well since this happened (the resident was transferred). She doesn't understand why she was moved. She had gotten more comfortable there, and her friends lived in [NAME]. The POA stated that resident 409's friends would visit the resident at least once a week, but they could not visit anymore because resident 409 had been transferred to a facility in Salt Lake, which was too far for the friends to travel. The POA stated that since being transferred to the new facility, resident 409 has been physically acting out, tried to escape . it exacerbated her dementia. It has gotten bad. She now doesn't recognize my brother. She is very angry because I won't take her out of there. She doesn't have the support system that she had before. Its been a nightmare that (they transferred the resident). It was so hard on her. On 4/13/23 at 2:28 PM, an interview was conducted with Administrator (ADM) 1. ADM 1 stated he did not recall being involved in resident 409's discharge planning. On 4/12/23 at 1:12 PM, an interview was conducted with the Resident Advocate (RA). The RA stated that it was the clinical team who decided who should be discharged , and where to. The RA stated that the clinical team consisted of the Medical Director, Director of Nursing and Assistant Director of Nursing. With regard to coordinating the resident's discharge with family members, the RA stated I would prefer to notify the families first if possible. When asked about resident 409's discharge, the RA stated that it was the previous AIT who had initated the discharge. The RA stated that the AIT had notified the family of the discharge via telephone, but had misdialed one of the numbers, so the family member did not receive the voicemail. The RA stated that both the family members and resident 409 were upset about the discharge. Neither the AIT or Director of Nursing who were present during resident 409's discharge were still employed at the facility, and therefore, not interviewed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined, the facility did not provide the necessary care and services to ensure that a resident's abilities in activities of daily living (ADL) do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. Specifically, for 7 out of 80 sampled residents, residents did not receive the bathing assistance they required and showers were missed. A resident was seen in same clothing for multiple days. In addition, multiple female residents were found to have had long chin chairs and did not receive the grooming assistance they required. Resident identifier: 32, 38, 51, 81, 86, 96, and 357. Findings Included: 1. Resident 38 was admitted to the facility on [DATE] with the following diagnoses that included Alzheimer's disease, type 2 diabetes mellitus, major depressive disorder, anxiety disorder, post-traumatic stress disorder, obsessive compulsive personality disorder and restless leg syndrome. Resident 38's medical record was reviewed 3/28/23 through 4/25/23. On 3/12/23, a quarterly Minimum Data Set (MDS) revealed that resident 38 had a Brief Interview of Mental Status (BIMS) score of 12 which revealed resident 38 was cognitively moderately impaired. Resident 38 required set up help from staff or bathing. A care plan initiated on 10/1/22 revealed resident 38 had an ADL self-care performance deficit related to (r/t) dementia, obesity, obsessive compulsive disorder, nail dystrophy, and depression. Interventions included to encourage the resident to participate to the fullest extent possible with each interaction and praise all efforts at self-care. Resident 38's physician orders were reviewed and revealed an order for showers, with a start date of 10/1/22, to be done on Tuesdays, Thursdays, and Saturdays for hygiene. Resident 38's progress note revealed the following shower entries: a. On 1/28/23 and 2/25/23, two order administration notes documented, short staffed. b. On 4/11/23, an order administration note documented, CNA [Certified Nursing Assistant] Coordinator was notified resident had not gotten a shower yet. CNA coordinator stated night shift will complete task. [Note: Resident 38's last documented shower was on 4/4/23. Resident 38 had to go 8 days without a shower until the next documented shower on 4/13/23.] Resident 38's Medication Administration Record (MAR) and Treatment Administration Record (TAR) were reviewed from January 2023 to April 2023 and documented the following shower entries: a. In the month of January, 2 showers were missed out of the 13 total opportunities. b. In the month of February, 3 showers were missed out of the 12 total opportunities. [Note: No documentation was located to indicate if resident 38 had been offered a shower on 2/28/23.] c. In the month of March, 2 showers were missed out of the 13 total opportunities. [Note: No documentation was located to indicate if resident 38 had been offered a shower on 3/28/23.] d. In the Month of April, 7 showers were missed out of the 11 total opportunities. [Note: No documentation was located to indicate if resident 38 had been offered a shower on 4/8/23 and 4/22/23.] On 4/24/23 at 2:31 PM, an interview was conducted with Certified Nursing Assistant 22. CNA 22 stated they had a shower schedule to follow. CNA 22 stated the shower schedule notified them which residents needed a shower for the day. CNA 22 stated if a resident refused their shower for the day, they still offered them a chance for a shower through different times of the day. CNA 22 stated they had a shower aide that bathed or showered residents but when they were short staffed the shower aide was pulled to help with patient care. CNA 22 stated there had been times when they were not able to get a shower done and notified the oncoming shift. CNA 22 stated resident 38 required very little help with her showers and stated the resident requested to be left alone while she showered herself. 6. Resident 96 was admitted to the facility on [DATE] with diagnoses which consisted of osteomyelitis, type 2 diabetes mellitus, sepsis, hypertension, retention of urine, major depressive disorder, personality disorder, insomnia, anxiety disorder, and acquired absence of right leg below the knee. On 3/29/23 at 9:15 AM, an interview was conducted with resident 96. Resident 96 stated that he did not get assistance with bathing. Resident 96 stated that he required set up assistance and then he could wash himself. Resident 96 stated that he would ask for a shower and staff would say that they would get to it, but they did not. Resident 96 stated that the facility did not have enough staff. Resident 96 stated that the staff would document that he refused his showers when he did not. Resident 96 stated that it had been awhile since his last shower. On 1/29/23, the admission MDS Assessment documented a BIMS score of 13/15, which indicated that resident 96 was cognitively intact. The assessment documented that resident 96 was a limited one person assist for transfers, dressing, and personal hygiene. The assessment documented that resident 96 required a one person extensive assist for toileting. The assessment documented that resident 96 required a one person assist with supervision for bathing. On 4/24/23, resident 96's medical records were reviewed. Review of resident 96's the bathing task for the past 30 days revealed the following: a. On 3/23/23, resident 96 had a one person physical assist for bathing. b. On 4/1/23, resident 96 had a one person physical assist for bathing. It should be noted that eight days lapsed since the last shower. c. On 4/8/23, resident 96 had a one person physical assist for bathing. The April 2023 TAR documented an order for Resident to shower/bathe one time a day every Tuesday, Thursday, and Saturday for Hygiene. The TAR documented that the bathing task was completed on 4/1/23, 4/4/23, 4/6/23, 4/8/23, 4/11/23, 4/13/23, 4/18/23. On 4/15/23, the TAR documented that resident 96 refused a bath. Review of the shower schedule revealed that resident 96 was scheduled to receive showers on Monday, Wednesday, and Friday in the evening. On 3/30/23 12:47 PM, an interview was conducted with SM 6. SM 6 stated that the CNAs think that there was a shower aide for the facility and because of this they believe they do not need to perform the shower tasks for residents. On 4/20/23 at 1:39 PM, an interview was conducted with Certified Nurse Assistant (CNA) 26. CNA 26 stated that the bathing schedule for resident 96 was Monday/Wednesday/Friday in the evening. CNA 26 stated that she had not assisted resident 96 with bathing prior. CNA 26 stated that the bathing task was documented in the electronic medical records and that the aides also filled out a shower sheet. CNA 26 stated that she would ask the resident what they felt comfortable with either a one or two person assist, and report would inform the aides if the resident required a one or two person assist with bathing. CNA 26 stated that she would document any skin alterations on the shower sheet and then give the skin assessment to the nurse. CNA 26 stated that resident 96's wound vac would need to be covered with a protective bag and taped shut. On 4/20/23 at 1:44 PM, an interview was conducted with Registered Nurse (RN) 11. RN 11 stated that the CNAs would give the licensed nurses the shower sheet and they would document if the task was completed in the TAR. RN 11 stated that the aides would also document any skin issues on the shower sheet. 7. Resident 357 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, type 2 diabetes mellitus, alcoholic cirrhosis, hemiplegia and hemiparesis following a cerebral infarction, dysphagia, concussion, repeated falls, chronic kidney disease stage 3, hypertensive heart and chronic kidney disease, and hypomagnesemia. On 3/28/23 at 12:33 PM, an interview was conducted with resident 357. Resident 357 was heard to tell the RN that she had not had a shower in 2 to 3 days. Resident 357 stated that she last received a bath on Saturday. Resident 357 stated that she would like a shower every other day. On 3/29/23, resident 357's medical records were reviewed. On 3/28/23, resident 357's admission MDS Assessment documented a BIMS score of 15/15, which indicated that resident 357 was cognitively intact. The assessment documented that resident 357 did not have hallucinations or delusions. Resident 357 was assessed as requiring a limited one person assist for bed mobility, transfer, locomotion off the unit, dressing, and personal hygiene; extensive one person assist for toilet use; and supervision one person assist for eating. The assessment documented that resident 357 required a one person physical assist for bathing. Review of resident 357's the bathing task for the past 30 days revealed the following: a. On 3/27/23, resident 357 had a one person physical assist for bathing. b. On 4/3/23, resident 357 had a one person physical assist for bathing. It should be noted that six days lapsed since the last shower. c. On 4/10/23, resident 357 had a one person physical assist for bathing. It should be noted that six days lapsed since the last shower. d. On 4/18/23, resident 357 had a one person physical assist for bathing. It should be noted that seven days lapsed since the last shower. Review of resident 357's TAR revealed no documentation of showers or bathing task completed. Review of the shower schedule revealed that resident 357 was scheduled to receive showers on Tuesday, Thursday, and Saturday in the evening. On 4/25/23 at 10:46 AM, an interview was completed with the Chief Nursing Officer (CNO). The CNO stated that he completely agreed that there was an issue with the frequency and lack of showers that have been provided. [Cross refer to F565] 2. Resident 32 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right side dominant side, toxic encephalopathy, paroxysmal atrial fibrillation, paranoid schizophrenia, depression, anxiety, and cognitive communication deficit. On 3/28/23 at 1:07 PM, an interview was conducted with resident 32. Resident 32 stated she would like to be showered every other day but was scheduled on Monday, Wednesday and Friday. Resident 32 stated that she was sometimes missed for a shower. Resident 32 stated she had gone 5 days at times without a shower. Resident 32 stated she felt awful when she was not showered. Resident 32 resided in the Cambridge unit which was the secured unit. On 4/11/23 at 10:46 AM, a follow-up interview was conducted with resident 32. Resident 32's hair was observed to be uncombed and greasy. Resident 32 stated she was going to therapy. On 4/25/23 at 10:14 AM, a follow-up interview was conducted with resident 32. Resident 32 stated she had been showered every other day for the last week and it felt so nice. Resident 32 stated she looked forward to her showers. Resident 32's medical record was reviewed 3/28/23 through 4/25/23. A quarterly MDS dated [DATE] revealed that resident 32 had a BIMS score of 15 which revealed resident 32 was cognitively intact. Resident 32 required 1 person physical assistance in part of bathing. A care plan dated 7/26/22 revealed that resident 32 had an ADL self care related to impaired mobility, advanced age with a diagnoses of hemiparesis to the right side and chronic pain. The goal was resident 32 would maintain current level of function in ADLs through the review date. Interventions included to encourage resident 32 to participate to the fullest extent possible with each interaction and encourage resident to use call bell for assistance. The tasks section documented by CNA's revealed for the previous 30 days, resident 32 received bathing on 3/31/23, 4/3/23, 4/5/23, 4/12/23, 4/14/23, 4/17/23, 4/19/23, 4/21/23, and 4/24/23. It should be noted that resident 32 was not showered for 7 days from 4/5/23 until 4/12/23. According to the March 2023 Treatment Administration Record (TAR) resident 32 was to be offered a shower on Monday, Wednesday and Friday. There was no documentation on 4/6/23 or 4/17/23 regarding if resident 32 was showered or not. 3. Resident 51 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia with behavioral disturbance, diabetes mellitus, cervicalgia, and major depressive behavior. Resident 51 resided in the Cambridge unit which was the secured unit. On 3/28/23 at 2:38 PM, an observation was made of resident 51. Resident 51 was observed with long chin hairs, approximately an inch in length. Resident 51's medical record was reviewed 3/28/23 through 4/25/23. An quarterly MDS dated [DATE] revealed that resident 51 required 2 person extensive assistance with personal hygiene. A care plan dated 7/4/21 revealed resident 51 had an ADL self-care performance deficit and limited physical mobility related to impaired mobility, altered gait, cognitive deficits and a diagnosis of dementia. The goal was resident 51 would maintain current level of function in ADL's through the review date. Interventions included resident 51 was able to perform personal hygiene and oral care with set up assistance and supervision. According to the Plan of Care CNA documentation for personal hygiene, resident 51 received personal hygiene one to three times a day in the previous month. The personal hygiene was defined as combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands. 4. Resident 81 was admitted to the facility on [DATE] with diagnoses which included dementia without behavioral disturbance, hyperlipidemia, hypertension, major depressive disorder and anxiety disorder. Resident 81 resided in the Cambridge unit which was the secured unit. On 3/28/23 at 9:26 AM, an observation was made of resident 81. Resident 81 was observed to have chin hair about an inch long. Resident 81 was observed to touch her chin and rub the chin hairs. Resident 81 was observed to cover her chin when talking to others. On 4/17/23 at 1:41 PM, an observation was made of resident 81. Resident 81 was observed to have chin chair about an inch long. Resident 81's medical record was reviewed 3/28/23 until 4/25/23. A quarterly MDS dated [DATE] revealed that resident 81 required set up assistance with supervision for personal hygiene. A care plan dated 6/8/22 and updated on 10/27/22 revealed that resident 81 had ADL self-care performance deficit related to weakness and altered mental status. The goal was resident 81 would maintain current level of function in ADL's through the review date. One of the interventions was resident 81 required supervision and cueing assistance by 1 staff with personal hygiene and oral care. On 4/25/23 at 10:28 AM, an interview was conducted with CNA 9. CNA 9 stated some resident did not want their chin hairs removed. CNA 9 stated she did not feel safe removing residents' chin hairs if they [residents] are not all in. CNA 9 stated that resident 81 sometimes would not let staff remove her chin hairs but sometimes would. CNA 9 stated CNA's should ask residents every time the residents were showered. 5. Resident 86 was admitted to the facility on [DATE] with diagnoses which included dementia with severity without behavioral disturbance psychotic disturbance, anxiety, mild protein-calorie malnutrition, depression, and insomnia. On 3/28/23 at 9:25 AM, an observation was made of resident 86 stating she needed to use the bathroom. Resident 81 was observed to offer resident 86 assistance. Resident 81 was observed to guide resident 86 to her room and into her bathroom by holding her hand. At 9:30 AM, resident 81 and resident 86 exited resident 86's bathroom. Resident 81 stated resident 86 used the bathroom and she was proud of resident 86. Resident 86 was observed to have inch long chin hairs. Resident 86 was observed in a pink shirt. On 3/30/23 at 11: 30 AM, an observation was made of resident 86. Resident 86 was wearing the same pink shirt as on 3/28/22. Resident 86 had long chin hairs, about an inch long. On 3/31/23 at 9:14 PM, an observation was made of resident 86. Resident 86 was observed to be wearing the same pink shirt. On 4/1/23 at 6:03 PM, an observation was made of resident 86. Resident 86 was observed to be wearing the same pink shirt. On 4/11/23 at 10:38 AM, an observation was made of resident 86. Resident 86 was observed in striped sweat pants with a hole on the left hip. On 4/17/23 at 3:36 PM, an observation was made of resident 86. Resident 86 was in a sweater with stars on them and pants with suns on them. On 4/18/23 at 8:55 AM, an observation was made of resident 86. Resident 86 was in a sweater with stars on them and pants with suns on them. Resident 86's medical record was reviewed 3/28/23 through 4/25/23. A quarterly MDS dated [DATE] revealed resident 86 had a BIMS score of 1 which revealed severe cognitive impairment. The MDS revealed resident 86 required 1 person extensive assistance for toilet use and personal hygiene. A care plan dated 8/17/22 and updated on 10/27/22 revealed resident 86 had an ADL self-care performance deficit related to metabolic encephalopathy and diagnosis of dementia and anxiety. A goal was resident 86 would maintain current level of function in ADLs through the review date. Interventions included to allow sufficient time for dressing and undressing. On 4/13/23 at 4:01 PM, an interview was conducted with hospice RN 1. Hospice RN 1 sated that the hospice CNA showered resident 86. Hospice RN 1 stated the facility staff should be changing resident 86's clothing daily except on the days the hospice CNA provided a shower. On 4/24/23 at 11:49 AM, an interview was conducted with Director of Nursing (DON) 3 and Chief Nursing Officer (CNO). DON 3 stated nurses should be assisting residents to the bathroom. DON 3 stated clothing should be changed daily unless soiled or dirty, then should be changed more than daily. DON 3 stated there were more CNA's staffed for the Cambridge unit in the last few weeks. DON 3 stated they were moving CNA charting to the floors so that the CNA's were on the hallway when charting. DON 3 stated that resident 86 refused to have clothing changed at times. DON 3 stated she was not sure how staff had been instructed to manage residents facial hair for women. DON 3 stated if the resident refused to have their facial hair removed it would have been care planned. On 4/13/23 at 2:19 PM, an interview was conducted with CNA 11. CNA 11 stated there was a daily list of residents that needed showers. CNA 11 stated that each CNA was assigned 2 residents to shower in the morning and 2 residents in the afternoon. CNA 11 stated if a resident refused, it depended on when the resident refused. CNA 11 stated showers were not able to be completed when there were 2 CNA's staffed in the Cambridge unit. CNA 11 stated she noticed facial hair on the women. CNA 11 stated when a resident was showered then facial hair was removed. CNA 11 stated when resident 51 was showered that required 2 CNA's, so there were no CNA's to watch the other residents in the hallway. CNA 11 stated she did not try to remove resident 51's facial hair because CNA 11 was scared she would cut resident 51 because she was combative. CNA 11 stated that resident 81 was very clean and gave herself a sponge bath every morning. CNA 11 stated that she would suggest facial hair removal to resident 81. CNA 11 stated that if CNA's insisted on facial hair removal with resident 81 then she would get upset. CNA 11 stated that resident 86 did not like showers but she allowed her hospice aide to shower her. CNA 11 stated showers were documented in the electronic medical record under the tasks section. CNA 11 stated there was a form that CNA's document the shower, along with any skin issues, and if nails were cut. CNA 11 stated the form was filled out by the CNA and then given to the nurse. On 4/24/23 at 1:17 PM, a follow-up interview was conducted with CNA 11. CNA 11 stated resident 86's clothing was not changed for days at time. CNA 11 stated she did not know why because resident 86 never refused to be have her clothing changed. On 4/13/23 at 2:16 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that showers were being completed in the Cambridge unit. LPN 3 stated if a resident refused then staff left the resident and tried later. LPN 3 stated if a resident continued to say no, then staff would document the refusal. LPN 3 stated if residents continue to refuse, then a bed bath should be offered. On 4/17/23, an interview was conducted with SM 18. SM 18 stated showers were done after breakfast since staff have more time. SM 18 stated almost every aide showered 2 residents each day. SM 18 stated there were 3 CNA's working in the Cambridge hallway on that day. SM 18 stated if a staff did a 12 hour shift then the staff member completed 4 showers. SM 18 stated showers were being completed with 3 CNA's. SM 18 stated when there were 2 CNA's for the Cambridge unit showers were not always completed. SM 18 stated CNA's shave both men and women and no residents had refused facial hair removal. On 4/24/23, an interview was conducted with SM 22. SM 22 stated residents facial hair was removed weekly, but it depended on the resident because a lot of them refused. SM 22 stated All we can do is try to ask them weekly if they would like their facial hair removed. SM 22 stated that resident 51 did not allow for her facial hair to be removed. SM 22 stated that resident 51 also refused showers and cares. SM 22 stated all we could do is ask. SM 22 stated that resident 81 had chin hair and she often refused showered. SM 22 stated that if we were to ask resident 81, and she had told the nurse that she did not have anything on her face. SM 22 stated she did not know who resident 32 was and if she had received showers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 75 was admitted to the facility on [DATE] with the following diagnoses but not limited to paraplegia, polyneuropathy, pressure ulcer of sacral region stage 4, anxiety disorder, major depressive disorder, cognitive communication deficit and insomnia. Resident 75's medical records were reviewed on 4/17/23. On 2/23/23, a Quarterly MDS documented resident 75 required extensive two person assist for bed mobility. The skin condition section of the MDS, documented resident 75 currently had 1 stage 4 pressure ulcer. On 4/30/22, a physician history and physical stated resident 75 was admitted to the facility for skilled therapy, wound care, and other needs. It documented resident 75 had a stage 4 pressure sore to the sacrum upon admission. Resident 75's progress notes were reviewed and documented as followed: a. On 5/5/22, a nurses note stated the wound care nurse practitioner (NP) applied and started resident 75's wound vac to his stage 4 sacral pressure sore. b. On 11/1/22 an order administration note documented, Wound vac is on and functioning properly, wound care team went in to change out vac today but pt was out of supplies in his room, ie canister, drape and tubing. c. On 11/3/22 at 10:17 am, an order administration note documented, Supplies for wound vac change not available at this time. Management notified. d. On 11/3/22 at 17:15, an order administration note documented, Canister and wound vac supply not available at this time. Management informed and looking for supplies. Wound vac removed and replaced with wet to dry dressing per ADON. e. On 11/4/22 at 11:34 AM and 9:33 PM, an orders administration notes documented, Wound vac currently not on d/t not having supplies. Wet to dry dressing in place, CDI [clean dry and intact]. Not in place. Need wound vac supplies. f. On 12/8/22, two orders administration notes documented, Not performed. Bandage equipment not present. Management informed and Bandage not changed. No vacuum attachments. Management informed. [Note: It was documented that resident 75 had run out of supplies on November 1 and due to the lack of supplies for at least 4 days, resident 75 had gone 2 days without his wound vac being in place.] On 12/8/22, a skin and weight note documented, Pressure wound on sacrum healing, with minor set-back. Increased size on one edge slightly. Continued wound vac treatments. On 4/20/23 at 2 PM, an interview was conducted with Licensed Practical Nurse (LPN) 5. LPN 5 stated resident 75 had a sore on his bottom. LPN 5 stated a wound vac was applied to resident 75's pressure sore to help aid in wound healing. LPN 5 stated resident 75 always had his wound vac on and functioning. LPN 5 stated his wound vac was not changed as ordered because it was so time consuming. LPN 5 did not give any specific dates on when resident 75 wound vac was not changed. LPN 5 stated resident 75 thanked her one time when she had changed his wound vac. LPN 5 stated resident 75 said his wound vac did not get changed often. LPN 5 stated that resident 75 bottom sore had improved significantly to where they discontinued the wound vac and have applied a skin graft. On 4/24/23 at 12:59 PM, an interview was conducted with the ADON. The ADON stated resident 75 had a stage 4 sacral pressure sore upon his admission to the facility. The ADON stated they outsourced a wound care company to manage his wounds. The ADON stated his wounds had improved. The ADON stated resident 75 had been on a wound vac and stated the wound vac aided in creating new tissue and approximate the wound due to the negative pressure that was applied. The ADON stated the wound vac needed to continually be working as indicated to help with wound healing. The ADON stated wound vac supplies should not take longer than 24 to 48 hours to get. The ADON stated there was a direct number they called to get supplies. Based on interview, observation, and record review it was determined for 3 of 80 sampled residents, that the facility did not ensure that residents received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable and residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, a resident who developed pressure ulcers while at the facility was not provided with appropriate cares to prevent or treat the pressure ulcers, the facility did not have the correct supplies to treat a residents pressure ulcers, and residents did not have wound vacuum (vac) applied per physician's orders. Resident identifiers: 7, 75, and 96. Findings include: 1. Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cerebral palsy, asthma, type 2 diabetes mellitus, systemic lupus, chronic respiratory failure, muscle weakness, cognitive communication deficit, hypertensive heart and chronic kidney disease without heart failure, open wound of abdominal wall, major depressive disorder, polyneuropathy, chronic kidney disease, ileostomy status, low back pain, hyperlipidemia, sleep apnea, and neuromuscular dysfunction of bladder. On 4/11/23 at 11:51 AM, an interview with resident 7 and resident 7's POA was conducted. Resident 7 stated that staff were supposed to turn her every two hours at night, however she stated she often woke up in the same position that she went to sleep in. Resident 7's POA stated that resident 7 had three new pressure ulcers because the staff did not turn her. A review of resident 7's medical record was conducted on 4/11/23. Resident 7 had three care plans related to pressure injuries. Resident 7's care plan dated 5/14/20 stated, [Resident 7] is at risk for impaired skin integrity related to a history of pressure ulcer development, Cerebral Palsy, diabetes mellitus type 2, hypotension, hypothyroidism, impaired mobility, and generalized weakness. The goal, initiated on 5/14/20 and revised on 5/31/22 stated, [resident 7] will have no unaddressed area of impaired skin integrity through next review. The interventions, initiated on 5/14/20, stated, Assist with frequent turning/repositioning while in wheelchair [sic], protect heels, manage moisture, promote nutrition, reduce friction and shear, use commercial moisture barrier, use absorbent pads or briefs that wick and hold moisture. Promote increase protein intake, increase calorie intake to spare proteins. Act quickly to alleviate deficits, consult dietitian. Increase frequency of turning by supplement with small shifts. Pressure pressure [sic] reduction support surfaces. Resident 7's Care Plan dated 3/28/23 stated, The resident has actual impairment to skin integrity of the right and left buttocks stage 3 PIs [Pressure Injuries] and abd [abdominal] wound. The goal, initiated 3/28/23, stated, The resident's will have no complications r/t [related to] pressure injuries or abd wound of the through the review date [sic]. The interventions, initiated on 3/28/23, stated, Encourage good nutrition and hydration in order to promote healthier skin. Low air loss AP [air pressure] mattress to bed. Encourage to assist and be repositioned often. On site wound care weekly NP [nurse practitioner] visits. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx [signs/symptoms] of infection, maceration etc. to MD [medical director]. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, types of tissue and exudate and any other notable changes or observations. Resident 7's Care Plan dated 7/11/21 and revised on 11/2/22 stated, [resident 7] is at risk for potential pressure ulcer development r/t immobility, altered mental status, cognitive loss limits mobility, sever pulmonary disease, devices that can cause pressure such as oxygen or indwelling catheter tubing. The goal, initiated on 7/11/21 and revised on 5/31/22, stated, [resident 7] will have intact skin, free of redness, blisters or discoloration by/through review date. The interventions, initiated 7/11/21 stated, Administer medications as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. If the resident refuses treatment, confer with the resident, IDT [interdiscipinary team] and family to determine why and try alternative methods to gain compliance. Document alternative methods. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. On 4/13/23 at 10:35 AM an observation of wound care for resident 7 was conducted. Registered Nurse (RN) 7 entered the room and asked resident 7 what side the wound was on, resident 7 responded, on the left side. RN 7 brought supplies and placed the supplies on the bed. RN 7 performed hand hygiene. Resident 7 was rolled on the right lateral side. Three Optifoam 4x4 bandages were observed on resident 7's left trochanter, left gluteal crease, and on the left buttocks. RN 7 performed hand hygiene with soap, water, and gloves were donned. On 4/13/23 at 10:47 AM Director of Nursing (DON) 3 entered the room to assist RN 7 with wound care. RN 7 removed the old dressing, doffed gloves, and donned new gloves. Hand hygiene was not performed prior to donning new gloves. Gauze 4x4 bandages were obtained from the bedside table and placed on the bed. Resident 7 was repositioned, and the old dressing was removed from the left buttock pressure ulcer. The gauze 4x4 were obtained, and the wounds were sprayed with wound cleaner and tapped dry with gauze. RN 7 stated resident 7 had a pressure ulcer on the left buttock and it was unstageable. Observed a dressing on the right buttock. RN 7 doffed gloves and new gloves were obtained from RN 7's pocket. RN 7 donned the gloves without performing hand hygiene. Alginate 2x2 was placed on the wound bed of the pressure ulcer and on the left trochanter. Optifoam dressing opened, and alginate was placed on the wound in the gluteal crease. A second Optifoam dressing was placed on the second open wound with alginate underneath. A third Optifoam dressing was placed over the pressure ulcer, then RN 7 doffed the gloves and hand hygiene was performed. RN 7 dated and initialed the dressings. RN 7 obtained more supplies, performed hand hygiene, and applied new gloves. Resident 7 was repositioned. The dressing covering the right buttocks was removed, and no dates were observed on the old dressing. The pressure ulcer was observed with a large gaping hole, skin fold observation in the middle of the right buttock, and maceration was noted to the peri wound, extending from the coccyx to the gluteal crease. RN 7 doffed gloves and donned new gloves without performing hand hygiene. Wound cleanser was sprayed into wound bed, and the peri wound was wiped with a 4x4 working outward. RN 7 doffed his gloves and applied new gloves without performing hand hygiene. Alginate was applied to the right wound bed and peri area. RN 7 stated that the alginate helped with the moisture. RN 7 applied Optifoam 6x6 over the alginate. An adhesive bordered dressing was placed in the gluteal cleft next to the anus. Skin breakdown was observed on the inner upper leg below the gluteal crease. RN 7 doffed gloves and donned new gloves without performing hand hygiene. Optifoam 6x6 was applied to the open moisture associated skin damage (MASD) distal to the gaping hole area, and the area was not cleansed with wound cleaner. A new brief was placed under the resident. The resident was moved up in bed. The dressing on the right side was not dated and signed. On 4/13/22 resident 7's Treatment Administration Record (TAR) was reviewed. Resident 7 had an order that stated, wound care: right buttocks cleanse with wound cleanser, aquacil rope to superior area, apply medihoney to inferior site cover with adaptic, cover with foam 3x/wk and prn [as needed]. One time a day every Tue [Tuesday], Thu [Thursday], Sat [Saturday] for wound care. Start date 4/8/23. Resident 7 did not have current wound care orders for the left buttocks. Wound care notes from 3/14/23 and 3/23/23 stated, Turn/reposition every 2 hours. Avoid direct pressure to wound site. A Point of Care (POC) response history for resident repositioning was reviewed from 3/13/23 to 4/8/23. The following was revealed. a. On 3/14/23 resident 7 was repositioned at 1:34 PM b. On 3/16/23 resident 7 was repositioned at 2:03 AM c. On 3/19/23 resident 7 was repositioned at 4:34 PM d. On 3/20/23 resident 7 was repositioned at 6:00 AM, 8:00 AM, 10:00 AM, and 12:00 PM. Resident 7 was not repositioned at night. e. On 3/21/23 resident 7 was repositioned at 9:53 AM and 12:00 PM. f. On 3/23/23 resident 7 was repositioned at 1:15 AM. g. On 3/24/23 resident 7 was repositioned at 3:58 AM and 3:59 AM. h. On 3/25/23 there was no documentation of resident 7 being repositioned. i. On 3/26/23 resident 7 was repositioned at 6:00 AM, 8:00 AM, 10:00 AM, and 12:00 PM. Resident 7 was not repositioned at night. j. On 3/27/23 there was no documentation of resident 7 being repositioned. k. On 3/28/23 resident 7 was repositioned at 12:07 PM and 12:08 PM. l. On 3/29/23 resident 7 was repositioned at 8:36 AM, 9:27 AM, 12:00 PM. Resident 7 was not repositioned at night. m. On 3/30/23 resident 7 was repositioned at 7:45 AM. n. On 4/7/23 resident 7 was repositioned at 9:07 PM. o. On 4/8/23 there was no documentation of resident 7 being repositioned. On 4/13/23 at 9:42 AM an interview with Certified Nursing Assistant (CNA) 5 was conducted. CNA 5 stated that resident 7 was supposed to be repositioned every two hours while resident 7 was in her bed. CNA 5 stated that the facility did not have enough staff to reposition resident 7 when required. 2. Resident 96 was admitted to the facility on [DATE] with diagnoses which consisted of osteomyelitis, type 2 diabetes mellitus, sepsis, hypertension, retention of urine, major depressive disorder, personality disorder, insomnia, anxiety disorder, and acquired absence of right leg below the knee. On 3/29/23 at 9:03 AM, an interview was conducted with resident 96. Resident 96 stated that he had a pressure ulcer on his left foot. Resident 96 stated that the wound had a wound vac dressing that was supposed to be changed three times a week. Resident 96 stated that the dressing never gets changed. Resident 96 stated that the staff left the machine alarming. The wound vac was observed not connected to the monitor. On 4/24/23, resident 96's medical records were reviewed. On 1/29/23, resident 96's admission Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 13/15, which would indicate that resident 96 was cognitively intact. Resident 96's physician orders revealed the following: a. WOUND CARE: LEFT HEEL- Cleanse with wound cleanser, apply betadine one time a day every Monday, Wednesday, and Friday for wound care. The order was initiated on 3/27/23. b. Resident to have left foot/ankle pressure relieving cushion/boot. This should be worn at all times, every shift for decubitus ulcer. The order was initiated on 3/17/23. c. Left Foot/Ankle pressure relieving cushion/boot for left heel decubitus, wear at all times. d. WOUND CARE: LEFT FOOT/ANKLE- Cleanse with wound cleanse, allow to sit for at least 5 minutes, DON'T USE WHITE FOAM IN BASE OF ULCER. Negative Pressure Wound Therapy (NPWT) Pressure 125 millimeters of mercury (mmHg) continuous - Black foam may be used for base of wound that can be seen. Black foam should cover all necrotic tissue that hasn't opened up yet one time a day every Monday, Wednesday, and Friday for wound care. The order was initiated on 2/22/23. e. WOUND ORDER : Right lower extremity - Below the Knee Amputation (BKA) - leave dressing clean and in-tact until further instructions from orthopedic surgeon. The order was initiated on 1/25/23. Review of resident 96's TAR for February, March and April 2023 revealed the following for the wound care to the left foot/ankle: a. On 2/24/23, the TAR did not have documentation that the wound care was completed. b. On 3/17/23 and 3/22/23, the TAR documented to see progress note. On 3/17/23 at 12:50 PM, the progress note documented, Pt [patient] has wound vac re-applied to left ankle and stated he had wound care done last night and asked me to leave it alone at this time. It should be noted that no documentation could be found of a progress note for the 3/22/23 wound care treatment. c. On 3/27/23, the TAR documented that the wound care was refused. d. On 3/29/23, the TAR did not have documentation that the wound care was completed. e. On 4/5/23, the TAR did not have documentation that the wound care was completed. f. On 4/14/23 and 4/17/23, the TAR documented to see progress note. On 4/14/23 at 9:28 PM, the progress note documented, Report from [local hospital]: Patient with I&D [incision and drainage] of left ankle as well as graft. Wound vac in place but started with 'leakage' alerts in PACU [post anesthesia care unit] but reported to be okay if green light is still on. On 4/17/23 at 12:51 AM, the progress note documented, Wound Vac in place and working properly. It should be noted that the note did not mention that the wound vac was changed per the physician's order. Resident 96's wound care notes revealed the following: a. On 2/10/23, the note documented resident 96 had a BKA of the right lower extremity. Resident 96 had had wounds on the stump and the left lower extremity that were being managed by the surgeon. Wound #1 was Partial thickness trauma wound to the toes, measurements were 2.2 centimeter (cm) length by by 0.8 cm width with no measurable depth, with an area of 1.76 square (sq) cm. No drainage noted, margins were flat and intact, 76-100% eschar. b. On 2/15/23, the note documented Wound #1 was exactly same as documented on 2/10/23. c. On 3/3/23, the note documented that the plan for the wound on the dorsal foot was, to eventually do a split-thickness skin graft (STSG) or dermal graft on this wound. There is a fair amount of devitalized tissue in the bound bed still. He has developed a significant PI on his heel from laying in bed all the time. This is covered with stable eschar at this time. Wound #1 Partial Thickness Trauma wound to the toes, measured 1.8 cm x 0.6 cm, 1.08 sq cm, wound was improving. Wound #2 Left Dorsal Ankle was a full thickness surgical wound and measured 11 cm length x 9.5 cm width x 0.5 cm depth, with an area of 104.5 sq cm. Tendon and ligament were exposed, small amount of sero-sanguineous drainage noted with no odor, wound margin attached to wound base. Wound bed had 1-25 % slough, 76-100 % pink granulation. Area surgically debrided. Wound #3 Left Heel was an unstageable Pressure Ulcer (PU) with full thickness skin and tissue loss. Initial measurements were 4 cm x 7 cm, with no measurable depth. Scant sanguineous drainage, no odor, wound margin flat and intact, wound bed 76-100% eschar. d. On 3/8/23, the note documented, Wound #1 Toes measured 0.8 cm x 0.4 cm. The wound was improving. Wound #2 and Wound #3 were not assessed. Orders for Wound #2 were to cleanse with wound cleaner and NPWT (negative pressure wound therapy) pressure at 125 mmHg continuous. The NPWT dressing was to be changed three times a week. Orders for Wound #3 were betadine applied daily. e. On 3/14/23, the note documented Wound #1 Toes measured 0.6 cm x 0.3 cm, and the wound was improving. Wound #2 documented that the tendon and ligament were exposed, no measurements were obtained. Wound #3 did not have any documented assessment. f. On 3/23/23, the note documented that the toenails looked great, no eschar. Left ankle has a wound vac that is managed by [physician name omitted]. Left heel Unstageable PI was macerated and smelled. Wound vac had no date of when it was changed but the order from [physician name omitted] is Mon [Monday], Wed [Wednesday], and Fri [Friday]. Wound #1 was documented as healed. Wound #2 was not measured. The tendon and ligament were exposed. There was a small amount of sero-sanguineous drainage noted with no odor, and the wound margin was attached to wound base. Wound bed had 1-25 % slough, 76-100 % pink granulation. Wound #3 measured 4.6 cm x 5.66 cm x 0.3 cm, no change in wound progression. No signs and symptoms of infection. g. On 3/31/23, the note documented Wound #1 was resolved. Wound #2 measured 8.5 cm x 8.9 cm x 0.4 cm. The tendon and ligament were exposed. A small amount of sero-sanguineous drainage was noted with no odor, and wound margin was attached to the wound base. Wound bed had 1-25 % slough, 76-100 % pink granulation. Wound was improving. Wound #3 4.6 cm x 5.6 cm, no drainage was noted. h. On 4/7/23, the note documented Wound #2 measured 8.5 cm x 8.6 cm x 0.4 cm, no other changed noted. Wound #3 measured 4.6 cm x 5.6 cm, no changes noted in wound progression. Resident 96's care plan for had a pressure injury to left heel, stage 3 wounds to toe and foot was initiated on 3/28/23. Interventions identified were to assess for signs and symptoms of pain with wound care; Schedule/administer analgesic prior to treatment; educate resident regarding interventions and benefits of compliance; implement wound care protocol; keep resident off affected area as tolerated; reposition frequently as tolerated for chair bound residents; and educate teachable residents about the benefits of shifting their weight when seated. On 3/30/23 an interview was conducted with Staff Member (SM) 6. SM 6 stated that resident 96 had a wound vac, and she was the only one that changed it. SM 6 stated that resident 96 told her the wound vac monitor had been alarming since Saturday. On 3/31/23 an interview was conducted with SM 15. SM 15 stated that resident 96's wound vac dressing was neglected and no one changed it. SM 15 stated that the wound vac monitor was beeping and needed to be changed and no one went in there. On 4/1/23 at approximately 5:15 PM, observed resident 96 in the hallway seated in the wheelchair. The wound vac was not connect to the monitor. On 4/4/23 at 1035 AM, resident 96 was interviewed in his room. Resident 96 was seated in his wheelchair. Resident 96 did not have the wound vac monitor operating at the time of the interview. The monitor was observed turned off. On 4/10/23 at 1:04 PM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated that she just gave resident 96 a pain pill 30 minutes prior to his dressing change. RN 5 stated that she liked to pre-medicate with pain medication prior to dressing changes. RN 5 stated that resident 96 had dressing changes 3 times a week. RN 5 stated that resident 96 knew how to charge the wound vac monitor, and he could have it with him on the wheelchair operating while he was mobile. RN 5 stated that resident 96 would wrap the monitor with an ace wrap to stabilize it while on the wheelchair. On 4/10/23 at 1:13 PM, a follow-up interview was conducted with resident 96. An observation was made of the wound vac monitor and tubing not connected to the dressing. Resident 96 stated the wound vac machine was on the floor next to his bed. Resident 96 stated that he had been reminding the nursing staff to change the wound vac dressing because he did not want to lose his other leg. Resident 96 stated that the wound vac monitor had been unhooked since yesterday because it kept on alarming. Resident 96 stated that SM 6 would always find the leak when it was alarming and fix it, but the other nurses would not do it. Resident 96 stated that the wound was getting nasty. Resident 96 stated that the licensed nurse told him yesterday to just leave the wound vac off because it was alarming and it was scheduled to be changed today. On 4/10/23 at 1:42 PM, an observation was made of wound care to resident 96's wounds provided by RN 5. RN 5 stated that resident 96 had 2 wounds that she was providing treatment to on the left lower extremity (LLE), and the right BKA was being treated by the surgeon. RN 3 was assisting RN 5 with the wound care. RN 5 stated that the wound vac was set to a pressure of 125 mmHg. RN 5 stated that she re-connected the wound vac, and that it was not connected earlier. RN 5 donned gloves and disconnected the wound vac tubing from the monitor. RN 5 removed the Podus boot and ace bandage from the LLE. A gauze roll was observed covering the wound vac dressing. RN 5 sprayed wound cleanser on the LLE heel to remove the gauze dressing. RN 5 doffed her gloves, performed hand hygiene, and new gloves were donned. The wound vac dressing was observed located on the LLE dorsal surface and lateral malleous. RN 5 removed the wound vac using a gauze 4x4 pad and wound cleanser to moisten the foam from the wound bed. RN 5 doffed her gloves, performed hand hygiene, and new gloves were donned. The wound bed was pink, with white slough noted. RN 5 placed a 4x4 gauze pad under the foot for wound cleanser absorption, and wound cleanser was sprayed onto the wound bed. RN 5 wiped the center of the wound bed, working outward towards the peri wound with a 4x4 gauze. RN 5 saturated a 4x4 gauze pad and placed it on the wound bed to soak for 5 minutes. RN 5 opened a new wound vac dressing and foam was cut to wound size with scissors obtained from the bedside table. Scissors were not observed cleaned prior to use. RN 5 did not change gloves prior to touching the new dressing. After 5 minutes had passed RN 5 removed the gauze dressing from the wound bed, and a dry 4x4 gauze pad was used to pat the wound bed dry. RN 5 doffed gloves, performed hand hygiene, and new gloves were donned. RN 5 applied skin prep to the wound margins. RN 5 applied a Tegaderm dressing to the peri wound and pieces were cut to the shape of the wound margins. RN 5 was observed to touch the LLE shin with the left hand and lift the leg to apply the Tegaderm film. The Tegaderm rolled onto itself near the ankle and stuck to RN 5's gloves. RN 5 placed the next Tegaderm strip over the rolled edge with wrinkling observed beneath. RN 5 stated that the Tegaderm stuck to her glove and rolled, but she could flatten it. RN 5 cut out the wrinkled section of the Tegaderm and reapplied. RN 5 opened a sterile foam package and the scissors were placed on the bed on top of resident 96's dirty sock. RN 5 doffed her gloves, and new gloves were donned. No hand hygiene was performed. RN 5 cut the foam wound vac dressing with a second pair of scissors, and those scissors were not observed disinfected prior to use. RN 5 doffed her gloves and exited the resident room to ask or assistance. RN 5 returned to resident 96's bedside and was accompanied by Regional Nurse Consultant (RNC) 1. RN 5 and RNC 1 donned new gloves, no hand hygiene was performed. RNC 1 held the foam wound vac dressing in place on the wound bed while RN 5 placed the Tegaderm over the top. RNC 1 lifted resident 96's leg with the right hand while the left hand held the foam dressing in place. RNC 1 then touched the foam dressing with the gloved right hand. RN 5 applied Tegaderm over the top of the entire foam dressing. RN 5 obtained new tubing to apply to the dressing. RN 5 used the scissors that were placed on the bed on top of resident 96's dirty sock to cut an opening into the Tegaderm and foam dressing to place the tubing inside. RN 5 removed the old canister and a new canister was placed on the wound vac and connected to the tubing. RN 5 doffed gloves, and new gloves were donned. No hand hygiene was performed. RN 5 set the wound vac pressure to 125 mmHg. RN 5 doffed gloves, performed hand hygiene, and new gloves were donned. The Tegaderm was observed lifting on the new wound vac dressing. RN 5 sprayed wound cleanser was onto the heel wound and wiped from the center outward with a 4 x 4 gauze pad. RN 5 cleaned the wound with a betadine swab from the edges inward with 2 betadine swabs. RN 5 applied a new ace bandage to the entire foot and the Podus boot was placed back on the left foot. Resident 96 asked RN 5 to place the wound vac monitor in the carrying bag so it was easier to move around. RN 5 instructed resident 96 to inform her if the monitor beeped as the pressure needed to be continuous or else it did no good. Resident 96 asked RN 5 what he should do if the licensed nurse did not do anything. RN 5 replied to let the aide know so they could find another nurse who could fix the wound vac for him. On 4/10/23 at 2:47 PM, an interview was conducted with RN 5. RN 5 stated that she was supposed to doff and donn new gloves before started a dressing change and if she touched anything that was dirty. RN 5 stated that she cleaned the scissors prior to the dressing change and will clean them afterwards. RN 5 stated that the gloves should have been changed prior to touching the foam wound vac dressing. RN 5 stated that wound beds should be cleaned from the center outwards. On 4/13/23 at 1:52 PM, an interview was conducted with Director of Nursing (DON) 3. DON 3 stated that when performing dressing changes hand hygiene [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 1 was initially admitted to the facility on [DATE] and again on 1/2/23 with diagnoses which included chronic obstructive pulmonary disease, acute respiratory failure, unspecified asthma, acute kidney failure, history of falling, muscle weakness, systolic heart failure, adult failure to thrive, hypothyroidism, lactose intolerance, insomnia, adjustment disorder, personality disorder, anxiety disorder, and bipolar disorder. On 4/5/23 resident 1's Medical Record was reviewed. A Nurses Note from 8/25/22 at 3:19 PM stated, Res [resident] c/o [complained of] increased fatigue, flank pain, urine freq [frequent], poor apatite [sic], memory lapses, and lowered ability to hear out of L ear. Contacted [Doctor's name redacted] and received an order to get UA [Urinalysis] via straight cath [catheter], CMP [comprehensive metabolic panel], CBC [complete blood count], ESR [Erythrocyte sedimentation rate], CRP [C-reactive protein]. Resident states she thinks she is getting a UTI. A Nurses Note from 8/25/22 at 5:41 PM revealed that the labs requested by the doctor were drawn. An Event/Alert Charting note from 8/25/22 at 10:48 PM stated, .Suspected UTI .Pt [patient] continues to have mood swings and complains of urinary burning. She states she has also lost control of her bladder control, and has frequent accidents . A Nurses Note from 8/27/22 at 10:47 AM stated, Pt [patient] sent to [Name redacted] hospital, pt has recent labs that come back indictive of fighting and [sic] infection, MD aware and notified. Was sent to the hospital to get a UA facility doesn't have straight catheter. Administration aware, MD aware. A Nurses Note from 8/27/22 at 5:33 PM stated, pt was sent to the ER to obtain a UA, facility was out of straight catheter supplies until next Friday. Pt expressed concerns of being more sleepy and tired, MD ordered stat UA. MD gave and [sic] okay to discharge pt to get a stat UA. A Nurses Note from 8/29/22 at 5:27 PM stated, Lab results received for UA/sensitivity results as follows: +[positive] Escherichia coli, + [positive] Enterococcus species . MD notified. Resident 1's orders were reviewed. It was revealed that an order for Macrobid Capsule 100 MG (milligrams) with instructions to Give 2 capsule by mouth two times a day for UTI for 7 days was started on 8/29/22 and ended on 9/5/22. It should be noted that this order was started five days after the resident was suspected of having a UTI. On 4/12/23 at 1:27 PM, an interview with Licensed Practical Nurse (LPN) 5 was conducted. LPN 5 stated that if she was unable to obtain a UA right away, she would try a few more times that day. LPN 5 stated that if she was still unable to obtain a UA after a few attempts on the day it was ordered, she would notify the doctor and ask for further instructions. On 4/13/23 at 2:37 PM, an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated that she was not aware of the facility not having straight catheters available. The ADON stated that if the facility was out of straight catheters, the facility had the ability to get a straight catheter that same day. The ADON stated that she would expect staff to collect a UA within 24 hours from when the UA was ordered. The ADON stated that she would expect staff to attempt to collect the UA a couple times, and if staff were unable to obtain the UA, staff should notify the doctor that day and ask for further instructions. The ADON stated that the staff should notified the administration on 8/25/22 if the facility was out of straight catheters. The ADON stated the staff should have notified the doctor on 8/25/22 when the staff were unable to obtain the UA for resident 1. Based on interview and record review it was determined, for 4 out of 80 sampled residents, that the facility did not ensure that a resident who was incontinent of bladder received the appropriate treatment and services to prevent urinary tract infections (UTI) and to restore continence to the extent possible. Specifically, a resident had a delay in treatment for a UTI, a resident with an indwelling Foley catheter did not receive flushes per the physician's order, a resident continued to have complaints of dysuria after the completion of antibiotics for the treatment of a UTI, and a resident complained of signs and symptoms of a UTI and a urinalysis was not obtained. Resident identifiers: 1, 77, 96, and 357. Findings included: 1. Resident 77 was admitted to the facility on [DATE] with diagnoses which included multiple sclerosis, Parkinson's disease, cirrhosis of liver, hypertension, pain in legs, edema, history of UTI, and anxiety disorder. On 3/28/23 at 1:32 PM, an interview was conducted with resident 77. Resident 77 stated that she was currently receiving antibiotics for a UTI. Resident 77 pointed to a left peripherally inserted central catheter (PICC) line. Resident 77 stated that when she urinated it hurt. On 3/28/23, resident 77's medical records were reviewed. On 12/29/22, the Quarterly Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of 13, which would indicate cognitively intact, the assessment documented yes to hallucinations and no to delusions. The assessment documented the resident's functional status as total dependence one person assist for bed mobility, locomotion on and off the unit, eating, toileting, and personal hygiene and total dependence two person assist for transfers. The assessment documented that resident 77 did not have any urinary appliances and did not have a trial of a toileting program. The assessment documented that resident 77 was always incontinent of urine and bowel. Review of resident 77's physician orders revealed the following: a. Collect urine sample for urinalysis (UA) with culture and sensitivity (C & S) one time only for UTI symptoms. The order was initiated on 3/15/23. b. Bactrim DS Tablet 800-160 milligram (mg) (Sulfamethoxazole-Trimethoprim), give 1 tablet by mouth every 12 hours for bacterial infection, UTI for 7 days. The order was initiated on 3/15/23 and discontinued on 3/22/23. c. Zosyn Intravenous Solution Reconstituted 3.375 (3-0.375) gram (gm) (Piperacillin Sodium-Tazobactam Sodium), use 3.375 mg intravenously (IV) every 6 hours for UTI for 7 Days. The order was initiated on 3/20/23 with and discontinued on 3/27/23. Review of resident 77's March 2023 Medication Administration Record (MAR) revealed: a. Macrobid Oral Capsule 100 mg (Nitrofurantoin Monohyd Macro), give 1 capsule by mouth two times a day for UTI for 7 Days. The order was initiated on 3/15/23 and discontinued on 3/20/23. The medication was documented as administered on 3/16/23 through 3/20/23 for a total of 9 doses. b. Zosyn Intravenous (IV) Solution Reconstituted 3.375 (3-0.375) gm (Piperacillin Sodium Tazobactam Sodium), use 3.375 mg intravenously every 6 hours for UTI for 7 Days. The order was initiated on 3/20/23. The medication was documented as administered on 3/21/23 through 3/27/23 for a total of 27 doses. Review of resident 77's progress notes revealed the following: a. On 3/14/23 at 6:33 PM, the note documented, urine discoloration observed. Pt [patient] reported discomfort while urinating. An order for UA with C&S and straight cath was requested. Waiting for orders. Med pass nurse notified. b. On 3/15/23 at 2:09 PM, the note documented, An order to collect urine sample via straight cath [catheter] obtained after several unsuccessful attempts for clean catch. Pt was straight cath and tolerated well. specimen sent to [laboratory]. c. On 3/15/23 at 6:46 PM, the note documented, UA results received. The following abnormal values noted: Appearance Turbid Abnormal WBC [white blood cells] Esterase 500 Occult blood Small abnormal WBC > [greater than]100 RBC [red blood cells] 6-10 Epithelial cells >15 Mucus threads 1+ Bacteria rare abnormal Culture will follow. NP [nurse practitioner] notified. Waiting for orders. d. On 3/15/23 at 6:53 PM, the note documented an order for Sulfa DS, 1 tablet by mouth two times a day for 7 days was received. e. On 3/15/23 at 7:20 PM, the note documented, Due to interaction alert, NP d/c [discontinued] order for Bactrim and gave order for Macrobid 100 mg po [by mouth] bid [two times a day] x [times] 7 days. f. On 3/16/23 at 2:38 AM, the note documented that the Macrobid was not available from the pharmacy. g. On 3/20/23 at 3:04 PM, the note documented to discontinue the Macrobid and change the antibiotic to Zosyn. h. On 3/20/23 at 7:58 PM, the note documented that the Zosyn Intravenous Solution was not administered due to no iv access awaiting placement. i. On 3/20/23 at 8:03 PM, the note documented, zosyn not started waiting for iv placement. j. On 3/20/23 at 10:00 PM, the note documented, Midline IV started to left upper arm by PICC RN [Registered Nurse] for zosyn, resident tolerated well. k. On 3/20/23 at 11:04 PM, the note documented, IV Zosyn not started waiting for IV placement. l. On 3/28/23 at 2:31 PM, the note documented, Pt's [patient's] IV abx [antibiotic] was [sic] been completed. IV still in place. MD [medical doctor] notified. An order to remove IV was obtained. IV was removed. line marked at 15. No bleeding noted. Pt tolerated well. Med [medication] pass nurse notified to monitor. m. On 3/30/23 at 2:05 PM, the physician note documented, SUBJECTIVE: laying in bed. Patient stated she still has pelvic pain and has a PICC line for antibiotic therapy in left arm. 3/15/23 UA: Leuko est 500, nitrite -, WBC >100; UCx [urine culture] corynebacterium striatum group >100,000 n. On 3/31/23 at 12:15 PM, the Orders - Administration Note documented, Event/Alert Charting following Event, Document every shift until resolved: UTI with IV antibiotics every shift for UTI related to PERSONAL HISTORY OF URINARY (TRACT) INFECTIONS This nurse did not see an IV nor is there any IV medications to give. o. On 4/1/23 at 2:21 PM, the note documented, Type of Infection: UTI, Assessment (S/Sx [signs and symptom] of Infection): None noted p. On 4/1/23 at 11:23 PM, the Event/Alert: Infection note documented, Type of Infection: UTI, Assessment (S/Sx of Infection): No s/s noted/reported. q. On 4/21/23 at 5:24 PM, the note documented that the physician ordered a UA with culture and sensitivity related to dysuria. r. On 4/23/23 at 3:36 PM, the note documented that the UA with C & S was collected via straight catheter and the specimen was sent to the laboratory for processing. On 3/15/23, the UA documented the following abnormal results turbid appearance, WBC esterase 500, small amt. occult blood, WBC >100, RBC 6-10, Epithelial cells >15, mucus threads 1+, rare bacteria. The urine culture documented Corynebacterium Striatum group >100,000. The report did not contain a susceptibility report. On 4/24/23 at 9:02 AM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated for medication that was not available, nursing staff contacted the pharmacy, and let the provider know that they were waiting for a delivery. RN 5 stated that the stat safe contained some medications, and most antibiotics were in the stat safe. RN 5 stated that Macrobid was in the stat safe. RN 5 stated that agency nurse's did not have access to the stat safe. RN 5 stated that they would document any pertinent medication information in the progress notes. RN 5 stated that she was not sure how long it took to receive a stat medication delivery from the pharmacy. RN 5 stated that a stat UA was not available, but they would conduct a dipstick urinalysis in the facility to see if it showed anything abnormal. RN 5 stated that sometimes the C & S results were quick but sometimes she would have to follow up with a call to the laboratory for the results. RN 5 stated that any Alert charting was done every shift. RN 5 stated that any antibiotic treatment had a three day post completion alert charting that was to be completed every shift and would be documented in the progress notes. RN 5 stated that if the C & S was completed they would fax the results or the preliminary results to the facility. RN 5 stated that once they obtained the lab results they would send them to the provider to see if the antibiotic was appropriate to treat the bacterial infection. On 4/24/23 at 11:35 AM, an interview was conducted with Director of Nursing (DON) 3 and the Chief Nursing Officer (CNO). DON 3 stated that the facility received deliveries from the pharmacy daily. DON 3 stated that she was unsure how long it took to receive a stat delivery and she would have to check. DON 3 stated that for medications that were not available the nurse should call the pharmacy notify that they were out. DON 3 stated that the nurse should also notify the physician that the medication was not available and document in a progress note. DON 3 stated that antibiotics were available in the stat safe. DON 3 stated that the agency nurses did not have access to the stat safe. DON 3 stated that the agency nurse would have to notify the DON or a nurse in the building to access the stat safe. DON 3 stated that she would make sure that the instructions were in the agency binder along with her contact number. DON 3 stated that the nursing staff should assess daily for any signs and symptoms of a UTI while the resident was being treated for a UTI and for 3 days after the completion of the antibiotic therapy. DON 3 stated that the licensed nurse should be able to place an IV access, but a PICC placement was completed by an outside provider. DON 3 stated that the outside provider for a PICC placement would get to the facility within a day of being contacted. DON 3 stated that the urine C & S took 2-3 days for results, and the laboratory faxed the results. DON 3 stated that the nurse should notify the physician of the results, so that they could choose the correct antibiotic to treat the organism. 2. Resident 96 was admitted to the facility on [DATE] with diagnoses which consisted of osteomyelitis, type 2 diabetes mellitus, sepsis, hypertension, retention of urine, major depressive disorder, personality disorder, insomnia, anxiety disorder, and acquired absence of right leg below the knee. On 3/29/23 at 9:01 AM, an interview was conducted with resident 96. Resident 96 stated that his Foley catheter did not get flushed, and the night nurses did not know how to flush it. Resident 96 stated that he emptied his own catheter bag because the staff did not do it. On 4/24/23, resident 96's medical records were reviewed. On 1/29/23, the admission MDS Assessment documented a BIMS score of 13/15, which would indicate that resident 96 was cognitively intact. The assessment documented that resident 96 was a limited one person assist for transfers, dressing, and personal hygiene. The assessment documented that resident 96 required a one person extensive assist for toileting. The assessment documented that resident 96 had an indwelling urinary catheter and did not have a trial of a toileting program. Resident 96's physician orders revealed the following: a. Discontinue Foley catheter one time only for patient refusal, no supporting diagnosis to keep in for 1 Day. The order was initiated on 1/31/23 and discontinued on 2/01/23. b. Straight cath resident. Resident unable to void. One time only for full bladder. The order was initiated on 2/01/23. c. Flush Foley catheter with 60 milliliters (ml) normal saline as needed (PRN) for catheter patency. The order was initiated on 2/13/23. d. Discontinue and remove Foley catheter per Medical Doctor (MD), one time only. The order was initiated on 2/16/23 and discontinued on 2/17/23. e. Insert Foley Catheter 16 french (F). Keep in until visit with urology. Change every 30 days and PRN for urinary retention. The order was initiated on 2/18/23. f. Flush catheter with acetic acid two times a day for infection prevention. The order was initiated on 3/08/23. g. Replace catheter now, use a 16 F 10 cubic centimeters (cc) Foley catheter one time only for acute urinary retention. The order was initiated on 3/19/23 and discontinued on 3/20/23. h. Foley catheter care each shift - Start at insertion site and wipe down toward the drainage bag. For men: Start from the top of penis where the catheter goes in, making sure to pull back the foreskin, and wipe back toward your anus. For women: separate the labia, and wipe back toward your anus. For a suprapubic catheter: Wipe the area of your belly around where the catheter goes in. Every shift for Foley Catheter care. The order was initiated on 3/28/23. i. Take out catheter and replace as needed for urinary retention one time only. The order was initiated on 4/03/23 and discontinued on 4/04/23. j. Remove catheter and watch for urinary retention, one time only for 1 day. The order was initiated on 4/04/23 and discontinued on 4/08/23. Resident 96's March 2023 Treatment Administration Record (TAR) revealed an order to flush the catheter with acetic acid two time a day for infection prevention. The order was not documented as completed on 3/15/23 at 8:00 PM, on 3/20/23 at 8:00 AM, on 3/25/23 at 8:00 AM, and on 3/31/23 at 8:00 PM. Resident 96's April TAR revealed that the Foley catheter care was not documented as completed on 4/8/23. Resident 96's Progress notes revealed the following: a. On 2/25/23 at 6:15 AM, the note documented , Resident stated his catheter needed to be flushed because he felt an overwhelming sense of bladder fullness and there was very little urine in his foley bag. After changing the foley bag due to a mucus clot, this nurse injected 60 mL of acetic acid into resident's bladder and let it sit for 30 minutes. The foley was then allowed to drain, and there was about 2000 mL in the bag over the next 2 hours. b. On 3/4/23 at 10:55 PM, the note documented, During med pass shift resident had C/O [complaints of] severe bladder pain and sediment in his catheter and requested a new one to be placed. 2 nurses offered to milk and flush catheter to see if this was effective prior to obtaining order for new catheter. Resident amenable to plan. Catheter was successfully flushed of all clogged sediment and resident voiced relief of symptoms. No further complaints voiced. c. On 4/19/23 at 6:47 PM, the note documented, Rounding provider ordered catheter change, Flush with NS [normal saline] daily due to sedementaion in urine On 4/10/23 at 1:13 PM, an observation was made of resident 96's urinary catheter bag. The urine bag was secured inside of a urinary privacy bag and was positioned to a down drain resting on the residents motorized wheelchair. The tubing was observed with clear yellow urine present, and no sediment was noted inside the tubing. On 4/20/23 at 11:45 AM, an interview was conducted with Registered Nurse (RN) 11. RN 11 stated that the Certified Nurse Assistant (CNA) provided resident 96 with catheter care earlier in the shift and observed the tubing and penile shaft being cleansed. RN 11 stated that she would provide more cares later and she was not sure if he is one that I flush but I will check the TAR. RN 11 stated that the catheter care would include cleaning the catheter tubing and penis. RN 11 stated that usually the down drain bag was changed weekly. RN 11 stated that she would document in the TAR and if a resident refused any cares she would document it in the TAR also. RN 11 stated that if no documentation was present on the TAR for a scheduled care she would assume it was not done. On 4/20/23 at 12:48 PM, a interview was conducted with DON 3. DON 3 stated that if staff were not charting then she would assume the task was not being done correctly and not charted. We have to assume that it did not get done because we have no documentation to say that it was. 3. Resident 357 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, type 2 diabetes mellitus, alcoholic cirrhosis, hemiplegia and hemiparesis following a cerebral infarction, dysphagia, concussion, repeated falls, chronic kidney disease stage 3, hypertensive heart and chronic kidney disease, and hypomagnesemia. On 3/28/23 at 1:02 PM, an interview was conducted with resident 357. Resident 357 stated that she felt like she had a UTI now and reported increased frequency and burning with urination. Resident 357 stated that she had reported these symptoms to the CNAs but had not had a UA yet. Resident 357 also stated that odor of her urine smells off. Resident 357 stated that she drinks water and cranberry juice for the prevention of a UTI. On 3/29/23, resident 357's medical records were reviewed. On 3/28/23, resident 357's admission MDS Assessment documented a BIMS score of 15/15, which would indicate that resident 357 was cognitively intact. The assessment documented that resident 357 did not have hallucinations or delusions. Resident 357 was assessed as requiring a limited one person assist for bed mobility, transfer, locomotion off the unit, dressing, and personal hygiene; extensive one person assist for toilet use; and supervision one person assist for eating. The assessment documented that resident 357 required a one person physical assist for bathing. The resident was assessed as requiring one person extensive assist for toileting. The assessment documented that the resident was occasionally incontinent of bladder and bowel. Resident 357's progress notes revealed the following: a. On 4/1/23 at 5:15 AM, the note documented Resident was found sitting on the floor next to her bed. Resident stated I just slid to the floor. I was trying to get to the bathroom. Resident was assisted off the floor and into her wheelchair. She was taken to the bathroom and returned to her bed. b. On 4/1/23 at 6:30 AM, the note documented, Resident was found on the floor of her bathroom, lying on her left side. Her head was resting on a box of gloves. Resident states, 'I hit my head. I was just trying to get to the bathroom.' Resident was assisted off the floor and onto the toilet. She was allowed to use the bathroom. c. On 4/4/23 at 10:16 AM, the note documented UA collect via clean catch. UA C&S sample sent to [lab]. d. On 4/10/23 at 6:39 PM, the note documented, UA results received that were collected on 4/4/23. Abnormal results are as follows: WBC estrase trace Nitrite, Urine Positive Bacteria Many Result 1 Klebsiella penumoniae Provider notified of results and new order received. 1. Macrobid 100 mg PO [by mouth] BID [two times a day] x [times] 5 days. Resident is aware of new order and agrees. It should be noted that urinalysis results were received 6 days after the specimen was sent to the laboratory. e. On 4/11/23 at 5:43 PM, the note documented that resident 357 had a UTI and no signs and symptoms of the infection were noted. f. On 4/12/23 at 1:01 AM, the note documented, Resident reports burning with urination and frequency at times, encouraged and consuming thickened liquids without issues, resident has yellow urine without odor, vital signs stable. g. On 4/12/23 at 6:50 PM, the note documented that resident 357 did not have any complaints of dysuria or frequency of urination. h. On 4/12/23 at 11:40 PM, the note documented that resident 357 had complaints of burning with urination. i. On 4/13/23 at 11:05 PM, the note documented that resident 357 had reported mild burning with urination at times, no frequency, encouraged fluids. j. On 4/15/23 at 3:23 AM, the note documented that resident 357 had no signs and symptoms of infection. k. On 4/16/23 at 6:19 PM, the note documented that resident 357 had no signs and symptoms of infection. l. On 4/17/23 at 7:25 PM, the note documented that resident 357 had no signs and symptoms of infection. m. On 4/21/23 at 6:38 PM, the note documented that resident 357 had no signs and symptoms of infection. On 4/3/23, the physician ordered a UA with C & S for resident 357. On 4/10/23, the UA abnormal findings were positive for nitrites, trace WBC esterase, and many bacteria. The C & S documented Klebsiella pneumoniae greater than 100,000 forming units per milliliter was identified. The sensitivity report documented that the organism was susceptible to Nitrofurantoin antibiotics. Resident 357's April MAR documented that the Macrobid (Nitrofurantoin) antibiotic was administered from 4/11/23 to 4/15/23 with 10 total doses administered. On 4/10/23, resident 357's had a care plan intitiated for an acute infection of a UTI. Interventions included to administer antibiotics as ordered, alert charting daily until 3 days after the stop of antibiotics, and assess for signs and symptoms of infection. The care plan was resolved on 4/17/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews and it was determined, for 1 of 80 sample residents, that the facility did not ensure necessary respiratory care consistent with professional standards of practices. Specifically, a resident did not have timely oxygen tubing changes for infection control measures. Resident identifiers: 209. Findings include: The following observations were made of residents and their oxygen tubing throughout the facility. a. On 3/28/23 at 10:12 AM, resident 209 was observed to have a nasal cannula attached to an oxygen concentrator, however no date was listed on the tubing or tubing bag. b. On 4/17/23 at 10:06 AM, Resident 209 no date marked on tubing no bag present on oxygen concentrator. c. On 4/24/23 at 10:58 AM, room [ROOM NUMBER]-1 and 247-2 no date marked on tubing no bag present on oxygen concentrator. d. On 4/24/23 at 10:59 AM, room [ROOM NUMBER]-1 and 244-2 no date marked on tubing no bag present on oxygen concentrator. e. On 4/24/23 at 11:14 AM, room [ROOM NUMBER]-1 no date marked on tubing, bag present on oxygen concentrator with date 4/12/23. f. On 4/24/23 at 11:15 AM, Resident 209 no date marked on tubing, bag present on oxygen concentrator with date 4/12/23. On 4/18/23 at 3:14 PM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated that she thought residents' oxygen tubing was changed weekly, and as needed, by the nursing staff or the Certified Nursing Assistants (CNAs) either Saturday night or early Sunday morning throughout facility. RN 5 stated that some staff were dating the tubing bags instead of the tubing. On 4/20/23 at 1:33 PM, an interview with Director of Nursing (DON) 3 was conducted. DON 3 stated that oxygen tubing should be changed weekly, on Saturday nights or early Sunday mornings. DON 3 stated that the CNA coordinator oversaw the oxygen tubing changes. DON 3 stated that oxygen tubing was supposed to be labeled with tape with change date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 51 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included unspecified dementia, type 2 diabetes mellitus, cervicalgia, major depressive disorder, dysthymic disorder, hypertension, gastro-esophageal reflux disease, anxiety disorder, insomnia, and post-traumatic stress disorder. On 3/29/23, resident 51's medical records were reviewed. On 2/10/23, resident 51's Quarterly Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 00, which would indicate that resident 51 was severely cognitively impaired. The assessment documented that resident 51 did not hallucinate but did have delusions. Review of resident 51's care plans revealed a care area for had impaired cognitive function/dementia or impaired thought processes related to confusion and impulsiveness. The care plan was initiated on 6/22/23. Interventions identified on the care plan were to administer medications as ordered, and monitor for side effects and effectiveness; ask yes/no questions in order to determine the resident's needs; communicate with the resident regarding their capabilities and needs; use the resident's preferred name; identify self at each interaction; face the resident when speaking; reduce any distractions; and provide the resident with necessary cues, reorient and supervise as needed. On 3/30/23 11:33 AM, an interview was conducted with LPN 3. LPN 3 stated there was a lot of behaviors on the dementia unit. LPN 3 stated that she asked to be on the dementia unit full time for continuity of care, because they have a lot of agency staff at the facility. LPN 3 stated that resident 51 liked to cuss you out, real feisty when you need to change her. LPN 3 stated that resident 51 had slapped others on the arm when she was aggravated and pushed other resident's wheelchair. LPN 3 stated that it usually started out with what the fuck are you looking out. LPN 3 stated that she just keeps an eye on resident 51 and makes sure her needs were met and engage with her. LPN 3 stated that this morning she bumped resident 51's wheelchair on accident, and resident 51 yelled at her. LPN 3 stated that resident 51 then she apologized. LPN 3 stated that if resident 51's in the mood, communication will work. LPN 3 stated she was not provided training on dementia care by the facility, but she was a dementia care specialist and was trained in another state. On 3/30/23 an interview was conducted with Staff Member (SM) 17. SM 17 stated that resident 51 did not like anyone taking care of her. SM 17 stated that resident 51 called the staff bad names and used profanities such as fucking bitch, idiots, stupid, and mother fucker. SM 17 stated that resident 51 called the other residents these names also. SM 17 stated that resident 51 hits, scratches, and yells at the other residents. Even if you try to be nice to her she is very aggressive. SM 17 stated that resident 51 was worse now in the last 3 months. SM 17 stated that when resident 51 behaved like this with other resident they separated her right away. SM 17 stated that resident 51 would get mad with the staff and does not want to be touched or changed. It's hard to take care of her. SM 17 stated that they usually only had 2 CNAs on the dementia unit. I don't know why they don't put 3 CNAs back here; these residents need a lot of help and attention. At night they only have 1 CNA for the entire unit. SM 17 stated that it was difficult to take care of all the residents, they needed more than 2 staff, and that they do the best they can. SM 17 stated that you need to be very alert that these patients don't fight, don't fall, that they are clothed and not walking around naked. SM 17 stated that sometimes resident 51 would walk around naked. On 3/30/23 an interview was conducted with SM 16. SM 16 stated that resident 51 was very verbal and physically abusive. SM 16 stated that when they attempt to provide incontinence care, 99% of the time resident 51 refused. She will refuse cares all day and every day. SM 16 stated that she used different distraction techniques to get resident 51 to agree with incontinence care or showering. SM 16 stated that sometimes this worked and other times she still refused and would scratch the staff. SM 16 stated that they tried to put her next to other residents that were more alert. Otherwise, she will grab something or get upset easily. SM 16 stated that resident 51 would call others bad names and use profanities a lot. SM 16 stated that resident 51 would call others a nasty pig and would get irritated if someone touched her. She doesn't like to be touched. SM 16 stated that resident 51 would hit when touched even by accident. SM 16 stated that resident 51 would calm down and be compliant with her. SM 16 stated that when there were altercations with resident 51, they take her aside and get her coffee, which she liked. We can deal with her. SM 16 stated that they usually had 2 aides in the dementia unit, and that was not enough especially with resident behaviors. SM 16 stated that showers do not get done because when they have resident behaviors, they cannot watch the resident and shower them. SM 16 stated that the dementia patients were like kids, they need love, attention, and care. SM 16 stated that the facility had not provided training for dementia. On 4/24/23 a follow-up interview was conducted with SM 16. SM 16 stated that she had not received any training related to dementia care. SM 16 stated that she had not received any instructions or guidance on how to treat resident 51's dementia behaviors. SM 16 stated that when she arrived resident 51's room smelled, and she was covered in urine and feces. SM 16 stated that she encouraged resident 51 to shower and showed her that she had feces on her. SM 16 stated that she started by putting water on her legs first and resident 51 responded that it felt good. SM 16 stated that she continued and afterwards resident 51 had said that the shower felt good. SM 16 stated that initially resident 51 had a very bad mouth. SM 16 stated that resident 51 liked her environment a certain way and liked to keep everything around her. SM 16 stated that resident 51 only wanted to wear certain clothes and she would request them. SM 16 stated that residents with dementia can be rude and mean to you. SM 16 stated that some facilities teach you how to manage residents with dementia and how to encourage them. SM 16 stated that this facility did not provide any training on dementia or how to care for those residents. [Cross-refer F600 and F689] Based on observation, interview wand record review it was determined, for 3 of 80 sampled residents, that the facility did not provide a resident who displayed or was diagnosed with dementia appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Specifically, a resident was not provided a psychiatric evaluation after the physician ordered one. In addition, the resident's behaviors escalated without interventions. Resident identifiers: 51, 54, and 79. Findings include: 1. Resident 79 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included major depressive disorder, anxiety disorder, altered mental status, history of traumatic brain injury (TBI) and intertrochanteric fracture of right femur. On 3/29/23 at 10:30 AM, a phone interview was conducted with resident 79's family member. Resident 79's family member stated that he wanted resident 79 discharged to a TBI speciality facility. Resident 79's family member stated that the facility was unable to care for resident 79's with a TBI. Resident 79's family member stated the facility was warehousing residents and unable to care for the residents. Resident 79's medical record was reviewed 3/28/23 through 4/25/23. A care plan dated 10/13/22 and revised on 2/24/23 revealed that resident 79 was verbally and physically abusive. The goal was to have resident express himself without becoming aggressive or abusive and to seek out staff when was angry or overwhelmed. Some interventions included 15 minute checks, moved rooms, redirect to a quiet play away from others if become upset and redirect resident from others who he is upset with. A care plan dated 9/27/22 and updated on 12/28/22 revealed resident 79 required long term care services related to diagnoses of dementia, altered mental status and major depression. The goals were that resident would adjust to daily activities in the long term care facility and resident 79 would receive services as necessary to meet his individualized needs. Interventions were to engage assistance from ombudsman as need; monitor for adjustment to long term care; provide care conference for residents and family; and review plan of care quarterly and as needed. On 10/11/22 at 3:13 PM, an order administration note revealed resident 79 had aggressive behaviors and stated I want to leave. On 10/23/22 at 8:37 PM, a nursing progress note revealed resident 79 complained to staff that another resident was a pedophile and needed to be taken to jail. Staff were unable to redirect. Resident 79 continued to yell at the other resident, stating he was going to brake one of the other residents arms, and he had probably been beating them. Resident 79 started making aggressive gestures towards the other resident. On 10/27/22 at 3:54 PM, a nursing progress note revealed resident 79 experienced behavioral change and aggressive outburst. Resident 79 pushed his way out of the secured unit when someone entered. Multiple staff members were trying to deescalate with no results. Resident 79 had stated he was leaving. Resident 79 went to an outside glass door and was violently pushing on it trying to release the magnetic strip. The nurse stated to resident that they did not want him hurt. Resident 79 replied I don't give a fuck. Resident 79 went to his room and shut the door. Staff heard loud bang so staff entered resident 79's room to see him trying to break the window. Resident 79 had tears in his eyes and grabbed a phone charging cord, wrapped each end of the cord around his hands and stated he was ready to go. Resident 79 seamed to calm down and nurse went to nurses station when resident 79 proceeded to greet another resident hostilely stating this man here was the problem and should be in jail. Nurse was able to get resident 79 to walk away and calm down. On 10/27/22 at 11:05 PM, a social services note revealed a referral was sent to another long term care facility. On 10/28/22 at 4:10 PM, a social service note revealed a referral was sent to another long term care facility. On 10/31/22 at 4:07 PM, an orders administration note revealed resident 79 had 3 mood swings noted. On 11/1/22 at 2:39 PM, a nursing progress note revealed that resident 79 experienced a behavioral outburst stating that he was leaving. Resident 79 was able to get out of the unit when another resident was entering the secured unit. Resident 79 made threats to break windows and doors but no physical violence was noted today. The nurse sat and talked with resident 79 in the front lobby for over an hour with no results. Resident 79 expressed gratitude to the nurse for listening and stated I don't like being tricked. On 11/4/22 at 1:45 AM, an orders administration note revealed resident 79 verbalized anxiety every shift. On 11/5/22 at 4:57 PM, a nursing progress note revealed resident 79 was banging on a window with plastic deodorant container. Resident 79 was re-directed but was depressed and tearful. Resident 79 needed to remain in locked unit. Nurse was able to sit, listen, and console. Resident 79 calmed down. On 11/9/22 at 11:33 AM, a nursing progress note revealed resident 79 hit another resident in the right arm. Resident 79 was screaming in the hallway and tried to run over nurse to get to the another resident. Resident 79 was assisted to the lounge area and placed on 15 minute checks. On 11/9/22 at 12:25 PM, a nursing progress note revealed resident 79 was aggressive toward staff, resident 79 was expressing frustration when he hit the lounge door and slammed door on nurse, nurse entered the lounge room and calmed resident down with the assistance of the administrator. On 11/9/22 at 1:06 PM, a social service note revealed a referral was sent to another long term care facility. On 11/12/22 at 3:41 PM, a nursing progress note revealed resident 79 slipped out of locked doors when another resident was coming into the secured unit. Staff intervened and brought resident 79 back into the secured unit. On 11/21/22 at 3:44 PM, a nursing progress note revealed that resident 79 had difficulty with communicating his needs and wants to staff and others. Resident 79 frequently used the wrong words and phrases. In the community, he would be unable to communicate with the general population and explain his medical needs with his doctor and pharmacy. The nurses concern was that resident 79 would easily get into a confrontation with the public because of his inability to communicate. At that time, resident 79 would be unable to hold a job or maintain a household. Resident 79 also had frequent confrontations with other residents thinking that they were criminals and ended many times in physical confrontation. On 11/22/22 at 5:10 PM, an order administration note revealed resident 79 was aggressive and impulsive behaviors noted throughout the day. On 11/25/22 at 2:15 PM, a nursing progress note revealed resident 79 was yelling aggressively and threatening physical violence toward another residents. Resident 79 required 30 minute redirection. On 11/27/22 at 6:18 PM, a nursing progress note revealed resident 79 had been irritated most of the day making comments to peers and trying to get off the unit. Resident self reported that he was hit in the face by a peer. On 11/28/22 at 3:27 PM, an orders administration note revealed resident had 2 mood swings. On 11/29/22 at 11:32 AM, an orders administration note revealed resident 79 was agitation and yelling at staff. On 12/2/22 at 8:22 AM, an orders administration note revealed that resident 79 showed signs of anxiety and agitation. On 12/2/22 at 11:52 AM, a Medical Director (MD) note revealed that resident 79 had dementia and had the ability to be aggressive. Resident 79 was his own power of attorney and needed a guardian. Resident 79's past medical history revealed a TBI from a car accident and communication deficits. Resident 79 had a psychiatric referral pending and needed TBI specialty follow up. On 12/2/22 at 5:35 PM, an orders administration note revealed that a behavior was noted in the morning. Resident 79 became agitated with another resident and was easily redirected with no further issues. On 12/8/22 at 2:52 PM, a nursing progress note revealed that resident 79 had increased confusion. On 12/12/22 at 7:16 PM, a nursing progress note revealed resident 79 had mood swings and aggressive behavior. On 12/13/22 at 11:21 PM, a nursing progress note revealed resident 79 had gradual cognition decline and was unable to express himself appropriately. Resident 79 spoke with provider and ordered urinalysis, culture, complete blood count, comprehensive metabolic panel, basil metabolic panel, thyroid, and vitamin D laboratory values. On 12/14/22 at 1:01 PM, an MDS note revealed resident 79 had mood swings, yelled and was physically or verbally aggressive with residents and staff. Resident 79 was at high risk for elopement according to staff. On 12/19/22 at 10:09 AM, a nursing progress note revealed resident 79 had increased confusion and spoke in word salad. Resident 79 became agitated when staff were not able to understand him. Resident 79 unplugged his larger flat screen television and carried it to the nurse's station and left it there. On 12/19/22 at 5:57 PM, a nursing progress note revealed resident 79 had extreme mood swings with intense yelling at staff, pushed a peer, repetitive vocals with a raised voice, and attempted to destroy property. The nurse attempted to reorient patient and it was unsuccessful. Physician ordered a one time dose of 0.5 milligrams (mg) of Haldol on top of scheduled Haldol. On 12/19/22 at 6:49 PM, a nursing progress note revealed resident 79 pushed another resident in the hallway. The nurse told resident 79 he could not initiate verbal or physical aggression toward others and needed to vocalize frustration to nurses. Resident 79 started yelling at the nurse I do notgive [sic] a shit you have done nothing. The physician was notified of the mood swings and resident was placed on 15 minute checks and 1 mg of Haldol. On 12/20/22 at 11:14 AM, a nursing progress note revealed resident 79 had increased behaviors and nurse was advocating for resident 79. Nurse stated that no pharmacological interventions are unsuccessful. [sic] Resident 79 was aggressive with repetitive vocals towards staff, elopement risk, and verbal assault toward peers. Resident 79 was administered Lexapro 10 mg daily. On 12/20/22 at 7:04 PM, a nursing progress note revealed that resident 79 showed increase of aggressiveness, various mood swings leading to verbal aggression towards staff and peers. Resident 79 called a nurse, bitch that doesn't do anything, fuck you, and I hate you. The nurse gave resident 79 five minute intervals and reapproached to redirect and nurse was unable to redirect. The Administrator was asked to speak with resident 79. Resident 79 initiated verbal aggression toward other residents. Resident 79 said fuck you, I hate the people here. The provider and abuse coordinator were notified and 15 minutes checks. On 12/21/22 at 4:33 PM, an event/alert charting revealed resident 79 was verbally aggressive with staff and other residents. On 12/22/22 at 5:10 AM, an event/alert charting revealed resident 79 was aggressive toward another resident. Resident 79 hit another resident. On 12/22/22 at 7:10 AM, a nursing progress note revealed resident 79 approached the nurses station and was became verbally aggressive and threatening the nurse. Resident became more verbally abusive and spit on nurse and desk. On 12/26/22 at 11:27 PM, a nursing progress note revealed resident 79 had been agitated all evening by yelling at staff, throwing cups and other small things at staff. Resident 79 was not listening to staff and was not redirectable. Resident 79 yelled and pulled another resident's hair. Resident 79 refused all interventions and staff continued to redirect. A short time later resident 79 started hitting another resident and the other resident started hitting back. On 12/27/22 at 7:12 PM, a nursing progress note revealed that resident 79 eloped and walked through the nurses station. Resident 79 repetitively yelled at staff and staff attempted to redirected with no success. On 12/29/22 at 1:21 PM, a nursing progress note revealed that resident 79 had behaviors, threatening to tear wall-mounted television off the wall. Staff intervened and tried to calm resident. Resident 79 stated he was feeling anxious. Resident 79 requested to talk with Administrator and Administration calmed resident. On 12/30/22 at 7:02 PM, a nursing progress note revealed resident 79 had aggressive behavior toward staff leading to repetitive raised vocals, attempted to elope, and attempted to destruct property. On 1/2/23 at 5:33 PM, a nursing progress note revealed Nurse overheard screaming and found the pt [patient] was walking out of hallway and yelled 'fuck you' and pt who received physical aggression from [resident 79] yelled 'fuck you too'. Pt then proceeded to shove other resident. Nurse separated both resident and advised physical aggression receiver and initiator to stay away from other resident while nurse spoke with both parties . On 1/2/23 at 5:34 PM, a nursing progress note revealed that resident 79 cut his own hair and forehead. On 1/2/23 at 8:40 PM, an orders administration note revealed resident 79 was administered Hydroxyzine 50 milligrams for anxiety. On 1/4/23 at 1:16 AM, a nursing progress note revealed the physician ordered to increase Lexapro dose from 10 mg to 20 mg daily. On 1/8/23 at 1:04 AM, an event/alert charting note revealed there was a resident to resident altercation. Resident 79 had an aggressive outburst during the day shift with another resident. Resident 79 had a female resident bothering him and he pushed her to the common area and told her not for you. On 1/8/23 at 12:43 PM, an orders administration note revealed Pt has had multiple discussions regarding another residents (female) who it [sic] bothering him, he is 'frustrated that he can not walk by and her not say something to him': Tired of being told he can not leave this place, He does not understand [NAME] [sic] he can't go to [another city] already' Had a nice conversation with resident, he was able to verbalize his feelings, and now is feeling much better, he is now calm, no other behaviors noted, since he was able to vent out his frustrations. On 1/9/23 at 8:09 PM, a physician's progress notes revealed resident 79 had been having increased episodes of aggression toward staff and others. Resident 79 has had increased agitation. On 1/10/23 at 4:30 PM, a nursing progress note revealed that admissions staff pulled nurse into the dining room who found resident supine grabbing onto another resident's arm and was covered in blood. On 1/10/23 at 5:32 PM, a social service note revealed a referral was sent to two long term care facilities. On 1/10/23 at 5:36 PM, a social service note revealed that resident 79 got in a physical altercation with another resident. On 1/13/23 at 11:21 AM, a physician's progress note revealed that resident 79 was involved in an altercation last night with another resident. On 1/17/23 at 5:39 PM, a social services note revealed there was a referral to be wait listed for a special program for TBI injuries. On 1/20/23 at 9:03 AM, a social services note revealed a referral was sent to another long term care facility for a transfer. On 2/1/23 at 6:58 PM, a nursing progress note revealed .Pt has short-term memory and long-term memory impairment requiring 24 hour supervision. Pt is exit-seeking and states 'I need to get out of this place' nurse provides distractionary [sic] actions, calm environment, and reassurance when these thoughts are expressed . On 2/5/23 at 1:29 PM, a nursing progress note revealed Resident returning from lunch in DR [dining room]. Walking down the hall. Another resident walked up to him and started hitting him. The other resident continued hitting, until nurse could get there, and separate the residents. This resident held the other residents' arms to prevent being hit further . On 2/10/23 at 11:19 AM, a social service progress note revealed Spoke to intake specialist at [local disability specialist] about application for this pt. received the application and will follow up with an additional paperwork that will be needed. On 2/24/23 at 12:58 PM, a social service progress note revealed a referral was sent to another long term care facility for transfer. On 2/27/23 at 11:32 AM, a social service progress note revealed the facility denied the referral. On 3/19/23 at 10:52 AM, a nursing progress note revealed Resident did well in day before afternoon, but had behaviors in afternoon. Verbally abusive, swearing at staff. Non-compliant with cares. On 3/19/23 at 11:47 AM, a nursing progress note revealed Resident had increasing violent behaviors. Throwing chairs, attempting to throw chair into nurses station. Verbally threatening staff. Call to MD. Order to send out for mental evaluation to [name of local] hospital. Contacted 911. Police escorted, medical transport arrived. Resident voluntarily went to hospital . On 3/19/23 at 2:55 PM, a nursing progress note revealed that resident 79 returned from ER with an order for Halperidol 0.5mg three times a day as needed for three days. This medication was already a scheduled medication for resident 79. The physician ordered to discontinue the order and add Ativan 0.5mg twice daily. Resident 79 continued to have outbursts and was argumentative. Able to re-direct with no further issues. On 3/19/23 at 5:36 PM, a nursing progress note revealed that resident 79 continued with behaviors upon return from hospital. Staff were unable to re-direct. Resident 79 was Inciting arguments, profanity and verbal aggression, threats toward staff. Resident stated to CNA 'Do you want me to spit on you? I will' the resident also stated to same CNA 'I will kill you.' Notified MD. Resident sent out via 'Blue sheet' [city] police department and EMT [emergency medical transport] transport, to [local hospital] for psych [psychiatric/mental evaluation. On 3/19/23 at 10:39 PM, a nursing progress note revealed Pt returned from [local] hospital ER at around 7:30 pm, blue sheet was cleared. Upon return pt was calm cooperative, took night medications. Pt came back with new orders. On 3/20/23 at 4:05 PM, a social service note revealed referrals were sent to multiple long term care facilities in the state. On 3/21/23 at 10:40 AM, a social service note revealed a quarterly note that resident 79 had several behavioral problems resulting in abuse allegations when he was first admitted . Staff were working with resident 79's and his behaviors had decreased significantly. Resident 79 seamed to get along better with other residents, and can be seen laughing and joking with others in the lobby area. The discharge planner was working with family to get resident 79 into a facility that specialized in TBI care. On 3/24/23 at 3:47 PM, a physician's progress note revealed a psychiatric IDT was the reason for the visit. The action was that it was inappropriate to have a gradual dose reduction due to active hallucinations. The physician ordered a psychiatric consult for schizophrenia diagnosis confirmation when able. On 3/24/23 at 3:47 PM, a social service note revealed that a referral was sent to local mental health company for a psychiatric consult to confirm schizophrenia diagnosis. It should be noted 12/2/22 the physician ordered a psychiatric evaluation to be done. On 3/24/23 at 9:59 PM, a nurses note revealed resident 79 had short-term and long-term memory impairments requiring 24-hour supervision. On 3/26/23 at 10:53 AM, a nursing progress note revealed resident 79 was alert with confusion. Resident 79 had increased frustration and agitation when not able to complete sentences or train of thought. On 3/28/23 at 10:45 AM, a social service note revealed the Department of Health and Human Services came to complete an assessment with resident 79 for TBI disability. Resident 79 refused to participate. On 3/28/23 resident 79 fell and sustained a right femur fracture. Resident 79 re-admitted to the facility on [DATE]. Resident 79 was admitted to a room outside of the secured unit. On 4/1/23 at 6:34 PM, an admission hourly charting note revealed that resident was alert and oriented but was unable to express his needs. Resident 79 spoke very few words and acted silly. Resident 79 was unaware of his situation. On 4/3/23 at 4:57 PM, a nursing progress note revealed that resident 79's family member called. The nurse informed family member that resident 79 had declined since fall and hit his head when he fell. On 4/9/23 at 2:01 PM, a nursing progress note revealed that resident 79 was trying to remove his wound dressing. Resident 79 seamed confused and oriented only to self. On 4/10/23 at 12:55 PM, a social service note revealed that there was a facility initiated transfer/IDT meeting due to facility not being able to meet the needs of the resident. Facility imitated transfer was arranged for resident to discharge to another facility in Price, Utah. Resident 79's family member was present at time of an IDT meeting.RA explained to the family that due to us not having a wander guard and [resident 79] being determined to not be a good candidate for memory care we are no longer unable to meet the residents needs. Family and [resident 79] were understanding of reasoning for transfer. They did mention concern that the progress of getting [resident 79] into the specialized TBI center in Salt Lake City would stop. RA and Discharge planner are going to coordinate with [name of facility] to ensure that the progress withcontinue [sic] as that is the end goal that family and [resident 79] given a copy of the paper work for facility transfer. On 4/11/23 at 1:22 PM, a physician discharge summary revealed that resident 79 would not be safe to go back to the memory care unit and he was a wander risk and required a wander guard which the facility did not have. Resident 79 would benefit going to a wander guard equipped facility for his safety. On 4/13/23 at 1:03 PM, a social service note revealed that resident 79 was notified of facility initiated discharge being canceled. A form titled Notice of Discharge dated 4/10/23 revealed that The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident. The discharge was to be effective 4/14/23. The discharge was necessary because the resident's welfare and the resident's need(s) could not be met, the facility attempted to meet the resident's needs, and the services available at the receiving facility to meet the resident's need(s). The form further revealed 2 signatures at the bottom of the form. On 4/12/23 at 11:11 AM, an interview was conducted with the RA. The RA stated there were two different ways to transfer to another facility. The RA stated if the facility was unable to care for the resident, like if there was no wander guard system. The RA stated she had heard there was a system at the facility but it was broken or not working. The RA stated the Cambridge unit was the locked memory care unit. The RA stated there were residents that needed to be monitored but not in the memory care unit. The RA stated if the resident's cognition was not low enough to need a locked unit, then the staff looked at their cognitive ability to determine if they qualify for the locked unit. The RA stated if a resident needed a different setting, then other facilities were contacted to determine who had a wander guard system. The RA stated the clinical team decided if they needed a wander guard. The RA stated she would rather notify families prior to calling other facilities. The RA stated if there was no guardianship and the resident was not cognitively intact, then she communicated with the resident. The RA stated she worked with the MD and the clinical team on what to do. The RA stated resident 79's discharge was a facility initiated by the facility. The RA stated resident 79 was in memory care unit, was on a higher cognitive function and hard time expressing himself. The RA stated resident 79 was able to have full conversations with him. The RA stated Administrator 4 and the discharge planner were working on getting resident 79 into a specialized TBI center. The RA stated since the facility did not have a wander guard system, then the facility was unable to meet his needs. The RA stated the the decision was made by the physician, clinical team and herself. The RA stated a facility with a wander guard system would be more appropriate for resident 79 over a memory care secured unit. The RA stated resident 79 would be better off surrounded by people who can converse with him because memory care residents had very low cognition. The RA stated resident 79 needed to be in a fa[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, recommendations to meet the social service needs were not followed up on. These included appropriate documentation; identification and investigation of potential abuse, potential neglect, injuries of unknown origin, behaviors and dignity. Resident identifiers: 2, 15, 44, 47, 51, 56, 74, 84, 86, 102 and 409. Findings include: 1. Resident 15 was admitted to the facility on [DATE] with diagnoses included diffuse sclerosis of the central nervous system, acute and subacute infective endocarditis, mild protein calorie malnutrition, psychoactive substance abuse, paroxysmal atrial fibrillation, acute systolic congestive heart failure, presence of cardiac pacemaker, and generalized anxiety disorder. Resident 15's medical record was reviewed from 3/28/23 through 4/25/23. On 4/29/22, a level II PASARR (Preadmission Screening and Resident Review) assessment was completed for resident 15. The assessment indicated that the evaluator's diagnostic impression was that resident 15 had major depressive disorder, recurrent, moderate; and generalized anxiety disorder. The assessment also indicated that [Resident 15] has had a long history of chaos and disruption in his life. His single mother was not very present in his life, he was partly raised by his aunt and grandparents, and he turned to drugs and alcohol during high school. [Resident 15] was unable to work consistently, had 'failed' relationships, was made to leave his last apartment, and when health and other issues hit he became homeless. [Resident 15] has resisted mental health treatment and has consistently turned to illegal drugs instead. He is seriously mentally ill for purposes of PASARR. The assessment listed the following: Recommendation for Specialized Services for mental illness treatment: It is recommended that [Resident 15] is encouraged to access mental health and substance abuse treatment as needed. Resident 15's medical record contained a psychosocial review dated 4/20/22, but no other social work notes. No indication of mental health and substance abuse treatment referrals could be located in resident 15's medical record. The Licensed Clinical Social Worker (LCSW ) consultant notes for December 2022 were reviewed. The consultant notes indicated that resident 15 needs a social history, quarterly note for October, and social service care plans. Resident's progress notes from October indicating a decline in mood and difficulty coping with 'past trauma', a referral was made for counseling. There should be follow up documentation in place regarding the outcome of the referral, the support resident is receiving, and how resident is currently doing. The LCSW consultant notes for February 2023 were reviewed. The consultant notes indicated the following: Resident 15 needs a social history, quarterly note that is past due for January, and social service care plans. Resident's progress notes from October indicating a decline in mood and difficulty coping with 'past trauma', a referral was made for counseling. There should be follow up documentation in place regarding the outcome of the referral, the support resident is receiving, and how resident is currently doing. This has been consistently called out in reports and no follow up documentation has been completed. The LCSW consultant notes for March 2023 were reviewed. The consultant notes indicated the following: Resident 15 needs a social history, quarterly note that is past due for January, and social service care plans. Resident's progress notes from October indicating a decline in mood and difficulty coping with 'past trauma', a referral was made for counseling. There should be follow up documentation in place regarding the outcome of the referral, the support resident is receiving, and how resident is currently doing. This has been consistently called out in reports and no follow up documentation has been completed. The LCSW also documented that Each resident should have a visit from RA and documentation of that visit within 48 hours of admit. This note should include where the resident was living and what their discharge plan is. Provision of ongoing emotional support to residents is documented in monthly notes. Monthly notes are the means by which we show how we are meeting each resident's psychosocial needs and Covid support related to isolation. At the time of the quarterly MDS (Minimum Data Set), a quarterly note should be completed by RA (Resident Advocate) . On 4/19/23 at 2:08 PM, an interview was conducted with a local county mental health LCSW. The local county mental health LCSW stated that she had not received a referral for services for resident 15. [Cross refer to F644] 2. Resident 84 was admitted to the facility on [DATE] with diagnoses that included liver cell carcinoma, chronic pain syndrome, chronic viral hepatitis C, anxiety, protein calorie malnutrition, and schizophrenia. The LCSW consultant notes for December 2022 were reviewed. The consultant notes indicated that Resident needs a social history and social service care plans. The LCSW consultant notes for February 2023 were reviewed. The consultant notes indicated that Resident needs a social history, quarterly note for February, and social service care plans. Resident has expressed thoughts of self harm and no follow up documentation has been completed around how resident is currently doing. The LCSW consultant notes for March 2023 were reviewed. The consultant notes indicated that Resident needs a social history, quarterly note for February, and social service care plans. Resident has expressed thoughts of self harm and no follow up documentation has been completed around how resident is currently doing. On 2/27 progress note indicates resident left AMA [against medical advice] and yet he is still at the facility, be sure to document follow up on this. 3. Resident 51 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included unspecified dementia, type 2 diabetes mellitus, cervicalgia, major depressive disorder, dysthymic disorder, hypertension, gastro-esophageal reflux disease, anxiety disorder, insomnia, and post-traumatic stress disorder. The LCSW consultant notes for December 2022 were reviewed. The consultant notes indicated that Resident needs a quarterly note/review for December . The LCSW consultant notes for February 2023 were reviewed. The consultant notes indicated that Resident is past due a quarterly note/review for February. Resident is triggering on the MDS for behaviors occurring daily and has some behavior documentation. Resident could be a good candidate for a behavior complex program. The LCSW consultant notes for March 2023 were reviewed. The consultant notes indicated that Resident is past due a quarterly note/review for February. Resident is triggering on the MDS for behaviors occurring daily and has some behavior documentation. Resident could be a good candidate for a behavior complex program. 4. Resident 102 was admitted to the facility on [DATE] and discharged from the facility on 3/29/23 with the following diagnoses that included but not limited to complete traumatic amputation of left great toe, superficial frost bite, difficulty in walking, unsteadiness, personality disorder, manic episode, traumatic stress disorder, and major depressive disorder. The LCSW consultant notes for March 2023 were reviewed. The consultant notes indicated that resident 102 had No SS [Social Services] Admit note, No SS Social History, No SS Discharge assessment. On 3/29/23, a social service note documented, pt to discharge today back to [name of previous home city and state] by train. Pt does not have a place to live and will be staying in a motel in [name of previous home city]. On 3/29/23, a discharge summary note stated resident 102 was admitted for 20 days at the facility while she healed form a toe amputation due to frostbite. It stated resident 102 had met the goals and was discharged from the facility on 3/29/23 at 6pm. It stated resident 102 was transported by facility staff to the bus station. [Cross refer to F624] 5. Resident 44 was admitted to the facility on [DATE] with diagnoses that included hypertension, coronary artery disease, and Alzheimer's disease. The LCSW consultant notes for December 2022 were reviewed. The consultant notes indicated that Resident needs a social history, current progress note and discharge planning assessment. The LCSW consultant notes for February 2023 were reviewed. The consultant notes indicated that Resident needs a social history, quarterly note/review, and discharge planning assessment. The LCSW consultant notes for March 2023 were reviewed. The consultant notes indicated that Resident needs a social history, quarterly note/review, and discharge planning assessment. No documentation completed since October. 6. Resident 56 was admitted on [DATE] with diagnoses that included hip fracture and dementia. The LCSW consultant notes for December 2022 were reviewed. The consultant notes indicated that Resident needs an admit note, social history, discharge planning assessment, and social service care plans. The LCSW consultant notes for February 2023 were reviewed. The consultant notes indicated that Resident needs a quarterly assessment note that is past due for January, social history, and social service care plans. No significant social service documentation since admission in October. The LCSW consultant notes for March 2023 were reviewed. The consultant notes indicated that Resident was laying on his bed with only a brief on and no sign of any clothes from which he may have disrobed. There were no sheets on his bed and the air mattress was deflated and had no mattress. Some may seen (sic) this as a case of neglect. 7. Resident 47 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included vascular dementia with mood and behavior disturbance, and diabetes mellitus. The LCSW consultant notes for December 2022 were reviewed. The consultant notes indicated that Resident needs a social history, quarterly note for November, and social service care plans. The LCSW consultant notes for February 2023 were reviewed. The consultant notes indicated that Resident needs a social history, quarterly note for February, and social service care plans. Referrals have been sent to multiple facilities without any documented reason as to why these are being sent. The LCSW consultant notes for March 2023 were reviewed. The consultant notes indicated that Resident needs a social history and social service care plans . [Name of resident] was in bed with him? Any follow up after incident? He was also victim of physical abuse? Any follow up? [Cross refer to F600 and F610] 8. The March 2023 notes also revealed that the LCSW identified the following concerns: a. Resident 44: SSW (Social Service Worker) did observe him being ushered out of a female resident's room by the female resident. She told SSW that she always has to get him out of her room. This female has a roommate that was only wearing her brief. This happened in close proximity to nurses station but was ignored by nursing staff and is a dignity issue needing immediate attention. b. Resident 74 was 'found face down, with her head on the bar of her side table, laying next to the left side of her bed. Assessed pt. [patient] Redness and swelling on forehead, upper nose. Redness to knees, belly, arms and breasts. Neuros [neurological checks] started. vitals stable. notified MD [medical doctor] and husband. Redness was no longer present by lunch time.' Was this situation investigated as possibly resulting from abuse? Was any cause determined? c. room [ROOM NUMBER] There was an extremely pungent smell of feces in the room indicating the resident likely needed to be changed. [Cross refer to F923] d. Resident 86: 'nurse found a bruise on the left side of forehead that is healing.' There is no documentation of any follow up investigation for this injury of unknown origin. In addition, the LCSW identified that the resident was receiving 3 antipsychotic medications without an appropriate diagnosis and stated Usage such as this could lead to claims that these antipsychotics are being used as chemical restraints. [Cross refer to F758] e. Resident 409: Progress notes indicates family was concerned because they were notified that she was 'moved' - aka discharged . Discharge summary says she was discharged to [name of facility] due to 'altercations'? Who was informed or what preparation was made r/t [related to] discharge. There is not 30 day notice in chart. Why is [name of facility] better able to manage her behavior? It is unclear why she was not first put on a behavior complex program. Lots of questions about this. [Cross refer to F660] f. Resident 2: Resident will be transferring to [name of facility] on 3/29 due to aggressive behavior directed towards one specific resident. PT [patient] approves of transfer. Family notified. 'What preparation was made r/t discharge? How is [name of facility] better able to meet her needs? No 30 day discharge notice in chart. It is unclear why she was not first put on a behavior complex program. g. In the charts reviewed, several falls were noted. Why are residents sitting by themselves without tab alarms?. Why are residents not involved in activities including sensory activities rather than justSomething [sic] sitting in front of tv or wandering the halls or wandering into other resident rooms? The LCSW then provided some activity suggestions for residents with dementia. [Cross refer to F689 and F679] h. Three issues require immediate attention. 1. There are many falls and we recommend that a root cause analysis be done for each resident who has sustained falls. 2. The lack of any recreation activities and failure to engage residents in any type of activity is likely a large contributor to the behaviors exhibited. 3. There are many cases of resident to resident sexual abuse without any successful interventions to deter the abuse. Residents at risk need to be monitored more closely all of the time. It is likely that much of the wandering and sexual abuse is due to the lack of activities. [Cross refer to F600 and F679] On 4/5/23 the Social Service Worker (SSW) provided the following recommendations to the Chief Nursing Officer (CNO) via email: Patient (resident 47) is diagnosed with Vascular Dementia with mood disturbances and affective mood disorder. Social Worker interviewed patient with PHQ9 and GAD7 to determine if there is a missed need. At this time there are signs of needs not being met . The SSW did not provide any additional information to indicate which of resident 47's needs were not being met. The only recommendation that the SSW made for the resident was a medication evaluation, and keep the resident separated from another resident to avoid altercations. On 4/17/23 at 1:17 PM, an interview was conducted with the SSW. The SSW confirmed that he had made medication recommendations for the above residents. The SSW stated that he was licensed as an SSW, but was unaware that he could not make recommendations for medications as a limitation on the SSW license. The SSW stated that he had been coming to the facility twice a month to do resident screenings to identify any symptoms of anxiety and depression. The SSW stated that after he completed his screenings, he would provide the information to the RA, and make a note in the electronic medical record. On 4/19/23 at 2:00 PM, an interview was conducted with the RA. The RA stated that the LCSW consultant notes were sent by the LCSW to the Administrator and the RA, so she was aware of the LCSW recommendations, as well as what needed to be followed up on in the PASARR. The RA did not state why she had not followed up on the LCSW or PASARR recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident 209 was admitted on [DATE] with diagnoses which included weakness, cognitive communication deficit, paroxysmal atrial fibrillation, need for assistance with personal care, adjustment disorder with mixed anxiety and depressed mood, abnormal coagulation profile, and chronic kidney disease. Resident 209's medical record was reviewed from 3/28/23 through 4/25/23. According to physician's orders, resident 209 was to receive the following: a. Sertraline 200 milligrams (MG). Give 200 mg by mouth one time a day for Depression. The MAR for resident 209 revealed sertraline was not administered on 4/17/23. On 4/17/23 an interview with RN 3 at 9:17 AM stated sertraline 200 mg was not on medication cart and was unable to be administered at that time for resident 209. 7. Resident 50 was admitted on [DATE] with diagnoses which included fluency disorder following unspecified cerebrovascular disease, hemiplegia and hemiparesis affecting right dominant side, dysphagia, bipolar II disorder, type 2 diabetes mellitus (DM), impulse disorder, and major depressive disorder. Resident 50's medical record was reviewed from 3/28/23 through 4/25/23. According to physician's orders, resident 50 was to receive the following: a. Insulin glargine solution inject (Lantus) 11 unit subcutaneously one time a day for DM. b. Multiple vitamin one tablet by mouth one time day for supplementation. The MAR for resident 50 revealed the Multiple vitamin was not administered on 4/17/23. During the medication pass on 4/17/23, RN 3 was observed omitting resident 50's multiple vitamin tablet. RN 3 was observed to only administer 4 units of Lantus. An interview with RN 3 at 9:13 AM was conducted regarding resident 50. RN 3 stated that the multiple vitamin tablet and additional units of Lantus were unavailable either on the medication cart or in the medication storage room, so she was unable to administer them. On 4/17/23 at 11:49 AM a follow up interview with RN 3 regarding resident 50 was conducted. RN 3 stated she spoke with Nurse Practitioner (NP) 1 about the unavailable 7 units of Lantus and only administering 4 units. RN 3 stated NP 1 told her that the resident should be fine until the prescription arrived later that day from the pharmacy, and to administer the remaining dose once Lantus arrived. As of 3:15 PM on 4/17/23 surveyors were not made aware that pharmacy had supplied the remaining Lantus nor witnessed the administration of the seven remaining units. 8. Resident 8 was admitted on [DATE] with diagnoses which included Wernicke's encephalopathy, unspecified dementia with other behavioral disturbance, iron deficiency anemia, acquired absence of right left below knee, and personal history of other malignant neoplasm of large intestine. On 4/17/23 at 8:23 AM, Registered Nurse (RN) 3 was observed to prepare and administer medications to resident 8. On 4/17/23 Resident 8's medical record was reviewed for the reconciliation of medications. According to physician's orders, resident 8 was to receive pantoprazole sodium oral packet 40mg (milligrams) one time a day for medical management. During the medication pass, RN 3 was observed omitting pantoprazole sodium and this medication was not dispensed for resident 8. On 4/17/23 at 8:45 AM, an interview with RN 3 was conducted. RN 3 stated that the pantoprazole sodium was not on medication cart, and so she was unable to administer the medication at that time. On 4/18/23 at 3:07 PM, an interview was conducted with RN 5 she stated that if a medication was not available in the medication cart, she would contact the pharmacy. RN 5 stated if they requested the medication early enough, the pharmacy would bring it by evening time that same day. RN 5 stated she did not completely know the pharmacy process. RN 5 stated if they did not get the medication that same day, it would be here the next day. RN 5 stated that sometimes there were issues with getting a refill because of preauthorization issues. RN 5 stated the pharmacy would notify the Director of Nursing (DON) if there were preauthorization issues and they would work things out. RN 5 stated they have medications available in the STAT (as soon as possible) safe. RN 5 stated they kept important medication such as anti-depressants, anti-psychotics, antibiotics, and insulin in the STAT safe. On 4/19/23 at 1:32 PM, an interview with Chief Nursing Officer (CNO) was conducted. CNO stated they would directly call the pharmacy and ask for a STAT delivery. CNO confirmed they would want a STAT delivery for antibiotics, insulin, or anything that was going to cause harm to the resident if not administered. At 11:40 AM on 4/24/23, an interview was conducted with DON 3. DON 3 stated the nurses should call the pharmacy and notify them if a resident was out of medication. DON 3 stated that nurses should also notify the provider if a resident was out of a medication, and that both notifications should be documented in progress notes. DON 3 stated that they did have a STAT safe, but that agency staff did not have access to the STAT safe and would need to find a staff nurse or contact the DON to access the STAT safe. Based on interview and record review, it was determined, that the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, for 8 out of 80 sampled residents, resident medications were not administered as ordered by the physician due to the medications not being available by the pharmacy. Resident identifiers: 8, 32, 38, 50, 79, 86, 209, and 357. Findings included: 1. Resident 38 was admitted to the facility on [DATE] with the following diagnoses that included but not limited to Alzheimer's disease, type 2 diabetes mellitus, major depressive disorder, anxiety disorder, post-traumatic stress disorder, obsessive compulsive personality disorder and restless leg syndrome. Resident 38's medical records were reviewed on 4/5/23 The February 2023 Medication Administration Record (MAR) was reviewed: a. An order for Duloxetine 90 milligrams (mg) one time a day for depression was started on 10/1/22. The medication was marked as not given on 2/12/22 and stated to see progress notes b. An order for Tradjenta 5 mg once a day for diabetes was started on 10/1/22. The medication was marked as not given on 2/12/22 and stated to see progress notes c. An order for Levothyroxine 112 micrograms (mcg) once a day for hypothyroidism was started on 10/1/22. The medication was marked as not given on 2/28/23 and stated to see progress notes. d. An order for Diflucan 150 mg one time a day for a yeast infection was started on 2/23/23. The medication was marked as not given on 2/26, 2/27, and 2/28 and stated to see progress notes. The March 2023 MAR was reviewed: a. An order for Tradjenta 5 mg once a day for diabetes was started on 10/1/22. The medication was marked as not given on 3/1/23 and stated to see progress notes. b. An order for Potassium Chloride 10 mEq (milliequivalent) once every 48 hours for fluid removal was started on 3/6/23. The medication was marked as not given on 3/6 and stated to see progress notes c. An order for Fluoxetine 10 mg once a day for obsessive compulsive disorder was started on 10/1/22. The medication was marked as not given on 3/15/23. d. An order for Torsemide 20 mg once a day for fluid removal was started on 10/29/22. The medication was marked as not given on 3/21/23. The April 2023 MAR was reviewed: a. An order for Farxiga 10 mg once a day for diabetic management was started on 4/6/23. The medication was marked as not given on 4/10, 4/11, 4/16, 4/17, 4/18, 4/19, and 4/20. Resident 38's progress notes revealed the following medication entries: a. On 2/12/23 at 10:52 PM, Duloxetine and Tradjenta were not available b. On 2/28 at 9:48, Levothyroxine was not available. c. On 2/26, 2/27 and 2/28 Diflucan was not available d. On 3/1/23 at 9:13 PM, Tradjenta was not available. e. On 3/6/23 at 11:21 PM, Potassium Chloride was not available f. On 3/15/23 at 9:31 PM, Fluoxetine was not available. Staff was waiting on pharmacy to deliver it. g. On 3/21/23 at 10:36 AM, Torsemide was not given because they were two different tablets. h. On 4/10, 4/11, 4/16, 4/17, 4/18, 4/19, and 4/20, Farxiga was not available since staff was waiting for pharmacy to deliver it. On 4/18/23 at 3:07 PM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated that if a medication was not available in the medication cart, she contacted the pharmacy. RN 5 stated if the facility staff requested the medication early enough, the pharmacy delivered it the same day. RN 5 stated she did not know the complete pharmacy process. RN 5 stated if they did not get the medication that same day, then it was delivered the next day. RN 5 stated that sometimes there were issues with getting a refill because of preauthorization issues. RN 5 stated the pharmacy notified the DON if there were preauthorization issues and they worked things out. RN 5 stated they had medications available in the stat safe at the facility. RN 5 stated they kept important medication such as anti-depressants, anti-psychotics, antibiotics, and insulin in the stat safe. RN 5 stated if the medication was something a resident needed to take every day, it was in the stat safe. RN 5 stated she let the provider know that resident 38 medication was not available and was going to call the pharmacy. RN 5 stated she hoped resident 38's medication was there by tonight. On 4/19/23 at 10:28 AM, an interview was conducted with the Director in Training (DIT). The DIT stated if a medication was not available, then the nurse called the pharmacy. The DIT stated he was unsure how long it took the pharmacy to deliver the medication but stated they hoped it was here within a couple of hours of notifying the pharmacy. The DIT stated the medication card tells the nurses when they need to fax a refill over to the pharmacy. The DIT stated once they got down to a certain number of pills in the medication card, there was a section on the right-hand side that stated to reorder the medications. On 4/19/23 at 1:36 PM, an interview was conducted with the Director of Nursing (DON) 3. DON 3 stated that if a medication was ordered to be taken every day, then the resident needed to be getting it every day. The DON 3 stated they had not received a phone call from the pharmacy about resident 38's medication. The DON 3 stated they were not familiar with the preauthorization process. On 4/24/23 at 11:40 AM, a follow up interview was conducted with DON 3 and Chief Nursing Officer (CNO). DON 3 stated that nurses needed to call the pharmacy and notify the provider when a medication was not available and include a progress note in the resident's medical record. DON 3 stated there were 2 places staff needed to check before they document a medication was not available. DON 3 stated if an over-the-counter medication was not available, staff should be able to run to pharmacy and obtain it. DON 3 stated central supply ordered the over-the-counter medication. The CNO stated the order administration was not triggering on the 24-hour report for management to follow up on so they were unaware there were any issues. DON 3 stated they could not fix any issues they were not aware of. DON 3 stated they only became aware once staff notified them. 5. Resident 357 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, type 2 diabetes mellitus, alcoholic cirrhosis, hemiplegia and hemiparesis following a cerebral infarction, dysphagia, concussion, repeated falls, chronic kidney disease stage 3, hypertensive heart and chronic kidney disease, and hypomagnesemia. On 3/29/23, resident 357's medical records were reviewed. Resident 357's physician orders revealed the following: a. Salonpas-Hot External Patch to be applied to the upper back topically two times a day for back pain. The order was initiated on 4/3/23. b. ProctoCare-HC (hydrocortisone) internal cream 2.5 %, apply two times a day for hemorrhoids. The order was initiated on 3/29/23. c. Mucinex Oral Tablet Extended Release 600 milligram (mg), give 1 tablet by mouth every 12 hours for congestion. The order was initiated on 4/3/23. Review of resident 357's April Medication Administration Record (MAR) and Progress notes revealed the following: a. On 4/4/23, during the morning medication administration the MAR documented for the Salonpas to Hold/See Progress Notes. On 4/4/23 at 8:31 AM, the progress note documented Held until delivered. b. On 4/5/23, during the morning medication administration the MAR documented for the Salonpas Other/See Progress Notes. On 4/5/23 at 8:28 AM, the progress note documented that the Salonpas was ordered from the pharmacy. c. On 4/6/23, during the morning and evening medication administration the MAR documented for the Salonpas Other/See Progress Notes. On 4/6/23 at 12:23 PM, the progress note documented, Medication is not available. On 4/6/23 at 7:51 PM, the progress note documented, Not available. d. On 4/6/23, during the morning medication administration the MAR documented for the ProctoCare-HC Other/See Progress Notes. On 4/6/23 at 12:27 PM, the progress note documented, Medication is not available. e. On 4/7/23 at 8:00 PM, the MAR documented for the Mucinex Other/See Progress Notes. On 4/7/23 at 9:59 PM, the progress notes documented, Needs to be ordered. f. On 4/9/23, during the evening medication administration the MAR documented for the Salonpas Other/See Progress Notes. On 4/9/23 at 7:02 PM, the progress note documented, Was not one on. g. On 4/9/23, during the evening medication administration the MAR documented for the ProctoCare-HC Other/See Progress Notes. On 4/9/23 at 9:22 PM, the progress note documented, do not have. h. On 4/19/23, during the evening medication administration the MAR documented for the ProctoCare-HC Other/See Progress Notes. On 4/19/23 at 11:45 PM, the progress note documented, ordered. On 4/24/23 at 11:35 PM, an interview was conducted with the Director of Nursing (DON) 3 and the Chief Nursing Officer (CNO). The DON 3 stated that over the counter medication was ordered through the central supply. The DON stated that Salonpas should be available in central supply. The DON 3 stated that for over the counter medication, someone should be able to run to the pharmacy and obtain that medication. There is no reason that it should not be available. The DON 3 stated that she could not fix it if she was not made aware of the situation. 2. Resident 32 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right side dominant side, toxic encephalopathy, paroxysmal atrial fibrillation, paranoid schizophrenia, depression, anxiety, and cognitive communication deficit. Resident 32's medical record was reviewed from 3/28/23 through 4/25/23. Resident 32's physician's orders revealed the following: a. On 2/22/23 with a start date of 3/22/23 revealed Invega Trinza Intramuscular Suspension prefilled syringe 546mg/1.75ML. Inject 1.75 ml intramuscularly one time a day every 3 month(s) starting on 22nd for 1 day for behaviors. b. On 12/15/22 revealed, Cyanocobalamin Solution. Inject 1 milliliter intramuscularly one time a day every 1 month(s) starting 15th for 1 day(s) for Vitamin B12 Deficiency. Resident 32's progress notes revealed the following: a. On 2/15/23 at 6:03 PM, vitamin b injection unavailable given one time order to push order back until available. b. On 3/22/23 at 2:56 PM, Invega Trinza is not on hand. Pharmacy phoned and they will have to order the medication and it will be here tomorrow. On 4/25/23 at 8:47 AM, an interview was conducted with RN 6. RN 6 stated if a medication was not available but another resident had the medication, then she administered the other residents medication and then replaced it when the medication was delivered from the pharmacy. RN 6 stated resident 32 was out of Invega or Vitamin B12 but could not remember exactly which one. RN 6 stated that she contacted the pharmacy and it was delivered the next day. RN 6 stated the pharmacy delivered medications a few times a day. RN 6 stated if the resident was almost out of a mediation, then she removed the tab from the medication and faxed the tab to the pharmacy. RN 6 stated that sometimes the pharmacy did not refill medications immediately. On 4/13/23 at 11:14 AM, an interview was conducted with the CNO. The CNO stated if the information was not in the medical record, then the facility did not have it. 3. Resident 86 was admitted to the facility on [DATE] with diagnoses which included dementia, mild protein-calorie malnutrition, anxiety, depression, and nicotine dependence. Resident 86's pharmacy reviews were reviewed. Resident 86 did not have a pharmacy review completed for January 2023. On 4/13/23 at 11:14 AM, an interview was conducted with CNO and the Regional Nurse. The CNO stated if it's not there, we don't have it. The Regional Nurse provided a pharmacy binder and stated that she had recreated the pharmacy book because they could not find one and that was all the information she had on pharmacy reviews. 4. Resident 79 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, major depressive disorder, anxiety, altered mental status, insomnia, personal history of traumatic brain injury, and history of thrombosis and embolism. Resident 79's medical record was reviewed 3/28/23 through 4/25/23. Resident 79's physician's order dated 3/19/23 revealed Ativan 0.5mg by mouth twice a day for agitation and aggression. Resident 79's Orders- Administration notes revealed: a. On 3/20/23 at 10:02 AM, revealed Ativan 0.5mg was not available to administer because Waiting to receive from pharmacy. b. On 3/20/23 at 7:34 PM revealed Ativan 0.5mg was not available to administer because Waiting for pharmacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 80 was admitted on [DATE] with diagnoses that included neurocognitive disorder with lewy bodies, history of falling, muscle weakness, unsteadiness on feet, need for assistance with personal care, difficulty in walking, cognitive communication deficit, hallucinations, delusional disorders, schizophrenia, osteoarthritis, gastro-esophageal reflux disease without esophagitis, insomnia, anxiety disorder, and altered mental status. Resident 80's medical record was reviewed from 3/28/23 through 4/25/23. Resident 80 ' s medication orders were reviewed. The following orders were prescribed: QUEtiapine Fumarate Tablet 100 MG Give 1 tablet by mouth three times a day for behaviors, hallucinations related to SCHIZOPHRENIA, UNSPECIFIED (F20.9) Pharmacy Active 11/3/2022 20:00 3/30/2023 TraZODone HCL tablet 50 mg Give 50 mg by mouth at bedtime for mood stabilization related to ANXIETY DISORDER, UNSPECIFIED. Ordered 1/4/2023. TraZODone HCl tablet 50 mg Give 1 tablet by mouth every 12 hours as needed for agitation and restlessness related to ANXIETY DISORDER, UNSPECIFIED until 5/31/2023. Ordered 4/4/2023. This order was written for a period of longer than 14 days without physician documentation to indicate a need for an extended order. There were no physician notes or other progress notes with documented indications for increasing dosage of this psychotropic medication. In addition, Resident 80's PASSAR II does not indicate that Resident 80 has schizophrenia, nor do any hospital notes from prior to Resident 80's admission to the facility. The Facility H&P indicates that Resident 80 was admitted with a Quetiapine prescription for dementia with behaviors. Schizophrenia was added as a diagnosis on 3/14/23. Based on interview and record review it was determined, for 4 out of 80 sampled residents, that the facility did not ensure that residents who used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record; residents who used psychotropic drugs received a gradual dose reduction and behavioral interventions, unless clinically contraindicated; and residents who had as needed (PRN) orders for psychotropic drugs were limited to 14 days unless the physician documented in the medical records a rationale to extend the duration of use and specified that duration of use. Specifically, residents were prescribed antipsychotic medications for the treatment of dementia, and a resident's antidepressant PRN order did not have a documented rationale to extend the medication past 14 days. Resident identifiers: 51, 54, 80, and 86. Findings included: 1. Resident 51 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included unspecified dementia, type 2 diabetes mellitus, cervicalgia, major depressive disorder, dysthymic disorder, hypertension, gastro-esophageal reflux disease, anxiety disorder, insomnia, and post-traumatic stress disorder. On 3/29/23, resident 51's medical records were reviewed. On 2/10/23, resident 51's Quarterly Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 00, which would indicate that resident 51 was severely cognitively impaired. The assessment documented that resident 51 did not have hallucinations but did have delusions. On 10/10/22, resident 51's physician ordered Olanzapine Tablet 5 mg, give 2 tablets by mouth one time a day for behaviors related to dementia. Review of the Nursing 2022 Drug Handbook documented that Olanzapine was a second generation (atypical) antipsychotic and was indicated for the treatment of Schizophrenia and psychosis, acute agitation, depression, or mania in bipolar I disorder. The handbook documented under contraindications that the medication had a Black Box Warning and Elderly patients with dementia-related psychosis treated with antipsychotics are at increased risk for death. Antipsychotics aren't approved for treatment of patients with dementia-related psychosis. Wolters Kluwer. Nursing 2022 Drug Handbook, 42 Edition, Philadelphia, PA, Wolters Kluwer, 2022, pp. 39. In June 2022, the licensed pharmacist documented that resident 51 was on Olanzapine, Divalproex, Sertraline, and Trazodone with a primary diagnosis of dementia, but this is not a labeled indication for these medications. This was discussed with the medical director and it was agreed that symptoms of psychosis, depression, and mood instability are common behavioral symptoms of dementia, and that these medications can be useful in treating these symptoms. It was agreed that the benefits of treatment currently outweigh any potential risks, and no recommendations are needed at this time. The pharmacist recommendation did not contain documentation by the physician that indicated agreement with the recommendation nor a signature from the physician. Review of resident 51's care plan revealed a care area of used psychotropic medications Olanzapine related to dementia with behaviors. The care plan was initiated on 4/7/22. The interventions identified were to monitor/document/report PRN any adverse reactions of PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia, EPS (extrapyramidal side effects)(shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, and behavior symptoms not usual to the person. On 4/13/23 at 11:14 AM, the Chief Nursing Officer (CNO) stated that if they did not have the documentation then it did not exist. On 4/13/23 at 1:52 PM, an interview was conducted with the Regional Nurse Consultant (RNC) 2. The RNC 2 stated that antipsychotics would be indicated for schizophrenia. The RNC stated that they usually had the physician document a risk vs. benefit and had some documentation for a rationale for an off label use of a antipsychotic for dementia. It should be noted that no documentation could be found that the physician documented a rationale for an off label use of the antipsychotic medication. 3. Resident 86 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, mild protein-calorie malnutrition, anxiety disorder, depression, and history of falling. On 4/5/23 the Social Service Worker (SSW) provided the following recommendations to the Chief Nursing Officer (CNO) via email: Patient (resident 86) is diagnosed with unspecified dementia with psychotic behaviors.Recommended interventions for patient are an increase to quetiapine furmate (sic) or introduce Trazadone (sic), Cognitive Behavioral Therapy to help manage behaviors, modify environment to reduce triggers. Resident 86's medical record was reviewed on 3/28/23 through 4/25/23. A physician's order dated 4/8/23 revealed Quetiapine Fumarate Oral tablet 50 mg. Give 50 milligrams by mouth one time a day related to unspecified dementia, psychotic disturbance, mood disturbance, anxiety and depression. A physician's order dated 4/7/23 revealed Trazodone HCl oral tablet 50 milligrams. Give 50 milligrams by mouth at bedtime related to insomnia. On 4/20/23 10:50 AM, an interview was conducted with Hospice Registered Nurse (RN) 1. Hospice RN 1 stated there had not been any changes to resident 86's medications for over a month. Hospice RN 1 stated all medications changes should be through the hospice physician. Hospice RN 1 stated medication changes without Hospice being notified had happened before. Hospice RN 1 stated that resident 86 had been extra drowsy recently. Hospice RN 1 stated that the family had asked the hospice nurse about resident 86 being extra drowsy. Hospice RN 1 stated that she had asked the nurse on 4/11/23 about why resident 86 was drowsy. Hospice RN 1 stated that the nurse reported to Hospice RN 1 that there had not been any medication changes. Hospice RN 1 stated she was unable to see a list of medication through the electronic medical record. Hospice RN 1 stated that hospice should be managing the medications. Hospice RN 1 stated if there was a medication change, it needed to go through the hospice physician. Hospice RN 1 stated Hospice pays for medications, so not sure where medication orders were not through Hospice. Hospice RN 1 stated that resident 86's Trazodone was discontinued in December 2022 right before she was admitted to hospice. Hospice RN 1 stated resident 86's family member were concerned the facility was sedating her. Hospice RN 1 stated hospice evaluated resident 86's medications and resident 86 was able to she was able to walk, eat and the family was happy. Hospice RN 1 stated the facility should contact hospice prior to any medication changes. On 4/20/23 12:07 PM, an interview was conducted with DON 3. DON 3 stated nurses should be calling hospice nurse or on call hospice agency with medication changes. DON 3 stated the hospice contact information was in the resident's care plan. DON 3 stated that the facility physician was unable to make medication changes for residents receiving hospice services. DON 3 stated the hospice agency physician should be changing medications. DON 3 stated anything going on with the resident, staff should notify the hospice company. DON 3 stated Hospice RN 1 had just brought up to her there were medication changes that hospice RN 1 had not been notified of. DON 3 stated she asked Hospice RN 1 to go through resident 86's medications so they could discuss what medications were changed. DON 3 stated on 4/7/23, the Medical Director gave her a list of orders that she input into the electronic medical record. DON 3 stated she was not sure why the Medical Director had her change medications. On 4/20/23 at 12:49 PM, a follow-up interview was conducted with DON 3. DON 3 stated that the house physician was able to provide order, but the new orders should be discussed with hospice regarding order prior to being ordered. 2. Resident 54 was initially admitted to the facility on [DATE] and again on 12/28/22 with diagnoses which include unspecified dementia, type 2 diabetes mellitus, obesity, acute respiratory failure, schizophrenia, sepsis, systolic heart failure, chronic kidney disease, hypertensive heart and chronic kidney disease with heart failure, metabolic encephalopathy, conversion disorder with seizures, unspecified convulsions, hyperlipidemia, hypotension, insomnia, and muscle weakness. Resident 54's medical record was reviewed from 3/28/23 through 4/25/23. On 4/5//23 the Social Service Worker (SSW) provided the following recommendations to the Chief Nursing Officer (CNO) via email: Patient (resident 54) is diagnosed with Unspecified Dementia with Psychotic Disturbances and mood disturbances. Patient has been exhibiting aggressive behavior due to above dx (diagnosis). Intervention recommendations for patient are anti-psychotic medication evaluation. Patient is currently taking Quetiapine Furmate (sic) 50 ml (milliliters) (sic) increase may be necessary. Electro Convulsive Therapy is recommended if behaviors cannot be maintained with medication evaluation . Resident 54's physician orders were reviewed. The orders revealed that on 4/7/23, resident 54's Quetiapine had been increased to 75 milligrams twice daily for a diagnosis of dementia. Per the Federal Drug Administration, Quetiapine has a black box warning indicating that Seroquel (quetiapine fumarate) is not approved for the treatment of patients with dementia-related psychosis. (https://www.accessdata.fda.gov/drugsatfda_docs/label/2008/022047s013lbl.pdf) On 4/17/23 at 1:17 PM, an interview was conducted with the SSW. The SSW confirmed that he had made medication recommendations for the above residents. The SSW stated that he was licensed as an SSW, but was unaware that he could not make recommendations for medications as a limitation on the SSW license. The SSW stated that he has been coming to the facility twice a month to do resident screenings to identify any symptoms of anxiety and depression. The SSW stated that after he completed his screenings, he would provide the information to the RA, and make a note in the electronic medical record. The SSW stated that he did not have any experience with Electro Convulsive Therapy but had written on paper on it for school and thought it might be worth a try for resident 54. On 4/25/23 at 8:45 AM, an interview was conducted with the facility Medical Director (MD). The MD stated that Director of Nursing (DON) 1 had approached him and that someone, maybe State recommended some changes for a few residents' medications, so I signed off on them. the recommendations I got were for 3 or 4 patients and the recommendations seemed reasonable. The MD confirmed that the medication changes were for residents 54 and 86. The MD then stated that I try to avoid Seroquel in dementia residents. There needs to be an indication for Seroquel.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview it was determined that for 3 of 80 sampled residents the facility did not ensure that its medication error rates were not five percent or greater. Observations of 30 opportunities on 4/17/23 revealed five medication errors which resulted in a 16.67% medication error rate. Specifically, medications were omitted, wrong doses were given, and one medication was administered against manufacturer's specifications. Resident identifiers: 8, 50, 209. Finding include: 1. Resident 8 was admitted on [DATE] with diagnoses which included Wernicke's encephalopathy, unspecified dementia with other behavioral disturbance, iron deficiency anemia, acquired absence of right left below knee, and personal history of other malignant neoplasm of large intestine. On 4/17/23 at 8:23 AM, Registered Nurse (RN) 3 was observed to prepare and administer medications to resident 8. On 4/17/23 Resident 8's medical record was reviewed for the reconciliation of medications. According to physician's orders, resident 8 was to receive pantoprazole sodium oral packet 40mg (milligrams) one time a day for medical management. During the medication pass, RN 3 was observed omitting pantoprazole sodium and this medication was not dispensed for resident 8. On 4/17/23 at 8:45 AM, an interview with RN 3 was conducted. RN 3 stated that the pantoprazole sodium was not on medication cart, and so she was unable to administer the medication at that time. 2. Resident 50 was admitted on [DATE] with diagnoses which included fluency disorder following unspecified cerebrovascular disease, hemiplegia and hemiparesis affecting right dominant side, dysphagia, bipolar II disorder, type 2 diabetes mellitus (DM), impulse disorder, and major depressive disorder. On 4/17/23 at 8:50 AM, RN 3 was observed to prepare and administer medications to resident 50. On 4/17/23 Resident 50's medical record was reviewed for the reconciliation of medications. According to physician's orders, resident 50 was to receive the following: a. Insulin glargine solution inject (Lantus) 11 units subcutaneously one time a day for DM. b. Multiple vitamin one tablet by mouth one time day for supplementation. During the medication pass, RN 3 was observed omitting resident 50's multiple vitamin tablet. RN 3 was observed to administer vitamin D 5,000 units and only 4 units of Lantus. No order for vitamin D could be located in resident 50's physician orders. An interview with RN 3 at 9:13 AM was conducted regarding resident 50. RN 3 stated that the multiple vitamin tablet and additional units of Lantus were unavailable either on the medication cart or in the medication storage room, so she was unable to administer them. On 4/17/23 at 11:49 AM a follow up interview with RN 3 regarding resident 50 was conducted. RN 3 stated she spoke with Nurse Practitioner (NP) 1 about the unavailable 7 units of Lantus and only administering 4 units. RN 3 stated NP 1 told her that the resident should be fine until the prescription arrived later that day from the pharmacy, and to administer the remaining dose once Lantus arrived. As of 3:15 PM on 4/17/23 surveyors were not made aware that pharmacy had supplied the remaining Lantus nor witnessed the administration of the seven remaining units. 3. Resident 209 was admitted on [DATE] with diagnoses which included weakness, cognitive communication deficit, paroxysmal atrial fibrillation, need for assistance with personal care, adjustment disorder with mixed anxiety and depressed mood, abnormal coagulation profile, and chronic kidney disease. On 4/17/23 at 9:17 AM, RN 3 was observed to prepare and administer medications to resident 209. On 4/17/23 Resident 209's medical record was reviewed for the reconciliation of medications. According to physician's orders, resident 209 was to receive 20 milliequivalents (mEq) of potassium chloride extended release (ER) via an oral tablet once daily. During the medication pass, RN 3 was observed asking resident 209 if she would like her potassium tablet to be split in half. Resident 209 agreed. RN 3 broke the tablet in half and administered to resident 209. RN 3 was not observed to check manufacturer guidelines regarding splitting the extended release tablets in half. An interview on 4/17/23 at 11:49 AM with RN 3 was conducted. RN 3 was asked why she split resident 209's potassium in half. RN 3 stated with her experience the patient would not take pills that were too large and would only take pills if they were smaller. RN 3 stated she should have followed up with the provider and suggested that the potassium supplement be ordered in a liquid or something that the resident is able to swallow and tolerate since the medication was in an extended release form.

Based on observation, interview, and record review it was determined that the facility did not provide food and drink that is palatable, attractive, and at a safe and appetizing temperature. Specifically, the facility served cold and late meals to residents. Resident identifiers: 14, 22, 23, 32, 34, 35, 79, 84, 85, 96, and 357. Findings include: 1. On 3/28/23 at 10:30 AM, an interview was conducted with Resident 14. Resident 14 complained of cold and late food. Resident 14 stated that, It takes them a long time to come in and assist with feeding and by the time they come in the food is cold. 2. On 3/28/23 at 12:23 PM, an interview was conducted with Resident 22. Resident 22 complained of cold and late food. Resident 22 stated that, The food is sometimes cold. 3. On 3/29/23 at 9:32 AM, an interview was conducted with Resident 23. Resident 23 complained of cold and late food. 4. On 3/28/23 at 1:00 PM, an interview was conducted with resident 32. Resident 32 stated she did not like the food. Resident 32 had an Minimum Data Set progress note dated 1/20/23 at 6:00 PM which revealed, .[resident 32] did state in her interview that she doesn't like and doesn't eat our facility's food. [Resident 32] stated she ordered takeout and will order groceries and keep in the fridge . 5. On 3/29/23 at 9:32 AM, an interview was conducted with Resident 34. Resident 34 complained of cold and late food. Resident 34 stated that sometimes the food served was so poor, she was not sure what was being served. 6. On 3/28/23 at 11:27 AM, an interview was conducted with Resident 35. Resident 35 complained of cold and late food. 7. On 3/29/23 at 10:24 AM, an interview was conducted with Resident 79. Resident 79 complained of cold and late food. Resident 79 stated that he did not like the food served. 8. On 3/28/23 at 9:31 AM, an interview was conducted with Resident 84. Resident 84 complained of cold and late food. Resident 84 stated that he followed a vegetarian diet and had told staff this, but despite this, he continued to receive meat and fish on his meal trays. 9. On 3/28/23 at 9:58 AM, an interview was conducted with Resident 85. Resident 85 complained of cold and late food. Resident 85 also stated that the food was barely edible, was gross, had a poor flavor, and had a strange texture. 10. On 3/29/23 at 9:19 AM, an interview was conducted with Resident 96. Resident 96 complained of cold and late food. Resident 96 stated that the food served was not always cooked all the way and was served cold. Resident 96 stated that his family would bring him in food because the facility did not cook the food right. 11. On 4/12/23 at 11:09 AM, an interview was conducted with Resident 357. Resident 357 complained of cold and late food. 12. Resident council notes were reviewed and included the following entries as concerns voiced by the residents: a. 5/27/22: . food is bland . b. 10/27/22: . Hall trays are being passed late, Res (resident) getting meals cold. The presentation of meals is bad . Food delivered cold . c. 11/30/22: . Meals not hot . d. 12/26/22: . Trays . Main dining . Snacks . Noodles not cooked . Potatoes too hard . Staff willingness to help in kitchen when asking for an alternative meal or snacks . Finding a solution for cold meals, staff not passing trays out when kitchen staff deliver carts . e: 1/23/23: . Trays, CNAS (Certified Nursing Assistants) or staff not helping cut foods or open drinks . milk is sour sometimes . ice cream is melted by the time it gets to residents .meals are cold . They want more variety of foods. f. 2/22/23: . CNAs not helping residents open containers or cut up food . Hydration . g. 3/22/23: . Meats not being cooked in the middle . The resident council notes documented that the residents repeatedly had the same concerns with food quality. The resident council notes did not indicate what interventions and/or solutions were put into place after the resident council meeting. On 4/24/23, an interview was conducted with the Kitchen Aide (KA). The KA stated that the kitchen followed up on complaints from residents about cold food and late trays. The KA stated that the kitchen had done everything they could on the kitchen side of things to ensure that food was out in a timely fashion. The KA stated that at one point management would help pass meal trays, but the KA was unsure if this was still happening. The KA stated that kitchen staff had no control of when the trays would get delivered once the meal carts were delivered to the different units in the facility. [Cross refer to F565]

Based on interview and record review, the facility did not conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility assessment must address or include both the number of residents and facility's resident capacity; the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that were present within that population; the staff competencies that were necessary to provide the level and types of care needed for the resident population; the physical environment, equipment, services, and other physical plan considerations that were necessary to care for this population; and any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including but not limited to, activities and food and nutrition services. Specifically, the facility did not have an accurate facility assessment that included all of the above. Findings include: On 3/28/23, the facility assessment was requested. Director of Nursing (DON) 1 provided a form titled Facility Assessment Report for February 2022 to January 2023 on 3/29/23. There were graphs for the resident age, payer type, admission day of the week and discharge day of the week. There were percentages for the days of the week that admissions and discharges happened. There was a graph and average numbers for resident diagnoses, treatments. There was a graph with Activities of Daily living (ADL) support and a RUG IV Distribution graph. The average daily census of 95 was listed. There was no additional information provided for the facility assessment. On 4/20/23 at 11:30 AM, an interview was conducted with Administrator (Admin) 2. Admin 2 was shown the assessment. Admin 2 stated there was a new facility assessment completed during the survey. Admin 2 stated he did not have additional information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 4/17/23 at 11:04 AM, an observation was made of Licensed Practical Nurse (LPN) 1. LPN 1 was observed to leave the nurses' cart with the computer screen open to residents' protective health information (PHI), which was visible to anyone that passed by. On 4/17/23 from 11:40 to 11:42 AM, an observation was made of LPN 1 leaving the nurses' cart unattended while the computer still displayed resident information. The nurse was observed to go into a resident's room to give them medication and then was observed to walk back to the nurse's cart. On 4/17/23 at 12:43 PM, an interview was conducted with LPN 1. LPN 1 stated she locked her screen and made sure any personal patient information was covered when she walked away from her computer. LPN 1 stated patient information needed to be kept confidential to ensure patient privacy. LPN 1 stated she made sure no one was standing behind her while she had resident information pulled up on her computer so resident's information was kept confidential. On 4/19/23 at 1:36 PM, an interview was conducted with Director of Nursing (DON) 3. DON 3 stated they have had in-services with the nurses on locking their cart when they walk away from it. DON 3 stated the nurses needed to lock the computer screen to make sure patient information was kept confidential. DON 3 stated they expected their staff to keep all resident information private. 5. Resident 51 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included unspecified dementia, type 2 diabetes mellitus, cervicalgia, major depressive disorder, dysthymic disorder, hypertension, gastro-esophageal reflux disease, anxiety disorder, insomnia, and post-traumatic stress disorder. On 3/29/23, resident 51's medical records were reviewed. Review of resident 51's progress notes revealed the following: a. On 10/4/22 at 4:13 PM, the progress note documented, Pt [patient] became irritated and began cussing and directing her anger towards [resident 460's name omitted]. b. On 2/7/23 at 2:31 PM, the progress note documented, 1440 [2:40 PM]- [resident 47's name omitted],resident, came to the nurse's station and alerted SN [skilled nurse] that a Resident had a fall. SN followed [resident 47's name omitted] to the kitchen area where [resident 51] was found lying on her right side on the floor next to her rolling walker. She was [NAME] [sic], oriented X [times] 2, and complained of back pain. She stated that she hit her head and this was confirmed by [resident 47's name omitted] who witnessed it. Based on observation, interview and record review it was determined that the facility did not maintain confidential medical records in accordance with accepted professional standards and practices. The facility did not maintain records that were complete, accurate, readily accessible and systematically organized. Specifically, the resident medical record information was not maintained in their medical records, other resident's names were used in nursing progress notes, and observations were made of resident's identifiable information accessible to other residents and visitors. Resident identifiers: 32, 44, 47, 51, 53, 62, 79, 83, and 409. Findings include: 1. Resident 32 was admitted [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction, toxic encephalopathy, paranoid schizophrenia and generalized anxiety. Resident 32's nursing progress note dated 11/23/22 at 7:00 AM revealed, .[resident 32] was verbally abusive towards her roommate [name removed] .Agency nurse added that [name removed] did not respond and was calm . 2. Resident 409 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, altered mental status, muscle weakness and cognitive communication deficit. Resident 409's medical record was reviewed from 3/28/23 through 4/25/23. On 1/4/23, a nurses note for resident 409 indicated that Resident was seen getting punched by another resident, [resident 44], in the back of the head and the face over the R (right) oribital area. The progress note listed resident 44's first and last name in resident 409's medical record. 3. Resident 47 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included diabetes mellitus and vascular dementia wtih behavior and mood disturbance. Resident 47's medical record was reviewed from 3/28/23 through 4/25/23. On 4/2/22, a progress note for resident 47 identified resident 79 by his first and last name. On 7/20/22, a progress note for resident 47 identified resident 62 by his first and last name. On 8/24/22, a progress note for resident 47 identified residents 83 and 53 by their first and last names.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not establish an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. Resident identifiers: 7, 35, and 77. Findings include: 1. Resident 35 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included fibromyalgia, dysphagia, protein calorie malnutrition, cognitive social or emotional deficit, anxiety disorder, major depressive disorder, adult failure to thrive scoliosis, dysarthria, chronic pain and hypertension. On 2/4/2023, the following nursing progress notes were documented in Resident 35 ' s Electronic Medical Record (EMR): a. Resident has been more confused this shift, and not drinking as much fluids as should (sic). Staff have been encouraging fluids and asking for assistance. MD ordered 1000mLs (milliliters) normal saline IV (intravenous) bolus for hydration and confusion. b. Received NS (normal saline) bolus via IV from previous shift, RN (Registered Nurse) went to go disconnect from IV and noticed [resident 35] was flushed and her breathing was very effortful, vital signs taken and temp was 101.7, respirations were 12. Tylenol was given. Contacted MD who ordered CBC [Complete Blood Count], CMP [Complete Metabolic Panel] , CRP [C-reactive Protein], BNP [B-type Natriuretic Peptide], and CXR [Chest X-ray]. all labs collected except for CRP. [resident 35] moved and butterfly came out before able to get lab. second attempt was tried and was unsuccessful. [Name of lab company] called on obtained labs, and [name of xray company] contacted for CXR (chest x-ray). upon reassessment temp was 98.7. On 2/4/2023, Resident 35 was prescribed the following: Doxycycline Hyclate Oral Tablet 100 MG. Give 100 mg by mouth one time only for infection for 1 day. On 4/18/2023, an interview was conducted with the facility's physician (MD). The MD stated that it was not normal to prescribe 1 dose of doxycycline, and that he would personally not order 1 dose of doxycycline, he would typically prescribe a 7 day treatment. The MD stated that since this incident occurred on a Saturday, an on call provider (MD2) would have been responsible. The MD stated that the weekend on call provider may have thought that Resident 35 had an infection, and that he may have later seen the order and discontinued it after realizing it was not an infection. The MD also stated that a nurse may have entered the order for Doxycycline incorrectly into the Electronic Medical Record. On 4/18/2023, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON pulled up secure messages from 2/4/2023 between a facility nurse and the on call physician. The message from the on call physician stated Sepsis Vs Pneumonia. Let ' s order 1 dose of doxycycline empirically. 3. Resident 7 was initially admitted to the facility on [DATE] and again on 4/7/23 with diagnoses which included cerebral palsy, asthma, type 2 diabetes mellitus, systemic lupus, chronic respiratory failure, muscle weakness, cognitive communication deficit, hypertensive heart and chronic kidney disease without heart failure, open wound of abdominal wall, major depressive disorder, polyneuropathy, chronic kidney disease, ileostomy status, low back pain, hyperlipidemia, sleep apnea, and neuromuscular dysfunction of bladder. Resident 7's Electronic Medical Record was reviewed. A progress note from 12/6/22 at 4:07 PM stated, resident has been more confused today. MD [medical director] notified, new order for UA [urinalysis] . A lab report titled Urinalysis, Routine was reviewed. The report revealed that the urine sample was collected on 12/6/22 and the results of the urinalysis were reported on 12/7/22. The urinalysis revealed that resident 7's WBC (white blood cell) esterase, occult blood, and WBC levels were indicated as Abnormal. A progress note from 12/7/22 at 1:38 PM stated, new order for Bactrim 1 tab BID [twice daily] x 10 days, flush PICC Q [every] shift with 10 ml [milliliters] NS [normal saline]. Resident 7's Medication Administration Record (MAR) from December of 2022 was reviewed. The MAR revealed that resident 7 had an order that stated, Bactrim DS Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet orally two times a day for UTI for 10 days, start date 12/7/2022 2000 [8:00 PM]. The MAR revealed that resident 7 received each dose as ordered until the antibiotic course was completed on 12/17/22. A lab report titled, Urine Culture, Routine was reviewed. The report revealed that the urine sample was collected on 12/6/22 and the results were reported on 12/14/22. The urine culture revealed that the organism was indicated as resistant to trimethoprim/sulfamethoxazole. On 4/19/23 at 10:01 AM an interview with the Director of Nursing (DON) and the Chief Nursing Officer (CNO) was conducted. The DON and CNO confirmed that resident 7 was placed on Bactrim (sulfamethoxazole-trimethoprim) from 12/7/22 to 12/17/22 for a UTI. The DON and CNO confirmed that resident 7's lab report indicated that the organism was resistant to Bactrim. The DON and CNO confirmed that resident 7 should not have been given Bactrim since the organism was resistant to that antibiotic. 2. Resident 77 was admitted to the facility on [DATE] with diagnoses which included multiple sclerosis, Parkinson's disease, cirrhosis of liver, hypertension, pain in legs, edema, history of UTI, and anxiety disorder. On 3/28/23 at 1:32 PM, an interview was conducted with resident 77. Resident 77 stated that she was currently receiving antibiotics for a UTI. Resident 77 pointed to a left peripherally inserted central catheter (PICC) line. Resident 77 stated that when she urinated it hurt. On 3/28/23, resident 77's medical records were reviewed. Review of resident 77's physician orders revealed the following: a. Collect urine sample for urinalysis (UA) with culture and sensitivity (C & S) one time only for UTI symptoms. The order was initiated on 3/15/23. b. Bactrim DS Tablet 800-160 milligram (mg) (Sulfamethoxazole-Trimethoprim), give 1 tablet by mouth every 12 hours for bacterial infection, UTI for 7 days. The order was initiated on 3/15/23 and discontinued on 3/22/23. c. Zosyn Intravenous Solution Reconstituted 3.375 (3-0.375) gram (gm) (Piperacillin Sodium-Tazobactam Sodium), use 3.375 mg intravenously (IV) every 6 hours for UTI for 7 Days. The order was initiated on 3/20/23 with and discontinued on 3/27/23. On 3/15/23, the UA documented the following abnormal results turbid appearance, [NAME] Blood Cells (WBC) esterase 500, small amt. occult blood, WBC greater than (>) 100, Red Blood Cells (RBC) 6-10, Epithelial cells >15, mucus threads 1+, rare bacteria. The urine culture documented Corynebacterium Striatum group >100,000. The report did not contain a susceptibility report. Review of the facility Policy/Procedure - Infection Prevention for Antibiotic Stewardship documented that the purpose of the Antibiotic Stewardship Program was to monitor the use of antibiotics. The policy further stated, When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. The policy was adopted on 09/2017. On 4/24/23 at 9:02 AM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated that sometimes the C & S results were quick but sometimes she would have to follow up with a call to the laboratory for the results. RN 5 stated that if the C & S was completed they would fax the results or the preliminary results to the facility. RN 5 stated that once they obtained the lab results they would send them to the provider to see if the antibiotic was appropriate to treat the bacterial infection. On 4/24/23 at 11:35 AM, an interview was conducted with the Director of Nursing (DON) 3 and the Chief Nursing Officer (CNO). The DON 3 stated that the urine C & S took 2-3 days for results, and the laboratory would fax the results. The DON 3 stated that the nurse should notify the physician of the results, so that they could choose the correct antibiotic to treat the organism. [Cross-refer F690]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, the facility did not ensure that each resident's medical record included documentation that indicated that the resident or resident's representative was provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunizations; and that the resident either received the influenza and pneumococcal immunizations or did not receive the influenza and pneumococcal immunizations due to medical contraindications or refusal. Specifically, 4 of 5 sampled residents, did not have documentation within the residents' medical record regarding the residents' pneumococcal and influenza consent status or education of the benefits and potential risks associated with the immunization. Resident identifiers: 68, 78, 84, and 357. Findings included: 1. Resident 68 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, traumatic brain injury, and major depressive disorder. On 4/25/23, resident 68's medical record was reviewed. A review of the immunization section of the medial record revealed no documentation regarding resident 68's influenza immunization status for the 2022 season. An immunization record dated 12/21/22 documented resident 68 was overdue for the influenza immunization since his last documented dose in January of 2021. A consent/refusal or education regarding the influenza immunization was not provided or located in resident 68's medical record. 2. Resident 78 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia, hallucinations, major depressive disorder, insomnia, and chronic respiratory failure. On 4/25/23, Resident 78 medical record was reviewed. A review of the immunization section of the medial record revealed no documentation regarding resident 78's current influenza and pneumococcal vaccines. An immunization record dated 3/28/23 documented resident 78 was overdue for the influenza vaccine and was past the minimum due date of 4/13/23 for the pneumococcal vaccine. A consent/refusal or education regarding the pneumococcal and influenza immunizations were not provided or located in resident 78's medical record. 3. Resident 84 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder, liver cell carcinoma, anxiety disorder, and visual disturbances. On 4/25/23, Resident 84's medical record was reviewed. A review of the immunization section of the medial record revealed no documentation regarding resident 84's current influenza and pneumococcal vaccines. An immunization record dated 11/11/22 documented resident 84 was overdue for the influenza immunization since his last documented dose in September of 2021 and was overdue for his pneumococcal booster. A consent/refusal or education regarding the pneumococcal and influenza immunizations were not provided or located in resident 84's medical record. 4. Resident 357 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, type 2 diabetes mellitus, alcoholic cirrhosis of liver without ascites, and chronic kidney disease stage 3. On 4/25/23, Resident 357's medical record was reviewed. A review of the immunization section of the medial record revealed no documentation regarding resident 357's current influenza and pneumococcal vaccines. An immunization history dated 3/28/23 documented resident 357 was overdue for the influenza immunization since her last documented dose in November of 2020 and was overdue for her pneumococcal vaccine. A consent/refusal or education regarding the pneumococcal and influenza immunizations were not provided or located in resident 357's medical record. On 4/25/23 at 11:17 AM, an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated residents were offered the immunizations upon admit and every season as indicated. The CNO stated there was a form residents filled out for consent or denial of the immunizations and it should be located their chart. The CNO stated he was unable to locate the documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, the facility did not ensure the resident's medical record included documentation that indicated, at a minimum, the following: that the resident or resident representative was provided education regarding the benefits and potential risks associated with Coronavirus Disease - 2019 (COVID-19) vaccine; each dose of COVID-19 vaccine administered to the resident; or if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. Specifically, 5 of 5 sampled residents, the facility did not keep documentation within the residents' medical record regarding the residents' COVID-19 vaccination refusal, acceptance or education of the benefits and potential risks associated with COVID-19 vaccination. Resident identifiers: 68, 77, 78, 84, and 357. Findings included: 1. Resident 68 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, traumatic brain injury, and major depressive disorder. On 4/25/23, Resident 68's medical record was reviewed. A review of the immunization section of the medial record revealed no documentation regarding resident 68's COVID-19 immunization status. An immunization record dated 12/21/22 documented resident 68 was overdue for the COVID-19 vaccine. A consent/refusal or education regarding the COVID-19 vaccination or booster was not provided or located in resident 68's medical record. A COVID-19 resident vaccination list provided by the facility documented resident 68 had not received the COVID-19 vaccine. 2. Resident 77 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, anxiety disorder, and multiple sclerosis. On 4/25/23, Resident 77's medical record was reviewed. A review of the immunization section of the medial record revealed no documentation regarding resident 77's COVID-19 immunization status. An immunization record dated 3/28/23 documented resident 77 was overdue for the COVID-19 vaccine. A consent/refusal or education regarding the COVID-19 vaccination or booster was not provided or located in resident 77's medical record. A COVID-19 resident vaccination list provided by the facility documented resident 77 had not received the COVID-19 vaccine. 3. Resident 78 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia, hallucinations, major depressive disorder, insomnia, and chronic respiratory failure. On 4/25/23, Resident 78 medical record was reviewed. A review of the immunization section of the medial record revealed no documentation regarding resident 78's COVID-19 immunization status. An immunization record dated 3/28/23 documented resident 78 was overdue for the COVID-19 vaccine. A consent/refusal or education regarding the COVID-19 vaccination or booster was not provided or located in resident 78's medical record. A COVID-19 resident vaccination list provided by the facility documented resident 78 had not received the COVID-19 vaccine. 4. Resident 84 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder, liver cell carcinoma, anxiety disorder, and visual disturbances. On 4/25/23, Resident 84's medical record was reviewed. A review of the immunization section of the medial record revealed no documentation regarding resident 84's COVID-19 immunization status. An immunization record dated 11/11/22 documented resident 84 was overdue for the COVID-19 vaccine. A consent/refusal or education regarding the COVID-19 vaccination or booster was not provided or located in resident 84's medical record. A COVID-19 resident vaccination list provided by the facility, documented resident 84 had not received the COVID-19 vaccine. 5. Resident 357 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, type 2 diabetes mellitus, alcoholic cirrhosis of liver without ascites, and chronic kidney disease stage 3. On 4/25/23, Resident 357's medical record was reviewed. A review of the immunization section of the medial record revealed no documentation regarding resident 357's COVID-19 immunization status. An immunization history dated 3/28/23 documented resident 357 was overdue for the COVID-19 vaccine. A consent/refusal or education regarding the COVID-19 vaccination or booster was not provided or located in resident 357's medical record. A COVID-19 resident vaccination list provided by the facility, documented resident 357 had not received the COVID-19 vaccine. On 4/25/23 at 11:17 AM, an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated their policy was to offer the COVID-19 vaccine upon admission. The CNO stated there was a consent form that needed to be filled out to indicate if a resident refused or accepted the vaccine. The CNO stated he was unable to locate the consent forms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** [Cross refer to F565] 3. Resident 84 was admitted to the facility on [DATE] with diagnoses which included polyneuropathy, protein-calorie malnutrition, liver cell carcinoma, chronic viral hepatitis C, schizophrenia, anxiety disorder, fibromyalgia, hypertension, chronic pain syndrome, and hearing loss. On 3/28/23 at 10:03 AM an observation of resident 84's bathroom was made. In the bathroom, there were two white towels around the base of the toilet with what appeared to be large urine stains on the towels. The bathroom had a strong urine odor. Based on observation, interview and record review it was determined that the facility did not have adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two. Specifically, the facility had odors throughout the survey. Resident identifier: 84. Findings include: 1. On 3/28/23 at 9:03 AM, a strong odor of urine was noted at the nurse's station on the Heritage unit next to the scale. On 3/28/23 at 9:15 AM, an observation was made in the Colonial unit. There was a strong urine odor. On 3/28/23 at 11:16 AM, an observation was made of the Cambridge Unit. The unit was noted to have a foul odor. On 3/28/23 at 1:32 PM, an observation was made in the Colonial unit. There was a strong urine odor. On 3/28/23 at 2:35 PM, an observation was made in the hallway to the Cambridge and Colonial units. There was a strong bowel movement odor. On 3/31/23 at 8:25 PM, an observation was made of the Colonial unit. There was a strong bowel movement odor through the hallway. On 3/31/23 at 10:11 PM, an observation was made outside room [ROOM NUMBER]. There was a strong urine and cigarette odor from the room into the hallway. On 4/1/23 at 5:18 PM, a strong odor of urine was noted in room [ROOM NUMBER]. On 4/3/23 at 7:15 AM, a strong odor of urine was noted upon entrance to the facility and continued from the front reception area all the way down the hallway leading to the Heritage unit. On 4/11/23 at 10:49 AM, an observation was made of in the hallway of the Cambridge unit. The hallway outside rooms 212, 213 and 216 had a body odor/musty odor that penetrated through the hallway. On 4/17/23 at 2:44 PM, an observation was made in the hallway outside room [ROOM NUMBER] and 130. There was a strong urine and bowel movement odor through the hallway. On 4/17/23 at 3:24 PM, an observation was made in the living room in the Cambridge unit. There was a strong bowel movement odor. There were 2 residents in the living room. On 4/17/23 at 3:36 PM, an observation was made in the Cambridge unit. There was a strong bowel movement odor in the hallway. On 4/17/23 an interview was conducted with SM 18. SM 18 stated the living room smelled like something. SM 18 stated right now it smells like poop. SM 18 stated that one of the residents in the living room was changed before lunch which was at noon and the resident let staff know if he had an incontinent episode, so he did not have a smell. SM 18 stated the other resident has been changed 45 minutes prior. SM 18 stated the odor was probably in the carpet. On 4/20/23 at 1:55 PM an observation was made of no ventilation in the woman's restroom near the front reception area. On 4/20/23 at 2:30 PM, an observation was made of the Rehab nurses station and Heritage hallway. There was a strong bowel movement odor. On 4/24/23 at 1:37 PM, an observation was made in the Cambridge unit. There was a strong bowel movement odor at the nurses station. On 4/24/23, an interview was conducted with Staff Member (SM) 16. SM 16 stated that residents were not changed during the night shift, if there was an incontinent episode. SM 16 stated residents had pads on their beds that were wet and sheets were wet. SM 16 stated there were a lot of beds with brown stains on the mattresses because residents were left soiled for long periods of time. On 4/20/23 at 3:13 PM an interview was conducted with Administrator (ADM) 2. Admin 2 stated he would talk to the Corporate Director of Maintenance to assess the ventilation in the facility. On 4/25/23 at 9:44 AM an interview was conducted with Assistant Director of Maintenance (ADOM) regarding ventilation issues. ADOM stated he knows about an issue in laundry and is currently looking for a belt that will fit the unit. ADOM stated he has not been informed about ventilation issues in the front bathrooms. If he is ever made aware of an issue, he would put a work order in to address the issue. They are in the process of putting up some fresheners in the building and just got started in the Colonial unit putting those up. ADOM stated if it is a Heating, Ventilation, Air Conditioning (HVAC) issue they look for the issues. 2. On 4/20/23 an observation was made of a mattress in room [ROOM NUMBER]. There was a large brown stain and cracks in the mattress. An interview was conducted with SM 23. SM 23 stated What do you think it is? SM 23 stated there were more mattresses with brown stains in the facility. On 4/20/23 at 2:49 PM, an interview was conducted with Administrator (Admin) 2. Admin 2 stated that was a stain needed to be sanitized but there were cracks in the mattress. Admin 2 stated he was going to be looking for another mattress or would be ordering a mattress. Admin 2 stated if he was unable to get a new mattress in, then they would find a way to sanitize the mattress until a new mattress was available. Admin 2 stated he found another mattress with the same discoloration. Admin 2 stated the green mattress was discolored to brown in the area of the abdomen and buttocks area was from cleaning. Admin 2 stated the cracks in the mattress were a bigger concern. Admin 2 stated he was aware of the strong bowel movement odor at the Rehab nurses station and the Heritage hallway.

Based on interview and record review, the facility did not provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property; and dementia management and resident abuse prevention. Resident identifier: 79. Findings include: On 3/30/23 an interview was conducted with Staff Member (SM 28). SM 28 stated when residents started to escalate, they moved them away from each other. SM 28 stated she tried to use de-escalation tactics to diffuse the situation. SM 28 stated they had not gotten formal abuse training and stated they had been learning about abuse while on the job. The SM 28 stated if a resident was combative, she was told to put them in their room and leave them there. The SM 28 stated most of the residents in the dementia unit only got agitated when they were being transferred or getting dressed. The SM 28 stated they had seen residents get verbal with each other and stated they said the F and B words a lot. The SM 28 stated the residents in the locked unit are capable of abuse but they were not given the opportunity to be abusive towards each other since they were being monitored and nothing would go unnoticed. On 4/24/23, an interview was conducted with SM 16. SM 16 stated resident 79 was really easy to work with, sweet and nice. SM 16 stated staff could not contradict him. SM 16 stated staff try to re-direct the resident verses fighting with him. SM 16 stated some of the nurses would tell him that he did not have court and then he would start to panic by walking and becoming aggressive. SM 16 stated she had to figure out how to calm him down. SM 16 stated once she figured out what he needed, everything was fine with him. SM 16 stated every resident had different routines and needed to be cared for based on that. SM 16 stated the bad thing with the new CNA's was they did not understand resident routines and it caused resident 79 to become upset. SM 16 stated that some of the new CNA's spent more time on the phones. SM 16 stated she had not been educated on how to care for residents with dementia. On 4/25/23 at 11:00 AM, an interview was conducted with the Chief Nursing Nursing Officer (CNO). The CNO stated that the last inservices provided for abuse were in April 2022, and he could not demonstrate that ongoing training had been completed since that time. [Cross refer to F600]

Based on interview and record review, the facility did not provide training to their nurse aides that was sufficient ensure the continuing competence of nurse aides, but must be no less than 12 hours per year; include dementia management training and resident abuse prevention training; address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff; and address the care of the cognitively impaired. Resident identifiers: 51 and 79. Findings include: On 3/30/23 an interview was conducted with Staff Member (SM 28). SM 28 stated when residents started to escalate, they moved them away from each other. SM 28 stated she tried to use de-escalation tactics to diffuse the situation. SM 28 stated they had not gotten formal abuse training and stated they had been learning about abuse while on the job. The SM 28 stated if a resident was combative, she was told to put them in their room and leave them there. The SM 28 stated most of the residents in the dementia unit only got agitated when they were being transferred or getting dressed. The SM 28 stated they had seen residents get verbal with each other and stated they said the F and B words a lot. The SM 28 stated the residents in the locked unit are capable of abuse but they were not given the opportunity to be abusive towards each other since they were being monitored and nothing would go unnoticed. On 3/30/23 11:33 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated there was a lot of behaviors on the dementia unit. LPN 3 stated that she asked to be on the dementia unit full time for continuity of care, because they have a lot of agency staff at the facility. LPN 3 stated she was not provided training on dementia care by the facility, but she was a dementia care specialist and was trained in another state On 4/24/23, an interview was conducted with SM 16. SM 16 stated resident 79 was really easy to work with, sweet and nice. SM 16 stated staff could not contradict him. SM 16 stated staff try to re-direct the resident verses fighting with him. SM 16 stated some of the nurses would tell him that he did not have court and then he would start to panic by walking and becoming aggressive. SM 16 stated she had to figure out how to calm him down. SM 16 stated once she figured out what he needed, everything was fine with him. SM 16 stated every resident had different routines and needed to be cared for based on that. SM 16 stated the bad thing with the new CNA's was they did not understand resident routines and it caused resident 79 to become upset. SM 16 stated that some of the new CNA's spent more time on the phones. SM 16 stated she had not been educated on how to care for residents with dementia. On 4/24/23 a follow-up interview was conducted with SM 16. SM 16 stated that she had not received any training related to dementia care. SM 16 stated that she had not received any instructions or guidance on how to treat resident 51's dementia behaviors. SM 16 stated that some facilities teach you how to manage residents with dementia and how to encourage them. SM 16 stated that this facility did not provide any training on dementia or how to care for those residents. On 4/25/23, an interview was conducted with SM 26. SM 26 stated she had not been provided education regarding how to care for residents with dementia. On 4/25/23 at 11:00 AM, an interview was conducted with the Chief Nursing Nursing Officer (CNO). The CNO stated that the last inservices provided for abuse were in April 2022, and he could not demonstrate that ongoing training had been completed since that time. [Cross refer to F740, F744 and F838]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. On 4/25/23 at 11:25 AM, an interview was done with the Chief Nursing Officer (CNO). The CNO stated they did not have an infection preventionist. The CNO stated the duty of the infection preventionist was to oversee the infection control program in the facility. The CNO stated the infection control logs helped identify trends. The CNO stated the infection control log was not at the level he wanted it to be at. The CNO stated there needed to be documentation on if the infection was acquired in house or if the resident was admitted with it. The CNO stated he expected to see more information in the logs, especially since there were 9 pages of infections. The CNO stated the expectation was to educated staff on updating the log weekly to prevent it from being done all at once and miss important trends that were preventable. The CNO stated the infection control tracking was not up to date and accurate to track infectious organisms to prevent the spread of infection. Based on interview, observation, and record review it was determined that the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Specifically, there was cross contamination during wound care, staff members were not wearing appropriate personal protective equipment (PPE), mattresses were contaminated, the facility did not have appropriate isolation rooms for residents with Covid-19, the facility did not have infection surveillance, and fecal matter was found in the washing machines. Resident identifiers: 7, 96, and 358. Findings include: 1. Resident 7 was initially admitted to the facility on [DATE] and again on 4/7/23 with diagnoses which included cerebral palsy, asthma, type 2 diabetes mellitus, systemic lupus, chronic respiratory failure, muscle weakness, cognitive communication deficit, hypertensive heart and chronic kidney disease without heart failure, open wound of abdominal wall, major depressive disorder, polyneuropathy, chronic kidney disease, ileostomy status, low back pain, hyperlipidemia, sleep apnea, and neuromuscular dysfunction of bladder. On 4/13/23 at 10:35 AM a wound care observation was conducted with resident 7. Registered Nurse (RN) 7 was completing the wound care. It was observed on four occasions during the wound care that RN 7 removed contaminated gloves and put on new gloves without performing hand hygiene. After the wound care was completed an interview with RN 7 was conducted. RN 7 stated that hand hygiene should be performed before, during, and after wound care, if anything came in contact with environmental surfaces, and when changing gloves from different wound so cross contamination does not occur. On 4/13/23 at 1:50 PM an interview with Director of Nursing (DON) 3 was conducted. The DON 3 stated that hand hygiene should be performed each times gloves are changed. 6. Resident 358 was admitted to the facility on [DATE] with a diagnoses which consisted of but were not limited to COVID-19, diabetes mellitus type 2, and chronic respiratory failure with hypoxia. On 3/28/23 at 9:08 AM, an observation was made of resident 358's room. The door to the room was closed and posted on the outside was a contact precautions stop sign and a droplet precautions sign. The contact precaution sign stated that providers and staff must clean hands, put on gloves, gown, and use dedicated equipment. The droplet precautions stop sign stated make sure eyes, nose and mouth were fully covered before entering room. A personal protective equipment (PPE) cart was located outside the room and contained N95 masks, disposable gowns, and surgical masks. A antibacterial hand rub (ABHR) was located outside the room along with a PPE garbage can. On 3/28/23 at 9:22 AM, an observation was made of Certified Nurse Assistant (CNA) 24 entering resident 358's room. CNA 24 donned gloves, a disposable gown and a N95 mask. CNA 24 did not donn any eye protection. On 3/28/23 at 12:19 PM, an observation was made of Nurse Assistant (NA) 2 delivering a lunch meal tray to resident 358's room. NA 2 donned a gown, and gloves before entering the room. NA 2 did not donn a N95 mask or goggles. Upon exit of the room NA 2 performed hand hygiene with ABHR. NA 2 did not change their surgical mask upon exit of the room. NA 2 was then observed to enter room [ROOM NUMBER] to answer a call light. Review of the facility Policy/Procedure - Infection Prevention and Control for the Novel Coronavirus documented that the policy of the facility was to conduct education, surveillance and infection control and prevention strategies to reduce the risk of transmission of the Novel Coronavirus (2019-nCoV). The policy stated that Transmission Based Precautions (TBP) (Quarantine) was necessary if the new admission was suspected or confirmed with COVID-19. The policy stated that HCP [healthcare professionals] should adhere to TBP and have eye protection in place. Residents with Confirmed COVID-19 should be cared for by staffing using N95 or equivalent respirators (updated 10/2022). Review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic documented HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or face shield that covers the front and sides of the face). On 4/24/23 at 9:26 AM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated that the PPE utilized when caring for COVID positive residents was a gown, gloves, N95 mask, and goggles. RN 5 stated that the PPE should be donned every time they entered the room. RN 5 stated that the N95 mask should be changed and a new surgical mask should be donned upon exit. 7. Resident 96 was admitted to the facility on [DATE] with diagnoses which consisted of osteomyelitis, type 2 diabetes mellitus, sepsis, hypertension, retention of urine, major depressive disorder, personality disorder, insomnia, anxiety disorder, and acquired absence of right leg below the knee. On 3/29/23 at 9:03 AM, an interview was conducted with resident 96. Resident 96 stated that he had a pressure ulcer on his left foot. Resident 96 stated that the wound had a wound vac dressing that was supposed to be changed three times a week. Resident 96 stated that the dressing never gets changed. Resident 96 stated that the staff would leave the machine alarming. The wound vac was observed not connected to the monitor. On 4/24/23, resident 96's medical records were reviewed. Resident 96's physician orders revealed the following: a. WOUND CARE: LEFT HEEL- Cleanse with wound cleanser, apply betadine one time a day every Monday, Wednesday, and Friday for wound care. The order was initiated on 3/27/23. b. Resident to have left foot/ankle pressure relieving cushion/boot. This should be worn at all times, every shift for decubitus ulcer. The order was initiated on 3/17/23. c. Left Foot/Ankle pressure relieving cushion/boot for left heel decubitus, wear at all times. d. WOUND CARE: LEFT FOOT/ANKLE- Cleanse with wound cleanse, allow to sit for at least 5 minutes, DON'T USE WHITE FOAM IN BASE OF ULCER. Negative Pressure Wound Therapy (NPWT) Pressure 125 millimeters of mercury (mmHg) continuous - Black foam may be used for base of wound that can be seen. Black foam should cover all necrotic tissue that hasn't opened up yet one time a day every Monday, Wednesday, and Friday for wound care. The order was initiated on 2/22/23. e. WOUND ORDER : Right lower extremity - Below the Knee Amputation (BKA) - leave dressing clean and in-tact until further instructions from orthopedic surgeon. The order was initiated on 1/25/23. On 4/10/23 at 1:42 PM, an observation was made of wound care to resident 96's wounds provided by RN 5. RN 5 stated that resident 96 had 2 wounds that she was providing treatment to on the left lower extremity (LLE), and the right Below the Knee Amputation (BKA) was being treated by the surgeon. RN 5 donned gloves and disconnected the wound vac tubing from the monitor. RN 5 removed the Podus boot and ace bandage from the LLE. A gauze roll was observed covering the wound vac dressing. RN 5 sprayed wound cleanser on the LLE heel to remove the gauze dressing. RN 5 doffed her gloves, performed hand hygiene, and new gloves were donned. The wound vac dressing was observed located on the LLE dorsal surface and lateral malleous. RN 5 removed the wound vac using a gauze 4 x 4 pad and wound cleanser to moisten the foam from the wound bed. RN 5 doffed her gloves, performed hand hygiene, and new gloves were donned. The wound bed was pink, with white slough noted. RN 5 placed a 4 x 4 gauze pad under the foot for wound cleanser absorption, and wound cleanser was sprayed onto the wound bed. RN 5 wiped the center of the wound bed, working outward towards the peri wound with a 4 x 4 gauze. RN 5 saturated a 4 x 4 gauze pad and placed it on the wound bed to soak for 5 minutes. RN 5 opened a new wound vac dressing and foam was cut to wound size with scissors obtained from the bedside table. Scissors were not observed cleaned prior to use. RN 5 did not change gloves prior to touching the new dressing. After 5 minutes had passed RN 5 removed the gauze dressing from the wound bed, and a dry 4 x 4 gauze pad was used to pat the wound bed dry. RN 5 doffed gloves, performed hand hygiene, and new gloves were donned. RN 5 applied skin prep to the wound margins. RN 5 applied a Tegaderm dressing to the peri wound and pieces were cut to the shape of the wound margins. RN 5 was observed to touch the LLE shin with the left hand and lift the leg to apply the Tegaderm film. The Tegaderm rolled onto itself on the near the ankle and stuck to RN 5's gloves. RN 5 placed the next Tegaderm strip over the rolled edge with wrinkling observed beneath. RN 5 stated that the Tegaderm stuck to her glove and rolled, but she could flatten it. RN 5 RN cut out the wrinkled section of the Tegaderm and reapplied. RN 5 opened a sterile foam package and the scissors were placed on the bed on top of resident 96's dirty sock. RN 5 doffed her gloves, and new gloves were donned. No hand hygiene was performed. RN 5 cut the foam wound vac dressing with a second pair of scissors, and those scissors were not observed disinfected prior to use. RN 5 doffed her gloves and exited the resident room to ask or assistance. RN 5 returned to resident 96's bedside and was accompanied by the Regional Nurse Consultant (RNC) 1. RN 5 and RNC 1 donned new gloves, no hand hygiene was performed. RNC 1 held the foam wound vac dressing in place on the wound bed while RN 5 placed the Tegaderm over the top. RNC 1 lifted resident 96's leg with the right hand while the left hand held the foam dressing in place. RNC 1 then touched the foam dressing with the gloved right hand. RN 5 applied Tegaderm over the top of the entire foam dressing. RN 5 obtained new tubing to apply to the dressing. RN 5 used the scissors that were placed on the bed on top of resident 96's dirty sock to cut an opening into the Tegaderm and foam dressing to place the tubing inside. RN 5 removed the old canister and a new canister was placed on the wound vac and connected to the tubing. RN 5 doffed gloves, and new gloves were donned. No hand hygiene was performed. RN 5 set the wound vac pressure to 125 mmHg. RN 5 doffed gloves, performed hand hygiene, and new gloves were donned. The Tegaderm was observed lifting on the new wound vac dressing. RN 5 sprayed wound cleanser was onto the heel wound and wiped from the center outward with a 4 x 4 gauze pad. RN 5 cleaned the wound with a betadine swab from the edges inward with 2 betadine swabs. RN 5 applied a new ace bandage to the entire foot and the Podus boot was placed back on the left foot. Resident 96 asked RN 5 to place the wound vac monitor in the carrying bag so it was easier to move around. RN 5 instructed resident 96 to inform her if the monitor beeped as the pressure needed to be continuous or else it did no good. Resident 96 asked RN 5 what he should do if the licensed nurse did not do anything. RN 5 replied to let the aide know so they could find another nurse who could fix the wound vac for him. On 4/10/23 at 2:47 PM, an interview was conducted with RN 5. RN 5 stated that she was supposed to doff and donn new gloves before started a dressing change and if she touched anything that was dirty. RN 5 stated that she cleaned the scissors prior to the dressing change and will clean it afterwards. RN 5 stated that the gloves should have been changed prior to touching the foam wound vac dressing. RN 5 stated that wound beds should be cleaned from the center outwards. On 4/13/23 at 1:52 PM, an interview was conducted with the Director of Nursing (DON) 3. The DON 3 stated that when performing dressing changes hand hygiene should be done before and after the wound care, and in between going from a dirty area to a clean area. The DON 3 stated that hand hygiene should be performed with each glove change. The DON 3 stated that when any environmental surfaces were touched gloves should be changed and hand hygiene should be performed. 4. On 4/20/23 at 2:29 PM, an observation was made of a mattress in room [ROOM NUMBER]. There was a large brown stain and cracks in the mattress. An interview was conducted with SM 23. SM 23 stated What do you think it is? SM 23 stated there were more mattresses with brown stains in the facility. On 4/20/23 at 2:49 PM, an interview was conducted with Administrator (Admin) 2. Admin 2 stated that was a stain needed to be sanitized but there were cracks in the mattress. Admin 2 stated he was going to be looking for another mattress or would be ordering a mattress. Admin 2 stated if he was unable to get a new mattress in, then they would find a way to sanitize the mattress until a new mattress was available. Admin 2 stated he found another mattress with the same discoloration. Admin 2 stated the green mattress was discolored to brown in the area of the abdomen and buttocks area was from cleaning. Admin 2 stated the cracks in the mattress were a bigger concern. Admin 2 stated he was aware of the strong bowel movement odor at the Rehab nurses station and the Heritage hallway. 5. On 3/30/23 at 11:52 AM, an interview was conducted with the Housekeeping Supervisor (HKS) 1. HKS 1 stated linens were being sent to the laundry with fecal matter on them. HKS 1 had a picture of the linens with fecal matter on them. HKS 1 stated she asked Administrator (Admin) 1 to instruct staff to wash out the fecal matter before sending linens to the laundry. HKS 1 stated that she was told by Admin 1 that the linens were to be put into the washing machine and since there were holes in the washing machine the fecal matter would wash out. 2. On 4/7/23 at 8:05 PM, Certified Nursing Assistant (CNA) 19 was observed in the Cambridge area of the facility. CNA 19 had her face mask pulled down, so that it was covering her chin but not her nose or mouth. This observation of CNA 19 was made again at 8:21 PM and 10:00 PM as the CNA was walking in the Cambridge hallway. 3. On 4/7/23 at 8:08 PM, CNA 20 was observed in the Cambridge area of the facility. CNA 20 had his face mask pulled down, so that it was covering his chin but not his nose or mouth.

Based on interview and record review, it was determined that the facility did not designate one or more individuals as the infection preventionist who are responsible for the facility's infection control program. Findings included: On 3/28/23, the facility entrance conference documentation outlined the Infection Preventionist (IP) job within the facility. It stated the IP played a critical role in the facilities Infection prevention and Control Program (IPCP), such as surveillance, analysis, interpretation and reporting of facility acquired infections. The IP educated staff and assisted with development, implementation, and enforcement of infection prevention and control policies and procedures. The IP will safeguard the health, safety and welfare of all guests, which includes residents, staff, volunteers and visitors by following applicable laws, regulations, and established nursing policies and procedures. [Note: The Director of Nursing (DON) 1 was documented to be IP for the facility before they relinquished their DON position in April of 2023.] On 4/25/23 at 11:25 AM, an interview was done with the Chief Nursing Officer (CNO). The CNO stated they did not have an infection preventionist. The CNO stated they were working on getting the Assistant Director of Nursing (ADON) trained and certified to be the facilities infection preventionist. The CNO stated the duty of the infection preventionist was to oversee the infection control program in the facility. The CNO stated their infection preventionist was the prior Director of Nursing (DON) who was let go a couple of weeks ago. The CNO stated the infection control logs helped identify trends. The CNO stated the infection control log was not at the level he wanted it to be at. The CNO stated there needed to be documentation on if the infection was acquired in house or if the resident was admitted with it. The CNO stated he expected to see more information in the logs, especially since there were 9 pages of infections. The CNO stated the prior DON had told him the infection logs had been done. The CNO stated the expectation was to educated staff on updating the log weekly to prevent it from being done all at once and miss important trends that were preventable. The CNO stated the infection control tracking was not up to date and accurate to track infectious organisms to prevent the spread 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 provide a resident's representative access to personal and medical records pertaining to the resident, within 24 hours of the written request. Specifically, for 1 of 8 sampled residents, a resident's Power of Attorney (POA) requested medical records and was not provided them within 24 hours of the written request. Resident identifier: 4. Findings include: Resident 4 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's, bipolar disorder, schizoaffective disorder, dementia, and depression. On 12/20/22 at 11:05 AM, a phone interview was conducted with resident 4's POA. The POA stated she came back to the facility sometime in the beginning of September and requested resident 4's medical records. The POA was told by a staff member that they could not give her the medical records because the resident's name was no longer in their system. The POA then stated, she filled out paper work with the Medical Records Director (MRD) to obtain resident 4's medical records from July 15 through the end of August. The POA stated she was told by the facility, they could only give her medical records 30 days prior to the date the resident was sent to the hospital. The POA stated she needed the medical records for personal use and resident 4's new facility. On 12/20/22 at 12:17 PM, a phone interview was conducted with the MRD. The MRD stated for someone to get their medical records, they had to submit a written request via a form. The MRD stated the person requesting the medical records had to be specific about what information they wanted since she was not allowed to give out any information that was not requested. The MRD stated that once the form was submitted, the medical records were given within 3-5 business days. The MRD stated she was told by the Regional Nurse Consultant that she had 3-5 business days for the form to be processed and the medical records to be given to the intended person. The MRD stated she held on to the physical request form for a month or two in case the resident or family stated they had not received them. The MRD stated they were only allowed to release medical records while the resident was at the facility. The MRD stated resident 4's POA had filled out a form to get resident 4's medical records and also recalled the POA had issues throughout the medical records request process. The MRD stated that the POA had to come to the facility on three separate occasions to obtain the form that needed to be filled out. The MRD stated the first time the POA came was on a Friday when she was not at work. The MRD stated that staff had not notified her, the first time the POA had requested records. The MRD stated the second time the POA came to the facility, she was on break and the POA did not obtain a medical record request form since the MRD was the only one with access to the form. The MRD stated that the POA came back for the third time and received the form. The MRD stated that the POA received her medical records within 3 to 4 days after she had requested them. The MRD stated she remembered this encounter with the POA because the previous Administrator had told her, the POA planned on suing the facility and needed someone to look over resident 4's medical records before they were given to the POA. The MRD stated she had the business office staff member looked over them and once they were ready, she notified the POA and the paper work was picked up the next day. The MRD stated she was the only one with access to the medical record request form and there was not a process in place on how to obtain the form when she was not at the facility. The MRD stated that she hoped the front desk called her if someone needed to obtain medical records if she was not present at the facility. The MRD stated she believed the process for obtaining resident 4's medical records felt long to the POA because of everything she had gone through just to obtain the records.

Based on interview and record review, it was determined for 2 of 8 sampled residents that the facility did not report an allegation of abuse within 2 hours of the allegation being made. Specifically, the facility did not report an allegation of physical abuse between two residents to the State Survey Agency (SSA) within 2 hours. Resident identifiers: 3, 7. Findings Included: On 12/20/22 at 10:55 AM, an interview was conducted with resident 3. Resident 3 stated she was moved to a new room after her previous roommate (resident 7) had accused resident 3 of physically abusing her. On 12/20/22 at 8:57 AM, the SSA received a copy of the initial report. The report stated that on 12/19/22 at 1:46 PM, staff and the facility administrator had been made aware of the allegations of abuse by resident 7. The facility report listed the submission time as 5:00 PM on 12/19/2022. On 12/20/22 at 1:21 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that 1:46 PM was when the ADON was made aware of the allegations through group text message. On 12/20/22 at 1:26 PM, an interview was conducted with the Resident Advocate (RA). The RA stated that 1:46 PM was when the RA was made aware of the allegations through group text message. The RA reported submitting the form to the SSA at 5:00 PM on 12/19/2022. The facility Abuse - Prohibiting policy and procedure reviewed 10/2022 was provided by the facility. The policy and procedure revealed the following: Reporting of Abuse: Reporting Abuse Any person who suspects that abuse, neglect, or the misappropriation of property may have occurred must immediately report the alleged violation to their immediate supervisor or the Administrator of the facility, State Survey Agencies and Law Enforcement. Time Period for Reporting 1. Serious Bodily Injury - 2 Hour Limit: If the events that cause the reasonable suspicion result in serious bodily injury to a resident, the covered individual (owner, operator, employee, manager, agent, or contractor) shall report the suspicion immediately, to State Survey Agencies and Law Enforcement, but no later than 2 hours after forming the suspicion. 2. All Others - Within 24 Hours: If the events that cause the reasonable suspicion do not result in serious bodily injury to a resident, the covered individual shall report the suspicion no later than 24 hours after forming the suspicion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined that the facility did not provide a safe, clean comfortable and homelike environment. Specifically, multiple resident rooms had debris on the floors, and debris was observed in resident hallways. Resident identifier 1. Findings included: 1. On 12/20/22 at 9:21 AM, an observation was made of the Heritage unit. The following was observed: a. room [ROOM NUMBER] had crumbs and debris on the floor at the foot of the bed and under the over bed table. There was a medication cup, sugar packet, napkin and other crumbs and debris. b. room [ROOM NUMBER] had a small medication cup on the floor and debris on the floor by the door. There was a sugar packet on the floor and other packaging. c. In the hallway of the Heritage unit there was a large blue rubber band and a tissue box lid. d. There was a cigarette butt in the hallway outside room [ROOM NUMBER]. e. room [ROOM NUMBER] had crumbs and debris including papers on the floor. f. room [ROOM NUMBER] had debris on the floor. 2. On 12/20/22 at 10:55 AM, an observation was made of the Cambridge unit. The following was observed: a. There were crumbs, debris, and cups on the floor in the hallway across from the nurses station. b. There was a sock, spoon, and debris in the handrail across from room [ROOM NUMBER] and outside the living room. c. There was bead board that was not secured to the wall into the dining room. The bead board was sticking out from the wall. d. room [ROOM NUMBER] had weather stripping that was pealing way from the door frame and sticking out. e. room [ROOM NUMBER] had a bathroom with white and black debris on the floor. f. There were crumbs, debris and wrappers in the hand rail at the nurses station. 3. On 12/20/22 at 3:03 PM, observations were made of the Heritage and Rehab units. The following were observed: a. room [ROOM NUMBER] had a bottle, baggie, medication cup, and trash on the floor. b. room [ROOM NUMBER] had a sugar packet, battery, trash and crumbs on the floor. c. room [ROOM NUMBER] had a tissue on the floor under the bed. d. room [ROOM NUMBER] had a medication cup on the floor by bed A. e. room [ROOM NUMBER] had crumbs and trash on the floor at the foot of the bed and under the bed. f. room [ROOM NUMBER] by bed A there was debris and crumbs on the floor. g. room [ROOM NUMBER] there was clothing on the floor next to the bed. h. room [ROOM NUMBER] had 13 cough drop wrappers on the floor. i. A light was out at the Rehab unit nurses station. On 12/20/22 at 12:13 PM, an interview was conducted with resident 1. Resident 1 stated that the facility cleanliness sucked. Resident 1 stated that garbage was left on the floor in the dining room from breakfast and was still present at the lunch meal. Resident 1 stated that the dining room tables were not clean and had coffee and food stains on them. Resident 1 stated that the dining room floors also had coffee stains on them. On 12/20/22 at 2:59 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated rooms in the Cambridge unit were cleaned by housekeeping daily. CNA 1 stated the house keeping staff vacuum by the nurses station once in a while. On 12/20/22 at 3:10 PM, an interview was conducted with CNA 2. CNA 2 stated housekeeping cleaned the hallways daily and sometimes multiple times a day. On 12/20/22 at 3:11 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated she had not seen housekeeping cleaning that day. RN 2 stated housekeeping cleaned the halls multiple times a day. On 12/20/22 at 3:51 PM, an interview was conducted with the Housekeeping Supervisor (HKS). The HKS resident rooms were cleaned daily. The HKS stated the resident's bathroom was cleaned, trash was emptied, floors cleaned, over bed table was wiped down, night stand was wiped down and the floors were swept and mopped. The HKS stated there were enough staff to clean the facility and if a staff member had the day off, staff were moved around. The HKS stated the Heritage unit was cleaned that day. The HKS observed the rooms above and stated the rooms did not look cleaned. At 4:08 PM, the HKS stated that she had a housekeeper coming in at 4:00 PM who was going to clean the rooms in the Heritage hallway.

Based on observation and interview it was determined, for 2 of 8 sampled residents, that the facility did not provide food prepared by methods that conserve nutritive value, flavor, and appearance. Specifically, residents complained of unappetizing food and the test tray was not palatable. Resident Identifiers: 3, 8 Findings Included: On 12/20/22 at 10:55 AM, an interview was conducted with resident 3. Resident 3 stated that sometimes the food was really awful, and sometimes the food was late. On 12/20/22 at 10:27 AM, an interview was conducted with resident 8. Resident 8 stated that the food all depended on what residents liked. Resident 8 stated the cook sometimes got a little crazy with the cheese. On 12/20/22 at 11:07 AM, an interview was conducted with resident 2. Resident 2 stated that the food was sometimes late and arrived cold. Resident 2 stated that when this happened she did not want to eat it. Resident 2 stated that the food was cold mostly during lunch and dinner meals. On 12/20/22 at 12:13 PM, an interview was conducted with resident 1. Resident 1 stated that the breakfast was ice cold this morning and it was the third time this week that it had arrived cold. Resident 1 also stated that the food typically tasted bland. On 12/20/2022 at 12:04 PM, the lunch tray line was observed. A test tray was requested. At 12:27 PM, the test tray went out on the final lunch cart. At 12:41 PM, staff completed delivering meals to the residents. The following temperatures were obtained: [Note: All temperatures were in degrees Fahrenheit.] a. Breaded meat - 120 b. Potatoes with gravy - 150 c. Mixed vegetables - 142 The mixed vegetables had a mushy texture and were bland to the taste. The cake had a soggy texture. Resident council minutes revealed the following complaints of food: a. On 10/27/2022: Hall trays are being passed late, Res (resident) getting meals late, The presentation of meals is bad, Food delivered cold, Would like more variety of snacks, desserts are better! b. On 11/30/2022: Meals not hot.

Based on observation, interview and record review it was determined that the facility did not have adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two. Specifically, there were lingering odors throughout the facility. Findings include: 1. On 12/20/22 at 8:05 AM, an observation was made at the lobby. There was a strong smoke odor through the hallway from the lobby to toward the Rehab unit. 2. On 12/20/22 at 9:12 AM, there was a bowel movement odor at the Rehab nurses station. 3. On 12/20/22 at 9:56 AM, there was a bowel movement odor from the Rehab unit into the Heritage Unit hallway. 4. On 12/20/22 at 10:40 AM, there was a strong cigarette smoke odor in the hallway outside the recreational therapy room toward the Cambridge unit. 5. On 12/20/22 at 2:34 PM, there was a bowel movement odor by the nurses station at the Rehab unit and permeated throughout the hallway. 6. On 12/20/22 at 2:53 PM, there was a bowel movement odor at the Colonial nurses station. 7. On 12/20/22 at 2:55 PM, there was a bowel movement odor in the Cambridge unit next to the nurses station. 8. On 12/20/22 at 3:51 PM, there was a bowel movement odor in the Heritage unit hallway. Grievance/Complaint Investigation Reports were reviewed and revealed residents complained of odors on the following dates: a. On 11/3/22, resident wanted to switch rooms because his roommate was urinating in the room and making it smell. b. On 11/30/22, resident admitted to a dirty room. There was a blanket that smelled like urine and resident had asked for a portable toilet but had not received one. c. On 12/15/22, resident was upset that her room smelled like urine. On 12/20/22 at 2:59 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated there were lingering odors in the facility. CNA 1 stated she thought the odors were coming from the bathrooms. On 12/20/22 at 3:51 PM, an interview was conducted with the Housekeeping Supervisor (HKS). The HKS stated she smelled bowel movement odors throughout the facility. The HKS stated there was a resident in the Heritage Unit with a colostomy and that was were the odor was coming from.