**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 out of 13 sampled residents, that the facility failed to ensure that all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, staff were not monitoring oxygen levels for a resident who had a diagnosis of pneumonia. Resident identifier: 1. Findings include 1. Resident 1 was admitted to the facility on [DATE] with diagnoses which included aneurysm, hypertensive heart disease, heart failure, moderate protein-calorie, gout, obstructive and reflux uropathy, muscle weakness, unsteadiness on feet, obstructive sleep apnea, urinary tract infection, prediabetes, and dysphagia. On 10/22/24 resident 1's medical record was reviewed. On 8/15/24 at 11:40 am a Nurses Note documented that resident 1 was sent to the hospital due to a blocked nasogastric (NG) tube. On 8/15/24 at 7:00 pm a Nurses Note documented that resident 1 had returned from the hospital with a diagnosis of pneumonia. An order of Amoxicillin-Pot Clavulanate Tablet 875 -125 milligrams (mg) twice a day for ten days was placed. Resident 1's orders were reviewed. Resident 1 had an order that stated, O2 [oxygen] per nc [nasal cannula] @ 2L/min [Liters per minute] PRN [as needed]. Goal to maintain Sats > 90%. Resident 1's care plan was reviewed. A care plan was initiated on 8/7/24 and revised on 8/27/24 documented, [resident 1] has altered respiratory status rt [related to] OSA [obstructive sleep apnea], pleural effusion, and PE [pulmonary embolism]. The interventions included, Monitor for s/sx [signs and symptoms] of respiratory distress and report to MD [medical direction] PRN: Increased Respirations; Decreased Pulse oximetry; Increased heart rate (Tachycardia); Restlessness; Diaphoresis; Headaches; Lethargy; Confusion . Resident 1's vitals were reviewed. Resident 1's medical record revealed that staff did not record oxygen saturation levels (O2 stats) 8/16/24, 8/17/24, 8/18/24, 8/20/24. On 10/23/24 an interview with the Director of Nursing (DON) was conducted. The DON explained that the Certified Nursing Assistants (CNAs) check and record the resident's vitals on a vital sheet, then give the vital sheet to the nurses to review and record in the electronic medical record. The nurses turn in the vitals sheet to the DON to be reviewed then shredded. The DON stated that she could not find the missing O2 stats for resident 1. The DON indicated that the facility would change the process to ensure that all vitals were recorded properly into the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined, for 2 of 40 sampled residents, that 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 lift, recognizing each resident's individuality. Specifically, residents were provided cowbells as an alternative to a broken call light and a resident was not provided privacy during a brief change. Resident identifiers: 6 and 26. Findings include: 1. Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizophrenia, type 2 diabetes mellitus, major depressive disorder, generalized anxiety disorder, dementia, repeated falls, vitamin b12 deficiency, extrapyramidal and movement disorder, and overactive bladder. On 2/21/24 at 9:16 AM, an observation was made of Certified Nursing Assistant (CNA) 2 assisting resident 6 with a brief change. CNA 2 was observed to leave resident 6's door open and the curtain was not fully closed to ensure resident 6 was provided privacy before the brief change. CNA 2 was observed to ask resident 6 if they were wet and then proceeded to check resident 6's brief. Resident 6's brief was removed and resident 6's buttocks area was observed to be erythematous with red dots of varying sizes present. CNA 2 was observed to wipe resident 6 clean and then applied barrier ointment to resident 6's posterior. CNA 2 stated they also tried to keep resident 6's diaper semi loose to prevent further skin irritation. A follow up interview was immediately conducted with the CNA 2 after they were done with resident cares. CNA 2 stated to ensure a patient's privacy during a brief change they either closed the door or closed the resident curtain. CNA 2 stated when there were a lot of people present, they closed both the door and the curtain. CNA 2 stated they did not close resident 6's door since the resident preferred the door open due to easily getting hot. On 2/21/24 at 10:44 AM, an interview was conducted with the Director of Nursing (DON). The DON stated they expected both the nurses and aids to provide privacy during patient cares such as brief changes. The DON stated privacy was to be provided to protect a resident's dignity. 2. Resident 26 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis of right ankle and foot, generalized muscle weakness, polyneuropathy, type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer of other part of right foot with bone involvement without evidence of necrosis, and necrotizing fasciitis. On 2/5/24 at 10:35 AM, an interview was conducted with resident 26. Resident 26 stated the call light had not been working for the last two days. Resident 26 stated their call light outside of the room was on for the last two days, so staff were unsure when they were actually calling. Resident 26 stated that using a cowbell made him feel as if he was being treated like an animal. On 2/5/24 at 10:39 AM, an observation was made of the Minimum Data Set Coordinator (MDSC) entering resident 26's room. The MDSC asked resident 26 what they needed help with since the call light was on. Resident 26 replied they did not need any help and that their call light would not turn off. The staff member was observed to briefly leave the room and returned with a red cow bell. The staff member explained the red cow bell was an alternative to the call light and they would need to ring the cowbell if they needed any assistance. On 2/14/24 at 3:15 PM, an interview was conducted with Nursing Assistant (NA) 3. NA 3 stated residents were provided cow bells if their call light was not working and stated it was not the best solution, but it was better than not having anything. On 2/20/24 at 1:23 PM, an interview was conducted with the Administrator (ADM). The ADM stated if a resident's call light was not working then residents were provided a cow bell within a short period of time until the call light was fixed. The ADM stated residents thought the cow bells were stupid at first. The ADM stated residents have used the cow bells when they were provided to them as an alternative to get a hold of staff. The ADM stated resident located further down the hall from the nurses' station were harder to hear then the ones located closer to the nurses station. On 2/20/24 at 2:06 PM, an interview was conducted with the DON. The DON stated they had a call light system located next to the nurses station. The DON stated staff were able to look at the system to see who's call light was going off. The DON stated if a call light had issues, they unplugged it to see if it fixed the issue. The DON stated if the call light was not working after unplugging it and plugging it back in then the resident's were given a bell. The DON stated the bell was used as a means to notify staff they needed help. The DON stated residents have expressed their dislike of the cow bells and have raised concerns about them. The DON stated residents have said they did not want to keep continually ringing their bell until someone could answer it. The DON stated they were able to understand how the bell was a dignity problem.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not ensure that the resident received services in the facility with reasonable accommodation of needs and preferences. Specifically, the resident requested a bed cane be provided for his bed to aid in mobility and the facility did not provide the assistive device. Resident identifier: 7. Findings include: Resident 7 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, morbid obesity, alcoholic cirrhosis, hepatic failure, type II diabetes mellitus with polyneuropathy, portal hypertension, narcolepsy, major depressive disorder, obstructive sleep apnea, personality disorder, bipolar II disorder, alcoholic dependence, restless leg syndrome, male erectile dysfunction, hypertension, heart failure, anxiety disorder, hyperlipidemia, hyperaldosteronism, and osteoarthritis. On 2/5/24 at 10:12 AM, an interview was conducted with resident 7. Resident 7 stated that he had two falls and had asked for a bed cane to assist him in bed mobility. Resident 7 stated that the facility would not provide one so he had to purchase his own from Amazon. Resident 7 stated that the device cost him $35. On 9/24/23, the admission Minimum Data Set (MDS) Assessment documented that resident 7 had a Brief Interview for Mental Status (BIMS) score of 14, which would indicate that the resident was cognitively intact. The assessment documented resident 7's mobility as a supervision with touch assist for rolling left to right, sit to lying, lying to sitting on side of the bed, sit to stand, chair/bed transfers, and toilet transfers. Resident 7's incident reports revealed the following: a. On 9/25/23 at 4:32 AM, the report documented that resident 7 had fallen and called the paramedics. Resident 7 claimed he was on the floor for half an hour and had used the call light to notify the staff. Minor skin tears were noted to the right lower extremity. The intervention identified was to educate resident 7 to call for assistance. b. On 10/4/23 at 12:05 PM, the report documented that resident 7 was found on the floor. Resident 7 stated that he missed the wheelchair when he tried to go to the bathroom. The report documented a skin cut and hematoma on the left leg, and bruise to the chest. The intervention identified was to encourage resident 7 to rise slowly and be sure of steadiness prior to ambulation or transfer. c. On 11/3/23 at 2:00 AM, the report documented that resident 7 reported a fall that happened last night. Resident 7 reported that he did not call for help because he did not want to bother anyone, and he got himself up by holding onto the bed. The intervention identified was a sign placed in the resident's room reminding him to call before ambulating. d. On 1/6/23 at 5:25 PM, the report documented that resident 7 called the nurse by phone to report that he had fallen. The report documented that there were a lot of things on the floor and he tripped and fell to his knees. No injuries were noted. The intervention identified was to declutter the resident's room. On 9/18/23, resident 7 had a care plan initiated for used a 1/4 repositioning bar for bed mobility. Interventions identified were that resident 7 would demonstrate the appropriate use of the 1/4 side rails to increase mobility; would not have any adverse effects from the assistive device; assess resident 7 for entrapment risk to ensure proper use of assistive device; check on resident 7 during rounds while in bed; provide education on proper bed mobility as indicated; and Physical Therapy/Occupational Therapy to evaluate and treat as ordered. On 11/13/23, a BED RAIL - 1/4 Side rail for bed mobility was ordered for resident 7. It should be noted that the order was initiated two months after the care plan was created for the use of the bed rail. On 2/8/24 at 10:18 AM, an interview was conducted with the Certified Nurse Assistant Coordinator (CNAC). The CNAC stated that resident 7 needed assistance with showers, could toilet himself, was independent in his room, and needed housekeeping assistance. The CNAC stated that staff were to provide care with two aides at a time for resident 7's aggressive behaviors. On 2/20/24 at 11:33 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that if a resident needed a mobility device they would refer them to therapy to evaluate and if it was deemed appropriate then the Administrator (ADM) would purchase the bed rail. On 2/20/24 at 11:39 AM, an interview was conducted with the Director of Therapy Services (DOT). The DOT stated that she never evaluated resident 7 for a bed rail. The DOT stated that she was not consulted about the bed rail, but did not think resident 7 would be a hazard with one. The DOT stated that resident 7 was not on therapy services and she was never consulted or told to evaluate resident 7 for a bed rail. On 2/20/24 at 11:52 AM, an interview was conducted with the ADM. The ADM stated that the process for obtaining a mobility device was to notify the nursing team about the request and either nursing or therapy would determine if it was appropriate, and then they would have an Interdisciplinary Team meeting to discuss it. The ADM stated that she did not recall if resident 7 was evaluated by nursing or therapy for a bed rail. The ADM stated that resident 7 informed her that he purchased a bed rail and she needed it evaluated to determine if it was safe. The ADM stated that she had informed resident 7 that she would purchase a bed rail but she needed to find a bed that would fit the rail. The ADM stated that the beds they had were old and were difficult to find parts for. The ADM stated that she did not reimburse resident 7 for the bed rail that was purchased from Amazon. The ADM stated that she did not recall the IDT meeting about the bed rail and did not recall who she asked to evaluate the device.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 out of 40 sampled residents, that the facility did not consult with the resident's physician when there was a significant change in the resident's physical, mental or psychosocial status, or when there was a need to alter treatment. Specifically, a resident had uncontrolled pain and the physician was not notified, and a resident's Trulicity was not administered for two consecutive weeks due to unavailability and the physician was not notified. Resident identifiers: 29 and 31. Findings include: 1. Resident 29 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included diffuse traumatic brain injury, hemiplegia and hemiparesis following a cerebral infarction, major depressive disorder, panic disorder, anxiety disorder, low back pain, acute hepatitis C, seizures, overactive bladder, benign prostatic hyperplasia, insomnia, migraine, schizoaffective disorder, lymphangioma, and a history of suicidal behavior. On 2/6/24 at 9:22 AM, an interview was conducted with resident 29. Resident 29 stated that he had pain in his back and head. Resident 29 stated that he received Oxycodone for the pain but it did not help. Resident 29 stated that his current pain level was a 9/10. Resident 29 stated that he would like the pain to be non-existent, but he had to live with the pain. On 2/6/24, resident 29's medical records were reviewed. On 9/28/23, resident 29 had an order for Oxycodone Capsule 5 milligram (mg), give 1 capsule by mouth every 4 hours as needed for moderate to severe pain initiated. On 1/26/24 at 7:56 PM, the Oxycodone 5 mg was administered for complaints of a headache. Resident 29 reported an initial pain score of 9/10. On 1/26/24 at 10:10 PM, resident 29's Oxycodone follow-up administration assessment was documented as Ineffective with a follow-up score of 7/10. No documentation could be found that the provider was notified of the ineffective pain control and no additional pain medication was administered. On 1/27/24 at 6:33 PM, the Oxycodone 5 mg was administered for complaints of bladder pain. Resident 29 reported an initial pain score of 9/10. On 1/27/24 at 8:22 PM, resident 29's Oxycodone follow-up administration assessment was documented as Ineffective with a follow-up score of 9/10. No documentation could be found that the provider was notified of the ineffective pain control and no additional pain medication was administered. On 12/21/23, resident 29's care plan for at risk for pain related to history of craniotomy, trauma and chronic migraines was initiated. Interventions identified included to anticipate the resident's need for pain relief and respond immediately to any complaints of pain; evaluate the effectiveness of pain interventions; review pain interventions for alleviation of symptoms, dosing schedules and resident satisfaction with results; monitor for side effects of pain medication and report occurrences to the physician; monitor/record/report any signs and symptoms of non-verbal pain; monitor/record/report to nurse loss of appetite, refusal to eat and weight loss; monitor/record/report to nurse resident complaints of pain or requests for pain treatment; notify physician if interventions are unsuccessful or if current complaint was a significant change from past experience of pain. Review of the facility policy for Administering Pain Medications documented that pain management was defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. The policy stated that staff were to document the effectiveness of non-pharmacological interventions. The policy stated that staff were to re-evaluate the resident's level of pain 30-60 minutes after administering pain medication. The policy stated that staff should report information in accordance with facility policy and professional standards of practice. The policy was last revised in January 2024. On 2/12/24 at 12:37 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated resident 29 did not report pain. RN 2 stated that resident 29 would say that he had bladder pain and needed to urinate and wanted to be catheterized. RN 2 stated that resident 29 goes to the bathroom [ROOM NUMBER] times a day and his bladder was never full. RN 2 stated that resident 29 had as needed pain medication. RN 2 stated that the resident did not get the pain medication unless he asked for it. RN 2 stated that they would obtain a pain score and location of the pain prior to the medication administration and then they would evaluate the effectiveness 30 minutes after administration. RN 2 stated that if the pain medication was not effective they should contact the physician. RN 2 stated that the notification to the physician would be documented in a progress note. On 2/13/24 at 7:56 AM, an interview was conducted with the Director of Nursing (DON). The DON stated for uncontrolled pain or pain that was not alleviated with pain medication the nurse should notify the physician. The DON stated the expectation for unresolved pain was to follow-up with physician immediately, and document in the nursing note that the physician was notified. 2. Resident 31 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis, type II diabetes mellitus, asthma, morbid obesity, anxiety disorder, major depressive disorder, insomnia, hypertension, pseudobulbar affect, hyperlipidemia, nondisplaced fracture of proximal phalanx left great toe, chondromalacia left knee, and dementia. On 2/10/24 resident 31's medical records were reviewed. On 11/3/23, resident 31 had an order initiated for Trulicity Subcutaneous Solution Pen-injector 0.75 milligram (mg)/0.5 milliliter (ml), Inject 0.75 mg subcutaneously one time a day every Friday related to type II diabetes mellitus. On 1/12/24 at 12:55 PM, the Orders - Administration Note documented that the Trulicity was not administered due to Pharmacy is to deliver today. On 1/12/24, the January 2024 Medication Administration Record (MAR) documented that the medication was not administered. On 1/19/24 at 5:14 PM, the Orders - Administration Note documented that the Trulicity was not administered due to waiting on pharmacy. On 1/19/24, the January 2024 MAR documented that the medication was not administered. It should be noted that no documentation could be found that the physician was notified that the Trulicity was not administered. On 2/12/24 at 7:44 AM, an interview was conducted with RN 2. RN 2 stated that the pharmacy usually had any medications delivered to the facility within in a day. RN 2 stated that the new pharmacy was taking longer, a couple of days, but they were getting better at having medications like antibiotics available. RN 2 stated if a medication was not available she would notify the DON and she would then notify the physician. RN 2 stated that the DON had been handling a lot of issues with the new pharmacy. RN 2 stated that if the medication was not available or if it was an insurance coverage issue the DON handled it. RN 2 stated that for a medication like Trulicity she would contact the DON or notify the physician. On 2/12/24 at 10:06 AM, an interview was conducted with the DON. The DON stated that if a medication was not available she would immediately let the pharmacy know and then pull from the Pixus overstock. The DON stated that they did not have Trulicity available in the Pixus. The DON stated that staff should notify her and she would notify the pharmacy immediately. The DON stated that any insulin should be at the facility within hours. The DON stated that staff should have notified the interim DON so that they could notify the Medical Director (MD) and get a new order or attempt to get the medication in the facility. The DON stated that staff should notify the MD immediately of something critical like insulin and then document the MD notification in a progress note.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 out of 40 sampled residents, that the facility did not ensure that the comprehensive care plan was prepared by the interdisciplinary team that included the attending physician, a registered nurse, a nurse aide, a member of the food and nutrition services, the resident or representative, and any other appropriate staff as determined by the resident's need; and that the plan was reviewed and revised by the Interdisciplinary team (IDT) after each assessment including quarterly review assessments. Specifically, nursing staff were not present at the resident's quarterly care conference. Resident identifier: 4. Findings included: Resident 4 was admitted to the facility on [DATE] with diagnoses which included mononeuropathy, chronic respiratory failure, type II diabetes mellitus, morbid obesity, chronic obstructive pulmonary disease, non-pressure ulcer of left calf, schizoaffective disorder, epilepsy, hypothyroidism, peripheral vascular disease, varicose veins, hypertension, bilateral osteoarthritis of hip, intervertebral disc disorder, edema, chronic pain syndrome, tremor, overactive bladder, hyperlipidemia, viral hepatitis C, insomnia, sleep apnea, post traumatic stress disorder, anxiety disorder, bipolar disorder, borderline personality disorder, and major depressive disorder. On 2/6/24 at 10:50 AM, an interview was conducted with resident 4. Resident 4 stated she had an IDT meeting the other day and only the Resident Advocate (RA), Activities, and therapy were present. Resident 4 stated that she thought the Administrator (ADM), Director of Nursing (DON), and Human Resource (HR) were supposed to be there. On 2/1/24, a quarterly care conference was conducted. The report documented that resident 4 attended the conference The report documented the staff members who participated in the care development were Physician Extenders (NP, PA), Licensed Nurse, Certified Nurse Assistant, Dietary Manager, Social Services, Activities, and Skilled Rehab. The report documented under Mood/Behavior Management, Resident states she is unhappy and feels emotionally overwhelmed. She wants to continue to speak with her therapist through [local behavioral health provider]. She has her therapist's phone number. The report documented under Activities and Daily Routine Preferences declines invitation to activities and prefers to do her own thing. [Resident 4] is our Resident Council President and enjoys helping others, visiting and being outdoors. We will continue to offer encouragement and support. The report documented under Interdisciplinary Team Member Attendees that the RA, Activities Director (AD) and the Director of Therapy Services (DOT) were present. On 2/20/24 at 10:00 AM, an interview was conducted with the DON. The DON stated that the staff that attended the IDT Care Conference meetings were herself, the RA, AD, DOT. The DON stated that they tried to have 3 departments present with the social services and DON as the primary attendees. The DON stated that ADM sometimes attended but not all the time. The DON stated that she did not attend resident 4's care conference on 2/1/24 because she was late, and no one from nursing attended in her absence. The DON stated that if she was not able to attend they should ask another nurse such as the Minimum Data Set (MDS) Coordinator or one of the experienced nurses for their feedback. The DON stated that someone from nursing should be present to discuss cares and medication. The DON stated that they do not have a process or policy that they follow for the IDT meetings. On 2/20/24 at 10:12 AM, an interview was conducted with the RA. The RA stated that she attended the resident IDT care conference meetings. The RA stated that the meetings were attended by herself, the DON, Activities, dietary, and resident and/or family, HR, and therapy. The RA stated that if the DON was not available she was not sure what to do. The RA stated that if the DON was not present then one of her nurses should be there in her place. I don't think we can not have nursing represented. The RA stated that she documented the 2/1/24 care conference for resident 4. The RA stated that on resident 4's quarterly care conference on 2/1/24 she indicated in section 2 that the Physician Extenders (NP, PA), Licensed Nurse, Certified Nurse Assistant, Dietary Manager, Social Services, Activities, Skilled Rehab were checked off. The RA stated that she was told by the corporate Licensed Clinical Social Worker (LCSW) to check these boxes. The RA stated that in section 4 she puts who actually attended the care conference and it did not reflect the checked departments in section 2. The RA stated that on 2/1/24 the people in attendance for resident 4's care conference were the RA, Activities, and Director of Activities. The RA stated that no one from nursing was present.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not ensure that the discharge needs of the resident was identified and resulted in the development of a discharge plan for the resident; that regular re-evaluation to identify changes that required modification to the discharge plan was completed; and referrals to local agencies for the purpose of returning to the community were documented. Specifically, the resident desired to return to the community through the New Choice Waiver (NCW) program and the facility did not submit the required paperwork. Resident identifier: 4. Findings included: Resident 4 was admitted to the facility on [DATE] with diagnoses which included mononeuropathy, chronic respiratory failure, type II diabetes mellitus, morbid obesity, chronic obstructive pulmonary disease, non-pressure ulcer of left calf, schizoaffective disorder, epilepsy, hypothyroidism, peripheral vascular disease, varicose veins, hypertension, bilateral osteoarthritis of hip, intervertebral disc disorder, edema, chronic pain syndrome, tremor, overactive bladder, hyperlipidemia, viral hepatitis C, insomnia, sleep apnea, post traumatic stress disorder, anxiety disorder, bipolar disorder, borderline personality disorder, and major depressive disorder. On 2/6/24 at 10:46 AM, an interview was conducted with resident 4. Resident 4 stated that she wanted to discharge with NCW, but the facility did not submit the paperwork and she was denied. Resident 4 stated she asked the Resident Advocate (RA) for a new application and she said she would lay it on her bed, this was on the previous Friday. Resident 4 stated that on Monday she asked again and it still was not given to her. On 10/14/23, resident 4's Annual Minimum Data Set (MDS) assessment documented that the Brief Interview for Mental Status score was 15, which would indicate that the resident was cognitively intact. Resident 4's progress notes revealed the following: a. On 11/2/23 at 11:21 AM, the Social Service Note documented, New Choice Waiver requested additional paperwork for processing. A new H&P [history and physical] might need to be done by facility Dr [doctor], waiting to her back from NCW. Paperwork was submitted. b. On 2/12/24 at 3:35 PM, the Social Service Note documented, Resident would like to apply for New Choices Waiver. Application submitted with supporting documents On 2/12/24 at 11:12 AM, an interview was conducted with the RA. The RA stated that she started at the facility on 12/19/23. The RA stated that the previous social worker handled all the NCW applications but she was going to be taking on that responsibility now. The RA stated that she was not sure of the application process for the NCW and she would find out more from the Corporate Social Service Worker (CSSW). The RA stated that she was not exactly sure who handled the NCW application prior to her as the facility did not have a SSW for awhile and there was no one here when she arrived. The RA stated that a couple of the residents had asked about their NCW status. The RA stated that the CSSW had just showed her how to access the NCW login. The RA stated that resident 4's application was returned and because it had been so long it needed to be re-submitted again. The RA stated that resident 4 had stated that she wanted to fill out the paperwork and have the facility fax it back to them. The RA stated that she did not know how the previous social worker was tracking the NCW applications prior to her. On 2/13/24 at 11:31 AM, a follow-up interview was conducted with the RA. The RA stated that resident 4's NCW application was submitted on 11/22/23 and the NCW program had requested additional information. The RA stated that on 12/22/23 the application was closed because the facility did not submit the additional information that was requested. The RA stated that she just barely got login access to the NCW. The RA stated that the login page did not reflect where the residents were in the application process. The RA stated that the website would say accepted but that only meant that the application was accepted and not that they had been accepted to the program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that for 2 of 40 sampled residents, that the facility did not provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. Specifically, the facility did not provide or maintain documentation of one on one activities for residents that had care plans for one on one activities and did not provide activities for residents on weekends. Resident Identifiers: 21 and 22. Findings include: 1. Resident 21 was admitted on [DATE] with diagnoses including unspecified cirrhosis of liver, generalized anxiety disorder, unspecified dementia moderate without behavioral disturbance psychotic disturbance mood disturbance and anxiety, personal history of traumatic brain injury, and major depressive disorder recurrent moderate. On 2/6/24 at 9:20 AM, an interview was conducted with Resident 21. Resident 21 stated that he was isolated and that staff do not provide him with activities. On 2/13/24, Resident 21's medical record was reviewed. Resident 21's most recent Brief Interview for Mental Status (BIMS) score was a 10, indicating a moderate cognitive impairment. On 8/16/23 at 12:53 PM, an Activity Interview for Daily and Activity Preferences assessment was completed. The answer not assessed was selected for all of the answers. No other Activity Interview for Daily and Activity Preferences assessments had been completed. There was a notification at the top of the resident's assessment tab that stated, ACT: ACTIVITY INTERVIEW FOR DAILY AND ACTIVITY PREFERENCES (3.0) 89 DAYS OVERDUE - 11/16/2023). A care plan dated 6/9/23 revealed a focus of, [Resident 21] exhibits impaired activity patterns manifested by: impaired mobility, little interest/pleasure in doing things (D0200/D0500), poor health/pain limits activity involvement, need for reminders and assistance to/from activities, mood diagnosis, cognitive impairment. The goal documented for this care area was, Will participate in independent leisure activities including stated interest of tv/movies, music, reading, etc. daily x 90 days. Will state or demonstrate an increase in interest/pleasure during activity involvement through next review. Will be oriented to make daily decisions regarding leisure participation x 90 days. Will accept at least 1 1: visit OR attend 1 social group per week for social engagement/leisure involvement x 90 days. The interventions for this care area were documented as, Monitor for satisfaction with leisure choices. Please post the calendar in room. Supply with independent leisure materials PRN [as needed]. Support independent leisure choices. Invite and/or assist to/from group activities. Help ensure proper lighting & sufficient space for activities both in and out of room. Encourage and support the continuation of life roles. Provide adaptation to activities PRN: Cognitive: short interventions Physical: low energy programming Please support family/friend involvement & need for privacy during visits. Use validation to help express my feelings appropriately. Provide assistance with orientation and decision making PRN. Provide 1:1 visit prn. On 2/14/24 at 12:23 PM, the Activity Director's one on one and group social engagement and leisure involvement documentation was reviewed. For the week of December 26th through December 29th, there was nothing documented for Resident 21. For the week of January 8th through January 12th, there was nothing documented for Resident 21. For the week of January 15th through January 19th, there was nothing documented for Resident 21. For the week of February 5th through February 9th, there was nothing documented for Resident 21. 2. Resident 22 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia unspecified, mild protein-calorie malnutrition, generalized anxiety disorder, major depressive disorder recurrent unspecified, cognitive communication deficit, and mild cognitive impairment of uncertain or unknown etiology. On 2/13/24, Resident 22's medical record was reviewed. Resident 22's most recent Brief Interview for Mental Status (BIMS) score was an 8, indicating a moderate cognitive impairment. A care plan dated 4/5/21, revised 8/29/23 revealed a focus of, [Resident 22} exhibits impaired activity patterns manifested by: impaired mobility, need for adaptive equipment, sensory problems, little interest/pleasure in doing things (D0200/D0500), poor health/pain limits activity involvement, need for reminders and assistance to/from activities, mood diagnosis, cognitive impairment, bed bound. The goal documented for this care area was,[Resident 22] will accept at least 1 1:1 visit per week for social engagement/leisure involvement x 90 days. [Resident 22] will state or demonstrate an increase in interest/pleasure during activities/1:1's weekly x 90 days. Will be oriented to make daily decisions regarding leisure participation x 90 days. The interventions for this care area were documented as, Monitor for satisfaction with leisure choices. Please post the calendar in room. Supply with independent leisure materials PRN. Support independent leisure choices. Invite and/or assist to/from group activities. Help ensure proper lighting & sufficient space for activities both in and out of room. Encourage and support the continuation of life roles. Monitor for fall risk. Provide adaptation to activities PRN: Cognitive: short interventions Vision: sit close to speaker Hearing: increase volume and speak clearly Physical: low energy programming Please support family/friend involvement & need for privacy during visits. Provide 1:1 visits weekly. Use validation to help express my feelings appropriately. Provide assistance with orientation and decision making PRN. On 2/14/24 at 12:23 PM, The Activity Director's one one one and group social engagement and leisure involvement documentation was reviewed. For the week of December 26th through 29th, Resident 22 declined to participate in a one on one activity. For the week of January 8th through January 12th, there was nothing documented for Resident 22. For the week of January 15th through January 19th, there was nothing documented for Resident 22. For the week of February 5th through February 9th, there was nothing listed for Resident 22. On 2/14/24 at 11:27 AM an interview was conducted with the Activities Director (AD). The AD stated she had a list of residents that required one on one visits. The AD stated that residents were identified to be on the one on list if they do not leave their room, frequently isolate, do not socialize, or if the facility interdisciplinary team requested for a resident to be added to the list. The AD stated that there was no set schedule for her weekly one on one visits with residents, the visits with residents just occur for 15-30 minutes sometime during the week. The AD stated that when she goes from room to room to visit residents, she will invite them to attend Bingo in the dining room or ask if there was anything the resident needed. The AD stated that she was unable to locate any documentation of one on one visits prior to her hire date in November. The AD stated that unless a resident was admitted on the weekend, their initial activities assessment should be completed within 24 hours of admission to the facility. The AD stated that there would be no reason to not assess a new resident for their activities preferences. The AD stated that she was responsible for completing yearly and quarterly activity assessments for residents. On 2/14/24 at 11:47 AM, an additional interview was conducted with the AD. The AD stated that there was no one on one documentation for the week of January 1st 2024 due to her being sick with COVID. On 2/14/24 at 12:33 PM, the Recreational Therapy Consultant's (RTC) documentation of resident activity care plans was reviewed. Resident 21's intervention was documented as ,1:1 or group weekly for social engagement/leisure involvement. On 2/18/24 at 2:30 PM, an observation was made of the facility activity calendar for the month of February 2024. There were no activities listed for Saturdays or Sundays other than, at your leisure. In addition, an observation was made of five residents sitting at a table in the dining room doing nothing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not ensure that residents received proper treatment and care to maintain mobility and good foot health. Specifically, a resident was not provided care with trimming his toenails and appointments to podiatry services were not made. Resident identifier: 7. Findings included: Resident 7 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, morbid obesity, alcoholic cirrhosis, hepatic failure, type II diabetes mellitus with polyneuropathy, portal hypertension, narcolepsy, major depressive disorder, obstructive sleep apnea, personality disorder, bipolar II disorder, alcoholic dependence, restless leg syndrome, male erectile dysfunction, hypertension, heart failure, anxiety disorder, hyperlipidemia, hyperaldosteronism, and osteoarthritis. On 2/5/24 at 10:21 AM, an interview was conducted with resident 7. Resident 7's toenails were observed to extend past the end of his toe. Resident 7 stated that the staff refused to cut his toenails and they needed to be cut by a podiatrist. Resident 7 stated that he had not seen a podiatrist since he had been at the facility. Resident 7 stated that he had asked the nurse to cut his nails and they said they could not. Resident 7 stated he was told that the facility did not have a podiatrist to provide services. On 2/16/24, the Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, which would indicate that resident 7 was cognitively intact. The assessment documented that resident 7 required substantial maximal assistance for bathing and the helper did more than half the effort. On 2/6/24, resident 7's medical records were reviewed. No documentation could be found to demonstrate that resident 7 had been provided podiatry services or foot care. On 9/18/23, resident 7 had a care plan initiated for had an Activities of Daily Living (ADL) self-care performance deficit. Interventions identified included Cares with Pairs: Assist of 2 with cares when in room related to behaviors; adjust ADL assistance per level of need at time of care; required limited/ partial/ moderate assist of 2 due to behaviors for bathing/showering; and required partial/ moderate assistance with putting on /taking off footwear. On 2/20/24 at 1:37 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that the facility had a podiatrist, but she was not sure how often he came to the facility. RN 3 stated that the social worker would set up appointments with the podiatrist. On 2/20/24 01:44 PM, an interview was conducted with the Resident Advocate (RA). The RA stated that she would be making the podiatry appointments, but she had not scheduled any yet. The RA stated that the nurses could help with the toenails if the resident did not have problems with their feet. The RA stated that her plan was to check with the residents to see if they need an appointment. The RA stated that the podiatrist office asked her to compile a list so they could set up a time. The RA stated that prior to her arrival she did not know who the facility podiatrist was or who was seen by them. On 2/21/24 at 2:19 PM, a follow-up interview was conducted with the RA. The RA stated that she contacted the previous facility podiatrist. The RA stated that they did not call her back to inform her of their last visit date and who they provided services to.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that 1 of 40 sampled residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range. Specifically, a resident was not provided their ordered supplement for 3 days. Resident identifier: 33. Findings Include: Resident 33 was initially admitted to the facility on [DATE] and readmitted with the following diagnoses that included severe protein calorie malnutrition, alcoholic cirrhosis of liver without ascites, dementia, opioid dependence, esophageal obstruction, gastrointestinal hemorrhage, generalized anxiety disorder, and alcohol dependence. Resident 33's medical record was reviewed on 2/6/24 through 2/22/24. On 2/6/24, resident 33's documented weight was 86 pounds. A nutrition care plan initiated on 10/22/23 documented resident 33 had Potential for/actual alteration in nutrition related to cachexia, hospital diagnosis of severe malnutrition, hx [history] of esophageal strictures, alcohol dependence with cirrhosis [sic], hx of gastric tube for nutrition . It stated resident 33 had a history of inadequate intake due to a low BMI [body mass index] and one of the interventions listed included to provide/serve diet and supplements as ordered. On 10/25/23, an admission nutritional assessment documented, Other dxs [diagnoses] include esophageal stricture, severe malnutrition, hx of alcohol use & current smoker .Intake meets estimated needs, however, considering BMI, she will benefit from increased nutrient needs. One of the recommendations made by the Registered Dietician (RD) included Medpass 60 milliliters (mls) to be given twice a day. On 1/17/24, a nutritional assessment documented, Intake meets estimated needs but considering malnutrition dx [diagnosis] and low BMI, she will benefit from increased nutrition provision. One of the recommendations made by the RD included a House Supplement 120 mls to be given twice a day. A physician order with a start date of 1/19/24 and end date of 1/30/24 stated, House supplement. Two times a day for low weight. GIVE 120ml [milliliter] twice daily. [This was restarted on 1/30/24 till current.] On 1/28/24 at 9:48 AM, an orders administration note documented, House Supplement two times a day for low weight GIVE 120ml twice daily. medication unavailable. On 1/28/24 at 4:58 PM, an orders administration note documented, House Supplement two times a day for low weight GIVE 120ml twice daily. Unavailable. On 1/29/24 at 11:29 AM, an orders administration note documented, House Supplement two times a day for low weight GIVE 120ml twice daily. not available. On 1/29/24 at 1:37 PM, an orders administration note documented, House Supplement two times a day for low weight GIVE 120ml twice daily. N/A [not applicable]. On 1/30/24 at 8:31 AM, an orders administration note documented, House Supplement two times a day for low weight GIVE 120ml twice daily. No Med Pass, Boost or Mighty Shakes available. On 1/30/24 at 1:48 PM, an orders administration note documented, House Supplement two times a day for low weight GIVE 120ml twice daily. No supplements available. It should be noted that resident 33 had an order for supplements since their admission to the facility due to a low BMI. On 2/20/24 at 12:49 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated resident 33 was a frail and tiny resident and needed all the nutrition they were able to get. RN 2 stated resident 33 did not eat most of their food and preferred to just eat snacks. RN 2 stated resident 33 received a supplement such as medpass or boost. RN 2 stated supplements were offered on a schedule since it was ordered by the physician, and it needed to be documented like a medication. RN 2 stated the supplements provided extra nutrition and were high in vitamins, calories, and proteins. RN 2 stated the supplements were used to help maintain and build body mass. RN 2 stated there had been times when they had run out of supplements and residents had to miss a couple of doses. RN 2 stated it was frustrating when a resident missed doses of their ordered supplements since some residents worked hard to gain weight or maintain their weight. RN 2 expressed concern for when some residents missed a dose and stated sometimes that was their only nutrition and it could have detrimental consequences for those residents. RN 2 stated the loss of a few calories for resident 33 affected their nutritional status. On 02/20/24 at 2:17 PM, a phone interview was conducted with the RD. The RD stated when a resident was admitted to the facility they did a nutritional evaluation and made recommendations and put interventions based on the findings. The RD stated resident 33 admitted with a low BMI and even though resident 33 had been meeting their caloric needs, they suggested adding medpass as a supplement. The RD stated the medpass was to encourage resident 33 to gain weight due to a low BMI. The RD stated resident 33's BMI had gone from 14 to 15.8 which suggested that the interventions in place were helping resident 33 maintain/gain weight. On 2/20/24 at 3:12 PM, an interview was conducted with the Director of Nursing (DON). The DON stated there was a time when medpass was on back ordered but they had other supplements available for residents. The DON stated supplements were ordered for a variety of reasons such as wound healing and nutritional means. The DON stated resident 33 had supplements ordered to help with caloric intake. The DON stated if the supplements were ordered then they expected them to be given as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined for 1 of 40 sampled residents that the facility did not ensure intravenous (IV) therapy was administered consistent with professional standards of practice as well as implement prevention of infection at the IV site to the extent possible. Specifically, a resident was observed to have IV fluid lying on a flat surface while being administered and no alcohol caps were observed on the IV hub. Resident Identifier: 26 Findings Include: Resident 26 was admitted to the facility on [DATE] with the following diagnoses of osteomyelitis of right ankle and foot, generalized muscle weakness, polyneuropathy, type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer of other part of right foot with bone involvement without evidence of necrosis, and necrotizing fasciitis. On 2/5/24 at 10:41 AM, an observation was made of resident 26's dual lumen peripherally inserted central catheter (PICC) line. One of the ports was observed to have been hooked up to a 500-milliliter bag of sodium chloride fluid which was laying on the bed next to resident 26. The other port was observed to not be covered. An interview was conducted with resident 26. Resident 26 stated the nurse had just connected the IV fluids to the PICC line about 10 minutes ago. Resident 26 stated it was not their job to tell the nurse how to administer the fluids. Resident 26 stated the nurse should have been aware to put the fluids on the pole they had in the corner of the room. Resident 26 stated they were not getting any of the fluids since it was lying next to him. Resident 26 expressed frustration related to the infection control process of their PICC line. Resident 26 stated that sometimes nurses used their PICC line without gloves and without wiping the port clean. On 2/8/24 at 2:39 PM, an observation was made of Registered Nurse (RN) 3. RN 3 was observed to have applied gloves and clean resident 26's PICC line port prior to use. An interview was conducted with RN 3 about resident 26's PICC line. RN 3 stated resident 26 required the PICC due to the intravenous (IV) antibiotics they need for an infection on resident 26's right foot. RN 3 stated the PICC line went into resident 26's subclavian vein which was in the heart. RN 3 stated they needed to disinfect the port prior to each use due to the port being exposed to the environment. RN 3 stated sometimes there were caps that could be put on the PICC line port to keep it clean, but the pharmacy had not sent any. The RN 3 stated they flushed resident 26's PICC line prior to every use to ensure the line was patent. The RN 3 stated resident 26's antibiotics were not hung on the pole since they were delivered in a pressurized ball that delivered the medication over a certain rate. The RN 3 stated a bag of IV fluids needed to be hung on a pole or have some kind of pump or flow regulator for the fluid to drip down since it was not pressurized. On 2/20/24 at 1:12 PM, an interview was conducted with RN 2. RN 2 stated resident 26 had a double lumen PICC that went right to the top of his heart. RN 2 stated the red port was mainly used for blood draws and the blue port was to administer medication. RN 2 stated both ports were flushed to prevent them from clotting off. RN 2 stated to prevent PICC line infections, they scrubbed the port with alcohol, waited for it to dry, and then used a sterile syringe. RN 2 stated they had used caps in the past but currently there was no need since it did not make a difference in preventing PICC line infections. RN 2 stated the caps caused more problems then what they were useful for. RN 2 stated residents were at risk for bed sores in those areas and there was no reason to introduce more problems. RN 2 stated there were studies that showed the same number of patients were getting infections were if they used caps or not on the PICC line port. RN 2 stated infections occurred when the port was not cleaned with an alcohol swab for 10 seconds and bacteria was introduced inside the body. RN 2 stated the alcohol killed any germs that were located on the port. RN 2 stated once the PICC line had been cleaned, they used a sterile syringe on the port to prevent any cross contamination. RN 2 stated resident 26 received two different types of antibiotics in a pressurized ball system which allowed it to be administered at a predetermined rate. RN 2 stated any IV medication in a bag needed to be put on the pole for the fluid to drip in. On 2/20/24 at 2:02 PM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 26 had a PICC line in place for IV antibiotics. The DON stated they noticed resident 26's IV fluid was not on a hook that day and educated the resident on why the fluid needed to stay on the pole. The DON stated since the IV fluid had not been on the pole, that meant the medication had not been infused. The DON stated the nurse was the one responsible to ensure the IV medication was given as ordered and using the appropriate equipment needed to administer the medication. A case study by The American Jornual of Infection Control published on 9/15/22 was referenced. A case study titled: Antiseptic barrier caps to prevent central line-associated bloodstream infections: A systemic review and meta-analysis; was reviewed and summarized why patients benefited from antiseptic barrier caps. It documented a frequent complication of a central venous catheter was the source of contamination at the hub due to micro-organisms colonizing and forming a biofilm and being spread into the bloodstream due to inadequate disinfection techniques which resulted in an increased risk for an acquired central line associated bloodstream infection (CLABSIs). The case study stated, Antiseptic barrier caps have been developed to decrease CLABSIs by reducing the effect of variations in scrubbing duration and techniques .The cap is screwed directly onto the needle-less connector and continuously bathes the access point in an antimicrobial agent and can be left in place between infusions, providing improved disinfection and preventing touch or airborne pathogens from invading the hub.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that for 1 of 40 sampled residents, that the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the the resident's goals and preferences. Specifically, the facility did not have physician's orders in place for a resident's oxygen tubing to be changed or documentation that the resident's oxygen tubing had been changed. Resident identifier: 7. Findings include: Resident 7 was originally admitted [DATE], readmitted [DATE], with diagnoses including chronic respiratory failure unspecified whether with hypoxia or hypercapnia, morbid (severe) obesity with alveolar hypoventilation, chronic obstructive pulmonary disease unspecified, interstitial pulmonary disease unspecified, and dependence on supplemental oxygen. On 2/5/24 at 10:25 AM, an observation was made of Resident 7 in his room. It was noted that the resident was using an oxygen concentrator and was receiving 4 liters per minute of oxygen via a nasal cannula. The oxygen tubing was not dated. On 2/20/24, Resident 7's medical record was reviewed. The following physician's orders were noted with start dates of 9/18/23: a. Oxygen (O2) per nasal cannula at 2 Liters/minute as needed. Goal to maintain oxygen saturations (Sats) greater than (>) 90%. Check O2 sat every shift. b. Monitor shortness of breath (SOB) or Difficulty Breathing: (1) SOB with Exertion (2) Sitting at Rest (3) Laying Flat. c. Check O2 Sats every shift. There were no orders for Resident 7's oxygen tubing to be changed. On 2/20/24, Resident 7's Treatment Administration Record (TAR) was reviewed for the months of September 2023 through February 2024. There was no documentation of oxygen tubing changes in the TAR. On 2/20/24 at 1:10 PM, an interview was conducted with Nursing Assistant (NA) 1. NA 1 stated that Certified Nursing Assistants were responsible for changing oxygen tubing. NA 1 stated that she was unsure when oxygen tubing was changed, but that she thought it happened after each shift change. On 2/8/24 at 10:18 AM, an interview was conducted with the Certified Nursing Assistant Coordinator (CNAC). The CNAC stated she changed Resident 7's oxygen tubing weekly. The CNAC stated that she labels the oxygen tubing with the date that it was changed. The CNAC stated that Resident 7 often refused his cannula tubing to be changed. On 2/20/24 at 1:15 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that oxygen tubing was changed once a week every Sunday. RN 3 stated that the nurse on duty each Sunday was responsible for changing the oxygen tubing. RN 3 stated that she was unsure where the oxygen tubing change would be documented if there was not an order for the tubing to be changed in the resident's chart. On 2/20/24 at 2:37 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the CNAC was responsible for oxygen tubing changes, or the DON's responsibility if there was no CNAC. The DON stated that oxygen tubing should be changed weekly. The DON stated that Resident 7's oxygen tubing had last been changed two weeks ago and that the date it was changed should be marked on the tubing with a piece of tape. The DON stated that she was unsure if the tubing changes would be documented elsewhere. The DON stated that the company policy was to change oxygen tubing each week. On 2/20/24 at 3:02 PM, a copy of the company oxygen tubing policy was requested from the DON. On 2/20/24 at 3:39 PM, an additional interview was conducted with the DON. The DON stated that the company does not have a policy for oxygen tubing changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 out of 40 sampled residents, that the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not submit and follow-up on the application process for the New Choice Waiver (NCW) program that provided support services to enable residents to reside in their own home or other community-based settings. Resident identifiers: 4 and 31. Findings included: 1. Resident 4 was admitted to the facility on [DATE] with diagnoses which included mononeuropathy, chronic respiratory failure, type II diabetes mellitus, morbid obesity, chronic obstructive pulmonary disease, non-pressure ulcer of left calf, schizoaffective disorder, epilepsy, hypothyroidism, peripheral vascular disease, varicose veins, hypertension, bilateral osteoarthritis of hip, intervertebral disc disorder, edema, chronic pain syndrome, tremor, overactive bladder, hyperlipidemia, viral hepatitis C, insomnia, sleep apnea, post traumatic stress disorder, anxiety disorder, bipolar disorder, borderline personality disorder, and major depressive disorder. On 2/6/24 at 10:46 AM, an interview was conducted with resident 4. Resident 4 stated that she wanted to discharge with NCW, but the facility did not submit the paperwork and she was denied. Resident 4 stated she asked the Resident Advocate (RA) for a new application and she said she would lay it on her bed, this was on Friday. Resident 4 stated that on Monday she asked again and it still was not given to her. On 10/14/23, resident 4's Annual Minimum Data Set (MDS) assessment documented that the Brief Interview for Mental Status score was 15, which would indicate that the resident was cognitively intact. Resident 4's progress notes revealed the following: a. On 11/2/23 at 11:21 AM, the Social Service Note documented, New Choice Waiver requested additional paperwork for processing. A new H&P [history and physical] might need to be done by facility Dr [doctor], waiting to her back from NCW. Paperwork was submitted. b. On 2/12/24 at 3:35 PM, the Social Service Note documented, Resident would like to apply for New Choices Waiver. Application submitted with supporting documents On 2/12/24 at 11:12 AM, an interview was conducted with the RA. The RA stated that she started at the facility on 12/19/23. The RA stated that the previous social worker handled all the NCW applications but she was going to be taking on that responsibility now. The RA stated that she was not sure of the application process for the NCW and she would find out more from the Corporate Social Service Worker (CSSW). The RA stated that she was not exactly sure who handled the NCW application prior to her as the facility did not have a SSW for awhile and there was no one here when she arrived. The RA stated that a couple of the residents had asked about their NCW status. The RA stated that the CSSW had just showed her how to access the NCW login. The RA stated that resident 4's application was returned and because it had been so long it needed to be re-submitted again. The RA stated that resident 4 had stated that she wanted to fill out the paperwork and have the facility fax it back to them. The RA stated that she did not know how the previous social worker was tracking the NCW applications prior to her. On 2/13/24 at 11:31 AM, a follow-up interview was conducted with the RA. The RA stated that resident 4's NCW application was submitted on 11/22/23 and the NCW program had requested additional information. The RA stated that on 12/22/23 the application was closed because the facility did not submit the additional information that was requested. The RA stated that she just barely got login access to the NCW. The RA stated that the login page did not reflect where the residents were in the application process. The RA stated that the website would say accepted but that only meant that the application was accepted and not that they had been accepted to the program. 2. Resident 31 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following a cerebral infarction, type II diabetes mellitus, asthma, morbid obesity, generalized anxiety disorder, major depressive disorder, insomnia, hypertension, pseudobulbar affect, hyperlipidemia, nondisplaced fracture of proximal phalanx of left great toe, and chondromalacia left knee. On 2/05/24 at 1:58 PM, an interview was conducted with resident 31. Resident 31 stated that she told management that she wanted to get her own place, but no one had helped her. Resident 31 stated that in November she signed up for the NCW and was assigned a case worker. Resident 31 stated that the facility did not turn in all the required paperwork. On 9/28/23, resident 31's Quarterly MDS assessment documented a BIMS score of 14, which would indicate that resident 31 was cognitively intact. Resident 31's progress notes documented the following: a. On 9/22/23 at 10:14 AM, the Social Service Note documented, NCW waiver sent off today. b. On 10/24/23 at 1:40 PM, the Social Service Note documented, New Choice Waiver website stated that the Resident had been approved. Will follow up with NCW office to find out what the next step for her is at this point. c. On 10/26/23 at 2:53 PM, the Social Service Note documented, Resident remains a valued LTC [long term care] resident of the facility. Resident continues to show signs of little to no cognitive impairment. Resident is oriented to person, place , and time. Resident denies any mood concerns at this time. She tends to be very pleasant upon contact and is a active member of the community. She tends not to participate in most of the scheduled activities but appears to socialize with other residents. She was recently approved for NCW and will start the process of transitioning to a ALF [assisted living facility]. In November 2023 and December 2023 the Specialized Rehabilitation Service (SRS) and Social Work Consultation Services note documented for resident 31, Recent progress notes indicate resident will be moving to an ALF, let's update her care plans to reflect this. It should be noted that no documentation could be found that a care plan was initiated for resident 31's anticipated discharge to the ALF. On 2/13/24 at 11:10 AM, an interview was conducted with the RA. The RA stated she did not know why the resident who had been approved for NCW was still at the facility. Stated she would have to check with the CSSW about this. 02/13/24 11:31 AM, a follow-up interview was conducted with the RA. The RA stated that resident 31 was denied for the NCW program on 10/12/23. The RA stated that resident 31 did not meet the level of care for Activities of Daily Living (ADLs) or cognitive function. The RA stated she did not know why the progress notes said resident 31 was accepted. The RA stated that maybe they thought the website meant they were accepted for the program and not that the application was accepted. The RA stated that if anything had changed in resident 31's level of care requirements then they could reapply for the program anytime.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined for 1 of 40 sampled residents, the facility did not ensure that each resident was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; excessive duration; without adequate monitoring; without adequate indication for its use; or in the presence of adverse consequences which indicated the dose should have been reduced or discontinued. Specifically, a resident's blood pressure was not monitored before being administered pain medication as ordered by the physician. Resident Identifier: 16. Findings Included: Resident 16 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the following diagnoses that included type 2 diabetes mellitus, stage 4 pressure ulcer of sacral region and stage 4 pressure sore of left heel, generalized anxiety disorder, post-traumatic stress disorder, personal history of adult physical and sexual abuse, suicidal ideation, vitamin D deficiency, moderate protein calorie malnutrition, hypomagnesemia, and hypothyroidism. Resident 16's medical record was reviewed on 2/6 through 2/14. A care plan focus area initiated on 2/23/23, documented resident 16 was on pain medication therapy. The listed interventions included administering the pain medication as ordered by the doctor and monitoring for respiratory depression and other adverse side effects such as sedation, dizziness, and altered mental status. A physician order with a start date of 9/7/23 documented, oxyCODONE HCL [hydrochloride] Oral Tablet 5 MG [milligram]. Give 10 mg by mouth every 6 hours as needed for pain. Please check blood pressure before administering this medication!! Resident 16's Medication Administration Record (MAR) was reviewed from February 1 to February 7, 2024. The MAR documented resident 16 had received their oxycodone 19 times in the last 7 days. Resident 16's oxycodone administration times documented the following: a. On February 1, oxycodone 10 mg was administered at 7:40 AM, at 1:59 PM, and at 9:43 PM. [note: there were no documented blood pressure readings 1 hour (hr) prior to the medication administration on this day.] b. On February 2, oxycodone 10 mg was administered at 7:29 AM, at 2:23 PM, and at 6:45 PM. [note: there was only one documented vital sign 1 hr prior to the medication administration on this day.] c. On February 3, oxycodone 10 mg was administered at 6:39 AM and at 12:42 PM. [note: there were no documented blood pressure readings 1 hr prior to the medication administration on this day.] d. On February 4, oxycodone 10 mg was administered at 1:17 AM, at 7:51 AM, at 1:51 PM, and at 7:42 PM. [note: there was only one documented vital sign 1 hr prior to the medication administration on this day.] e. On February 5, oxycodone 10 mg was administered at 1:33 AM, at 11:45 AM, and at 7:11 PM. [note: there were no documented blood pressure readings 1 hr prior to the medication administration on this day.] f. On February 6, oxycodone 10 mg was administered at 3:28 AM and at 12:35 PM. [note: there were no documented blood pressure readings 1 hr prior to the medication administration on this day.] g. On February 7, oxycodone 10 mg was administered at 9:24 AM and at 7 PM. [note: there was only one documented vital 1 hr prior to the medication administration on this day.] Resident 16's vitals were reviewed from February 1 to February 7. Resident 16 had 14 documented vitals in the last 7 days but only 3 of the documented vitals were obtained 1 hour prior to the oxycodone administration. It should be noted a comparison between the documented MAR times and vital times revealed resident 16 was administered their oxycodone 16 times without having a blood pressure checked 1 hour prior. On 2/20/24 at 1:26 PM, an interview was conducted with Registered Nurse (RN) 1. The RN 1 stated vitals were obtained twice a day depending on the resident. The RN 1 stated there were certain medications that a resident's vitals needed to be checked more often such as blood pressure medications. The RN 1 stated the certified nursing assistants (CNAs) tried to get vitals before the medication pass. The RN 1 stated their charting system alerted them if a medication required a vital check prior to administration. The RN 1 stated once the vital had been documented, the system alerted them if the medication could be given. The RN 1 stated if they followed the doctor's orders as instructed. The RN 1 stated resident 16 had a history of low blood pressure and if given the pain medication with another medication it bottomed her out. The RN 1 stated a resident could be hospitalized due to a low blood pressure. The RN 1 stated if a resident had a blood pressure 100/60 or lower then they worried about medication side effects. On 2/20/24 at 3:05 PM, an interview was conducted with the Director of Nursing (DON). The DON stated if there were directions included in the orders, then they expected the nurse to follow them. The DON stated resident 16 oxycodone order indicated a blood pressure check prior to administration. The DON stated it was always best practice to have supplementary documentation included with the order, so the nurses were prompted to obtain the additional information needed prior to the medication administration. The DON stated there was no supplementary documentation included with resident 16 oxycodone order which meant the nurses were not made aware to check resident 16 blood pressure. The DON stated those directions were put in place by the provider to avoid resident 16 from becoming hypotensive and dizzy if their blood pressure was on the lower side prior to the medication administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not ensure that residents were free from any significant medication errors. Specifically, a resident's Trulicity medication was omitted for two consecutive weeks due to unavailability from the pharmacy. Resident identifier: 31. Findings included: Resident 31 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis, type II diabetes mellitus, asthma, morbid obesity, anxiety disorder, major depressive disorder, insomnia, hypertension, pseudobulbar affect, hyperlipidemia, nondisplaced fracture of proximal phalanx left great toe, chondromalacia left knee, and dementia. On 2/10/24 resident 31's medical records were reviewed. On 11/3/23, resident 31 had an order initiated for Trulicity Subcutaneous Solution Pen-injector 0.75 milligram (mg)/0.5 milliliter (ml), Inject 0.75 mg subcutaneously one time a day every Friday related to type II diabetes mellitus. On 1/12/24 at 12:55 PM, the Orders - Administration Note documented that the Trulicity was not administered due to Pharmacy is to deliver today. On 1/12/24, the January Medication Administration Record (MAR) documented that the medication was not administered. On 1/19/24 at 5:14 PM, the Orders - Administration Note documented that the Trulicity was not administered due to waiting on pharmacy. On 1/19/24, the January Medication Administration Record (MAR) documented that the medication was not administered. It should be noted that no documentation could be found that the physician was notified that the Trulicity was not administered. On 2/12/24 at 7:44 AM, an interview was conducted with RN 2. RN 2 stated that the pharmacy usually had any medications delivered to the facility within in a day. RN 2 stated that the new pharmacy was taken longer, a couple of days, but they were getting better at having medications like antibiotics available. RN 2 stated if a medication was not available she would notify the DON and she would then notify the physician. RN 2 stated that the DON had been handling a lot of issues with the new pharmacy. RN 2 stated that if the medication was not available or if it was an insurance coverage issue the DON handled it. RN 2 stated that for a medication like Trulicity she would contact the DON or notify the physician. On 2/12/24 at 10:06 AM, an interview was conducted with the DON. The DON stated that if a medication was not available she would immediate let the pharmacy know and then pull from the Pixus overstock. The DON stated that they did not have Trulicity available in the Pixus. The DON stated that staff should notify her and she would notify the pharmacy immediately. The DON stated that any insulin should be at the facility within hours. The DON stated that staff should have notified the interim DON so that they could notify the Medical Director (MD) and get a new order or attempt to get the medication in the facility. The DON stated that staff should notify the MD immediately of something critical like insulin and then document the MD notification in a progress note.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not provide or obtain laboratory services to meet the needs of the residents. Specifically, a resident had orders for labs that were not obtained by the facility. Resident identifier: 31. Findings included: Resident 31 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following a cerebral infarction, type II diabetes mellitus, asthma, morbid obesity, generalized anxiety disorder, major depressive disorder, insomnia, hypertension, pseudobulbar affect, hyperlipidemia, nondisplaced fracture of proximal phalanx of left great toe, and chondromalacia left knee. On 2/10/24 resident 31's medical records were reviewed. Resident 31's physician laboratory orders revealed the following: a. On 1/19/24, an order was initiated to obtain a Hemoglobin A1c (HbA1c) and a Glomerular Filtration Rate (GFR). b. On 2/1/24, an order was initiated to obtain a HbA1C and a Basic Metabolic Panel (BMP). Review of resident 31's laboratory results revealed no documentation of the physician ordered labs on 1/19/24 and 2/1/24. On 2/12/24 at 10:06 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she checked resident 31's medical records and called the laboratory for the lab results. The DON stated that she could not find any lab results for the HbA1c and GFR on 1/19/24 and the HbA1c and the BMP on 2/1/24.

Based on observation, interview, and record review, it was determined that the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition. Specifically, the facility dishwasher spilled water onto the floor whenever a dishwashing cycle was run. Findings included: On 2/12/24 at 12:35 PM, an interview was conducted with the Dietary Manager (DM). The Dietary Manager stated that the dish machine was serviced by Ecolab once a month. On 2/12/24 at 12:36 PM, the facility's mechanical dishwashing machine was tested. While the dishwashing machine was running, water flowed from the bottom of the machine onto the floor. On 2/14/24 at 9:21 AM, an interview was conducted with the Custodial Staff (CS). The CS stated that it was not normal for the dish machine to flood water onto the floor. The CS stated that either he or the facility maintenance staff usually mopped any spills from the machine. The CS stated that there was currently no maintenance staff at the facility. On 2/20/24 at 2:40 PM, an interview was conducted with the Registered Dietitian (RD). The RD stated that she had observations and reports of water coming out of the bottom of the dish machine. The RD stated that the Dietary Manager was aware of it. The RD stated that maintenance was aware of the issue and working on it. On 2/20/24 at 4:28 PM, The RD provided copies of her January 2024, interim, and February 2024 sanitation audits. The interim audit stated that, The drain doesn't drain fast enough to keep up with the dishwasher output. It does all drain down, it just takes a bit of time. Maintenance has snaked the dishwasher drain multiple times. External plumbing service serviced the drain January 2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews it was determined, for 2 of 40 sampled residents, that the facility did not adequately equip each resident with a communication system that was relaying calls directly to staff or a centralized work area. Specifically, residents call lights were not functioning properly. Resident identifiers: 26 and 30. Findings Included: On 2/8/24 at 1:52 PM, an observation was made of the maintenance log located next to the nurse's station. The maintenance log dated 2/4/24 documented there was a repair/safety concern that needed to be fixed for room [ROOM NUMBER] b and c. It documented the following issue, Light needs fixed please. Call light stays on. On 2/5/24 at 10:35 AM, an interview was conducted with resident 26 who resided in room [ROOM NUMBER] B. Resident 26 stated the call light had not been working for the last two days. Resident 26 stated their call light outside of the room had been on for the last two days, so staff were unsure when they needed assistance. On 2/6/24 at 8:44 AM, an interview was conducted with resident 30 who resided in room [ROOM NUMBER] C. Resident 30 stated they believed their call light had been working the last couple of days. Resident 30 stated they do not use their call light and instead went into the hallway to find staff for assistance. Resident 30 stated they were unsure why they had the red cowbell. Resident 30 stated staff must have found it under their roommate's bed and assumed it was theirs. Resident 30 stated they were unaware that was an alternative for a call light. On 02/14/24 at 1:33 PM, an interview was conducted with Corporate Maintenance (CM). The CM stated he was temporary and had only been here for 3 days. The CM stated he was responsible for project management and trying to help out the building. The CM stated he came to the building depending on how big the project was. The CM stated they oversaw big projects such as replacing toilets, working on AC units, doing floor repairs and doing a fluff and puff on a new room. The CM stated he did not do the day-to-day maintenance stuff and did not generally look at the maintenance log. The CM stated the administrator oversaw the maintenance log. The CM stated they assumed the administrator would notify them of anything they needed to fix from the maintenance log. The CM stated he did not look at the facility maintenance log unless he was asked to. On 2/14/24 at 3:15 PM, an interview was conducted with Nursing Assistant (NA) 3. The NA 3 stated if the call light system was not working, first they tried to replace the cord. The NA 3 stated on the weekends, staff present tried to fix the call light and if they were unable to then they wrote it down on the maintenance log. The NA 3 stated if the problem occurred on the weekday, they notified the maintenance man or administration. The NA 3 stated residents were provided cow bells if their call light was not working and stated it was not the best solution, but it was better then not having anything. On 2/20/24 at 1:23 PM, an interview was conducted with the Administrator (ADM). The ADM stated if a resident's call light was not working then residents were provided a cow bell within a short period of time until the call light was fixed. The ADM stated residents thought the cow bells were stupid at first. The ADM stated residents have used the cow bells when they were provided to them as an alternative to get a hold of staff. The ADM stated residents located further down the hall from the nurses' station were harder to hear then the ones located closer to the nurses station. On 2/20/24 at 2:06 PM, an interview was conducted with the Director of Nursing (DON). The DON stated they had a call light system located next to the nurse's station. The DON stated staff were able to look at the system to see who's call light was going off. The DON stated if a call light had issues, they unplugged it to see if it fixed the issue. The DON stated if the call light was not working after unplugging it and plugging it back in then the resident's were given a bell. The DON stated the bell was used to notify staff they needed help. The DON stated residents have expressed their dislike of the cow bells and have raised concerns about them. The DON stated residents have said they did not want to keep continually ringing their bell till someone could answer it. The DON stated they were able to understand how the bell was a dignity problem.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not promptly act upon the grievances and recommendations of the resident council concerning issues of resident care and life in the facility. In addition, the facility was not able to demonstrate their response and rationale for resident concerns. Specifically, recurring concerns were voiced by the resident council over the period of approximately 14 months with no follow up to or resolution of the concerns. Findings include: The resident council notes for the previous 14 months were reviewed and revealed the following concerns voiced by the residents: a. On 1/25/23: i. The parking lot is hard to maneuver, it's dangerous. People keep falling and hard to maneuver with a wheelchair. ii. Agency staff don't always understand specific needs. High turn over rate. Affecting care. iii. Dietary: I like him [name of staff member] he's doing better. Tray transfer needs to be thought over, need to use second cart so dirt/grime does not get on the bottom trays. Larger portions. b. On 2/24/23: i. Water jugs. (switch off.) instead of being picked up and waiting. Just switch them off. ii. Dietary: . Portions are too small, need another set of hands. c. On 3/31/23: i. Water (takes hours). [Note: There was no specific information regarding what this concern referred to.] ii. Call lights are not being answered (1 hr (hour) [and] 45 minutes went by). iii. Medications are late iv. A lot of slacking, there should always be someone on the floor. v. Speak to CNA's (Certified Nursing Assistants) about not forcing residents to go to sleep (not allowed). vi. Staff is slacking, every day can't be an emergency. Wait time is too long. They have to do what they have to do. I'm going backwards in my disability not getting the assistance I need. vii. Dietary: Food portions are small. Reassess drinks (many are not receiving milk.) Tickets are not being followed. Food is cold. They need to learn portion control. Bring out alternative menus to fill out. d. On 4/25/23: i. Water is still not being distributed (not being passed out). ii. CNA's are not answering call lights in appropriate timing. iii. Nurses are no where to be found (solution would be to hire another nurse. iv. CNA's only doing their section whey they can help. (Help where you can.) (Spend more time charting.) v. Run out of toilet paper. vi. Laundry: a lot of clothes have gone missing. vii. Dietary: Not being served enough food (reach out to corporate to fix portions or double up portions.) Need to serve mechanical soft food. e. On 5/30/23 i. Residents state that nurses need to pay better attention to them. ii. Residents want more ice cream! They also want their ice cream to not be melted by the time they are ready to eat it - Arrives directly with the meal. iii. Issues: Residents need to receive care within a timely matter. Cold food. Missing items in laundry. iv. Dietary: Food is often late 15 - 45 minutes better portions - they want. v: Nursing: need to be more attentive to residents [and] their needs. vi. Problems - Nurses don't pay attention to the people they need to pay attention to. Someone will be yelling to get nurse's attention and it takes forever to get attention and help they need. They need to be taken care of . Call lights not being answered. vii. [Resident name] his served is food, but no one is available to help him for at least a half hour. Food is always cold. viii. [Resident name] said she is missing several pairs of clothing - 6 times! She is concerned that the clothes always go missing. her clothes are getting washed and she is not getting them back . f. On 6/13/23: i. Call lights not being answered promptly .CNA's need to do their job ii. Housekeeping: Wondering if they still work here?? Floors need to be cleaned, rooms need more attention - cockroaches iii. Laundry: Needs to make sure clothes are getting returned to residents. Multiple residents were documented to have missing laundry items. iv. Dietary: food is cold. v. Someone pooped outside [and] has been peeing [and] throwing up on side of the building. pooped over the weekend below the bird food area is - happened on Sunday. vi. Water mugs have not been consistently going out the last few days. g. On 7/27/23: i. Staff and other residents walking into other people's rooms without notice. ii. Residents want beds made. iii. Snacks not being passed out in evenings. iv: Dietary: Food could be better. h. On 8/8/23: i. Nursing: Working their tails off . Sad they lost hope. CNA's - short-handed. ii. Dietary: Cold food. Portions are too small. High turnover. Too salty .Chicken is not cooked all the way. Still pink in the middle. Worried that food is cold in kitchen before it comes out. i. On 9/12/23: i. [Name of resident] - wants to meet with dietician (sic) about high protein diet - wants protein drinks - not allowed to have them of (sic) the facility. Been told several [NAME] (sic) to remove from building. ii. Housekeeping: . doesn't sweep floor [and] just mops, pushes things around. iii. Nurses [and] CNA's . need to be more on top of it - waiting a long time answer residents. [Note: No documentation could be located to indicate what the facility's response to the resident council concerns were for the months of January, February, March April, May, June, July, August, and September 2023.] j. On 10/11/23: i. Housekeeping: . doesn't sweep - just mops over it, bathrooms need more attention . black mold. ii. Dietary: cold food, [name of resident] receiving food she doesn't want . bland food, want more seasoning - veggies too mush or too hard. Never medium. iii. CNA's - call lights are taking 45 minutes - 1 hour. iv. New Business: String in bathroom for emergency .More access to ice - resident waited an hour. v. Issues: not getting water daily - 4/5 days no hydration cup. This month a Resident Council Departmental Response Form was attached to the resident council notes. In response to the dietary concerns, the interventions included Will have department head pull a test tray regularly to ensure consistency of food. In response to the housekeeping concerns, the interventions included Education completed on housekeeping cleaning procedures . correct mold spray purchased, facility housekeeping to clean bathrooms. k. No resident council notes for November 2023 were provided by the facility. l. On 12/19/23: i. Housekeeping: [Name of staff member] is nice but cleaning is not up to par. Community needs a deep clean. ii. Laundry: Clothes missing. Need follow through. This month a Resident Council Departmental Response Form was attached to the resident council notes. In response to the housekeeping concerns, the interventions included Housekeeping staff re-education on duties and cleaning responsibilities completed. m. On 1/9/24: i. Housekeeping - [Administrator] has had talks with housekeeping - re education however residents haven't seen a change. Place is not clean - Gotten better but still need work. ii. Nursing: . Residents don't feel heard by CNAs. iii. Maintenance: .Building seems run down needs TLC. iv. Dietary: . Feels like the same thing all the time. Portions are small. Not a lot of care put into it. Worn out menu. Food not up to par. Dining room not clean. Stuff runs out. Meals not Complete. Kitchen is just sad! v. Some residents feel neglect. [Note: There was no other specific information as to what the resident council discussed with regard to possible neglect.] This month a Resident Council Departmental Response Form was attached to the resident council notes. In response to the dietary concerns, the interventions included Audited meal service on portion sizes with cook, RD (Registered Dietitian) and I. Admin (Administrator) pruchesed (sic) condiment holders for tables. [Note: Not all of the concerns voiced by the residents were addressed on the response form.] n. On 2/6/24: i. Issues: Water is not warm enough - Not enough hot water. ii. Administration: . I think she trys (sic) hard overall but need to stop making excuses for everyone. She sucks. iii. Housekeeping: . Does not thurgly (sic) clean - nice guy but cleaning is not good. iv. Maintenance: . Going down hill fast - they didn't even know we had one - Clean filters! MOLD! v. Dietary: . Like kitchen staff. Do not like food. Portions are small. Stay on top of stuff you run out off (sic). There was no Resident Council Departmental Response Form connected with the February 2024 resident council notes. On 2/14/24 at 11:26 AM, an interview was conducted with the facility Activities Director (AD). The AD stated that she has only worked here since December 2023. The AD stated that after she has conducted a resident council meeting, she brings the notes to stand up meeting the following morning, where department heads go over everything, and then they write out how they will correct the issue. The AD stated that the department heads then filled out a correction form, and would give the form to the Administrator (ADM). The AD stated that she would present the correction forms to the resident council the following month. On 2/14/23 at 1:03 PM, an interview was conducted with the facility ADM. The ADM stated that prior to October 2023, there were no response forms being completed by facility staff in regard to concerns voiced at resident council. The ADM stated that after a resident council was conducted, the AD would write out the response forms for the department that it goes to, then the department head comes up with a solution, and sends back the forms to her. When asked if recurring issues raised in resident council were incorporated into the facility Quality Assurance (QA) program, the ADM stated, theoretically if we are working on it, it should be in QA, but that it had not been brought to QA at that time. [Cross refer to F584 and F804]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, the facility did not have a full time maintenance worker, resident areas were dirty, there was a lack of hot water in resident bathrooms and communal shower room, a resident bathroom door was in disrepair, a resident had missing items which had not been replaced and a column from the gazebo area outside had a loose metal base which caused a resident to fall resulting in a laceration. Resident identifiers: 4, 21, 26, 30, 31, 33, and 34. Findings Include: MAINTENANCE AND HOUSEKEEPING 1. On 2/7/24 at 9:32 AM, an interview was conducted with resident 4. Resident 4 stated that the dining room tables and table linens were filthy and the dining room usually had a bad odor. Resident 4 stated that the drinking fountain in the dining room had a sewer smell. Resident 4 stated that they ran out of toilet paper a week ago and they were out for 3 days. Resident 4 stated that they had to use Kleenex or paper towels instead of toilet paper during that time. Resident 4 stated that the staff reported to her that they were out of toilet paper because supplies were not ordered. Resident 4 stated that her air conditioner/heater unit was full of dust and the unit itself was not sealed. Resident 4 stated that the heating unit had a big gap and it let cold air and spiders in from the outside. The heating unit was observed with a gap and the light from outside could be observed from inside. Resident 4 stated that she placed a ace wrap bandage over the top of the heating unit to cover the gap to the outside in an attempt to keep the cold and spiders out. 2. On 2/5/24 at 10:35 AM, an interview was conducted with resident 26. Resident 26 stated no one cleaned their room on the weekend. Resident 26 stated six residents shared a restroom and it had not been cleaned in 3 days. 3. On 2/5/24 at 9:34 AM, an observation was made of the floor directly inside the door of room [ROOM NUMBER]. The floor was dirty with dried splatter marks on the floor. 4. On 2/5/24 at 10:27 AM an observation of resident 33's room was made. The floor next the bed was observed to have dried dirt. The floor underneath the bed was observed to have cigarettes and food crumbs present. 5. On 2/22/24 at 8:45 AM, an observation was made of room [ROOM NUMBER]'s bathroom door with the Administrator (ADM). The bathroom door was observed to have wood missing and the bottom rail of the door was no longer intact. The administrator was observed to pull the wood panel away from the bottom rail. An interview was immediately conducted with the ADM. The ADM stated the door needed to be replaced because it was a hazard to residents. 6. On 2/6/24 at 9:20 AM, an observation was made of resident 21's room. The bedside table by the window was observed to have multiple sticky areas and debris on it. The legs of the bedside table were noted to have black grime, dust and debris on them. The blinds in the room had several areas that were broken and/or missing. Resident 21's room was observed to have multiple spills with sticky and grimy areas on the floor. An interview was immediately conducted with resident 21. Resident 21 stated he had his own bedside table, so he was unsure what the extra table in his room was for. 7. On 2/13/24 at 9:48 AM, an observation was made of a brown substance on the white banisters near room [ROOM NUMBER]. 8. On 2/13/24 at 10:43 AM, an observation was made of the facility shower room. There was a plastic garbage liner covering the toilet in the room. There were several soiled wipes on top of the toilet tank. The trash bin next to the toilet was overflowing with visibly soiled incontinence wipes and paper towels. There was a bottle of Vagisil body wash laying in the middle of the floor in between the north shower and the toilet. There was black mold in the north shower near the drain and the southern wall of the shower. There was a soiled hospital gown laying on the floor near the toilet. There were numerous brown stains and streaks consistent with the texture and appearance of feces on the walls near the toilet and the sinks. The insides of all three doors in the shower room were visibly soiled, and the bottoms of the doors were peeling upwards. On 2/13/24 at 3:16 PM, an interview was conducted with the Certified Nursing Assistant Coordinator (CNAC). The CNAC stated that to her knowledge, the shower room was never cleaned unless it was in enough of a poor condition for staff to notice. The CNAC stated that up until the week prior, there had been mold on the ceiling of the shower room. The CNAC stated that she was unsure if the mold had been cleaned off or painted over. The CNAC stated that no one was assigned to clean the bathroom and that there was no cleaning schedule. The CNAC stated that laundry staff will go into the shower room and clean it to the best of their ability and that housekeeping staff will occasionally clean the room. The CNAC stated that the weekend housekeeping staff quit and that there was no coverage of Fridays, Saturdays, or Sundays. The CNAC stated that due to the absence of a weekend housekeeper this caused the weekday housekeeper to struggle to catch up. The CNAC stated that she had observed residents of the facility urinating on the plastic liner covering the toilet in the shower room. The CNAC stated that the facility ran out of toilet paper the week prior. On 2/14/24 at 8:54 AM, an interview was conducted with the Laundry Attendant (LA). The LA stated that the facility housekeeper was responsible for cleaning the shower room each day. The LA stated that there should be a housekeeper on the weekends and a laundry attendant on the weekends. On 2/14/24 at 8:58 AM, an interview was conducted with the Custodial Staff Member (CS). The CS stated that he worked Monday through Friday and weekends as needed. The CS stated that during the week he was the only housekeeper and on weekends as well. The CS stated that the weekend housekeeping staff member keeps quitting. The CS stated that there were currently no weekend housekeeping staff. The CS stated that the shower room should be cleaned by housekeeping once daily and that he cleaned it each day he worked. The CS stated that it would be too much work to clean the shower room after each individual shower. The CS stated that the Certified Nursing Assistants (CNAs) should sanitize the shower room after each shower. The CS stated that the sanitizer was stored in the utility closet at the end of the hall. The CS stated that the shower room did not get cleaned on the weekends that he did not work. The CS stated that when he comes in on Mondays the shower room was covered in feces due to there being no housekeeping staff on the weekends. The CS stated that the toilet in the shower room had not been functional for 2-3 days. The CS stated that residents frequently try to flush paper towels down the toilet and that it then become clogged afterwards. The CS stated that residents will continue to try and use the toilet while it was clogged despite him putting up an out of order sign on the door, which then further clogged the toilet. The CS stated that there was a toilet in room [ROOM NUMBER] that did not flush because of a broken chain. The CS stated that there were two other rooms with toilets that were not functional. The CS stated that the caulking on many of the toilets in the facility was damaged, and that he had addressed this with the facility administrator multiple times. The CS stated that it was difficult to keep the toilets clean in their current state as the caulking was stained and breaking off. The CS stated that the shower in room [ROOM NUMBER] did not have a shower curtain and that the shower in either room [ROOM NUMBER] or room [ROOM NUMBER] did not properly drain due to the drain being clogged. The CS stated the dining room should be cleaned at least three times a day, but he can only get to it twice a day. The CS stated that floors, tables, plastic clothes covers, sink area, water fountain, and microwave should all be cleaned in the dining room. The CS Stated that there had not been a deep cleaning in the dining room in several months. The CS stated that a deep cleaning would include cleaning the vents, baseboards, floorboards, and walls. The CS stated that the facility did not currently have any maintenance staff. The CS stated that the facility had not had maintenance staff for two weeks. The CS stated that the facility pest control was provided by an outside company named EcoLab. The CS stated that EcoLab had just visited the facility the week prior. The CS stated that the facility administrator was responsible for pest monitoring. The CS stated that EcoLab employees spray pesticides around the outside of the building, the baseboards in the hallways, and the baseboards in the dining room. The CS stated that EcoLab did not spray the pesticide inside of resident rooms. The CS stated that residents have complained about cockroaches, but he personally had not seen any. The CS stated that he had never seen rodent droppings or dead spiders in the facility. The CS stated that he frequently runs out of cleaning supplies including soap, paper towels, toilet paper, garbage liners, and floor cleaner. The CS stated that he had to put a lock on the cabinet where the small garbage liners were stored because the facility kept running out of liners too quickly. The CS stated that he leaves the key to the supply closet with the weekend laundry staff when he leaves for the weekend. The CS stated that if anything in the facility needed to be fixed, he had to call in the corporate maintenance staff and that it could be at least 1-2 days before the corporate maintenance staff could come in and make repairs. The CS stated that there was a maintenance log that staff members could fill out, however there was currently no maintenance staff to address the maintenance log. On 2/14/24 at 1:33 PM, an interview was conducted with the Corporate Maintenance (CM). The CM stated he was temporary and had only been here for 3 days. The CM stated that he got a text from the Administrator to replace the toilet and that was why he was here. The toilet he was replacing was old and worn out and got a lot of usage. The CM stated he was responsible for project management and helped with the building. The CM stated he came to the building depending on how big the project was. The CM stated they oversaw big projects such as replacing toilets, working on air conditioning (AC) units, doing floor repairs, and doing a fluff and puff on a new room. The CM stated he did not do the day-to-day maintenance stuff and generally did not look at the maintenance log. The CM stated the Administrator oversaw the maintenance log. The CM stated they assumed the Administrator would notify them of anything they needed to fix from the maintenance log. The CM stated he also oversaw other buildings. The CM stated he did not look at the facility maintenance log unless he was asked to. The CM visualized the black areas in the main shower room and stated the black areas were not mold and it looked more like algae. The CM stated the black areas could be removed if the area was cleaned/disinfected. The CM stated the caulking around the toilet was not a requirement. The CM stated the caulking served as a sealant. The CM stated if there was no sealant then fluid might be able to get under the toilet. The CM stated if a resident voided on the floor or had diarrhea on the floor and it happened to go under the toilet then he expected a smell to be present underneath it since there was no sealant to prevent the fluid from going underneath and there was no way to clean underneath the toilet. The CM stated depending on the substance spilled on the floor around the toilet, then a smell might have been present. The CM stated the in-house maintenance man was the one responsible for changing the vents. The CM stated if the vent was dusty then they expected there to be a restriction in the airflow due to the dust so it would not work as efficiently. The CM stated they recently looked at a resident's AC/heater system on Monday and stated there was nothing wrong with it. The CM stated they checked to make sure nothing was impeding the seal and then put the cover back on and screwed it on tight. The CM stated the resident told them they had bugs coming in from the vent, but they stated they believed the bugs were coming from all the plants she had in her room. The CM stated he believed the plants gave the bugs a place to live and that was where they were coming from. The CM stated he did not come to the building every day. 9. The resident council notes for the previous 14 months were reviewed and revealed the following concerns voiced by the residents regarding the cleanliness and maintenance of the facility: a. On 1/25/23: i. The parking lot is hard to maneuver, it's dangerous. People keep falling and hard to maneuver with a wheelchair. b. On 4/25/23: i. Run out of toilet paper. c. On 6/13/23: i. Housekeeping: Wondering if they still work here?? Floors need to be cleaned, rooms need more attention - cockroaches ii. Someone pooped outside [and] has been peeing [and] throwing up on side of the building. pooped over the weekend below the bird food area is - happened on Sunday. d. On 7/27/23: i. Residents want beds made. e. On 8/8/23: i. Housekeeping: . doesn't sweep floor [and] just mops, pushes things around. f. On 10/11/23: i. Housekeeping: . doesn't sweep - just mops over it, bathrooms need more attention . black mold. ii. New Business: String in bathroom for emergency . This month a Resident Council Departmental Response Form was attached to the resident council notes. In response to the housekeeping concerns, the interventions included Education completed on housekeeping cleaning procedures . correct mold spray purchased, facility housekeeping to clean bathrooms. g. No resident council notes for November 2023 were provided by the facility. h. On 12/19/23: i. Housekeeping: [Name of staff member] is nice but cleaning is not up to par. Community needs a deep clean. This month a Resident Council Departmental Response Form was attached to the resident council notes. In response to the housekeeping concerns, the interventions included Housekeeping staff re-education on duties and cleaning responsibilities completed. i. On 1/9/24: i. Housekeeping - [Administrator] has had talks with housekeeping - re education however residents haven't seen a change. Place is not clean - Gotten better but still need work. ii. Maintenance: .Building seems run down needs TLC. iv. Dietary: . Dining room not clean. Kitchen is just sad! j. On 2/6/24: i. Issues: Water is not warm enough - Not enough hot water. ii. Housekeeping: . Does not thurgly (sic) clean - nice guy but cleaning is not good. iii. Maintenance: . Going down hill fast - they didn't even know we had one - Clean filters! MOLD! There was no Resident Council Departmental Response Form connected with the February 2024 resident council notes. 10. Resident 34 was admitted to the facility on [DATE] with diagnoses which included intracranial injury with loss of consciousness, unsteadiness on feet, history of Traumatic Brain Injury (TBI), intellectual disabilities, anxiety disorder, major depressive disorder, and impulse disorder. Resident 34's medical records were reviewed between 2/12/24 and 2/22/24. On 11/18/23, resident 34's admission Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) was conducted. Resident 34's scored a BIMS of 8, which indicated a moderate cognitive impairment. Resident 34's care plans were reviewed and indicated the following: a. A care plan dated 11/10/23, with a focus area documented resident 34 has limited physical mobility r/t [related to] neurological deficits r/t TBI, intellectual disability, weakness, altered gait, unsteadiness on feet. Interventions included, AMBULATION: Requires supervise/touching assist of 1 with ambulation (provide cues, reminders) with use of cane. Observe for changes in ability . Now has a quad cane but resident doesn't comprehend how to use at times-- will just care [sic] it. b. A care plan dated 11/8/23, with a focus area documented resident 34 was at risk for falls per standardized fall scale, wandering/elopement risk, unsteadiness on feet, altered gait . epilepsy, cognitive impairment . history of frequent falls, weakness an loss of balance. Interventions included, safety awareness training daily for 2 weeks, then weekly and therapy evaluation and treatment if indicated related to a fall. Nursing notes for resident 34 revealed the following: a. On 12/13/23 at 4:00 PM, a nurses progress note documented, Resident 34 had witnessed fall in backyard, tripping over a piece of the support pole of the awning, open laceration to right eyebrow, assessment completed, neuro-checks initiated, per physician resident to be transferred to ER [emergency room] for stitches to eyebrow. b. On 12/13/23 at 5:01 PM, a nurses progress note documented, resident 34 was Transferred to [a local hospital] via [emergency medical services] for stitches to eyebrow. c. On 12/14/23 at 5:54 AM, a nurses progress note documented, Resident returned from [a local hospital] at [9:00 PM]. Resident was seen for head laceration . Instructions: Sutures need to be removed in 7-10 days, keep wound clean and dry . d. On 12/14/23 at 9:30 AM, an Interdisciplinary Team (IDT) Event Review note documented, resident did fall, tripping on a piece of metal from a column, root cause found to be that the base of the column was coming loose--this has been removed and maintenance is also looking at all the columns in the backyard today to ensure that there are no tripping hazards, [Resident 34] did suffer an eyebrow laceration and was taken to [a local hospital] for stitches, intervention is that CNA Coordinator will meet with [Resident 34] once a day to discuss safety awareness x 14 days[on weekdays], all other least restrictive interventions in place, will continue with plan of care. A review of the facility's risk report dated 12/13/24 at 7:52 PM, documented, Patient was outside smoking with the CNA [name removed] supervising. He was walking towards the table and his foot caught on the bottom of the pole that supports the roof. He fell and hit his R [right] eye and it cut his eyebrow line and was bleeding. He also hit the back of his heads [sic] after bouncing his eyebrow off the table. On 2/21/24 at 10:50 AM, an interview was conducted with the Director of Therapy services (DOT). DOT stated that she would perform safety checks for safety awareness. DOT stated that resident 34's retention was not amazing and that education had to be very repetitive. DOT stated that she was unsure if other staff educated resident 34 on his safety awareness. On 2/21/24 at 11:20 AM, an observation was made of the smoking area where resident 34 had fallen. An observation was made of 4 columns were holding up a gazebo. Three of the columns had a square metal base surrounding the columns and the bases were observed rusty and nailed into the concrete. On 2/21/24 at 11:34 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that Resident 34 was difficult and that resident 34 needed more supervision than he could get at the facility. RN 2 stated that resident 34 needed supervision while smoking. RN 2 stated that the day resident 34 fell, he was outside smoking and had supervision. RN 2 stated that there was a column outside in the smoking area that had a metal piece on the metal plate that had lifted up off of the cement. The metal piece was no longer bolted down and was a tripping hazard. RN 2 stated that after resident 34 fell the metal piece had been removed. RN 2 stated that resident 34 had alterations with his gait and that he walked with a limp so staff should try to keep a close eye on him. On 2/21/24 at 12:20 PM, an interview was conducted with the Administrator in Training (AIT). The AIT stated that the metal base resident 34 had tripped on was in a high traffic area and was a tripping hazard. He stated that a screw holding the metal base to the concrete had fallen through and the metal base began flaring upward. The AIT stated that the metal bases resident 34 had tripped on had been removed. COLD WATER 11. On 2/6/24 at 8:44 AM, an interview was conducted with resident 30. Resident 30 they were having to take a cold shower because staff had recently turned down the water heater temperature. Resident 30 stated the sink in their restroom had no warm water. On 2/7/24 at 9:56 AM, an interview was conducted with resident 31. Resident 31 stated she wanted to shower yesterday, but management said that there was no hot water. On 2/8/24 at 10:18 AM, an interview was conducted with the Certified Nurse Assistant Coordinator (CNAC). The CNAC stated that if they had 3 or 4 showers back to back that they would run out of hot water and the aides would have to wait for a hour or so for the water to heat up On 2/6/24, the facility water temperatures were checked in the communal shower room and various resident rooms. At 12:37 the shower head was turned on in the communal shower room and the warmest temperature documented was 100.6 Fahrenheit (F). The water temperature for 3 resident bathrooms were randomly checked and the temperature varied from 54.7 F to 55.8 F. There was no hot water coming out of the resident sinks. On 2/14/24 at 1:33 PM, an interview was conducted with the Corporate Maintenance (CM). The CM stated the water regulator was set at 116 degrees, so they expected there to be a variation between 2-4 degrees from the set temperature due to a line droppage in temperature. The CM stated the rooms located the furthest away from the water heater had the greatest variation in water temperatures. MISSING ITEMS 12. Resident 31 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis, type II diabetes mellitus, asthma, morbid obesity, anxiety disorder, major depressive disorder, insomnia, hypertension, pseudobulbar affect, hyperlipidemia, nondisplaced fracture of proximal phalanx left great toe, chondromalacia left knee, and dementia. On 2/05/24 at 1:55 PM, an interview was conducted with resident 31. Resident 31 stated she was missing a couple pairs of legging, a shirt, a blanket, and socks. Resident 31 stated that she reported it to the Director of Nursing (DON) and the Administrator (ADM). Resident 31 stated that they had not replaced anything. On 2/10/24 resident 31's medical records were reviewed. On 11/29/23, the grievance binder documented that resident 31 reported that someone went through her drawers and she was missing a [NAME] mac & cheese box. The facility replaced the missing item. No documentation could be found for any missing clothing items for resident 31. No documentation could be found of a personal inventory list for resident 31. On 2/12/24 at 9:05 AM, an interview was conducted with Nursing Assistant (NA) 4. NA 4 stated that missing items were reported to the DON and ADM. NA 4 stated that as she was cleaning a resident's room she would look for any reported missing items. On 2/13/24 at 11:46 AM, an interview was conducted with the DON. The DON stated that resident 31 did not report any missing personal items to her. On 2/12/24 at 11:12 AM, an interview was conducted with the Resident Advocate (RA). The RA stated that she handled all grievances. The RA stated that grievance forms were located all over the facility for resident access and staff could assist with filling out the form. The RA stated that if the form was not delivered directly to her it could be placed on her desk. The RA stated that depending on what the grievance was she would follow-up with the resident and verify the information contained on the form. The RA stated that the form contained a spot to document witness statements or other investigation documentation. The RA stated that sometimes the grievance was about missing clothing. The RA stated that if a piece of clothing goes missing the form was still filled out. The RA stated that sometimes they mark the clothing with the resident's name. The RA stated that she did not recall that resident 31 had missing clothing. The RA stated that during the investigation she would look through the resident room, ask other residents in the room about the missing item, go to laundry and look for it, and if she was not able to locate the items she would notify the ADM to replace the items. On 2/13/24 at 11:37 AM, a follow-up interview was conducted with the RA. The RA stated that the personal inventory list was at the nurses station, and staff would add items to the list. That form then was scanned into the electronic medical records. The RA stated that if the personal inventory list was not located in the electronic medical records than it probably did not get completed. The RA stated that she would still replace any missing items for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. NEGLECT [Cross refer to F624, F644, F676, F689, F690, F697, F725, F740, F760, and F804] Based on interview and record review it was determined, for 4 out of 40 sampled residents, that the facility did not ensure that the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Specifically, a resident to resident verbal altercation escalated to an incident of physical abuse when a resident threw a can of food at another resident and struck them in the leg. Additionally, a resident to resident verbal altercation escalated to an incident of physical abuse when a resident cut another resident with a razor. In addition, multiple areas of neglect were identfied during the survey. Resident identifiers: 7, 19, 31, and 36. Findings included: ABUSE 1. A. Resident 36 was admitted to the facility on [DATE] with diagnoses which included traumatic subdural hemorrhage, cirrhosis, type II diabetes mellitus, excoriation (skin picking) disorder, major depressive disorder, stimulant abuse, chronic pain, gout, polyneuropathy, hepatitis C, chronic kidney disease, insomnia, history of suicidal behavior, and unilateral inguinal hernia. On 2/05/24 at 9:45 AM, an interview was conducted with resident 36. Resident 36 stated that he had problems with resident 7 and he talked shit about him. Resident 36 stated that he used to be resident 7's roommate. On 2/07/24 at 9:43 AM, a follow-up interview was conducted with resident 36. Resident 36 stated that a couple of weeks ago he and resident 7 were arguing and resident 7 alleged he hit him. Resident 36 stated that the police were notified and he was moved to another room after this incident. Resident 36 stated that yesterday resident 7 threw a can of food at him and hit his left leg. Resident 36 stated he wanted to press changes. Resident 36 stated that the Administrator (ADM) told him not to go into resident 7's room. Resident 36 stated that he was outside of the room trying to speak to resident 29 who resided in that room and was his friend. Resident 36 stated that he did not enter the room. Resident 36 stated that resident 7 got up and threw the can at his leg and screwed it up. Resident 36 stated that resident 7 should have gone to jail for throwing the can. On 12/30/23, the admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 11, which would indicate a moderate cognitive impairment. Review of the facility abuse investigations revealed the following: a. On 1/11/24 at 11:30 AM, the facility became aware of an allegation of verbal abuse between the resident 36 and resident 7. Resident 36 alleged that resident 7 was being racist and calling him names and it escalated to a verbal argument. Resident 36 stated that he was fine and that he was not hurt emotionally or mentally. The report documented that resident 36 stated that he was called the N word. He was upset because [resident 7] kept interrupting his conversations with the staff. [Resident 36] stated he only called [resident 7] fat after [resident 7] had called him the 'N*****'. Resident 36 denied calling resident 7 fat prior to this incident. The facility report documented an interview with the custodial staff (CS) who witnessed the incident. The CS reported that he was cleaning resident 36's room and resident 7 started antagonizing resident 36 saying he was dirty and used racial slurs. The CS reported that resident 36 requested he clean under his bed and resident 7 called resident 36 Dirty N*****. The CS reported, There was no reason for [resident 7] to say anything to [resident 36]. The report documented that resident 29 who was the roommate stated that he heard both resident 7 and resident 36 call each other names. The conclusion of the facility investigation confirmed the verbal altercation was verbal abuse and both parties engaged in inappropriate verbal dialogue. b. On 1/17/24 at 12:13 PM, the facility became aware of an allegation of physical abuse between the resident 36 and resident 7. Resident 7 alleged that resident 36 punched him in the forehead with an open-ended fist. The report documented that resident 7 refused a skin check, but that the regional nurse did not observe any redness or bruising in the area that the resident alleged he was hit. The summary of the interviews documented that resident 7 stated that he was in a verbal altercation with resident 36 because his phone was too loud. Resident 7 said that resident 36 was calling him names and getting in his face when resident 36 open fisted punched resident 7 in the forehead. Resident 7 reported that there was no marks but he felt dizzy. The report documented that resident 29, the roommate, stated that resident 36 did not hit or touch resident 7. Resident 36 denied ever touching resident 7. The report documented that no action was taken by the police as there was no evidence of assault. The interview with resident 36 stated that he got angry at resident 7 due to resident 7 talking smack. Resident 36 reported that he got in resident 7's face and told him to shut up. The report documented that resident 36 requested a room change. The conclusion of the facility investigation was that the allegation of physical abuse was not substantiated or verified. c. On 2/6/24 at 5:00 AM, the facility became aware of an allegation of physical abuse between resident 36 and resident 7. Resident 36 alleged that resident 7 threw a can at him during a verbal dispute. Resident 36 stated he was in the doorway talking to his friend (resident 29) who was the roommate of resident 7. The report documented that the incident occurred in the doorway to room [ROOM NUMBER], and redness and swelling was noted to resident 36's left ankle. The facility reported that resident 36 said he was going to see if resident 29 wanted to smoke when resident 7 started yelling at him and then threw a can at him hitting him on the ankle. The report documented that an agency aide heard from another room yelling and someone say get the F*** out. The aide stated she saw a can on the ground and resident 7's hand in the air like he had thrown it. The report documented that the nurse heard resident 36 yell, he threw a can at me. Resident 7 reported that he was woken up early in the morning by resident 36 talking to resident 29 from the doorway of his room. Resident 7 stated that he told resident 36 to get out of the doorway and resident 36 did not acknowledge him. Resident 7 verbalized he regrets what he did and apologizes and said it would not happen again. The conclusion of the facility investigation was that the allegation was verified and physical injury was sustained by resident 36. Resident 36's progress notes revealed the following: a. On 2/6/24 at 6:30 AM, the Nurses Note documented, Resident had an altercation with another resident in building. Staff intervened immediately. Resident has minor swelling to left ankle d/t [due to] an object hitting bone area. Nurse wrapped ankle per residents request. Non-emergent contacted. Administration contacting state, aps [adult protective services], and ombudsman. NP [nurse practitioner] is aware and will be in to assess later in morning. b. On 2/6/24 at 8:17 AM, the Nurses Note documented that the NP assessed the swelling of left ankle and recommended that the resident rest the ankle, ice as needed and as needed Tramadol for pain. c. On 2/7/24 at 2:12 PM, the Nurses Note documented, After an altercation with another resident on 2/6/24 resident is managing well. Resident stated his ankle still hurts a bit but otherwise doing great. Stated he had 'cool' staff last night that chatted with him to help improve mood. Resident does not want ice or pain medication at this time. On 1/17/24, resident 36 had a care plan initiated for at risk for potential abuse related to history of abuse, history of behaviors and impaired cognition. Interventions identified included to encourage the resident to attend activities of his choice; follow abuse protocol if allegations were made; monitor for behavior changes; observe for symptoms of increased isolation, depression, agitation, combativeness; and social service visits monthly and as needed. On 2/6/24, resident 36 had a care plan initiated for has minor swelling to left ankle d/t [due to] an object hitting the bone area. Interventions identified included to wrap the area; NP notified and requested to assess injury; observe/document location, size and treatment of injury; and report any abnormalities such as failure to heal or signs of infection to the physician. On 2/08/24 10:18 AM, an interview was conducted with the Certified Nurse Assistant Coordinator (CNAC). The CNAC stated that resident 7's behaviors were being inappropriate with females, and yelling for no reason. The CNAC stated that resident 7 would drop items just to watch people bend over to pick them up. The CNAC stated that a month ago resident 7 attempted to hit her with a cane. He can have aggressive behaviors. The CNAC stated that they tried to have 2 staff provide cares with him for safety reasons. The CNAC stated that resident 7 did not get along with resident 36, it's a racial thing, racial slurs. The CNAC stated that resident 7 started calling resident 36 the N word. The CNAC stated that after the second altercation between resident 7 and resident 36 they initiated a room change. The CNAC stated after the first altercation the Administrator tried to move resident 36 but he declined until the second altercation occurred. The CNAC stated that she was not aware of any altercations with other residents and resident 36. The CNAC stated that the Administrator was the abuse coordinator. The CNAC stated staff should be calling the ADM immediately for any incidents of abuse. The CNAC stated that staff should attempt to de-escalate the situation right away and try to keep the resident safe. The CNAC stated that if the staff did not know what to do they should notify the nurse, but the first step was keeping the resident safe. The CNAC stated that the last abuse training was either January 2024 or December 2023. The CNAC stated that the education covered what verbal, physical, and sexual abuse was and who to notify. The CNAC stated that resident 7 had not made himself likable and only comes out of his room to shower. On 2/14/24 at 11:15 AM, an interview was conducted with the facility ADM. The ADM stated that the resident 36 was talking to resident 29 loudly and she educated him to grab a staff member to get resident 29 when he wanted to talk to him. The ADM stated that she provided resident 7 with education on not using personal items to harm another individual, and that they would store those items for him if it continued to be a behavior. The ADM stated that resident 36 was not happy about the intervention but that she had other residents complain that he had entered their personal space too. The ADM stated that they substantiated the physical abuse because resident 36 was hit with the can and when the Director of Nursing assessed it there was some redness and swelling. The ADM stated that resident 7 and resident 36 did not get along and had quite a few altercations. The ADM stated that the first verbal altercation resident 7 was calling resident 36 racial slurs. The ADM stated that she talked to resident 7 and he verified he had said the racial slur, but that resident 36 had called him fat. The ADM stated that the second altercation between resident 36 and resident 7 on 1/17/23 was not verified. The ADM stated that resident 7 initially declined skin checks, but a second attempt was made for a skin check and no evidence of a physical punch to the forehead was observed. The ADM stated that after the first altercation she asked if they could do a room change and both residents refused. The ADM stated that after the second altercation resident 36 agreed to a room change. B. Resident 7 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, morbid obesity, alcoholic cirrhosis, hepatic failure, type II diabetes mellitus with polyneuropathy, portal hypertension, narcolepsy, major depressive disorder, obstructive sleep apnea, personality disorder, bipolar II disorder, alcoholic dependence, restless leg syndrome, male erectile dysfunction, hypertension, heart failure, anxiety disorder, hyperlipidemia, hyperaldosteronism, and osteoarthritis. On 2/16/24, the Quarterly MDS assessment documented a BIMS score of 15, which would indicate that resident 7 was cognitively intact. Resident 7's progress notes revealed the following: a. On 2/6/24 at 5:50, an Incident Note documented, Resident threw a full can of sliced tomatoes at another resident, [resident 36] Per [resident 36 and resident 29] [resident 36] stood at the doorway and was speaking to [resident 29] and asked for a cigarette. [Resident 7] then threw a closed can of sliced tomatoes and the can hit [resident 36] left ankle. During this time, CNA [6] was at the scene and saw [resident 7] standing after throwing the can. Per [resident 7], he stated he feels threatened and traumatized by [resident 36]. b. On 2/6/24 at 7:35 AM, the Nurses Note documented, Non-emergent police came to question resident about physical aggression to another resident. Police took statements and left. Will consult NP today about possible interventions for residents aggression. c. 2/6/24 at 8:14 AM, the Nurses Note documented, DON [Director of Nursing] and [NP] discussed physical aggression with resident. Resident stated 'I am a little grouchier lately.' NP recommended a medication be added into daily schedule. NP recommended trying out small dose of Depakote daily. Resident was firmly against adding Depakote. Resident wanted Clonazepam but NP stated it is contraindicated with other medications he currently takes. Resident does not want any medication changes at this time. d. On 2/7/24 at 7:44 AM, the Nurses Note documented, Resident polite with this nurse. Was [sic] Had an episode of agitation while roommate was talking to visitors. Able to redirect him and calm him down. On 1/1/24, resident 7 had a care plan initiated for at risk for abuse related to history of abuse and history of behaviors. Interventions identified included to follow the abuse protocol if allegations were made; monitor for behavior changes; and social services to visit monthly and as needed. On 11/29/23, resident 7 had a care plan initiated for had the potential to be physically aggressive related to anger, depression, and history of harm to staff. Interventions identified included administer medications as ordered; monitor/document for side effect and effectiveness of medication; provide physical and verbal cues to alleviate anxiety; give positive feedback; assist with verbalization of source of agitation; assist to set goals for more pleasant behavior; encourage seeking out staff when agitated; give the resident as many choices as possible; and document observed behavior and attempted interventions in behavior log. On 2/21/24 at 2:49 PM, an interview was conducted with Registered Nurse (RN) 4. RN 4 stated that resident 7 was able to get up and come out of his room. RN 4 stated that he had seen resident 7 independently transfer to his wheelchair. RN 4 stated that resident 7 was difficult to deal with most of the time. RN 4 stated that they try to have a second staff when administering medication. RN 4 stated that the company asked that we care with cares or use a two person to conduct any treatment. RN 4 stated that resident 7 could be aggressive and he was now in a room by himself because of his aggression. RN 4 stated that resident 7 had one roommate that he had issues with him and a can was thrown at him. RN 4 stated that resident 7 was such a mean person and really, really hard to deal with. RN 4 stated that on two occassions resident 7 had lunged towards him in an aggressive manner and had asked him inappropriate questions about his sexuality. RN 4 stated that there were little arguments that go on constantly and he felt like he was babysitting sometimes. RN 4 stated that if there was not anything physical, and it was a quick little shouting match then he would not report that to the DON. RN 4 stated that if it was a little quarrel don't pass it on. RN 4 stated that if it was something bigger it would be passed on. RN 4 stated that a lot of his job was about redirection with the residents. Review of the facility policy on Abuse, Neglect, Exploitation, and Misappropriation Prevention Program documented that the facility objective was to protect the residents from abuse, neglect, exploitation, and misappropriation of property by anyone. The policy stated that the facility would provide staff orientation and training on abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. The policy stated that all allegations of possible abuse would be investigated and reported within the timeframe's required by federal requirements. The policy was last revised in January 2024. 2. A. Resident 19 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis of dementia, muscle weakness, heart failure, anemia, major depressive disorder, primary pulmonary hypertension, and history of falling. Resident 19's medical record was reviewed on 2/6/24. On 1/23/24, an Annual Minimum Data Set (MDS) documented resident 19 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated resident 19 had severe cognitive impairment. On 2/5/24 at 9:49 AM, an interview was conducted with resident 19. Resident 19 stated they had no recollection of being cut by a razor. Resident 19 stated if that had happened to them, they would have put up a fit. On 11/9/23 at 11:27 AM, a Facility Incident report documented resident 19 arguing with resident 31. Resident 31 was heard shouting expletives at resident 19 due to resident 19 attempting to use resident 31's restroom. Once staff intervened, resident 19 was observed to have a cut on their hand. Resident 19 stated the resident 31 had cut them with a used razor. The resident 31 was witnessed to have been holding a safety razor with the blunt end facing forward. Resident 31 stated resident 19 attempted to get into their room and use the restroom. Resident 31 stated resident 19 had cut their hand on resident 31's wheelchair after swinging at them. Resident 31 denied cutting resident 19 with a razor. Resident 19 was observed to have 5 small shallow parallel bleeding cuts. When resident 19 was asked about the incident they stated, she cut me, and I was just looking to see what was going on. Both residents were advised to avoid each other. The additional notes section of the incident report documented that an interdisciplinary team review had been done on 11/13. It documented that a physical altercation had occurred with another resident and the root cause of the incident was due to resident 19's dementia. B. Resident 31 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following a cerebral infarction, type II diabetes mellitus, asthma, morbid obesity, generalized anxiety disorder, major depressive disorder, insomnia, hypertension, pseudobulbar affect, hyperlipidemia, nondisplaced fracture of proximal phalanx of left great toe, and chondromalacia left knee. On 9/28/23, the Quarterly MDS assessment documented a BIMS score of 14, which would indicate that resident 31 was cognitively intact. On 11/9/23 at 1:56 PM, the facility reported to the State Survey Agency (SSA) resident 31's altercation with resident 19. The findings of the facility investigation documented that resident 31 used a razor to scratch resident 19. Resident 31 stated in her interview that resident 19 came into her room looking for the bathroom. I told her this is not your bathroom, then [resident 19] called me a bitch she was pushing her wheelchair at me and kept calling me names. I grabbed a razor and scratched her. The summary of interview documented, Staff witnessed [resident 19] outside of [resident 31's] room. Staff 4 NA saw [resident 31] take something off a table and swing at [resident 19]. The report documented that resident 19 had small cuts to the hand. The corrective action identified in the facility investigation was that resident 31 would no longer have access to sharp objects and the resident was educated to seek out a caregiver when feeling agitated. The conclusion of the investigation was that the allegation of physical abuse was verified. Resident 31's progress notes and incident report revealed the following: a. On 10/26/23 at 2:53 PM, the Social Service Note documented, Resident remains a valued LTC [long term care] resident of the facility. Resident continues to show signs of little to no cognitive impairment. Resident is oriented to person, place, and time. Resident denies any mood concerns at this time. She tends to be very pleasant upon contact and is a active member of the community. She tends not to participate in most of the scheduled activities but appears to socialize with other residents. She was recently approved for NCW [New Choice Waiver] and will start the process of transitioning to a ALF [assisted living facility]. b. On 11/9/23 at 11:27 AM, the Nurses Note documented, 1115 - an argument was heard coming from in front of room [ROOM NUMBER] where [resident 19] was witnessed in her chair arguing with [resident 31]. [Resident 31] was shouting explatives [sic] at [resident 19] and stating that she was trying to use the wrong bathroom. Staff quickly intervened and found that [resident 19's] hand was cut. [Resident 19] said that [Resident 31] cut her with a used razor. [Resident 31] was witnessed holding a safety razor in her hand with the blunt end of the handle facing forward in her closed fist, razor blades in her palm. SN [skilled nurse] asked [resident 31] to give the razor to them and [resident 31] threw it at the feet of the SN. [Resident 31] was asked what happened and she stated that [resident 19] tried to get into her room and bathroom and she didn't use the razor, rather [resident 19] 'probably cut her hand on her wheelchair when she swung at me'. [Resident 19's] hand was cleaned and dressed with wound cleanser, abx [antibiotic] ointment and an bandaid. There appeared to be 5 small, shallow, parallel cuts which were bleeding. [Resident 19] denied pain and tolerated treatment well. Razor was collected and labeled, MD [Medical Director] notified. Family notified. Resident was confused, polite, non-hostile. Residents advised to avoid each other. SN will monitor both residents for further hostile interactions. Management fully advised. On 11/9/23 at 1127 AM, the incident report documented that resident 31 initially stated that she used the end of the razor handle to cut resident 19. Resident 31 later stated that she did not strike resident 19 at all and thought that resident 19 cut her hand when reaching out to strike her. The immediate action taken was that the residents were separated and counseled on aggression avoidance. Resident 31 stated that she has a short temper. c. On 11/13/23 at 9:45 AM, the Interdisciplinary Team (IDT) Event Review note documented, IDT Review: Event: Physical altercation with another resident Root cause found to be other resident's dementia. Interventions: Medication changes, resident no longer allowed to have sharp objects in room and resident educated to seek staff assistance when agitated. All other least restrictive interventions in place, will continue plan of care. On 11/13/23, resident 31 had a care plan initiated for has the potential to be verbally aggressive related to history of shouting expletives at another resident. Interventions identified included administer medications as ordered and monitor for side effects and effectiveness; analyze key times, places, circumstances, triggers, and what de-escalates behavior and document; asses resident's understanding of the situation; allow time for the resident to express self and feelings toward the situation; when the resident becomes agitated intervene before agitation escalates; guide resident away from source of distress; engage calmly in conversation; and if response was aggressive staff to walk calmly away and approach later. On 11/13/23, resident 31 had a care plan initiated for has the potential to be physically aggressive related to History of harm to others. Interventions identified included the resident triggered for physical aggression when personal space was invaded; staff to provide appropriate personal space; administer medications as ordered and monitor for side effects and effectiveness; provide physical and verbal cues to alleviate anxiety; give positive feedback; assist with verbalization of source of agitation; assist to set goals for more pleasant behavior; encourage seeking out a staff member when agitated; resident should no longer have access to sharp objects; medication change, dose increased of psychotropic medication; and resident educated to go to staff when agitation occurs. Review of resident 31's [NAME] report documented the following under Behavior/Mood: *The resident's triggers for physical aggression are (when personal space in invaded). The resident's behaviors is de-escalated by (intervention by staff to provide appropriate personal space.) *COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. *Monitor/record occurrence of for target behavior symptoms (SPECIFY pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. *When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. On 2/12/24 at 9:10 AM, an interview was conducted with NA 1. NA 1 stated that resident 31 did not have any behaviors and was always calm with her. NA 1 stated that resident 31 did not have any restrictions. NA 1 stated resident 31 got along with almost everyone. On 2/12/24 at 9:14 AM, an interview was conducted with CNA 4. CNA 4 stated that resident 31 had not had any altercations with other residents. CNA 4 stated that resident 4 went fast in her wheelchair and needed to slow down. CNA 4 stated that resident 31 did not have any restrictions. On 2/21/24 at 7:31 AM, an interview was conducted with RN 2. RN 2 stated that resident 31 sometimes lashed out by yelling or threatening other residents. RN 2 stated that resident 31 could be redirected away from the situation. RN 2 stated that if there was aggression then they would document the incident in the progress notes or the Treatment Administration Record (TAR). RN 2 stated that depending on the intensity of the behavior they may not report it. RN 2 stated that if it was harmful aggression they would notify the DON and MD. RN 2 stated that she was not aware of any incidents of harmful aggression from resident 31. RN 2 stated that resident 31 had a lot of resident to resident altercations with yelling. RN 2 stated that resident 31 did not have any restrictions on things that she could do or things that she could have. RN 2 stated she was not aware of an incident where resident 31 cut another resident. RN 2 stated that she should be aware of it because it was a safety issue for them and for other residents. RN 2 stated that when residents were first admitted they could sometimes have a lot of aggression, with the change in environment. RN 2 stated that they addressed it with medication modification. RN 2 stated that any restrictions or alert charting should be on the pass off sheet during change of shift, and it could be listed on the dashboard under special instructions. RN 2 stated that they communicated updates on resident's care verbally when they arrived on shift. RN 2 stated she was not aware of the aides documentation to know where these instructions would be located. On 2/21/24 at 8:34 AM, an interview was conducted with the DON. The DON stated that resident 31 did not have any behaviors, but gets verbally aggressive and shouts. The DON stated that she was not aware of any resident to resident altercations with resident 31. The DON stated that she did not know resident 31 had any restrictions or monitoring. The DON stated that she would expect to see monitoring in a progress note or TAR. The DON stated that she was not aware of any incident of cutting. The DON stated she should be aware of any such incidents as they were potential abuse situations. The DON stated that education on behaviors and monitoring would be communicated to staff directly and the aides could find the information in the [NAME]. The DON stated that she would expect to see interventions re-evaluated every 2 weeks initially. The DON stated that they needed to make sure that the resident was following any restrictions and that the staff were following it as well.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. Resident 93 was admitted [DATE], discharged [DATE] with diagnoses including limb girdle muscular dystrophy unspecified, unspecified injury of lower back subsequent encounter, quadriplegia unspecified, secondary polycythemia, dehydration, restless legs syndrome, other specified abnormal findings of blood chemistry, tobacco use, pyuria, sleep apnea unspecified, and history of falling. On [DATE], resident 93's Brief Interview for Mental Status Score was assessed as a 15, indicating no cognitive impairment. Resident 93's admission screener indicated that he was oriented to person, place, time, and situation. On [DATE] at 10:23 AM, resident 93 signed the facility leave of absence form prior to leaving the facility and listed the time that he would return to the facility as 5:00 PM the same day. The facility staff became aware that resident 93 had not returned to the facility at 6:00 PM on [DATE]. The facility administration was notified that resident 93 had not returned to the facility at 6:30 AM on [DATE]. The elopement was reported to the local police department at 7:15 AM on [DATE]. The elopement was reported to Adult Protective Services and the Ombudsman at 7:30 AM on [DATE] The state survey agency was notified of the elopement on [DATE] at 7:32 AM. The facility submitted their follow up investigation on [DATE] at 3:29 PM. Review of the facility policy on Abuse, Neglect, Exploitation, and Misappropriation Prevention Program'' documented that the facility objective was to protect the residents from abuse, neglect, exploitation, and misappropriation of property by anyone. The policy stated that the facility would provide staff orientation and training on abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. The policy stated that all allegations of possible abuse would be investigated and reported within the timeframe required by federal requirements. The policy was last revised in [DATE]. 8. Resident 16 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the following diagnosis that included type 2 diabetes mellitus, stage 4 pressure ulcer of sacral region and stage 4 pressure sore of left heel, generalized anxiety disorder, post-traumatic stress disorder, personal history of adult physical and sexual abuse, and suicidal ideation. Resident 16's medical records were reviewed from [DATE] through [DATE]. On [DATE], an annual minimum data set (MDS) documented resident 16 had a brief interview for mental status (BIMS) score of 14 which indicated they were cognitively intact. It should be noted resident 16's progress notes were reviewed for the month of [DATE] and there were no notes located for the incident that had occurred on [DATE]. The Facility Incident Reports were reviewed and documented resident 16 had two allegations of sexual abuse for [DATE]. On [DATE] at 9:00 PM, a Facility Incident Report documented resident 16 had told a nurse that they had been roughly grabbed by a male CNA who then proceeded to grab their left breast and rub it. The male CNA then asked resident 16 if it felt good and stated if resident 16 reported them, then they would lie. Resident 16 stated this had happened 2 weeks ago on the evening shift around 9:00 PM. The Nursing description documented resident 16's right arm had been grabbed while the resident description documented their left arm had been grabbed prior to the left breast. The incident report documented resident 16 described the male CNA to be thin, tall and dark haired and when showed a picture was able to identify them. It documented both the administrator and the DON had been notified of the incident. In the notes section of the incident report, it documented that on [DATE] an investigation had been done on the incident and it had been reported to the state. [ Note: no there was no documentation located to indicate this had been reported to the State Survey Agency (SSA).] There were no exhibits 358's and 359's submitted to the SSA. On [DATE] at 10:17 AM, a phone interview was conducted with the Previous Administrator (PADM). The PADM stated when they got any sort of abuse allegation they tried to report it within the two hours. The PADM stated they recalled resident 16 had accused a CNA of a sexual allegation. The PADM stated they had done the investigation and determined the person who they accused had not been in the building during the time of the incident. The PADM stated they believed there was one incident where they had mistakenly filed two incident reports and stated this might have been that incident. 4. Resident 4 was admitted to the facility on [DATE] with diagnoses which included mononeuropathy, chronic respiratory failure, type II diabetes mellitus, morbid obesity, chronic obstructive pulmonary disease, non-pressure ulcer of left calf, schizoaffective disorder, epilepsy, hypothyroidism, peripheral vascular disease, varicose veins, hypertension, bilateral osteoarthritis of hip, intervertebral disc disorder, edema, chronic pain syndrome, tremor, overactive bladder, hyperlipidemia, viral hepatitis C, insomnia, sleep apnea, post traumatic stress disorder, anxiety disorder, bipolar disorder, borderline personality disorder, and major depressive disorder. On [DATE] at 10:00 AM, the facility initial abuse investigation, form 358, documented that Registered Nurse (RN) 2 was informed of an allegation of verbal abuse by staff towards resident 4. The SSA was informed of the incident on [DATE] at 11:43 AM, and APS was informed of the incident on [DATE] at 11:42 AM. On [DATE] at 5:05 PM, the facility initial abuse investigation, form 358, documented that the facility Administrator (ADM) was informed of an allegation of verbal abuse by staff towards resident 4. The SSA was informed of the incident on [DATE] at 2:57 PM. It should be noted that both allegations of abuse were not reported to the SSA and APS within 2 hours of the allegation being made. 5. Resident 29 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included a traumatic brain injury (TBI), hemiplegia and hemiparesis, major depressive disorder, panic disorder, anxiety disorder, low back pain, hepatitis C, seizures, hyperlipidemia, overactive bladder, benign prostatic hyperplasia, insomnia, migraine, schizoaffective disorder, lymphangioma, history of transient ischemic attack, and history of suicidal behavior. On [DATE] at 9:24 AM, an interview was conducted with resident 29. Resident 29 stated that he recalled previously sharpening a butter knife with the intent to stick his old roommate under the arm. Resident 29 stated that his old roommate, resident 99, was having sex with his old girlfriend and because of this he was going to stab resident 99. Resident 29 stated that resident 4 witnessed him sharpening the knife and asked him not to do it. Resident 29 stated that resident 4 liked resident 99 and did not want to see him hurt. Resident 29 stated that he never tried to hurt resident 99. Resident 29 stated that he never spoke to anyone at the facility about the incident and never spoke to the nurse about it. On [DATE] at 10:55 AM, an interview was conducted with resident 4. Resident 4 stated that she vaguely recalled another resident sharpening a knife. Resident 4 stated that she took the knife away and gave it to the nurse. On [DATE] at 2:56 PM, the Nurses Note documented, Resident was depressed about his ex-girlfriend. Stated that she was here this am and left and he need to tell her to bring him money. then worry about her getting into his money. He told [name omitted] in activities that he wanted to cut his wrist or kill himself. MD [Medical Director] notified. new order to transfer resident to ER [emergency room] for eval. [evaluation] paramedic came and transported him to [local hospital name omitted] hospital at 14:56 [2:56 PM]. On [DATE] at 2:56 PM, the incident report documented, Resident made statements to several staff members today about wanting to kill himself, he told [name omitted] in Activities that he had attempted suicide this morning via cutting his wrists but was not successful. The resident stated, I just want to die. Immediate action taken was the resident was transferred to the hospital for a psychiatric evaluation. The report documented that the MD was informed on [DATE] at 3:03 PM. On [DATE] at 1:53 PM, the Nurses Note documented, It was brought to this nurses attention that resident was outside sharpening a butter knife to use to stab another resident. It should be noted that no documentation could be found of a facility investigation into the incident with the knife as documented in the nurse note on [DATE], and reporting to the SSA or APS was not completed. On [DATE] at 1:04 PM, an interview was conducted with the Administrator (ADM). The ADM stated that she had been conducting education at staff meetings on the types of abuse with examples, the reporting policy, and her phone number was on posters throughout the facility. The ADM stated that staff should report immediately the incident to her and she had 2 hours to report to the SSA. The ADM stated that was the expectation. The ADM stated that they communicated the abuse policy to agency staff and it was contained in the agency binder. The ADM stated that the agency staff were to sign the policy in acknowledgement that they had read it. The ADM stated that was a system that needed improvement. The ADM stated that they did not have a staff member responsible for verifying that agency staff had reviewed the education. The ADM stated that they had a lot of agency that were return staff, and she informed them of her phone number and they could reach out to her. The ADM stated that this was a verbal communication to those agency personnel. The ADM stated that this was an incident that should have been reported to her. The ADM stated that they had not seen aggression from resident 29 in the past. The ADM stated that he was sent out for a suicidal ideation evaluation. The ADM stated that this should have been brought to her attention. On [DATE] at 2:00 PM, an interview was conducted with the Corporate Social Service Worker (CSSW). The CSSW stated that resident 29 was sent to the hospital in [DATE] for suicidal ideation and the previous Resident Advocate (PRA) was supposed to have made a referral for mental health services. The CSSW stated that her understanding was that it was a suicidal ideation and not a suicidal attempt. The CSSW stated that resident 29's care plan should address the suicidal ideation, Preadmission Screening and Resident Review (PASRR) and recommendations and any mental health issues. The CSSW stated that interventions to prevent future attempts should address removing any sharp objects from the room, monitoring for access to those objects and re-assessing upon return to the facility to determine safety needs. The CSSW stated that the monitoring should occur until the MD made a determination to discontinue. The CSSW stated that the staff should also be monitoring for the resident's access to any sharp objects and they should be putting in a progress note or alert charting for the monitoring. The CSSW stated it should also be in the Kardex as well. The CSSW stated that staff should be able to tell her that they were monitoring resident 29 for this and if he had any restrictions. The CSSW stated that it would be concerning if resident 29 had repeat access to sharp objects again. [Cross-refer F740] 6. Resident 92 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included hemiplegia and hemiparesis due to cerebral infarction, type II diabetes mellitus, senile degeneration of brain, dysphagia, major depressive disorder, contracture left hand and left foot, osteoporosis, dementia, thyrotoxicosis, anxiety disorder, mood disorder, hypertension, gout, and urinary incontinence. On [DATE] at 4:10 PM, the Fall Note documented, found on floor next to bed. bed not low to ground. put in bed and assessed. c/o [complained of] left hip pain. MD notified. xray left hip ordered. family notified On [DATE] at 4:10 PM, the incident report documented that the CNA notified the nurse that resident 92 was found on the floor next to his bed and was complaining of hip pain. The resident was assisted to the bed and was assessed. The MD was notified and ordered an immediate (STAT) x-ray. The x-ray revealed a fracture and the resident was taken to the hospital for further evaluation. Hospital reports the fracture could be from the past. The report documented that the location of the injury was the left trochanter. Resident 92's Pain Assessment in Advanced Dementia (PAINAD) score was documented as a 5, which would indicate moderate pain. The predisposing environmental factors were documented as bed/chair height. On [DATE] at 10:18 AM, an interview was conducted with the Certified Nurse Assistant Coordinator (CNAC). The CNAC stated that resident 92 had fallen out of bed and broken his hip, and this resulted in him screaming more. The CNAC stated that at the time resident 92 resided in a room with resident 7 and resident 29. The CNAC stated that resident 7 and resident 29 did not like the commotion and would throw water on resident 92. The CNAC stated that they ended up moving resident 92 to another room. The CNAC stated that she witnessed resident 7 and resident 29 throwing water on resident 92. The CNAC stated that she asked resident 7 and resident 29 why they did that and they replied to make resident 92 be quieter. The CNAC stated that she asked resident 7 and resident 29, Do you think that will make him quieter? Now he's cold and wet. The CNAC stated that this was not the only time this had happened. The CNAC stated that she had talked to the other aides and was told that this had happened multiple times. The CNAC stated that she asked the aides why they did not say anything, and that behaviors like that are not okay. The CNAC stated that resident 92 was moved right after she walked in on this. The CNAC stated that the other aides did not know who to reach out to, what to say at the time, or knew that it was abuse. They didn't understand that it was abuse at the time. The CNAC stated that was when they started doing behavioral training and how to de-escalate situations. The CNAC stated that the previous Director of Nursing (DON) did the training. The CNAC stated that staff should be calling the Administrator (ADM) immediately, de-escalating the situation right away, and try to keep the resident safe. The CNAC stated, If they don't know what to do, notify the nurse. First step is keeping the resident safe. It should be noted that no documentation could be found of a facility investigation into the incident of resident 7 and resident 29 throwing water on resident 92 and reporting to the SSA or APS was not completed. [Cross-refer F689] 7. Resident 96 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included central cord syndrome at cervical (C)6, acute respiratory failure, type II diabetes mellitus, polyneuropathy, hepatic failure, pneumonia, lack of coordination, reduced mobility, muscle weakness, dysphagia, contusion of right wrist, cervicalgia, Parkinson's Disease, dementia, pressure ulcer of sacrum, atrial fibrillation, chronic kidney disease, hypertension and hyperlipidemia. On [DATE] at 1:53 PM, the Incident Note documented, I received a phone call today from the CNA Coordinator, who was providing transportation for this resident to an appointment at the [name of hospital omitted], the CNA Coordinator stated that when coming to a stop, the wheelchair became dislodged and tipped backwards, CNA Coordinator immediately stopped vehicle and called for assistance from EMS [emergency medical services], the Administrator and I arrived at the scene at about 14:20 [1:20 PM], the resident was complaining of head and neck pain, EMS was treating him, the police officer and the EMS workers all stated that the resident was still strapped into the wheelchair with the seatbelts (EMS reported that there was tension in the belts still), resident was transferred via EMS to [local area hospital] for evaluation, provider notified, family notified. On [DATE] at 1:04 PM, the Nurses Note documented, Central cord syndrome found on MRI [magnetic resonance imaging], resident currently in ICU [Intensive Care Unit] r/t [related to] he was having a difficult time maintaining his blood pressure, he is currently not on any supplemental blood pressure medication and the nurse stated that he will soon be ready to transfer either to a step down unit or back to facility, I gave them my name and phone number as a contact for [resident 96], will call again tomorrow for a new update. On [DATE] at 5:14 PM, the Nurses Note documented, Resident had hair cut today, then shower this afternoon. Within minutes after laying him back down he stopped breathing. The nurses performed assessment on him, he had no pulse and was not breathing. DNR [Do Not Resuscitate]. Family notified, MD notified. On [DATE] at 2:37 PM, an interview was conducted with the Certified Nurse Assistant Coordinator (CNAC). The CNAC stated that resident 96 passed away that day, and he was not on hospice and it was not expected. The CNAC stated that she assisted resident 96 during his hair cut. The CNAC stated that resident 96's cervical (c)-collar was removed for the haircut and she held his head still, with no sudden movements and no flexion or extension of the neck. The CNAC stated that Nurse Assistant (NA) 3 and NA 5 had assisted resident 96 with a shower. The CNAC stated that she believed resident 96's c-collar was removed for the shower under the direction of the PDON. The CNAC stated that NA 3 and NA 5 were both new aides that time. The CNAC stated that the PDON called her at approximately 5:15 PM, on the day that resident 96 received his haircut and shower and was told that resident 96 had just passed away. On [DATE] at 2:22 PM, an interview was conducted with NA 3. NA 3 stated that she showered resident 96 one time with the assistance of the CNAC on the day that he passed away. NA 3 stated that the CNAC told her that when resident 96 received a shower they took his c-collar off, and that the CNAC was the person who removed the collar. NA 3 stated that while the CNAC was holding the shower head she was guiding NA 3, saying that as long as she was washing the neck gently and the neck and spine were aligned it would be okay. NA 3 stated that no one was holding or stabilizing resident 96's head once the c-collar was removed, and the c-collar was off for approximately 20 minutes for the duration of the shower. NA 3 stated that she and NA 5 took resident 96 back to his room. NA 3 stated that they tried to transfer resident 96 back to bed, but they could not physically do it. NA 3 stated that she and NA 5 attempted to do the same transfer method as the PDON and CNAC, the towel transfer. NA 3 stated that this transfer method had a towel under the resident's knees and the staff arm under the resident armpit, and as you hold the towel you shift the resident's weight to transfer them. NA 3 described the towel transfer method as standing at the residents side facing him with the arm closest to the resident placed under his arm and the arm further away was crossed and holding the towel. NA 3 stated that when you transferred the resident the staff arms slightly uncross, enough to move the resident legs. NA 3 stated that this method caused the aide to twist her upper back during the transfers. NA 3 stated that she and NA 5 could lift resident 96. NA 3 stated that resident 96's bed was positioned against the wall, and they placed his wheelchair in front of the bed. NA 3 stated that she was on the side closest to the bed which was on the resident's left side. NA 3 stated that NA 5 was able to lift resident 96's weight, but as they were transferring him she felt like she did not have a good enough grip. NA 3 stated that they placed resident 96 back into the wheelchair and he was seated on the edge. He was starting to fall off of his chair. NA 3 stated that they grabbed resident 96's arms to pull him back, and his body went forward. NA 3 stated that she went behind him and tried to grab him from behind with both arms under his arms. NA 3 stated that resident 96 fell to the floor, he slipped down to the floor. NA 3 stated that resident 96 did not fall to the knees, but instead landed on his buttock with his legs extended in front of him. NA 3 stated that resident 96 did not say anything when he fell, and that resident 96 was really only able to say owe when he was in pain. NA 3 stated that resident 96 was a bigger man and weighed approximately 180 pounds. NA 3 stated that it was pretty hard to hold him. NA 3 stated that resident 96 was unable to assist with lowering himself to the ground, but once on the ground he was able to hold his weight up and was not slumped over. NA 3 stated that NA 5 went to go get help to lift resident 96 off the floor. NA 3 stated that when CNA 3 arrived in the room she asked what had happened and stated that she did not think the resident was breathing. NA 3 stated that she and CNA 3 placed the towel under resident 96's legs and lifted him back into the wheelchair. NA 3 and CNA 3 then transferred resident 96 to the bed. NA 3 stated that they placed him back on the bed and she noticed that resident 96 was not breathing. NA 3 stated that CNA 3 replied, oh ya I think he passed away. NA 3 stated that NA 5 went to find a nurse. On [DATE] at 10:13 AM, an interview was conducted with the previous Director of Nursing (PDON). The PDON stated that she was with resident 96 before he died. The PDON stated that resident 96 had a shower and a shave and she talked to him 5 minutes before he died. The PDON stated that she was in the shower room with resident 96 and he was already dressed. The PDON stated that one of the aides came and got her and said she thought resident 96 had passed. The PDON stated that resident 96 was in bed when she went down to assess him. The PDON stated that resident 96 had falls prior to the accident but not afterwards, I don't think so. The PDON stated that if resident 96 had fallen she should have been notified. The PDON stated that resident 96 was a one person assist for transfers, bed mobility, and brief changes prior to accident. After the accident he was a two person assist for transfers, bed mobility, and toileting. The PDON stated that resident 96 was a big guy and needed a 2 person assist. On [DATE] at 12:38 PM, a follow-up interview was conducted with the PDON. The PDON stated that resident 96's c-collar should stay on him, but nurses could remove it to assess his skin. The PDON stated that if someone took the c-collar off during showers that would not be consistent with care. The PDON stated that at the time he passed, she became aware immediately. The PDON stated that she assisted in resident 96's shower the day that he died. The PDON stated as his shower ended she asked him about it and the resident replied, ya. The PDON stated that not many minutes went by before the aide came to get her and said something was wrong and he had passed. The PDON stated that she did not recall who the aide was and it was not someone she knew well. The PDON stated that resident 96 was laying in bed when she assessed him and determined he was dead. The PDON stated It was so unusual for it to happen like that. I was just talking to him. The PDON stated that when she went to assess resident 96 at the time of his death the aides and the nurse were already in the room with him. The PDON stated that she thinks it may have been Registered Nurse (RN) 1 who was in the room. On [DATE] at 3:58 PM, a telephone interview was conducted with RN 1. RN 1 stated that she was working the 4:00 PM to 8:00 PM medication pass shift the day that resident 96 died. RN 1 stated that she recalled a resident at the facility that had a c-collar. RN 1 stated that the aides had taken the resident to the shower. RN 1 stated that later one of the aides came and got her and said resident 96 had fallen. RN 1 stated the aide was asking if resident 96 was a Do Not Resuscitate (DNR). RN 1 stated that the aide told her to hurry down to the room. RN 1 stated that she replied Oh gosh his neck. Did he fall? What part of his body hit the floor? RN 1 stated that the aides said he just went forward and his knees went down but they caught him. RN 1 stated that the aides reported that resident 96 was really pale in bed. RN 1 stated that she went running down to the resident's room, and when she entered he was in bed and had already died. RN 1 stated that the PDON entered the room after her. RN 1 stated that she was not present at the time of the fall and they thought he may have died right after the fall. RN 1 stated that she thought she informed the PDON of the fall, but can not say with certainty. RN 1 stated that there was no indication that resident 96 was going to pass away. It should be noted that no documentation could be found of a facility investigation into resident 96's fall on [DATE], and reporting to the SSA or APS was not completed. [Cross-refer F689] Based on interview and record review it was determined, for 11 out of 40 sampled residents, that the facility did not implement polcies and procedures that ensured all allegations of neglect and/or abuse were reported and investigated timely. Resident identifiers: 4, 7, 16, 29, 38, 92, 93, 94, 96, 97 and 99. Findings included: 1. Resident 38 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, protein calorie malnutrition, and dementia without behaviors. Resident 38's medical record was reviewed from [DATE] through [DATE]. Resident 38 had a Montreal Cognitive Assessment (MOCA) completed on [DATE]. Resident 38's MOCA score was 21/30 indicating mild cognitive impairment. A physician's note dated [DATE] for resident 38 indicated that resident 38 was homeless prior to his stay at the facility. Seen at the rescue home. He says biggest concern is he is losing his memory, says mostly short term. Had a TBI (traumatic brain injury) in the past he says. The note indicated that the physician diagnosed resident 38 with Vascular Dementia, Moderate/Severe, foot deformities, weakness, low vision, chronic pain, mass lesion of brain, and malnutrition. On [DATE], a quarterly Minimum Data Set (MDS) quarterly assessment indicated that resident 38 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Progress notes for resident 38 revealed the following: a. On [DATE] at 10:38 AM, a nurses note indicated that This resident did not return last night, his cell phone was called multiple times but resident did not respond, police called or welfare check this morning. b. On [DATE], an Interdisciplinary Team (IDT) note indicated that resident located by activities director at [name of local homeless shelter], he stated that he is okay and safe, and that he will not be returning to the facility. On [DATE] at 11:00 AM, the facility submitted form 358 with regard to resident 38 to the State Survey Agency (SSA). Form 358 indicated that on [DATE] at 10:00 AM, Registered Nurse (RN) 2 reported to the Previous Director of Nursing (PDON) that resident 38 had signed out on an Leave of Absence (LOA) and did not return from his going out yesterday. The form indicated that the PDON immediately reported this to the Administrator (ADM). The form 358 indicated that this was reported to the State Survey Agency (SSA) on [DATE] at 11:00 AM. On [DATE] at 1:33 PM, the facility submitted form 359 to the SSA. Form 359 stated that resident 38 was located and interviewed at a local homeless shelter. The form also documented that Staff members and co-residents noted it is common for [resident 38] to go out for hours and return to the facility and that [resident 38] always come back. CNA [Certified Nurse Assistant] stated he saw [resident 38] leave aprox (approximately) 5:40 am on Monday ([DATE]), normal behavior for him to leave. Per interview, nurses stated that [resident 38] checked out on monday ([DATE]) on NOC (night) shift. Day nurse noted he was not back by the time she left for her shift so she attempted to call patient and did not get through. Nurse arrived back on shift and NOC nurse informed Patient had still not returned. Nurse notified DON. On [DATE] at 9:47 AM, an interview was conducted with the PDON regarding resident 38. The PDON stated that when staff noticed that resident 38 did not return from an LOA on [DATE], they began calling the resident, but the resident would not answer their calls. The PDON stated that if a resident signed out on an LOA, they should indicate when they are returning, and that if a resident was not back within an hour of when they said they would return, then she would start trying to contact the resident. The PDON stated that she was upset that she was not informed that resident 38 did not return to the facility on the evening of [DATE]. The PDON stated that I should have gotten a call during the night of [DATE]. On [DATE] at 12:05 PM, an interview was conducted with the ADM regarding resident 38. The ADM stated that if someone signs out on an LOA, that information should be passed on to the next nurse on shift. The ADM also stated that the night shift staff should have done rounds and communicated the status of the residents overnight to the nurse on shift. The ADM stated that if a resident signed out on an LOA, they should indicate when they are returning, and that if a resident was not back within 30 to 60 minutes of when they said they would return, then action should be taken. 2. Resident 94 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Wernicke's encephalopathy, dementia, major depressive disorder, other amnesia, and history of traumatic brain injury. Resident 94's medical record was reviewed from [DATE] through [DATE]. An admission Minimum Data Set (MDS) assessment dated [DATE] for resident 94 was reviewed. The MDS indicated that a Brief Interview for Mental Status (BIMS) was completed. The BIMS indicated that the resident was unable to report the correct month and year. The resident received a score of 8 on the BIMS, indicating that the resident was moderately cognitively impaired. Progress notes for resident 94 included the following: a. On [DATE] at 7:30 PM, Cna (Certified Nursing Assistant) supervising smoke break came to this nurse and said that while resident was outside smoking he went down the sidewalk and around the building and could hear the side gate rattling and that by the time she got there, the resident was gone. Said that sheyelled (sic) for the cna's to assist in the search for resident. The side gate door was opened inwards and bent. One cna followed resident while the other cna came and alerted this nurse. Cna . got in her car and drove around the near-by streetslooking (sic) for him while this nurse called 911 asking for assistance with the search. b. On [DATE] at 8:30 PM, a police officer contacted facility staff to inform them he had located the resident and was on his way back to the facility with the resident. On [DATE] at 9:22 PM, the facility submitted form 358 with regard to resident 94 to the SSA. The form 358 indicated[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. Resident 93 was admitted [DATE], discharged [DATE] with diagnoses including limb girdle muscular dystrophy unspecified, unspecified injury of lower back subsequent encounter, quadriplegia unspecified, secondary polycythemia, dehydration, restless legs syndrome, other specified abnormal findings of blood chemistry, tobacco use, pyuria, sleep apnea unspecified, and history of falling. On [DATE], Resident 93 was admitted to the facility. Resident 93's Brief Interview for Mental Status Score was assessed as a 15, indicating no cognitive impairment. Resident 93's admission screener indicated that he was oriented to person, place, time, and situation. On [DATE] at 10:23 AM, Resident 93 signed the facility leave of absence form prior to leaving the facility and listed the time that he would return to the facility as 5:00 PM the same day. The facility staff became aware that Resident 93 had not returned to the facility at 6:00 PM on [DATE]. The facility administration was notified that Resident 93 had not returned to the facility at 6:30 AM on [DATE]. The elopement was reported to the local police department at 7:15 AM on [DATE]. The elopement was reported to Adult Protective Services and the Ombudsman at 7:30 AM on [DATE]. The state survey agency was not notified of the elopement until [DATE] at 7:32 AM. The facility submitted their follow up investigation on [DATE] at 3:29 PM. 8. Resident 16 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the following diagnosis that included type 2 diabetes mellitus, stage 4 pressure ulcer of sacral region and stage 4 pressure sore of left heel, generalized anxiety disorder, post-traumatic stress disorder, personal history of adult physical and sexual abuse, and suicidal ideation. Resident 16's medical records were reviewed from [DATE] through [DATE]. On [DATE], an annual minimum data set (MDS) assessment documented resident 16 had a brief interview for mental status (BIMS) score of 14 which indicated they were cognitively intact. It should be noted resident 16's progress notes were reviewed for the month of [DATE] and there were no notes located for the incident that had occurred on [DATE]. The Facility Incident Reports were reviewed and documented resident 16 had two allegations of sexual abuse for [DATE]. On [DATE] at 9 PM, a Facility Incident Report documented resident 16 had told a nurse that they had been roughly grabbed by a male CNA who then proceeded to grab their left breast and rub it. The male CNA then asked resident 16 if it felt good and stated if resident 16 reported them, then they would lie. Resident 16 stated this had happened 2 weeks ago on the evening shift around 9 pm. The Nursing description documented resident 16's right arm had been grabbed while the resident description documented their left arm had been grabbed prior to the left breast. The incident report documented resident 16 described the male CNA to be thin, tall and dark haired and when showed a picture was able to identify them. It documented both the administrator and the DON had been notified of the incident. In the notes section of the incident report, it documented that on [DATE] an investigation had been done on the incident and it had been reported to the state. [ Note: no there was no documentation located to indicate this had been reported to the State Survey Agency (SSA).] There were no exhibits 358's and 359's submitted to the SSA. On [DATE] at 10:17 AM, a phone interview was conducted with the Previous Administrator (PADM). The PADM stated when they got an sort of abuse allegation they tried to report it within the two hours. The PADM stated they recalled resident 16 had accused a CNA of a sexual allegation. The PADM stated they had done the investigation and determined the person who they accused had not been in the building during the time of the incident. The PADM stated they believed there was one incident where they had mistakenly filed two incident reports and stated this might have been that incident. Based on interview and record review it was determined, for 10 out of 40 sampled residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, injuries of unknown source and misappropriation of resident property was reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency (SSA), Adult Protective Services (APS), and law enforcement. Specifically, reporting of alleged incidents of abuse and neglect were not submitted to the SSA or APS within 2 hours of the allegation being made. Resident identifiers: 4, 7, 16, 29, 38, 92, 93, 94, 96, and 97. Findings included: 1. Resident 4 was admitted to the facility on [DATE] with diagnoses which included mononeuropathy, chronic respiratory failure, type II diabetes mellitus, morbid obesity, chronic obstructive pulmonary disease, non-pressure ulcer of left calf, schizoaffective disorder, epilepsy, hypothyroidism, peripheral vascular disease, varicose veins, hypertension, bilateral osteoarthritis of hip, intervertebral disc disorder, edema, chronic pain syndrome, tremor, overactive bladder, hyperlipidemia, viral hepatitis C, insomnia, sleep apnea, post traumatic stress disorder, anxiety disorder, bipolar disorder, borderline personality disorder, and major depressive disorder. On [DATE] at 10:00 AM, the facility initial abuse investigation, form 358, documented that Registered Nurse (RN) 2 was informed of an allegation of verbal abuse by staff towards resident 4. The SSA was informed of the incident on [DATE] at 11:43 AM, and APS was informed of the incident on [DATE] at 11:42 AM. On [DATE] at 5:05 PM, the facility initial abuse investigation, form 358, documented that the facility Administrator (ADM) was informed of an allegation of verbal abuse by staff towards resident 4. The SSA was informed of the incident on [DATE] at 2:57 PM. It should be noted that both allegations of abuse were not reported to the SSA and APS within 2 hours of the allegation being made. 2. Resident 29 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included a traumatic brain injury (TBI), hemiplegia and hemiparesis, major depressive disorder, panic disorder, anxiety disorder, low back pain, hepatitis C, seizures, hyperlipidemia, overactive bladder, benign prostatic hyperplasia, insomnia, migraine, schizoaffective disorder, lymphangioma, history of transient ischemic attack, and history of suicidal behavior. On [DATE] at 9:24 AM, an interview was conducted with resident 29. Resident 29 stated that he recalled previously sharpening a butter knife with the intent to stick his old roommate under the arm. Resident 29 stated that his old roommate, resident 99, was having sex with his old girlfriend and because of this he was going to stab resident 99. Resident 29 stated that resident 4 witnessed him sharpening the knife and asked him not to do it. Resident 29 stated that resident 4 liked resident 99 and did not want to see him hurt. Resident 29 stated that he never tried to hurt resident 99. Resident 29 stated that he never spoke to anyone at the facility about the incident and never spoke to the nurse about it. On [DATE] at 10:55 AM, an interview was conducted with resident 4. Resident 4 stated that she vaguely recalled another resident sharpening a knife. Resident 4 stated that she took the knife away and gave it to the nurse. On [DATE] at 1:53 PM, the Nurses Note documented, It was brought to this nurses attention that resident was outside sharpening a butter knife to use to stab another resident. It should be noted that no documentation could be found of a facility investigation into the incident with the knife as documented in the nurse note on [DATE], and reporting to the SSA or APS was not completed. On [DATE] at 1:04 PM, an interview was conducted with the Administrator (ADM). The ADM stated that she had been conducting education at staff meetings on the types of abuse with examples, the reporting policy, and her phone number was on posters throughout the facility. The ADM stated that staff should report immediately the incident to her and she had 2 hours to report to the SSA. The ADM stated that was the expectation. The ADM stated that they communicated the abuse policy to agency staff and it was contained in the agency binder. The ADM stated that the agency staff were to sign the policy in acknowledgement that they had read it. The ADM stated that was a system that needed improvement. The ADM stated that they did not have a staff member responsible for verifying that agency staff had reviewed the education. The ADM stated that they had a lot of agency that were return staff, and she informed them of her phone number and they could reach out to her. The ADM stated that this was a verbal communication to those agency personnel. The ADM stated that this was an incident that should have been reported to her. The ADM stated that they had not seen aggression from resident 29 in the past. The ADM stated that he was sent out for a suicidal ideation evaluation. The ADM stated that this should have been brought to her attention. [Cross-refer F740] 3. Resident 92 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included hemiplegia and hemiparesis due to cerebral infarction, type II diabetes mellitus, senile degeneration of brain, dysphagia, major depressive disorder, contracture left hand and left foot, osteoporosis, dementia, thyrotoxicosis, anxiety disorder, mood disorder, hypertension, gout, and urinary incontinence. On [DATE] at 10:18 AM, an interview was conducted with the Certified Nurse Assistant Coordinator (CNAC). The CNAC stated that resident 92 had fallen out of bed and broken his hip, and this resulted in him screaming more. The CNAC stated that at the time resident 92 resided in a room with resident 7 and resident 29. The CNAC stated that resident 7 and resident 29 did not like the commotion and would throw water on resident 92. The CNAC stated that they ended up moving resident 92 to another room. The CNAC stated that she witnessed resident 7 and resident 29 throwing water on resident 92. The CNAC stated that she asked resident 7 and resident 29 why they did that and they replied to make resident 92 be quieter. The CNAC stated that she asked resident 7 and resident 29, Do you think that will make him quieter? Now he's cold and wet. The CNAC stated that this was not the only time this had happened. The CNAC stated that she had talked to the other aides and was told that this had happened multiple times. The CNAC stated that she asked the aides why they did not say anything, and that behaviors like that are not okay. The CNAC stated that resident 92 was moved right after she walked in on this. The CNAC stated that the other aides did not know who to reach out to, what to say at the time, or knew that it was abuse. They didn't understand that it was abuse at the time. The CNAC stated that was when they started doing behavioral training and how to de-escalate situations. The CNAC stated that the previous Director of Nursing (DON) did the training. The CNAC stated that staff should be calling the Administrator (ADM) immediately, de-escalating the situation right away, and try to keep the resident safe. The CNAC stated, If they don't know what to do, notify the nurse. First step is keeping the resident safe. It should be noted that no documentation could be found of a facility investigation into the incident of resident 7 and resident 29 throwing water on resident 92 and reporting to the SSA or APS was not completed. [Cross-refer F689] 4. Resident 96 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included central cord syndrome at cervical (C)6, acute respiratory failure, type II diabetes mellitus, polyneuropathy, hepatic failure, pneumonia, lack of coordination, reduced mobility, muscle weakness, dysphagia, contusion of right wrist, cervicalgia, Parkinson's Disease, dementia, pressure ulcer of sacrum, atrial fibrillation, chronic kidney disease, hypertension and hyperlipidemia. On [DATE] at 1:53 PM, the Incident Note documented, I received a phone call today from the CNA [Certified Nurse Assistant] Coordinator, who was providing transportation for this resident to an appointment at the [name of hospital omitted], the CNA Coordinator stated that when coming to a stop, the wheelchair became dislodged and tipped backwards, CNA Coordinator immediately stopped vehicle and called for assistance from EMS [emergency medical services], the Administrator and I arrived at the scene at about 14:20 [1:20 PM], the resident was complaining of head and neck pain, EMS was treating him, the police officer and the EMS workers all stated that the resident was still strapped into the wheelchair with the seatbelts (EMS reported that there was tension in the belts still), resident was transferred via EMS to [local area hospital] for evaluation, provider notified, family notified. On [DATE] at 1:04 PM, the Nurses Note documented, Central cord syndrome found on MRI [magnetic resonance imaging], resident currently in ICU [Intensive Care Unit] r/t [related to] he was having a difficult time maintaining his blood pressure, he is currently not on any supplemental blood pressure medication and the nurse stated that he will soon be ready to transfer either to a step down unit or back to facility, I gave them my name and phone number as a contact for [resident 96], will call again tomorrow for a new update. On [DATE] at 5:14 PM, the Nurses Note documented, Resident had hair cut today, then shower this afternoon. Within minutes after laying him back down he stopped breathing. The nurses performed assessment on him, he had no pulse and was not breathing. DNR [Do Not Resuscitate]. Family notified, MD notified. On [DATE] at 2:37 PM, an interview was conducted with the Certified Nurse Assistant Coordinator (CNAC). The CNAC stated that resident 96 passed away that day, and he was not on hospice and it was not expected. The CNAC stated that she assisted resident 96 during his hair cut. The CNAC stated that resident 96's cervical (c)-collar was removed for the haircut and she held his head still, with no sudden movements and no flexion or extension of the neck. The CNAC stated that Nurse Assistant (NA) 3 and NA 5 had assisted resident 96 with a shower. The CNAC stated that she believed resident 96's c-collar was removed for the shower under the direction of the PDON. The CNAC stated that NA 3 and NA 5 were both new aides that time. The CNAC stated that the PDON called her at approximately 5:15 PM, on the day that resident 96 received his haircut and shower and was told that resident 96 had just passed away. On [DATE] at 2:22 PM, an interview was conducted with NA 3. NA 3 stated that she showered resident 96 one time with the assistance of the CNAC on the day that he passed away. NA 3 stated that the CNAC told her that when resident 96 received a shower they took his c-collar off, and that the CNAC was the person who removed the collar. NA 3 stated that while the CNAC was holding the shower head she was guiding NA 3, saying that as long as she was washing the neck gently and the neck and spine were aligned it would be okay. NA 3 stated that no one was holding or stabilizing resident 96's head once the c-collar was removed, and the c-collar was off for approximately 20 minutes for the duration of the shower. NA 3 stated that she and NA 5 took resident 96 back to his room. NA 3 stated that they tried to transfer resident 96 back to bed, but they could not physically do it. NA 3 stated that she and NA 5 attempted to do the same transfer method as the PDON and CNAC, the towel transfer. NA 3 stated that this transfer method had a towel under the resident's knees and the staff arm under the resident armpit, and as you hold the towel you shift the resident's weight to transfer them. NA 3 described the towel transfer method as standing at the residents' side facing him with the arm closest to the resident placed under his arm and the arm further away was crossed and holding the towel. NA 3 stated that when you transferred the resident the staff arms slightly uncross, enough to move the resident legs. NA 3 stated that this method caused the aide to twist her upper back during the transfers. NA 3 stated that she and NA 5 could lift resident 96. NA 3 stated that resident 96's bed was positioned against the wall and they placed his wheelchair in front of the bed. NA 3 stated that she was on the side closest to the bed which was on the resident's left side. NA 3 stated that NA 5 was able to lift resident 96's weight, but as they were transferring him she felt like she did not have a good enough grip. NA 3 stated that they placed resident 96 back into the wheelchair and he was seated on the edge. He was starting to fall off of his chair. NA 3 stated that they grabbed resident 96's arms to pull him back, and his body went forward. NA 3 stated that she went behind him and tried to grab him from behind with both arms under his arms. NA 3 stated that resident 96 fell to the floor, he slipped down to the floor. NA 3 stated that resident 96 did not fall to the knees, but instead landed on his buttock with his legs extended in front of him. NA 3 stated that resident 96 did not say anything when he fell, and that resident 96 was really only able to say owe when he was in pain. NA 3 stated that resident 96 was a bigger man and weighed approximately 180 pounds. NA 3 stated that it was pretty hard to hold him. NA 3 stated that resident 96 was unable to assist with lowering himself to the ground, but once on the ground he was able to hold his weight up and was not slumped over. NA 3 stated that NA 5 went to go get help to lift resident 96 off the floor. NA 3 stated that when CNA 3 arrived in the room she asked what had happened and stated that she did not think the resident was breathing. NA 3 stated that she and CNA 3 placed the towel under resident 96's legs and lifted him back into the wheelchair. NA 3 and CNA 3 then transferred resident 96 to the bed. NA 3 stated that they placed him back on the bed and she noticed that resident 96 was not breathing. NA 3 stated that CNA 3 replied, oh ya I think he passed away. NA 3 stated that NA 5 went to find a nurse. On [DATE] at 10:13 AM, an interview was conducted with the previous Director of Nursing (PDON). The PDON stated that she was with resident 96 before he died. The PDON stated that resident 96 had a shower and a shave and she talked to him 5 minutes before he died. The PDON stated that she was in the shower room with resident 96 and he was already dressed. The PDON stated that one of the aides came and got her and said she thought resident 96 had passed. The PDON stated that resident 96 was in bed when she went down to assess him. The PDON stated that resident 96 had fallen prior to the accident but not afterwards, I don't think so. The PDON stated that if resident 96 had fallen she should have been notified. The PDON stated that resident 96 was a one person assist for transfers, bed mobility, and brief changes prior to accident. After the accident he was a two person assist for transfers, bed mobility, and toileting. The PDON stated that resident 96 was a big guy and needed a 2 person assist. On [DATE] at 12:38 PM, a follow-up interview was conducted with the PDON. The PDON stated that resident 96's c-collar should stay on him, but nurses could remove it to assess his skin. The PDON stated that if someone took the c-collar off during showers that would not be consistent with care. The PDON stated that at the time he passed, she became aware immediately. The PDON stated that she assisted in resident 96's shower the day that he died. The PDON stated as his shower ended she asked him about it and the resident replied, ya. The PDON stated that not many minutes went by before the aide came to get her and said something was wrong and he had passed. The PDON stated that she did not recall who the aide was and it was not someone she knew well. The PDON stated that resident 96 was laying in bed when she assessed him and determined he was dead. The PDON stated It was so unusual for it to happen like that. I was just talking to him. The PDON stated that when she went to assess resident 96 at the time of his death the aides and the nurse were already in the room with him. The PDON stated that she thinks it may have been Registered Nurse (RN) 1 who was in the room. On [DATE] at 3:58 PM, a telephone interview was conducted with RN 1. RN 1 stated that she was working the 4:00 PM to 8:00 PM medication pass shift the day that resident 96 died. RN 1 stated that she recalled a resident at the facility that had a c-collar. RN 1 stated that the aides had taken the resident to the shower. RN 1 stated that later one of the aides came and got her and said resident 96 had fallen. RN 1 stated the aide was asking if resident 96 was a Do Not Resuscitate (DNR). RN 1 stated that the aide told her to hurry down to the room. RN 1 stated that she replied Oh gosh his neck. Did he fall? What part of his body hit the floor? RN 1 stated that the aides said he just went forward and his knees went down but they caught him. RN 1 stated that the aides reported that resident 96 was really pale in bed. RN 1 stated that she went running down to the resident's room, and when she entered he was in bed and had already died. RN 1 stated that the PDON entered the room after her. RN 1 stated that she was not present at the time of the fall and they thought he may have died right after the fall. RN 1 stated that she thought she informed the PDON of the fall but cannot say with certainty. RN 1 stated that there was no indication that resident 96 was going to pass away. It should be noted that no documentation could be found of a facility investigation into resident 96's fall on [DATE], and reporting to the SSA or APS was not completed. [Cross-refer F689] Review of the facility policy on Abuse, Neglect, Exploitation, and Misappropriation Prevention Program documented that the facility objective was to protect the residents from abuse, neglect, exploitation, and misappropriation of property by anyone. The policy stated that the facility would provide staff orientation and training on abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. The policy stated that all allegations of possible abuse would be investigated and reported within the timeframe's required by federal requirements. The policy was last revised in [DATE]. 5. Resident 38 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, protein calorie malnutrition, and dementia without behaviors. Resident 38's medical record was reviewed from [DATE] through [DATE]. Resident 38 had a Montreal Cognitive Assessment (MOCA) completed on [DATE]. Resident 38's MOCA score was 21/30 indicating mild cognitive impairment. A physician's note dated [DATE] for resident 38 indicated that resident 38 was homeless prior to his stay at the facility. Seen at the rescue home. He says biggest concern is he is losing his memory, says mostly short term. Had a TBI (traumatic brain injury) in the past he says. The note indicated that the physician diagnosed resident 38 with Vascular Dementia, Moderate/Severe, foot deformities, weakness, low vision, chronic pain, mass lesion of brain, and malnutrition. On [DATE], a quarterly Minimum Data Set (MDS) quarterly assessment indicated that resident 38 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Progress notes for resident 38 revealed the following: a. On [DATE] at 10:38 AM, a nurses note indicated that This resident did not return last night, his cell phone was called multiple times but resident did not respond, police called or welfare check this morning. b. On [DATE], an Interdisciplinary Team (IDT) note indicated that resident located by activities director at [name of local homeless shelter], he stated that he is okay and safe, and that he will not be returning to the facility. On [DATE] at 11:00 AM, the facility submitted form 358 with regard to resident 38 to the State Survey Agency (SSA). Form 358 indicated that on [DATE] at 10:00 AM, RN 2 reported to the Previous Director of Nursing (PDON) that resident 38 had signed out on an a Leave of Absence (LOA) and did not return from his going out yesterday. The form indicated that the PDON immediately reported this to the ADM. The form 358 indicated that this was reported to the State Survey Agency (SSA) on [DATE] at 11:00 AM. On [DATE] at 1:33 PM, the facility submitted form 359 to the SSA. Form 359 stated that resident 38 was located and interviewed at a local homeless shelter. The form also documented that Staff members and co- residents noted it is common for [resident 38] to go out for hours and return to the facility and that [resident 38] always come back. CNA stated he saw [resident 38] leave aprox (approximately) 5:40 am on Monday ([DATE]), normal behavior for him to leave. Per interview, nurses stated that [resident 38] checked out on monday ([DATE]) on NOC (night) shift. Day nurse noted he was not back by the time she left for her shift so she attempted to call patient and did not get through. Nurse arrived back on shift and NOC nurse informed Patient had still not returned. Nurse notified DON. On [DATE] at 9:47 AM, an interview was conducted with the PDON regarding resident 38. The PDON stated that when staff noticed that resident 38 did not return from an LOA on [DATE], they began calling the resident, but the resident would not answer their calls. The PDON stated that if a resident signed out on an LOA, they should indicate when they are returning, and that if a resident was not back within an hour of when they said they would return, then she would start trying to contact the resident. The PDON stated that she was upset that she was not informed that resident 38 did not return to the facility on the evening of [DATE]. The PDON stated that I should have gotten a call during the night of [DATE]. On [DATE] at 12:05 PM, an interview was conducted with the ADM regarding resident 38. The ADM stated that if someone signs out on an LOA, that information should be passed on to the next nurse on shift. The ADM also stated that the night shift staff should have done rounds and communicated the status of the residents overnight to the nurse on shift. The ADM stated that if a resident signed out on an LOA, they should indicate when they are returning, and that if a resident was not back within 30 to 60 minutes of when they said they would return, then action should be taken. 6. Resident 94 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Wernicke's encephalopathy, dementia, major depressive disorder, other amnesia, and history of traumatic brain injury. Resident 94's medical record was reviewed from [DATE] through [DATE]. An admission Minimum Data Set (MDS) assessment dated [DATE] for resident 94 was reviewed. The MDS indicated that a Brief Interview for Mental Status (BIMS) was completed. The BIMS indicated that the resident was unable to report the correct month and year. The resident received a score of 8 on the BIMS, indicating that the resident was moderately cognitively impaired. Progress notes for resident 94 included the following: a. On [DATE] at 7:30 PM, Cna (Certified Nursing Assistant) supervising smoke break came to this nurse and said that while resident was outside smoking he went down the sidewalk and around the building and could hear the side gate rattling and that by the time she got there, the resident was gone. Said that sheyelled (sic) for the cna's to assist in the search for resident. The side gate door was opened inwards and bent. One cna followed resident while the other cna came and alerted this nurse. Cna . got in her car and drove around the near-by streetslooking (sic) for him while this nurse called 911 asking for assistance with the search. b. On [DATE] at 8:30 PM, a police officer contacted facility staff to inform them he had located the resident and was on his way back to the facility with the resident. On [DATE] at 9:22 PM, the facility submitted form 358 with regard to resident 94 to the SSA. The form 358 indicated that resident 94 went out to the back smoking patio during smoke break. He went down the side of the building and ripped open the gate that was locked with a pad lock (sic). Our CNA caught up with him in the process trying to get him to stop and come back in the building. As he continued out to the front of the property and the CNA, after repeated attempts realized that she wasn't going to be able to get him to come back into the building, she went to get help. When the rest of the staff came out, they started driving around searching for him while the nurse called the police. The police arrived and started their search. They later found him down the road and brought him back to the building. The facility did not submit a form 359 to the SSA regarding this incident until [DATE], approximately 2 months later. The form 359 indicated that all staff had been trained on elopement on [DATE], and not in February 2023 directly after the elopement occurred. On [DATE] at 4:05 PM, an interview was conducted with the PADM. The PADM stated that on [DATE], resident 94 shoved the locked gate open. The PADM stated that a staff member followed the resident out of the gate and into the parking lot, but that the staff member could not talk the resident into coming back inside the facility. The PADM stated that at that time, the staff member left the resident alone and came back inside the facility to report the elopment to other staff. The PADM stated that two staff members then went back outside to locate resident 94. The PADM did not state why the form 359 was submitted approximately 2 months after the incident instead of the required 5 days. 7. Resident 97 was admitted to the facility on [DATE] with diagnoses that included cardiomyopathy, severe protein-calorie malnutrition, viral hepatitis C, generalized anxiety disorder, muscle weakness, adjustment disorder with anxiety, major depressive disorder, dysphagia, and insomnia. Resident 97's medical record was reviewed from [DATE] through [DATE]. Resident 97's quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident's BIMS score was 9, indicating moderate cognitive impairment. Resident 97's progress notes indicated the following: a. On [DATE] at 4:00 PM, a nurses note read, Resident approached nurses' station and resident informed nurse that he was going to look at apartments with a friend. Resident had walker with him when leaving. Resident signed LOA (leave of absence) book and resident assisted to front door and visitor waiting at front door for resident. Resident did not return as of midnight and informed oncoming nurse he had not come back from LOA. b. On [DATE] at 8:18 PM, a social services note read, Resident 97 left with someone around 4:00pm signed out and said he was going to look for apartment. Hasn[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 16 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the following diagnoses that included type 2 diabetes mellitus, stage 4 pressure ulcer of sacral region and stage 4 pressure sore of left heel, generalized anxiety disorder, post-traumatic stress disorder, personal history of adult physical and sexual abuse, and suicidal ideation. Resident 16's medical records were reviewed from 2/6/24 through 2/15/24. On 1/5/24, an annual minimum data set (MDS) assessment documented resident 16 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated they were cognitively intact. A care plan focus area initiated on 4/26/23 documented resident 16 was at increased risk for potential abuse due to a history of abuse and behaviors. It stated resident 16 had a history of making allegations/accusations of abuse. An identified intervention included following the abuse protocol if allegations were made. Resident 16's progress notes were reviewed and documented the following sexual abuse allegation: a. On 4/27/23 at 9:09 PM, a nurse note stated, Pt [patient] told a CNA [certified nursing assistant] that she had been touched and grabbed inappropriately a few weeks ago. [name removed] the Rn [registered nurse] questioned the pt and I listened. The pt stated that an aid that work the later in the night but not the all night shift had come in to reposition her and grabbed her forcefully and touched her breast with his other hand. She then stated that he asked if that felt good and if she would do a Blowjob for him. She stated that this happened about two weeks ago and that she just now remembering it because of a nightmare. She stated that the patient was tall and skinny. He also had dark shorter hair. [name removed] has been informed. b. On 4/28/23 at 7:27 AM, a nurse note stated, During HS [nighttime] med pass residents CNA asked this nurse to come and speak to her in her room. Resident reports that a guy grabbed her really hard on the right arm then grabbed her lt [left] breast. Said that this happened 2 weeks ago. Said that she doesn't know his name but he was thin, tall, and had black hair. Showed her a pic [picture] of a CNA and she said that he is the person. Said that this happened on night shift then said that it happened on evening shift around 2100. c. On 4/28/23 at 10:05 AM, a nurse note stated, At approximately 0930 resident was up in the main activity room for bingo when the practitioners came in for an assessment it was reported to them that the resident has stated she was now raped. the conversation was cut to preserve patient privacy as there were other residents very near the table. this was then reported to myself at which point the DON [Director of Nursing] was notified with myself and the Practitioners present. d. On 4/28/23 at 10:45 AM, a nurse note stated, Checked residents skin head to toe. Small 3mm [millimeter] round bruise on back of left arm. Appears to be approx. [approximately] 4-5 days old, faded dark with yellowish haze around it. Catheter in place draining well, no redness noted to peri-area, cleansed peri area well . On 4/13/23 at 9 PM, a Facility Incident Report documented resident 16 had reported to a nurse that they had been roughly grabbed by a male CNA who then proceeded to grab their left breast and rub it. The male CNA then asked resident 16 if it felt good and stated if resident 16 reported them, then they would lie. Resident 16 stated this had happened 2 weeks ago on the evening shift around 9 pm. The Nursing description documented resident 16's right arm had been grabbed while the resident description documented their left arm had been grabbed prior to the left breast. The incident report documented resident 16 described the male CNA to be thin, tall and dark haired and when showed a picture was able to identify them. It documented both the administrator and the DON had been notified of the incident. In the notes section of the incident report, it documented that on 5/22/23 an investigation had been done on the incident and it had been reported to the state. [ Note: there was no documentation located to indicate this had been reported to the State Survey Agency (SSA).] On 4/27/23 at 9:32 PM, a Facility Incident Report documented resident 16 stated an aid had come in to reposition them and was forcefully grabbed by the aid who then touched resident 16's breast and asked for a blow job. It documented resident 16 remembered these details due to a nightmare they had. No new information was provided in the incident report. A Form titled Exhibit 358 was submitted to the State Survey Agency (SSA) on 4/27/23 at 10:15 PM. The form revealed there was an allegation of sexual abuse. The form revealed that resident 16 reported a CNA had touched her breast over clothing approximately 2 weeks prior to 4/27/23. Resident 16 stated this had happened in their room during the evening hours. Resident 16 was documented not having any changes in behaviors after the incident, but it stated resident 16 did not want to be around the CNA. The following steps taken to ensure the safety of resident 16 after the incident included the suspension of the CNA involved and resident cares needed to be provided in pairs of two. The form documented that the accused CNA had not been working at the time resident 16 made the allegation. A Form titled Exhibit 359 was submitted to the SSA on 5/3/23 at 9:02 PM. The form revealed the detailed summary of resident 16's account which stated, Interviews started with her saying that a male CNA was turning her and in the process grasped her arm very firmly as he helped her turn (she said that was all). Next nurse interviewed her and inadvertently leaded her into more (as stated by the nurse and 2 witnesses). Story then became he grasped her arm, brushed up against a breast and asked for a blow job and she stated that was all. The next morning, she was telling people she was raped. Then later that day she told me it was just the second story. She said that it had happened about 2 weeks prior. Staff and her roommate all said that during those 2 weeks up until when she told the story, she had acted normal with no signs this [NAME] [sic]. The witness summary interview documented, All staff interviewed independently said that she showed no signs of psychological [NAME] [sic] for the 2 weeks after the timeframe she stated it happened to the day after she made the accusations all the way to the day I'm writing this report. Completely normal behaviours [sic] until she would relate her 3 different versions of the story that happened. Two witness of the interview both independently stated that the unintended leading interview seemed to have her embellishing what happened. 2 nurse practitioners that spoke with her on the day of the accusation both said she did not exhibit any typical signs that a rape victim. The alleged perpetrator interview revealed the male CNA was not working at the time resident 16 alleged the incident had occurred. It documented the male CNA worked earlier that day, but he was not assigned to care for resident 16 and they had no idea of what resident 16 was talking about. The form revealed the summary of the investigation findings to be No typical signs exhibited of rape or other sexual [NAME] [sic]. Nurse performed detailed inspection of [resident 16] for possible rape or other [NAME] [sic] and found none. The form revealed that the sexual allegation had not been verified since the allegations did not match the findings or testimonies. The form also documented that due to resident 16's past of similar allegations at other facilities, cares needed to be provided by 2 CNAs with no males if possible. [Note: There was no documentation available to identify when staff were interviewed and who all was interviewed and what staff member had performed resident 16's inspection. There was no documentation located to indicate the accused CNA had been interviewed by the administrator. The detailed assessment done on resident 16 to rule out rape and trauma was not located in the resident records.] On 2/20/24 at 10:26 AM, an interview was conducted with the Administrator (ADM). The ADM stated if there was any allegation of abuse such as physical, emotional, mental or neglects then it was reported to the state. The ADM stated there should be risk management associated with the 358. The ADM stated an incident report was an internal document they use to follow up with the resident on top of doing their investigation. On 2/21/24 at 10:17 AM, a phone interview was conducted with the Previous Administrator (PADM). The PADM stated when they got any sort of abuse allegation they tried to report it within the two hours. The PADM stated they recalled resident 16 had accused a CNA of a sexual allegation. The PADM stated they had done the investigation and determined the person who they accused had not been in the building during the time of the incident. The PADM stated they believed there was one incident where they had mistakenly filed two incident reports and stated this might have been that incident. The PADM stated this incident happened a while ago but believed a head to toe was done on resident 16. The PADM stated they included any additional documentation with the investigation. 3. Resident 33 was initially admitted to the facility on [DATE] and readmitted with the following diagnoses that included severe protein calorie malnutrition, alcoholic cirrhosis of liver without ascites, dementia, opioid dependence, esophageal obstruction, gastrointestinal hemorrhage, generalized anxiety disorder, and, alcohol dependence. Resident 33's medical record was reviewed on 2/6/24 through 2/15/24. On 1/14/24, a Quarterly Minimum Data Set (MDS) assessment documented resident 33 had a Brief Interview Mental Status (BIMS) score of 11 which indicated resident 33 had moderate cognitive impairment. On 12/9/23 at 10 AM, a late entry nurse note stated, An alleged physical altercation occurred between this resident and another resident today. On 12/13/23 at 9:28 AM, an IDT (Interdisciplinary Team) event review stated, root cause is found to be the other resident's dementia, medication review completed on other resident with medication changes, alert charting added to [resident 33] to monitor for s/s [signs/symptoms] of abuse, all other least restrictive interventions in place, will continue to monitor. On 12/14/23 at 9:41 AM, an IDT event review stated, upon investigation it was found that the other resident did not push [resident 33], but merely brushed past her on his way out of her room and that [resident 33] states she feels safe here, all other least restrictive interventions in place, will continue with plan of care. On 12/9/23 at 10 AM, a Facility Incident Report documented another resident had come into resident 33's room and was going through the drawers and cupboards when resident 33 asked them to leave and resident 33 was pushed as the other resident left the room. Resident 33's statement of the incident stated, He was going through everything making a mess. I told him to 'get out, this is not your room' and then he pushed me. The immediate actions identified a change in the other resident medication. A Form titled Exhibit 358 was submitted to the State Survey Agency (SSA) on 12/11/23 at 10:50 AM. It documented an allegation of physical abuse had been made. The following statement was made by resident 33 about the allegation, [Resident 33] alleged that [name of other resident removed] Walked into her room and was going through her items. When [resident 33] Asked him to leave, he got mad and got physical. It documented that a CNA had witnessed the altercation between the two residents. The written witness statement documented, he went inside 11 room (women's room) and started slamming the drawers in the 11c room. [resident 33] was yelling at him to get out then he was walking out. He pushed [resident 33] and attempted to flip over a wheelchair. A Form titled Exhibit 359 was submitted to the SSA on 12/12/23 at 5:10 PM. The summary of the investigation documented that another resident had entered resident 33's room and started going through resident 33's stuff. Resident 33 then asked the other resident to leave and resident 33 was moved out of the way by the other resident as they left resident 33's room. Resident 33 stated they did not feel threatened by the other resident and understood the other resident was confused and was a big man. The form revealed the summary of the investigation findings to not have been substantiated. It documented resident 33 did not feel abused or harmed and the contact made had been by accident and there was no intention of harm perceived by the patient or victim. [Note: There was no documentation located to indicate the staff that had witness the altercation had been interviewed to obtain the clarification needed on if resident 33 had been pushed or moved out of the way when the other resident exited the room.] On 2/20/24 at 10:26 AM, an interview was conducted with the Administrator (ADM). The ADM stated if there was any allegation of abuse such as physical, emotional, mental or neglects then it was reported to the state. The ADM stated there should be risk management associated with the 358. The ADM stated an incident report was an internal document they use to follow up with the resident on top of doing their investigation. The ADM stated they conducted their investigation by interviewing all parties involved in the incident which included the victim, perpetrator, and witnesses. The ADM stated if no witness were available then they interviewed residents that were near the surrounding area and staff on shift. The ADM stated there had been an incident between resident 33 and another resident. The ADM stated it had initially been reported that resident 33 had been shoved and it had been physical. The ADM stated resident 33 then reported the other resident brushed past them when they were interviewed. The ADM stated resident 33 had said it was not a threatening brush and had walked past resident 33. The ADM stated what happened between resident 33 and the other resident was an accident. The ADM stated there needed to be more clarification with the written witness statement on what pushed meant and stated they obtained that clarification with resident 33's interview. On 2/20/24 at 10:56 AM, a follow up interview was conducted with the ADM. The ADM stated the other resident was confused did not intend to harm resident 33. The ADM stated when resident 33 was interviewed resident 33 made it seem like the other resident's actions were not willful and the other resident brushed up against resident 33 as they were leaving the room. The ADM stated resident 33 believed it was an accident and based their investigation findings off of what resident 33 said during their interview. The ADM stated they had a written witness statement from the CNA that saw the incident. The ADM stated based of the witness statement they should have obtained more clarification by interviewing the CNA. The ADM stated they were the one responsible for obtaining the clarifying information. Based on interview and record review, the facility did not have evidence that all allegations of abuse were thoroughly investigated for 3 of 40 sampled residents. Resident identifiers: 16, 33, and 97. Findings included: 1. Resident 97 was admitted to the facility on [DATE] with diagnoses that included cardiomyopathy, severe protein-calorie malnutrition, viral hepatitis C, generalized anxiety disorder, muscle weakness, adjustment disorder with anxiety, major depressive disorder, dysphagia, and insomnia. Resident 97's medical record was reviewed from 2/5/24 through 2/22/24. Resident 97's quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident's Brief Interview for Mental Status (BIMS) score was 9, indicating moderate cognitive impairment. Resident 97's progress notes indicated the following: a. On 9/28/22 at 4:00 PM, a nurses note read, Resident approached nurses' station and resident informed nurse that he was going to look at apartments with a friend. Resident had walker with him when leaving. Resident signed LOA (leave of absence) book and resident assisted to front door and visitor waiting at front door for resident. Resident did not return as of midnight and informed oncoming nurse he had not come back from LOA. b. On 9/28/22 at 8:18 PM, a social services note read, Resident 97 left with someone around 4:00pm signed out and said he was going to look for apartment. Hasn't returned yet. discharged him on LOA. c. On 9/30/22 at 11:55 AM, a nurses note read, Got a call from a lady by the name of [name deleted]. she was calling to check on [resident 97]. explained [resident 97] hasnt returned from LOA Visit. [name deleted] stated she brought him back at 9/29/22 around [8:00 PM]. stated she wound (sic) call his family but was adamant she dropped him off last night. per records [resident 97] checked himself out with [name deleted] but never checked back after his visit. d. On 9/30/22 at 9:30 PM, a nurses note read, Received (sic) a call from a female asking if resident is here at the facility. Says that she dropped him off around 830pm but did not watch him come inside of facility. Staff went outside and searched the premises for him but he was not there. Was not at 7-11 either. Notified DON of situation. Also mentioned this to [name of physician]. e. On 10/8/22 at 3:50 PM, a nurses note read, [Resident 97] showed up this afternoon and stated he was here to pick up his personal items. he appeared impaired and was arguing with staff. explained to him is admission required which was to go to the ER for readmission (sic). pt refused. told staff to get his electronic (sic) wheelchair and pack his electronics in his back pack. stated he will come back on Monday to pick up the rest of his items. The facility filed an Initial Entity Report with the State Survey Agency (SSA) on 10/3/22, approximately 6 days after resident 97 left the facility. The report documented that resident 97 signed the leave of absence (sic) book on Wednesday 9/28 at around 4:30pm and left with a friend to go look at appartmnets (sic). It was our understanding that he would be back later that day however he has left with friends before, stayed at their place and not come back for a couple days. On Friday 9/30 at around 8:45pm the friend he left with reported that she had dropped him off in front of our building. He hadn't come in to the building at that time and so we sent some people out to search for him because he only had his walker. After we couldn't find him we thought that he must have called another friend and so we dediced (sic) to give him the weekend. We talked with the original friend he originally left with multiple times through the weekend and tried to reach out to the cell phone number we had for him as well in attempt to find him. The following Monday he still hadn't come back and so we reached out to the police to file a missing person's report. The Alleged Abuse Verification of Investigation Report form completed by staff on 10/3/22 for resident 97 was reviewed. The report indicates that on 10/3/22 one staff member was interviewed. The staff member stated that resident 97 signed our Leave of Absence book stating that he was going to look at apartments and would be back later that evening. He left with a friend who came to pick him up. He left with his walker and the clothes on his back. He never came back that night or several nights later. No other interviews were documented on the report. The Alleged Abuse Verification of Investigation Report form also documented that resident 97 has been at our facility for the better part of a year. He has progressed in all his care measures to the point that we have been trying to help him transition out to living on his own. The doctor was prepared to discharge him as soon as we found a safe discharge location. On 2/13/24 at 4:05 PM, an interview was conducted with the Previous Administrator (PADM). The PADM stated that resident 97 was often drunk or high due to a drug problem. The PADM stated that resident 97 would often leave for longer than a day, so we were telling him this wasn't a hotel. If he's there he has to follow the regulations in order to get care. The PADM stated that he attempted to reach out to resident 97 but that resident 97 was under the influence of whatever it was. The PADM stated that when it was evident he wasn't coming back after what we had done to try and get him back, the facility discharged resident 97. The PADM was unable to explain why the resident was not reported missing sooner, why no other staff were interviewed during the investigation, and why the resident was not appropriately oriented for discharge on ce he returned to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not provide the appropriate treatment and services to 5 of 40 sampled residents to maintain or improve his or her ability to carry out the activities of daily living. Specifically, multiple residents did not receive showers as desired or scheduled. Resident identifiers: 7, 8, 28, 31, and 34. Findings include: 1. Resident 7 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, morbid obesity, alcoholic cirrhosis, hepatic failure, type II diabetes mellitus with polyneuropathy, portal hypertension, narcolepsy, major depressive disorder, obstructive sleep apnea, personality disorder, bipolar II disorder, alcoholic dependence, restless leg syndrome, male erectile dysfunction, hypertension, heart failure, anxiety disorder, hyperlipidemia, hyperaldosteronism, and osteoarthritis. On 2/5/24 at 10:21 AM, an interview was conducted with resident 7. Resident 7 stated that his scheduled shower days were Wednesday and Saturday. Resident 7 stated that the last month they had been following the schedule, but prior to that he was not provided showers. Resident 7 stated that he needed assistance with washing his genitals and back and needed his oxygen while showering. On 2/16/24, the Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, which would indicate that resident 7 was cognitively intact. The assessment documented that resident 7 required substantial maximal assistance for bathing and the helper did more than half the effort. On 2/20/24, resident 7's bathing tasks documented the bathing schedule was Wednesday and Saturday morning, and the last 30 days documented no showers were provided. On 12/6/23, resident 7's skin check/shower sheet documented that a shower was provided. No other shower sheets were noted. Resident 7's progress notes revealed the following: a. On 9/20/23 at 1:58 PM, the admission note documented, refused shower from hospice. He said he will do it tomorrow. poor hygiene noted. b. On 9/21/23 at 2:57 PM, the Nurses Note documented, He was assisted in the shower by hospice cna today. He refused shower yesterday. and he got upset when the nurse asked him to shower today. After the shower today, he refused to wear clean pants. He still wants to wear dirty pants. hospice nurse notified. c. On 9/21/23 at 5:00 PM, the admission: 72 Hour Charting note documented, required 1 person extensive with shower, dressing. pull up use for incontinent of bowel. refused to change his pants even he has stool on after the shower. d. On 11/22/23 at 2:14 PM, the Nurses Note documented, RNC [regional nurse consultant] and Administrator went to speak with this resident regarding his care concerns. resident expressed he does not want 2 staff for his cares including showers and housekeeping to clean. He often refuses when attempts are made to clean his room and it has a foul odor and belongings everywhere which he will not allow to be cleaned up. He did report that he was showered yesterday. e. On 11/29/23 at 5:11 AM, the Nurses Note documented, Resident came out of his room demanding a shower, although he was not on the list for showers. Resident is to shower on Saturdays. Resident proceeded to yell at staff and scratched a CNA [certified nurse assistant]. Nurse informed the DON [Director of Nursing] and was instructed to call 911 for a police report. Nurse encouraged resident to be polite, respectful and patient. Resident continued to yell and argue with the staff. Police came to facility and completed a police report. f. On 12/10/23 at 1:18 AM, the Nurses Note documented, no issues with behaviors although patient claims to have asked for a shower and didn't receive one. g. On 12/10/23 at 11:47 AM, the Nurses Note documented, Resident has been calm and cooperative with cares. Took meds as prescribed minus lactulose. Resident still looking for armodafinil prescription that hasn't been filled. He claims he wasn't showered yesterday, nurse asked CNAs to please accommodate him today. h. On 1/31/24 at 10:47 AM, the Social Service Note documented, He was excited to be having pizza for dinner and then have a shower. He states he has no other concerns at this time. i. On 2/1/24 at 3:16 PM, the Nurses Note documented, Patient has not been abusive to this nurse or residents but earlier he was demanding to have a shower when he refused his shower yesterday, He kept telling his aid that he was busy. j. On 2/1/24 at 3:23 PM, the Nurses Note documented, When the patient was demanding a shower the aid explained to him that it was not his shower day and that it was 12 oclock and lunch was being served and he needed to get the lunch trays out. the resident started yelling and said that he is a priority patient, and needed a shower. The patient went to his room. The aid that tried to shower him yesterday said that he would try and get him in the shower today. On 9/18/23, resident 7 had a care plan initiated for had a Activities of Daily Living (ADL) self-care performance deficit. Interventions identified included Cares with Pairs: Assist of 2 with cares when in room related to behaviors; adjust ADL assistance per level of need at time of care; and required limited/ partial/ moderate assist of 2 due to behaviors for bathing/showering; On 2/8/24 at 10:18 AM, an interview was conducted with the CNA Coordinator (CNAC). The CNAC stated that the shower sheet was posted in a binder so that the aides could see who was scheduled for a shower that day. The CNAC stated that they were struggling with showers being completed due to staff turn over. The CNAC stated that the shower sheet should be uploaded into the residents' electronic medical records. The CNAC stated that if a resident wanted more showers they were allowed, but first they would complete that days scheduled showers. The CNAC stated that if a resident refused a shower the aides were to fill out the refusal sheet and take it to the nurse to sign. The CNAC stated that resident 7 needed 2 staff to provide cares for moody and aggressive behaviors. The CNAC stated that resident 7 needed assistance with showers. On 2/20/24 at 1:06 PM, an interview was conducted with Nursing Assistant (NA) 1. NA 1 stated that resident 7 required a two person assist for transferring and a one person assist for showers. NA 1 stated that they documented showers in the shower sheet and in the electronic medical records. On 2/20/24 at 1:11 PM, and interview was conducted with NA 2. NA 2 stated that they documented the showers on the shower sheet and any refusals. On 2/20/24 at 1:16 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she could not locate any shower sheets for resident 7. 2. Resident 31 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following a cerebral infarction, type II diabetes mellitus, asthma, morbid obesity, generalized anxiety disorder, major depressive disorder, insomnia, hypertension, pseudobulbar affect, hyperlipidemia, nondisplaced fracture of proximal phalanx of left great toe, and chondromalacia left knee. On 2/5/24 at 1:45 PM, an interview was conducted with resident 31. Resident 31 stated that she needed stand by assist for showers due to her stroke. Resident 31 stated that she was able to transfer herself but need assistance with washing her feet and and lower legs. Resident 31 stated she would ask for a shower and sometimes it never gets done. Resident 31 stated that her showers were supposed to be on Monday, Wednesday, and Friday. On 2/7/24 at 9:56 AM, a follow-up interview was conducted with resident 31. Resident 31 stated she wanted to shower yesterday, but management said that there was no hot water. Resident 31 stated she liked to shower daily. Resident 31 stated that the other day she wanted to shower, but the aide told her it was not her day to shower. Resident 31 stated that she had to have a shower today because she had an accident this morning. On 6/28/23, resident 31's admission MDS assessment documented a one person physical assist with supervision for personal hygiene. The assessment documented that resident 31 required supervision with bathing and set up assistance. On 9/28/23, the Quarterly MDS assessment documented a BIMS score of 14, which would indicate that resident 31 was cognitively intact. The assessment documented that resident 7 required substantial maximal assistance for bathing and the helper did more than half the effort. On 1/31/24, resident 31 had an order initiated to shower two times a week on Wednesday and Saturday in the evening. On 2/8/24, resident 31's bathing tasks documented the bathing schedule was Wednesday and Saturday in the evening. The task stated must assist at all times in shower and that resident 31 was a high risk for falls. Resident 31's bathing task for the last 30 days documented that the resident received a shower on 1/27/24 at 3:13 PM. Resident 31's skin check/shower sheet documented that an assessment was completed on 9/24/23, 12/11/23, 12/19/23, and 1/3/24. It should be noted that per the skin check/shower sheet and bathing task resident 31 was provided 2 showers in December 2023 and 2 showers in January 2023. On 7/11/23, resident 31 had a care plan initiated for had an ADL self-care performance deficit related to hemiplegia and hemiparesis affecting the left non-dominant side. Interventions identified included to adjust the ADL assistance per the level of need at the time of care and that resident 31 required a one person partial to moderate assistance for bathing or showering. On 2/8/24 at 11:52 AM, a follow-up interview was conducted with the CNAC. The CNAC stated that resident 31 showers, I know we shower her. I don't know why it isn't documented. The CNAC stated that resident 31 needed a one person standby assist for showers. The CNAC stated that she told the aides to go back and recall who was given a shower the previous week and then go and document it. The CNAC stated that the skin check was completed when a shower was provided, but confirmed that the skin check sheet did not document anywhere that a shower or bed bath had been provided. On 2/8/24 at 12:06 PM, an interview was conducted with the DON. The DON stated that she had been at the facility for 3 weeks. The DON stated that the shower schedules were two times a week. The DON stated that if a resident refused a shower then it was documented and given to the charge nurse. The DON stated that refusals were documented on a sheet with the resident name and the nurse had to sign it. The DON stated that if the aides could not give the shower then the nurse should attempt to do it. The DON stated that if a resident requested more showers than the twice weekly schedule they would accommodate them. The DON stated that they would fit those extra shower requests into the schedule but sometimes it did not happen until the following day. The DON stated that those extra shower requests would have to wait until the scheduled showers were completed first. The DON stated that the aides had been instructed to document showers in the electronic medical records under tasks. The DON stated that the facility did not have a designated shower aide. The DON stated that she would expect to see at least 8 plus showers each month for a twice weekly and as needed shower schedule. 3. Resident 34 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included moderate protein calorie malnutrition, intellectual disabilities, chronic pain, scoliosis, major depressive disorder, anxiety disorder, impulse control disorder, mood disorder, and intracranial injury. On 2/5/24 at 10:09 AM, an interview was conducted with resident 34. Resident 34 stated that his preference was to shower every day, but that he was not being assisted with showers every day. Resident 34 stated that it had been two weeks since his last shower. Resident 34 stated that he had been asking for showers but that I just gave up asking because they aren't helping. The resident was observed to have an odor of stale urine at the time of the interview. Resident 34's medical record was reviewed from 2/5/24 through 2/22/24. Resident 34's admission Minimum Data Set (MDS) assessment dated [DATE] documented that resident 34 could not shower independently, but required partial/moderate assistance of staff for showers. A care plan dated 11/10/23 documented that resident 34 requires substantial/maximum assistance of 1 for showering. On 2/20/24, the resident's history of showers over the previous 30 days was reviewed. Only one shower had been documented in the previous 30 days, on 1/24/24. On 2/8/24 at 10:18 AM, an interview was conducted with the Certified Nursing Assistant Coordinator (CNAC). The CNAC stated that there were shower sheets for resident because there was a lot of paper charting. The CNAC stated that staff used showers for resident 34 as a de-escalation technique. The CNAC stated that if a resident wants a shower every day, they have to wait to make sure the scheduled showers were completed first. No shower sheets could be located for resident 34. On 2/20/24 at 11:35 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 34 received a shower on 2/19/24, and that staff were supposed to be documenting resident showers in the electronic health record. The DON stated that there was also a shower binder located at the nurses station, and that staff often documented showers in the shower binder instead of the electronic health record. 4. Resident 28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia, subarachnoid hemorrhage, muscle weakness, and generalized anxiety disorder. Resident 28's medical record was reviewed from 2/5/24 through 2/22/24. Resident 28's admission MDS assessment dated [DATE] indicated that resident 28 required physical assistance from one staff member to bathe. Resident 28's care plan dated 7/19/23 documented that the resident had an Activities of Daily Living (ADL) self-care performance deficit related to activity intolerance, confusion, dementia and impaired balance. The ADL care plan indicated that resident 28 required substantial/maximum assist of 1 staff member for bathing. On 2/5/24, an observation was made of resident 28. Resident 28's hair was observed to be uncombed and greasy. On 2/8/24, the resident's history of showers over the previous 30 days was reviewed. No showers had been documented in the previous 30 days. Resident 28's skin sheets and shower refusals were reviewed. Only three skin sheets were located for resident 28, dated 12/8/23, 12/11/23 and 1/8/24. Only one shower refusal for resident 28 could be located and was dated 12/14/23. On 2/8/24 at 11:53 AM, an interview was conducted with the CNAC. The CNAC stated that resident 28 required total assistance for showering. The CNAC stated that skin checks were completed when a resident received a shower, so if a skin check was done, a shower was done. When asked about the missing documentation, the CNAC stated that I just tell the staff to go in and document their showers from the previous week if they aren't there. 5. Resident 8 was readmitted to the facility on [DATE] with diagnoses that included diabetes, dementia, Parkinson's disease, and schizoaffective disorder. On 2/5/24 at 11:13 AM, an interview was conducted with resident 8. Resident 8 stated that the facility used to schedule three showers a week for residents, but the schedule was changed, and now residents were only scheduled for two showers a week. Resident 8 stated she would like showers three times a week. Resident 8 stated that she was not receiving the scheduled showers twice a week. Resident 8's hair was observed to be greasy all over, and matted in the back. Resident 8's medical record was reviewed from 2/5/24 through 2/22/24. Resident 8's care plan was reviewed. A care plan dated 7/11/19 indicated that resident required the supervision of one staff member for showers due to her physical limitations such as weakness, poor coordination and poor balance. On 2/8/24, the resident's history of showers over the previous 30 days was reviewed. Only two showers had been documented as occurring in the previous 30 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis that included schizophrenia, type 2 diabetes mellitus, major depressive disorder, generalized anxiety disorder, dementia, repeated falls, vitamin b12 def, extrapyramidal and movement disorder, and overactive bladder. On 2/6/24 at 9:29 AM, an interview was conducted with resident 6. Resident 6 stated recently they were not given a brief change the entire night and there had been numerous times where they were left in a brief for a long time. Resident 6 stated sometimes they were left in a dirty brief for more hours than they appreciated. Resident 6 complained about the redness on their bottom. On 2/21/24 at 9:16 AM, an observation was made of Certified Nursing Assistant (CNA) 2 assisting resident 6 with a brief change. The CNA 2 was observed to ask resident 6 if they were wet and then proceed to check resident 6's brief. Resident 6's brief was removed and resident 6's buttocks area was observed to be erythematous with red dots of varying sizes present. The CNA 2 was observed to wipe resident 6 clean and then applied barrier ointment to resident 6's posterior. The CNA 2 stated they also tried to keep resident 6's diaper semi loose to prevent further skin irritation. On 12/27/23, a Quarterly Minimum Data Set (MDS) documented resident 6's bowel and bladder function as incontinent. Resident 6 was also documented to have moisture associated skin damage (MASD) as a skin condition. Resident 6's care plan was reviewed and documented the following care areas associated with incontinence: a. A care plan focus area, initiated on 11/7/23 documented resident 6 was at risk for skin break related to incontinence and a history of MASD to peri-area. Documented intervention included but not limited to weekly skin checks. b. A care plan focus area, initiated on 11/20/23 documented resident 6 had an alteration in bowel and bladder elimination due to incontinence and it stated resident 6 required assistance with toileting care. Documented interventions included but not limited to changing resident 6's disposable brief every shift and during rounds as needed. c. A care plan focus area, initiated on 2/18/24 documented resident 6 had MASD to their bottom related to incontinence. Documented interventions included but not limited to keeping the skin clean and dry and checking for incontinence frequently. Resident 6's physician orders were reviewed and documented the following orders in regard to resident 6's skin condition: a. An order with a start date of 1/8/24 stated as followed, Calmoseptine External Ointment 0.44-20.6 % (Menthol-Zinc Oxide). Apply to coccyx fissure topically every shift for MASD May D/C [discontinue] once resolved. This order was discontinued on 2/27/24. b. An order with a start date of 2/1/24 stated as followed, Nystatin External Powder 100000 UNIT/GM [gram] (Nystatin (Topical). Apply to under breast, groin topically every shift for yeast, redness. c. An order with a start date of 2/19/24 stated as followed, WOUND CARE - MASD breakdown to crack of buttocks Cleanse with wound cleanser and pat dry. Apply medihoney sheet (cut to fit) to wound bed and cover with silicone foam dressing. Change daily and as needed for soiling/dislodgement. On 11/21/23, a weekly skin review/assessment documented, Patient is incontinent of bowel and bladder. She does try and use the restroom but constantly has soiled briefs. She has slight redness in groin area, using Nystatin to help. She has no other skin breakdown. Skin warm, dry and intact. On 11/28/23, weekly skin review/assessment documented, Patient is incontinent of bowel and bladder. She does try and use the restroom but constantly has soiled briefs and needs assistance to get changed. She has slight redness in groin area, using Nystatin to help. She has no other skin breakdown. Skin clear, warm, dry and intact. Will continue to monitor. On 12/31/23, a weekly skin review/assessment documented, Resident continues to have some redness and applied nystatin to groin, [NAME] and buttock and encouraged resident to take scheduled showers. On 1/7/24, a weekly skin review/assessment documented, Resident continues with treatment of rash to groin, [NAME] and buttock folds. Nystatin applied with brief changes. On 1/8/24 at 11:06 AM, a nurse note stated, Aide came to LN [licensed nurse] and stated that when they went to go and change pt [patient] brief, that they noticed pt had an open area. LN went in and assessed; pt has some redness noted to their coccyx area, with open fissure noted. LN communicated with management and received instruction to go ahead and apply calmoseptine r/t [related to] MASD and use Q [every] Shift, until resolved. On 1/14/24, a weekly skin review/assessment documented as followed, No skin issues skin is clean dry and intact barrier cream being used because of incontinences, WCTM [will continue to monitor]. On 2/4/24, a weekly skin review/assessment documented, Resident continues with treatment for redness under breasts, [NAME] and groin skin is pink and dry flaking around the edges. On 2/11/24, a weekly skin review/assessment documented, Resident continues with treatment for redness under breasts, [NAME] and groin skin is more inflammed [sic] and dry flaking around the edges. On 2/18/24 at 11:23 AM, a nurse note stated, MASD noted in buttocks along the crack skin has broken down - area cleansed and dressing applied. MD [medical doctor] and administration notified to add to wound rounds. new orders for daily dressing changes. On 2/18/24, a weekly skin review/assessment documented the following, Resident continues with nystatin under both breasts (both very red and starting to breakdown, bilateral [NAME] (light pink areas on each side). MASD noted in buttocks along the crack skin has broken down - dressing applied. On 2/21/24 at 8:32 AM, an interview was conducted with Nursing Assistant (NA) 4. The NA 4 stated resident 6 was able to reposition themselves in bed and used a brief. The NA 4 stated resident 6 was a heavy wetter and was able to notify staff when they needed a brief change. The NA 4 stated staff attempted to check on resident 6 between every 1-2 hours. The NA stated when they did their rounding, there was a high probability that resident 6 needed to be changed. The NA stated resident 6 had a bad rash on their butt and described it as red, patchy, and peeling like dry skin. On 2/21/24 at 8:40 AM, an interview was conducted with Certified Nursing Assistant (CNA) 5. The CNA 5 stated resident 6 did very minimal to help with their cares. The CNA 5 states resident 6 was able to reposition themselves in bed and was able to help turn themselves with brief changes. The CNA 5 stated resident 6 was incontinent but was able to notify staff when they needed a brief change and became impatient if not changed quick enough. The CNA 5 stated resident 6 had a rash on their bottom and believed it was either due to a reaction to the brief or because of resident 6's excessive sweat. The CNA 5 described resident 6 had a rash with red dots on their bottom and stated that ointment was applied with every brief change to help the rash. On 2/21/24 at 9:06 AM an interview was conducted with CNA 2. The CNA 2 stated resident 6 had a hard time communicating their needs and stated resident 6 sometimes yelled and screamed to get staff's attention. The CNA 2 stated resident 6 had some mental delays and behaved like a child. The CNA 2 stated resident 6's briefs were changed at least every 2 hours. The CNA 2 stated resident 6 had been told to go in their brief since they are heavy to get up. The CNA 2 stated resident 6 was able to call when they needed a brief change. The CNA 2 stated resident 6 had sensitive skin which has lead to their current skin problems. The CNA 2 stated resident 6's skin around their bottom was irritated like when a baby had diaper rash. The CNA 2 stated they applied cream with every brief change to prevent it from getting worse. The CNA 2 stated resident 6 had a history of this and this irritation was new. The CNA 2 stated the type of rash resident 6 had occurred more frequently on light colored skin since that skin was more sensitive. On 2/21/24 at 10:44 AM, an interview was conducted with the Director of Nursing (DON). The DON stated they were unsure if resident 6 was able to make their needs known to staff and expected staff to check on resident 6 frequently. The DON stated they expected the CNAs to go in and check on resident 6 at least every two hours and that included incontinence care if needed. The DON stated if a resident was left in a soiled brief multiple times for a prolonged period, it affected the resident's skin integrity. The DON stated the outcome of compromised skin integrity included MASD which led to further skin break down and wounds if not treated appropriately. The DON stated staff had to be diligent on checking incontinent residents and applying barrier cream to prevent MASD. The DON stated resident 6 had MASD and was being followed by the wound care provider due to this. [Cross refer to F690] 7. Resident 90 was admitted to the facility on [DATE] with diagnosis which included cellulitis of right lower limb, cellulitis of left lower limb, chronic venous hypertension with inflammation of left lower extremity, chronic venous hypertension with inflammation of right lower extremity, non-pressure chronic ulcer of unspecified part of left lower leg with fat layer exposed, non-pressure chronic ulcer of unspecified part of right lower leg with fat layer exposed, pain in unspecified limb, pain in unspecified foot, peripheral vascular diseases, diabetes type 2, and need for assistance with personal care. On 2/6/24 at 10:43 AM, an interview was conducted with resident 90. She stated that she tells the staff she was in pain from her legs to her feet. She stated that her pain was often at a 10 and that it was currently at a 10 and staff had not given her any pain medications that morning. She stated that when she tells staff she was in pain the staff will say they will get her something but never come back, and that it takes a lot of time to get somebody to help. Resident 90's medical record was reviewed from 2/12/24 thru 2/22/24. On 2/4/24 an admission Minimum Data Set (MDS) assessment was conducted. The functional ability of the MDS documented resident 90's functional limitation range of motion impairment for the upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) was impairment on both sides. Resident 90 required substantial/maximal assistance with mobility, upper and lower body dressing, toileting, and shower/bathe. On 2/5/24 an admission MDS assessment for pain was conducted. The pain interview documented, pain frequency as almost constantly. Resident 90 was asked, Please rate your pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine. The response was 10. Resident 90's care plan dated 2/3/24 indicated that the resident was at risk for pain related to wounds to bilateral lower extremities with infection. The interventions documented were the following: a. Administer analgesia a per orders. Observe for efficacy and side effects. Give 1/2 (half) hour before treatments or care. b. Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. c. Monitor/record/report to nurse resident complaints of pain or requests for pain treatment. d. Resident 90's pain is aggravated by walking, movement, and wound treatment as has foot wounds. e. Resident 90's pain is alleviated by pain meds, rest, elevated legs. On 2/3/24 resident 90's physician orders revealed that resident 90 had the following orders: a. oxyCODONE Hydrochloride (HCI) Oral Tablet 5 milligram (MG) (Oxycodone HCI). Give 1 tablet by mouth every 6 hours as needed for Pain. b. Acetaminophen Oral Tablet 500 MG (Acetaminophen). Give 1 tablet by mouth every 6 hours as needed for Pain. On 2/4/24 at 2:22 PM, a pain level score was documented as 10 out of 10 (using a numerical scale from 0-10, 10 being the worst). On 2/4/24 at 2:22 PM, an administration note documented resident 90 received Oxycodone 5 MG for pain. On 2/4/24 at 5:06 PM, an administration note documented, oxyCODONE HCl Oral Tablet 5 MG[Miligrams] . Administration was: Ineffective. Follow-up Pain Scale was: 9. On 2/4/24 at 8:03 PM, an administration note documented Oxycodone was given for pain, resident reports pain 10/10. On 2/5/24 at 10:20 AM, a pain level score was documented as 8 out of 10. On 2/5/24 at 10:20 AM an administration not documented resident 90 was given Oxycodone 5 MG for pain. On 2/5/2024 at 1:29 PM, an administration note documented, oxyCODONE HCl Oral Tablet 5 MG . Administration was: Ineffective. Follow-up Pain Scale was: 6. On 2/6/24 at 6:15 PM, an administration note documented resident 90 received Oxycodone 5 MG, pt [patient] c/o [complained of] px [pain] 8/10. On 2/6/24 at 9:10 PM, an administration note documented, oxyCODONE HCl Oral Tablet 5 MG . Administration was: Effective. Follow-up Pain Scale was: 3. On 2/7/24 at 3:19 PM, a nurses note documented, the nurse spoke with the physician about resident experiencing pain but not asking for pain medication. PCP [primary care physician] ordered to schedule 5 mg Oxycodone BID [twice a day] to help with pain management . On 2/7/24 at 7:00 Pm a physicians order documented, oxyCODONE HCl Oral Tablet 5 MG (Oxycodone HCl). Give 1 tablet by mouth two times a day for Pain [It should be noted that a physician was not contacted for 3 days regarding resident 90's documented uncontrolled pain and ineffective pain score after receiving medication.] On 2/14/24 at 10:34 AM, an observation was made of resident 90's receiving bilateral leg wound care. Resident 90 was observed to have her wound dressings already removed by the Wound Care Nurse Practitioner (WCNP). Resident 90 was observed to have her eyes tightly closed and eyebrows furrowed. The WCNP lifted each leg to observe the wounds, resident 90 stated ouch. At 10:46 AM, RN 2 and RN 3 entered the room and stated they were giving resident 90 medication for pain. At 10:47 AM WCNP and RN 3 lifted resident 90's left leg and continued wound care, while resident 90 cried out in pain stating ouch and crying. RN 2 stated resident 90 could hold her hand squeeze as hard as you need, I can take it. At 10:50 AM, Resident 90 cried louder stating, All of it hurts, the WCNP pressed on her heel and she cried out in pain, the WCNP asked the resident to state where she was feeling pain and where the WCNP was touching, resident 90 stated again, it all hurts, my heel. The WCNP stated she was sorry. At 10:52 AM, the WCNP began cleaning her wounds with gauze and wound cleanser, while the resident continues to have eyes shut tightly and crying while stating ouch multiple times. RN 2 stated for resident 90 to just squeeze her hand and that she could handle it. At 10:58 AM resident 90's left leg was being wiped with gauze and wound cleanser, with each wipe of the gauze on the skin she would say ouch. At 11:03 AM resident 90's legs were being wrapped in the outer layer of the wound dressing, she appeared calm, her eyes were no longer closed tightly and her eyebrows were not furrowed. [It should be noted that resident 90 did not receive pain medication a half hour prior to wound care and that it took approximately 30 minutes for her to look calm. It should be noted that after approximately 30 minutes the first 30 minutes of wound care include cleaning and directly touching the wounds and after the cleansing wound care consisted of wrapping resident 90's legs and no longer directly wiping the open wounds.] On 2/14/2024 at 10:45 AM, a physicians order documented, oxyCODONE HCl Oral Tablet 5 MG (Oxycodone HCl). Give 5 mg by mouth every 24 hours as needed for pain with wound care. On 2/14/24 at 1:54 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that pain scores are considered on of the resident vitals and that if they are out of control the expectation is that staff would call the physician immediately to report if it is not being controlled with their current medication regimen. The DON stated that if a resident is taking oral Oxycodone for pain, it takes 15 to 30 minutes for it to become effective. The DON stated that if someone is getting wound care that is painful, she would expect the resident to receive the medication at least 15 minutes prior to wound care because the pain would be considerably less. The DON stated that if the resident did not receive pain medication prior to wound care, the resident would not have pain relief during wound care for the time it would take to become effective. She stated that resident 90 should have gotten the pain medication earlier, but that the nurses were busy and can only go so quickly. She stated that a wound care can be delayed or rescheduled in order for the resident to receive pain medication. The DON stated that during wound care when resident 90 was crying the WCNP did tell the resident they could stop wound care, but that the process of giving pain medication prior to wound care is to prevent pain during wound care, that ideally we do not inflict pain on the resident. [Cross refer to F697] 9. Resident 7 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, morbid obesity, alcoholic cirrhosis, hepatic failure, type II diabetes mellitus with polyneuropathy, portal hypertension, narcolepsy, major depressive disorder, obstructive sleep apnea, personality disorder, bipolar II disorder, alcoholic dependence, restless leg syndrome, male erectile dysfunction, hypertension, heart failure, anxiety disorder, hyperlipidemia, hyperaldosteronism, and osteoarthritis. On 2/05/24 at 10:21 AM, an interview was conducted with resident 7. Resident 7 stated that his scheduled shower days were Wednesday and Saturday. Resident 7 stated that the last month they had been following the schedule, but prior to that he was not provided showers. Resident 7 stated that he needed assistance with washing his genitals and back and needed his oxygen while showering. On 2/16/24, the Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, which would indicate that resident 7 was cognitively intact. The assessment documented that resident 7 required substantial maximal assistance for bathing and the helper did more than half the effort. On 2/20/24, resident 7's bathing tasks documented the bathing schedule was Wednesday and Saturday morning, and the last 30 days documented no showers were provided. On 12/6/23, resident 7's skin check/shower sheet documented that a shower was provided. No other shower sheets were noted. Resident 7's progress notes revealed the following: a. On 9/20/23 at 1:58 PM, the admission note documented, refused shower from hospice. He said he will do it tomorrow. poor hygiene noted. b. On 9/21/23 at 2:57 PM, the Nurses Note documented, He was assisted in the shower by hospice cna today. He refused shower yesterday. and he got upset when the nurse asked him to shower today. After the shower today, he refused to wear clean pants. He still wants to wear dirty pants. hospice nurse notified. c. On 9/21/23 at 5:00 PM, the admission: 72 Hour Charting note documented, required 1 person extensive with shower, dressing. pull up use for incontinent of bowel. refused to change his pants even he has stool on after the shower. d. On 11/22/23 at 2:14 PM, the Nurses Note documented, RNC [regional nurse consultant] and Administrator went to speak with this resident regarding his care concerns. resident expressed he does not want 2 staff for his cares including showers and housekeeping to clean. He often refuses when attempts are made to clean his room and it has a foul odor and belongings everywhere which he will not allow to be cleaned up. He did report that he was showered yesterday. e. On 11/29/23 at 5:11 AM, the Nurses Note documented, Resident came out of his room demanding a shower, although he was not on the list for showers. Resident is to shower on Saturdays. Resident proceeded to yell at staff and scratched a CNA [certified nurse assistant]. Nurse informed the DON [Director of Nursing] and was instructed to call 911 for a police report. Nurse encouraged resident to be polite, respectful and patient. Resident continued to yell and argue with the staff. Police came to facility and completed a police report. f. On 12/10/23 at 1:18 AM, the Nurses Note documented, no issues with behaviors although patient claims to have asked for a shower and didn't receive one. g. On 12/10/23 at 11:47 AM, the Nurses Note documented, Resident has been calm and cooperative with cares. Took meds as prescribed minus lactulose. Resident still looking for armodafinil prescription that hasn't been filled. He claims he wasn't showered yesterday, nurse asked CNAs to please accommodate him today. h. On 1/31/24 at 10:47 AM, the Social Service Note documented, He was excited to be having pizza for dinner and then have a shower. He states he has no other concerns at this time. i. On 2/1/24 at 3:16 PM, the Nurses Note documented, Patient has not been abusive to this nurse or residents but earlier he was demanding to have a shower when he refused his shower yesterday, He kept telling his aid that he was busy. j. On 2/1/24 at 3:23 PM, the Nurses Note documented, When the patient was demanding a shower the aid explained to him that it was not his shower day and that it was 12 oclock and lunch was being served and he needed to get the lunch trays out. the resident started yelling and said that he is a priority patient, and needed a shower. The patient went to his room. The aid that tried to shower him yesterday said that he would try and get him in the shower today. On 9/18/23, resident 7 had a care plan initiated for had a Activities of Daily Living (ADL) self-care performance deficit. Interventions identified included Cares with Pairs: Assist of 2 with cares when in room related to behaviors; adjust ADL assistance per level of need at time of care; and required limited/ partial/ moderate assist of 2 due to behaviors for bathing/showering; On 2/08/24 at 10:18 AM, an interview was conducted with the CNA Coordinator (CNAC). The CNAC stated that the shower sheet was posted in a binder so that the aides could see who was scheduled for a shower that day. The CNAC stated that they were struggling with showers due to staff turn over. The CNAC stated that the shower sheet should be uploaded into the resident's electronic medical records. The CNAC stated that if a resident wanted more showers they were allowed, but first they would complete that days scheduled showers. The CNAC stated that if a resident refused a shower the aides were to fill out the refusal sheet and take it to the nurse to sign. The CNAC stated that resident 7 needed 2 staff to provide cares for moody and aggressive behaviors. The CNAC stated that resident 7 needed assistance with showers. On 2/20/24 at 1:06 PM, an interview was conducted with Nursing Assistant (NA) 1. NA 1 stated that resident 7 required a two person assist for transferring and a one person assist for showers. NA 1 stated that they documented showers in the shower sheet and in the electronic medical records. On 2/20/24 at 1:11 PM, and interview was conducted with NA 2. NA 2 stated that they documented the showers on the shower sheet and any refusals. On 2/20/24 at 1:16 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she was not seeing any shower sheets for resident 7. [Cross refer to F676] 10. Resident 4 was admitted to the facility on [DATE] with diagnoses which included mononeuropathy, chronic respiratory failure, type II diabetes mellitus, morbid obesity, chronic obstructive pulmonary disease, non-pressure ulcer of left calf, schizoaffective disorder, epilepsy, hypothyroidism, peripheral vascular disease, varicose veins, hypertension, bilateral osteoarthritis of hip, intervertebral disc disorder, edema, chronic pain syndrome, tremor, overactive bladder, hyperlipidemia, viral hepatitis C, insomnia, sleep apnea, post traumatic stress disorder, anxiety disorder, bipolar disorder, borderline personality disorder, and major depressive disorder. On 2/12/24 at 12:43 PM, an interview was conducted with resident 4. Resident 4 stated that on Saturday night at approximately 11:00 PM the nurse left for 45 minutes because he locked the keys inside the medication cart and had to drive to the Director of Nursing (DON) house to get a second set of keys. Resident 4 stated that the residents were left with only one aide for an hour. Resident 4 stated that the nurse on shift was Registered Nurse (RN) 4. On 2/12/24 12:49 PM, an interview was conducted with the DON. The DON stated that she got a call after 10:00 PM on Saturday night from RN 4. The DON stated that RN 4 had reported that he had locked the keys to the medication cart inside the cart and there were no spare keys. The DON stated that she called the pharmacy to see if they had any spare keys inside the Pixus and they did not. The DON stated that they were in the process of obtaining a spare key to have in a lock box in the medication room. The DON stated that the aide on shift came to her home to get her office keys and then RN 4 was able to get into her desk to obtain the spare medication cart keys. The DON stated that she did not know who the aide was that came and picked up the keys. The DON stated that she placed her office key under her front door mat for them to retrieve. The DON stated that the nurse should not have left the facility and it should have been the aide to come and pick up the spare key. The DON stated that she would verify with RN 4 who came to pick up the key. On 2/12/24 at 1:49 PM, a telephone interview was conducted with Nurse Assistant (NA) 7. NA 7 confirmed that she worked on Saturday night and RN 4 locked the keys in one of the carts. NA 7 stated that RN 4 left the facility and went to the DON's house to get a spare key. NA 7 stated that there were no issues with the resident while the licensed nurse was gone from the facility. 11. On 2/21/24 at 7:37 AM, an interview was conducted with RN 2. RN 2 stated that the hallway was divided into two sections, the North side and the South side. RN 2 stated the North side had a licensed nurse scheduled for a 12 hour shift from 6:00 AM to 6:00 PM, and the South side had a licensed nurse schedule from 6:00 AM to 2:00 PM. RN 2 stated that a licensed nurse was also scheduled from 4:00 PM to 8:00 PM to pass medication and complete any scheduled treatments. RN 2 stated that during the day shift they usually had 3 aides. RN 2 stated that on the evening shift from 2:00 PM to 10:00 PM they had 3 aides scheduled. RN 2 stated that on the night shift from 10:00 PM to 6:00 AM they had 2 aides scheduled. RN 2 stated that the facility conducted monthly training that was held during the mandatory meeting for all staff. RN 2 stated that the training went over any issues that had come up such as any safety issues and methods on how to treat resident behaviors. It is usually reflective of any issues that have come up and they try to address it right away. On 2/15/24 at 10:51 AM, an interview was conducted with the Administrator (ADM). The ADM stated that the licensed nurses had a 6:00 AM to 6:00 PM shift, a 6:00 PM to 6:00 AM shift and a medication pass shift from 6:00 AM to 2:00 PM and 4:00 PM to 8:00 PM. The ADM stated that up through December 20, 2023 the previous Assistant Director of Nursing was doing the nursing schedule. The ADM stated that after that time period the Certified Nurse Assistant Coordinator (CNAC) was doing the CNA and licensed nurse schedule. The ADM stated that depending on the census they may not have a second nurse for the 4:00 PM to 8:00 PM shift and the cutoff was less than 37 residents. The ADM stated that the schedule for the aides was day shift 3 aides, evening shift 3 aides, and night shift 2 aides. Based on interview, observation and record review, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, multiple residents voiced concern about the staffing level both individually and in a group setting, showers were not provided as scheduled, pain medication was not provided timely, incontinence care was not provided timely, and a nurse left the facility to retrieve the keys to the medication cart from the Director of Nursing. Resident identifiers: 1, 4 6, 7, 8, 16, 30, 31, and. Findings included: 1. On 2/5/24 at 1:47 PM, an interview was conducted with resident 31. Resident 31 stated that approximately one month prior, she was left in the shower for 10 to 15 minutes alone. She stated that she had the emergency light on because she needed to go to the bathroom, but because no one came, she attempted to get to the toilet, but slipped on the wet floor, went down on her knees, and ultimately defecated on herself. The resident stated that this was embarrassing for her. 2. On 2/6/24 at 10:37 AM, an interview was conducted with resident 30. Resident 30 stated that the facility was badly understaffed. 3. On 2/5/24 at 12:11 PM, an interview was conducted with resident 1. Resident 1 stated that there was never enough staff, that's why they have agency. Resident 1 stated that during the night shift he has had to wait a long time for assistance. Resident 1 stated that on one occasion, his bowel movement was coming and he needed to be positioned on his side and he had to scream for help. 4. On 2/5/24 an interview [TRUNCATED]

Based on interview and record review, the facility used individuals working in the facility as a nurse aide for more than 4 months, on a full-time basis. Specifically, three Nursing Assistants were providing resident cares despite working at the facility for more than 120 days and not being certified. Findings include: On 2/13/24, the files of 3 Nursing Assistants (NAs) were reviewed and revealed the following: a. NA 2 had a hire date listed as 9/25/23. b. NA 3 had a hire date listed as 9/1/23. c. NA 7 had a hire date listed as 8/7/23. The facility staff schedule for the week of 2/4/24 through 2/10/24 was reviewed. NA 2, NA 3 and NA 7 were all scheduled and assigned a section of the facility to provide cares for residents during that week. On 2/7/24 at 9:55 AM, an interview was conducted with Nurse Assistant (NA) 2. NA 2 stated that he had worked at the facility for 2 months and he was working on getting his certificate. On 2/14/24 at 2:22 PM, an interview was conducted with NA 3. NA 3 stated that she had not taken the test to become certified yet. NA 3 stated that she was training other NAs and Certified Nursing Assistants (CNAs) at the facility. On 2/7/24 at 11:45 AM, an interview was conducted with NA 4. NA 4 stated that she was a new hire and planned to work at the facility for 30 days and then the facility would start her certification class work. NA 4 stated that she would be obtaining her certification through a separate program. NA 4 stated that she trained for a few days with the staff at the facility and they showed her how to do everything. On 2/13/24 at 10:50 AM, the Business Office Manager (BOM) was interviewed. The BOM confirmed that NA 2, NA 3, and NA 7 had been working at the facility for longer than 120 days. The BOM stated that NA 2 was finishing his clinical's and then taking his test. The BOM stated that per corporate policy, staff members who had not been employed at the facility for 60 days as an NA were not enrolled in school to become certified. On 2/13/24 at 12:05 PM, an interview was conducted with the facility Administrator (ADM). The ADM stated that because of the high turnover rate of staff, NAs were not enrolled in a certification program until they had been employed for at least 60 days. The ADM confirmed that NA 2, NA 3 and NA 7 had been working at the facility providing cares for residents for longer than 120 days. The ADM stated that it was the Certified Nursing Assistant Coordinator (CNAC) who was responsible for ensuring NAs were certified before they worked at the facility for 120 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 7 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including narcolepsy without cataplexy, major depressive disorder recurrent moderate, personality disorder unspecified, bipolar II disorder, and generalized anxiety disorder. Resident 7's medical record was reviewed on 2/20/24. Resident 7's most recent Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. A physician's order dated 9/18/23 revealed,traZODone HCl [hydrochloride] Oral Tablet (Trazodone HCl) Give 400 mg by mouth one time a day for insomnia. A physician's order dated 11/23/23 revealed, Chart hours of sleep every morning and at bedtime. A care plan dated 9/18/23 revealed a focus area of,Potential for adverse side effects d/t [due to] uses antidepressant medication r/t [related to] Depression, INsomnia [sic]. The goal documented for this focus area was [Resident 7] will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. The interventions for this care area were documented as: a. Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT [each shift]. b. Monitor for target behavior sx [symptoms]: negative statements to self, verbalizes sadness. c. Monitor/document/report PRN [as needed] adverse reactions to ANTIDEPRESSANT [sic] therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL [activities of daily living] ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs [problems], movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt [weight] loss, n/v [nausea/vomiting], dry mouth, dry eyes. d. Psychotropic Review per IDT [interdisciplinary team] at least quarterly and PRN [as needed]. A care plan dated 9/30/23 revealed a focus area of, Potential for/actual alteration in mood r/t Major Depressive Disorder, Generalized ANxiety [sic] Disorder, Insomnia, stimulant use, phq9 [patient health questionnaire 9] score indicating moderate depression, PL2 findings, H/o [history of] abuse Refuses MD prescribed Seroquel and Lithium 11/10/2023 for new diagnosis of BIPOLAR DISORDER, CURRENT EPISODE MIDED [sic], MODERATE. The goal documented for this focus area was, [Resident 7] will have less than daily symptoms of depression, anxiety or sad mood by/through review date. The interventions for this care area were documented as: a. Administer medications as ordered. Monitor/document for side effects and effectiveness. b. Arrange for psych consult, follow up as indicated. c. Monitor/document/report PRN [as needed] any s/sx [signs/symptoms] of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. Resident 7's September 2023 through February 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) were reviewed. The MAR revealed that Resident 7 received Trazodone daily from 9/18/23 through 2/19/24. The TAR revealed that Resident 7's hours of sleep (HS) were not being monitored for the medication given 9/18/23 through 2/19/24. On 2/21/24 at 10:08 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that she had seen orders for hours of sleep to be monitored for residents taking Trazodone before. RN 3 stated that she was not sure if hours of sleep should be monitored for Resident 7. On 2/21/24 at 10:53 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she expected residents with orders for Trazodone for insomnia to have their hours of sleep monitored. The DON stated that the nurse who originally entered the order for Resident 7's hours of sleep to be monitored did not enter the order correctly and that it was not showing up in the electronic medical record for floor nurses to document. Based on interview and record review it was determined, for 3 of 40 sampled residents, that residents who have not used psychotropic (anti-psychotics; anti depressants; anti-anxiety; and hypnotics) drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Additionally, the facility did not ensure that a resident who used psychotropic drugs received gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, residents that used psychotropic medication did not receive gradual dose reductions as required, and a resident with orders to document sleeping patterns was not being monitored, after being prescribed a medication for insomnia. Resident identifiers: 2, 7, and 31. Findings included: 1. Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included bipolar disorder, schizophrenia, generalized anxiety, major depressive disorder, delusional disorder, catatonic disorder, and dementia. Resident 2's medical record was reviewed on 2/12/24 through 2/21/24. A care plan dated 8/15/23 with a revision dated 1/12/24, documented resident 2 meets PASRR (Preadmission Screening and Resident Review) II Level of determination secondary to serious mental illness diagnosis. Gradual dose reductions: Dose reductions should be approached with caution & not without the oversight of a physician or psychiatrist. On 2/13/24 at 10:23 AM, a review of the facilities psychotropic binder was conducted. A document titled psychotropic medication monthly review stated a GDR was due for the following medications: Aracept, mirtazapine, ativan, gabapentin, seroquel, duloxetine. The document indicated a change was clinically contraindicated and documented there were no new recommendations. The document stated that the MD [medical director] agrees with recommendations, the document had an area for the MD signature. The document did not have an MD signature. On 2/12/24 at 12:50 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that a GDR review was done every 90 days and the purpose was to discuss every psychotropic medication a resident was taking and the last GDR date. The DON stated that the pharmacist, the DON and primary care physician were present at the meetings, and would sign off any changes being made to any of the medications. The DON stated that the MD's signature should be on the GDR sheet for the review, if the physician signature was not on the form then it would not be anywhere else. The DON stated that there would be no way of knowing if the physician was present or not with out their signature. 2. Resident 31 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following a cerebral infarction, type II diabetes mellitus, asthma, morbid obesity, generalized anxiety disorder, major depressive disorder, insomnia, hypertension, pseudobulbar affect, hyperlipidemia, nondisplaced fracture of proximal phalanx of left great toe, and chondromalacia left knee. Resident 31's physician orders revealed the following: a. On 6/21/23, an order was initiated for Clonazepam Oral Tablet 0.5 milligram (mg), give 0.5 mg by mouth two times a day for anxiety. The order was discontinued on 1/30/24. b. On 1/30/24, an order was initiated for Clonazepam Oral Tablet 0.5 milligram (mg), give 0.5 mg by mouth two times a day for anxiety. c. On 6/21/23, an order was initiated for Escitalopram Oxalate Oral Tablet, give 20 mg by mouth one time a day for depression. The order was discontinued on 1/30/24. d. On 1/31/24, an order was initiated for Escitalopram Oxalate Oral Tablet, give 20 mg by mouth one time a day for depression. e. On 11/10/23, an order was initiated for Trazodone, give 50 mg by mouth one time a day related to major depressive disorder. The order was discontinued on 1/30/24. f. On 1/31/24, an order was initiated for Trazodone, give 50 mg by mouth one time a day related to major depressive disorder. g. On 6/21/23, an order was initiated for Trazodone, give 100 mg by mouth one time a day for insomnia. The order was discontinued on 1/30/24. h. On 1/30/24, an order was initiated for Trazodone, give 100 mg by mouth one time a day for insomnia. On 9/29/23, a psychotropic review of Trazodone, Clonazepam, and Escitalopram was conducted. The review documented that a Gradual Dose Reduction (GDR) was due. The new recommendation was to start Dextromethorphan 20 mg by mouth daily for 7 days then increase to 40 mg daily. It should be noted that no changes or GDR was made to the Trazodone, Clonazepam, and Escitalopram. On 11/16/23, the psychotropic review of Trazodone, Clonazepam, and Escitalopram was conducted. The review documented that a Gradual Dose Reduction (GDR) was due. Target symptoms/behaviors were increased lability, crying, and acting out. New symptoms identified were crying and aggression. The new recommendation was to decrease Dextromethorphan to 20 mg daily and to obtain a prior authorization and start Neudexta. It should be noted that no changes or GDR was made to the Trazodone, Clonazepam, and Escitalopram. On 2/12/24 at 10:06 AM, an interview was conducted with the Director of Nursing. The DON stated that resident 31's Trazodone 50 mg was administrated in the morning and was for depression and the Trazodone 100 mg was administered at night for insomnia. The DON stated that she did not have any attempted GDR nor documentation of a contraindication for a GDR for the Trazodone, Clonazepam and Escitalopram.

Based on observation, interview and record review it was determined that the facility did not ensure that all drugs and biologicals were stored and labeled in accordance with accepted professional principles, under proper temperature controls and cautionary instructions, and the expiration date when applicable. Specifically, the temperature in both medication fridges was not within a safe temperature range for medication storage, medications did not have resident information, and medication was available for use past the expiration date. Resident identifiers: 6, 9, 14, 21, 26, 28, 31, and 33. Findings included: On 2/21/24 at 9:35 AM, an observation was made of the facility medication refrigerators. Two mini fridges were observed at the nurse's station located under the desk. The first fridge temperature gauge measured 49 degree Fahrenheit (F). The first fridge was observed with a large block of ice in the freezer section of the fridge that was partially melted and was obstructing the door from closing properly. The locked medication box was located on the shelf directly below the block of ice. The lock box was not accessible and could not be removed from the shelf as the ice was blocking it. The following items were located in the first refrigerator: a. A Tresiba flex touch pen was observed frozen to the side of the block of ice. b. A box of Biscodyl suppositories was placed on the shelf directly below the block of ice and was located in a puddle of melted water. Water was observed dripping from the block of ice directly onto the boxed medication. The label on the box identified that the medication belonged to resident 33. c. A box labeled Cathflo Activase 2 milligram (mg). No resident information was located on the package. d. A Humira Pen 40 mg/0.8 milliliters (ml) pen for resident 6. e. A Prevnar 20-valent multi-use vial. f. A Respiratory Syncytial Virus (RSV) vaccine multi-use vial. g. Trulicity 1.5 mg/0.5 ml, 10 pens for resident 31. h. Lorazepam 2 mg/ml, 80 syringes for resident 14. i. Lorazepam 2 mg/ml, 19 syringes for resident 21. j. Lorazepam 2 mg/ml oral concentration for resident 28. k. Risperdal consta 50 mg, 2 vials for resident 6. An immediate interview was conducted with Registered Nurse (RN) 2. RN 2 pulled the box of Tresiba flex touch pen from the block of ice tearing the box in the process. RN 2 stated that the medication belonged to resident 9. RN 2 stated that she did not know who the Cathflo Acitvase 2 mg was for, I don't even know what it is. The Cathflo had an expiration date of September 2023. The second fridge temperature gauge measured 27.7 F. The following items were located in the second fridge: a. Meropenem 1gram (gr)/100 ml, 5 medicine balls for resident 26. b. Vancomycin 800 mg/120 ml, 6 medicine balls for resident 26. c. Tuberculin purified protein derivative (PPD), 7 multi-use vials. An interview was conducted with RN 3. RN 3 stated that the Cathflo was used to unclogged a peripherally inserted central catheter (PICC) line. RN 3 stated that she does not know what to do about the block of ice. RN 3 stated that she did not know how to get the ice out and they had no where to transfer the medication to. RN 3 stated she thinks that the ice developed when the power was going out frequently over the last week. RN 3 stated that she would reorder the Biscodyl suppository. RN 2 stated, at least it will get fixed now. On 2/21/24 at 9:56 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she did not know what the Cathflo was for. The DON stated that she was going to get one of the corporate supervisors to come look at the medication fridge, and she was going to get a new fridge for the medication. On 2/21/24 at 10:05 AM, an interview was conducted with the DON and the Chief Nursing Officer (CNO). The CNO stated that the first fridge was at room temperature. The DON stated that she was on the phone with the facility pharmacist. The Pharmacist stated that the Biscodyl and insulin was safe to save, and the Trulicity could be stored up to room temp for 14 days. The pharmacist stated he would have to check to see if it was still safe to administer the Meropenem and Vancomycin. The CNO attempted to pry the locked medication box free from under the block of ice and was not successful. The CNO stated he was not sure what medication was in the locked box. The facility policy and procedure for Storage of Medications documented under interpretation and implementation that 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. The policy was last revised in January 2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 11. The resident council notes for the previous 14 months were reviewed and revealed the following concerns voiced by the residents: a. On 1/25/23: i. Dietary: I like him [name of staff member] he's doing better. Tray transfer needs to be thought over, need to use second cart so dirt/grime does not get on the bottom trays. Larger portions. b. On 2/24/23: i. Water jugs. (switch off.) instead of being picked up and waiting. Just switch them off. ii. Dietary: . Portions are too small, need another set of hands. c. On 3/31/23: i. Water (takes hours). [Note: There was no specific information regarding what this concern referred to.] ii. Dietary: Food portions are small. Reassess drinks (many are not receiving milk.) Tickets are not being followed. Food is cold. They need to learn portion control. Bring out alternative menus to fill out. d. On 4/25/23: i. Water is still not being distributed (not being passed out). ii. Dietary: Not being served enough food (reach out to corporate to fix portions or double up portions.) Need to serve mechanical soft food. e. On 5/30/23 i. Residents want more ice cream! They also want their ice cream to not be melted by the time they are ready to eat it - Arrives directly with the meal. ii. Dietary: Food is often late 15 - 45 minutes better portions - they want. iii. [Resident name] is served is food, but no one is available to help him for at least a half hour. Food is always cold. f. On 6/13/23: i. Dietary: food is cold. ii. Water mugs have not been consistently going out the last few days. g. On 7/27/23: i.Snacks not being passed out in evenings. ii: Dietary: Food could be better. h. On 8/8/23: i. Dietary: Cold food. Portions are too small. High turnover. Too salty .Chicken is not cooked all the way. Still pink in the middle. Worried that food is cold in kitchen before it comes out. i. On 9/12/23: i. [Name of resident] - wants to meet with dietician (sic) about high protein diet - wants protein drinks - not allowed to have them of (sic) the facility. Been told several [NAME] (sic) to remove from building. j. On 10/11/23: i. Dietary: cold food, [name of resident] receiving food she doesn't want . bland food, want more seasoning - veggies too mush or too hard. Never medium. This month a Resident Council Departmental Response Form was attached to the resident council notes. In response to the dietary concerns, the interventions included Will have department head pull a test tray regularly to ensure consistency of food. k. No resident council notes for November 2023 were provided by the facility. l. On 1/9/24: i. Dietary: . Feels like the same thing all the time. Portions are small. Not a lot of care put into it. Worn out menu. Food not up to par. Dining room not clean. Stuff runs out. Meals not Complete. Kitchen is just sad! This month a Resident Council Departmental Response Form was attached to the resident council notes. In response to the dietary concerns, the interventions included Audited meal service on portion sizes with cook, RD (Registered Dietitian) and I. Admin (Administrator) pruchesed (sic) condiment holders for tables. [Note: Not all of the concerns voiced by the residents were addressed on the response form.] m. On 2/6/24: i. Dietary: . Like kitchen staff. Do not like food. Portions are small. Stay on top of stuff you run out off (sic). There was no Resident Council Departmental Response Form connected with the February 2024 resident council notes. It should be noted that dietary concerns were identified by residents in 13 of the 14 months of resident council notes reviewed. On 2/12/24 at 12:39 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that when receives complaints about the food served from an individual resident, he will meet with the individual resident, talk to them, and put relevant notes in their dietary profile or care plan. The DM stated that if there are complaints from resident council about the food served, he will then come up with a correction and interview members of the resident council after the correction has been implemented. The DM stated that if residents file a grievance, he will address the grievance and file the resolution in the grievance log. 8. On 2/5/24 at 10:35 AM, an interview was conducted with resident 26. Resident 26 stated they have asked for extra portions but do not get them. Resident 26 stated they were diabetic and wished to eat a variety of healthy foods such as broccoli, cucumbers, and lettuce and had been told by the kitchen they did not have those vegetables. Resident 26 stated a salad only consisted of spinach and tomatoes. On 2/12/24 at 12:46 PM, a follow up interview was conducted with resident 26. Resident 26 stated that over the weekend he was served a salad that consisted solely of tomato and lettuce. Resident 26 showed a photo of the salad that he had taken with his cell phone camera. The photo showed a salad that solely consisted of lettuce and diced tomatoes. 9. On 2/5/24 at 11:14 AM, an interview was conducted with resident 33. Resident 33 stated the food could be better. Resident 33 stated they were not served enough portions, so they ate baby food to supplement for the lack of food. Resident 33 stated they had been hospitalized due to an eating problem and they wanted to stay on top of what they ate to avoid going to the hospital again. 10. On 2/6/24 at 8:44 AM, an interview was conducted with resident 30. Resident 30 stated they were on a specific diet and sometimes they had to eat hamburgers 3 times a week. Resident 30 stated sometimes the food was bland and cold and they were often served the same thing. Resident 30 stated it would be nice if they changed out the menu. 4. On 2/5/24 at 1:43 PM, an interview was conducted with resident 31. Resident 31 stated that the food was nasty. Sometimes it was good depending on who cooked. Resident 31 stated that the food was the same every week, and they served hot dogs all the time. Resident 31 stated that she gets tired of the same food, and had a can of Chef Boyardee ravioli in her closet. Resident 31 stated that sometimes the hot food was served cold. Resident 31 stated that she had lost weight, but she did not mind because she felt she needed to. Resident 31 stated that the snacks were always peanut butter and jelly sandwiches, a cheese and ham sandwich, or fish crackers. Resident 31 stated that she would like cheese or fresh fruit, and rarely had yogurt or a banana. 5. On 2/5/24 at 9:49 AM, an interview was conducted with resident 36. Resident 36 stated that snacks were peanut better and jelly sandwich or a bologna and cheese sandwich every day. Resident 36 stated that he asked for double portions for his food otherwise he would not get enough to eat. 6. On 2/6/24 at 10:53 AM, an interview was conducted with resident 4. Resident 4 stated that she was served cold eggs everyday and it was a small portion size. Resident 4 stated that the food was disgusting and bland. 7. On 2/5/24 at 12:16 PM, an interview was conducted with resident 1. Resident 1 stated that the food sucked, and the product was not good quality. Resident 1 stated that the food was comparable to TV dinners. Resident 1 stated that the food was bland and he had to over salt his food. Based on interview and record review, the facility did not provide food that was palatable for 10 of 40 residents. Specifically, residents voiced concerns regarding the food quality in individual interviews, as well as resident council minutes. Resident identifiers: 1, 4, 8, 21, 26, 30, 31, 33, 34 and 36. Findings included: 1. On 2/5/24 at 11:13 AM, an interview was conducted with resident 8. Resident 8 stated that the food is fair. I don't care for it. Sometimes its warm, but not always. 2. On 2/5/24 at 10:09 AM, an interview was conducted with resident 34. Resident 34 stated that the food is not very good. 3. On 2/6/24 at 10:36 AM, an interview was conducted with resident 21. Resident 21 stated that the food was edible, but that's all . we all get the same slop. Resident 21 stated that he felt he had lost weight due to the poor quality of the food.

Based on observation, interview, and record review, it was determined that the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food safety. Specifically, the kitchen was not clean or sanitary and resident meal trays were subject to physical contamination while being served. Findings Included: On 2/12/24 at 11:33 AM, a walk through of the facility kitchen was conducted. Hotel pans were stored on visibly soiled white painted shelves. There were metal colanders stored on top of the ice machine. There was a carafe stored upside down on a chipped laminate shelf. The carafe was not dry, and a watery pink liquid was dripping from the carafe into the chips on the laminate shelf. Inside of the shelf was made of particle board. The chips in the laminate indicate that the storage space cannot be fully sanitized. The laminate counter where the coffee machine was stored was covered with multiple coffee stains. A window air conditioning unit was observed to be blowing cold air across two trays with uncovered cake slices on the trays. A vent on the wall in the dry storage was visibly covered in dust. There were crumbs of food on the bottom shelves of two of the refrigerators in the dry storage area of the kitchen. Cleaning chemicals were stored in the dry storage area. On 2/12/24 at 12:34 PM, the February 2024 Kitchen cleaning schedule was reviewed. The cleaning schedule was documented as completed on February 1st, 12th, 13th, and 14th. On 2/12/24 at 11:58 AM, an observation was made of the tray cart used to pass meal trays to residents. The tray cart was covered with a plastic cover. The plastic cover was visibly soiled. The bottom of the plastic cover touched the two trays on the bottom rung of the cart. On 2/12/24 at 12:43 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that the plastic cart covers should be cleaned after each meal served. The DM stated that shelves used to store utensils should be cleaned every other day. On 2/12/24 at 12:07 PM, an observation was made of Nursing Assistant (NA) 4 passing meal trays to residents during lunch mealtime. As CNA 4 removed a tray from the meal cart, the plastic covering of the meal cart brushed across and made contact with an uncovered slice of cake on the meal tray. On 2/14/24 at 3:11 PM, an interview was conducted with Nursing Assistant (NA) 3. NA 3 stated that it was not acceptable for the plastic covering on the tray cart to brush across uncovered food on resident meal trays. On 2/13/244 at 3:27 PM, an interview was conducted with the Certified Nursing Assistant Coordinator (CNAC). The CNAC stated that it was not acceptable for the plastic covering on the tray cart to brush across uncovered food on resident meal trays when serving meals to residents.

Based on interview and record review it was determined that the facility did not establish and maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility infection control tracking and trending was not complete. Findings included: On 2/12/24 at 1:24 PM, the facility infection control tracking and trending log was requested. A review of the log revealed no mapping, tracking, trending or analysis of the data for June, July, August, and September of 2023. A review of the Infection Prevention policy and procedure documented, goals of the infection prevention and control program which included: A. Decrease the risk of infection to residents and personnel. B. Monitor for occurrence of infection and implement appropriate control measures. C. Identify and correct problems relating to infection prevention and control practices. D. Maintain compliance with state and federal regulations relating to infection prevention and control . There is on-going monitoring for infections among residents, employees . and subsequent documentation of infections that occur . Infection prevention and control is a component of the facility's quality assessment and assurance (QAA) program and infection prevention and control reports are made to the QAA committee. In addition, infection prevention and control rounds/audits are made to assess the level of quality provided and actions for improvement are taken as needed. On 2/12/24 at 1:58 PM, an interview was conducted with the administrator (ADM). The ADM stated that she was unable to locate the infection control information for the months of June through September 2023. On 2/14/24 at 4:41 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she was unable to locate the files pertaining to those missing months for infection control, and that tracking and trending would be difficult without documentation.

Based on interview and record review it was determined that the facility did not ensure that the antibiotic stewardship program included antibiotic use protocols and a system to monitor the antibiotic use. Specifically, the facility infection control tracking and trending was not complete. Findings included: On 2/12/24 at 1:24 PM, the facility infection control tracking and trending log was requested. A review of the log revealed no mapping, tracking, trending or analysis of the data for June, July, August, and September of 2023. A review of the Infection Prevention policy and procedure documented, goals of the infection prevention and control program which included: A. Decrease the risk of infection to residents and personnel. B. Monitor for occurrence of infection and implement appropriate control measures. C. Identify and correct problems relating to infection prevention and control practices. D. Maintain compliance with state and federal regulations relating to infection prevention and control. There is on-going monitoring for infections among residents, employees . and subsequent documentation of infections that occur . Infection prevention and control is a component of the facility's quality assessment and assurance (QAA) program and infection prevention and control reports are made to the QAA committee. In addition, infection prevention and control rounds/audits are made to assess the level of quality provided and actions for improvement are taken as needed. On 2/12/24 at 1:58 PM, an interview was conducted with the administrator (ADM). The ADM stated that she was unable to locate the infection control information for the months of June through September 2023. On 2/14/24 at 4:41 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she was unable to locate the files pertaining to those missing months for infection control, and that tracking and trending would be difficult without documentation.

Based on observation and interview, 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 odors throughout the facility. Findings Included: On 2/13/24 at 10:43 AM, an observation was made of the facility shower room. It was noted that there was a strong odor of both feces and urine in the shower room. On 2/12/24 at 11:33 AM, a walk through of the facility kitchen was conducted. A vent on the wall in the dry storage was visibly covered in dust. On 02/14/24 at 1:33 PM, an interview was conducted with the Corporate Maintenance (CM). The CM stated he was temporary and had only been here for 3 days. The CM stated that he got a text from the admin to replace the toilet and that was why he was here. The CM stated he was responsible for project management and helped with the building. The CM stated he came to the building depending on how big the project was. The CM stated they oversaw big projects such as replacing toilets, working on AC units, doing floor repairs, and doing a fluff and puff on a new room. The CM stated he did not do the day-to-day maintenance stuff and generally did not look maintenance log. The CM visualized the black stuff in the main shower room and stated the black stuff was not mold and it looked more like algae. The CM stated the black stuff could be removed if the area was clean/disinfected. The CM stated the caulking around the toilet was not a requirement. The CM stated the caulking served as a sealant. The CM stated if there was no sealant present then fluid was able to get under the toilet. The CM stated if a resident voided or had diarrhea on the floor and it happened to go under the toilet then he expected a smell to be present underneath it since there was no sealant to prevent the bodily fluid from going underneath and there was no way to clean underneath the toilet. The CM stated depending on the substance spilled on the floor around the toilet, then a smell might have been present. The CM stated the in-house maintenance man was the one responsible for changing the vents. The CM stated if the vent was dusty then they expected there to be a restriction in the airflow due to the dust so it would not work as efficiently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure that nursing assistants received training to ensure ongoing competence, and include dementia management training. Findings included: 1. A list of inservices provided to staff for the previous 12 months was requested and revealed the following: a. On [DATE] an inservice was provided on Wandering Residents. However, only 8 staff members' signatures were listed on the signature sheet. b. On [DATE] an inservice was provided on Elopements, garbage bags, CNA duties. However, only 10 staff members' signatures were listed on the signature sheet. c. On [DATE] an inservice was provided on Resident issues, Infection Prevention, PHI (protected health information). However, only 7 staff members' signatures were listed on the signature sheet. d. On [DATE] an inservice was provided on Behavioral interventions, abuse training [and] reporting requirements, dignity and customer service. However, only 13 staff members' signatures were listed on the signature sheet. On [DATE] at 12:05 PM, an interview was conducted with the facility Administrator (ADM). The ADM stated that since she began employment at the facility in [DATE], monthly trainings had been provided to CNAs. When asked how she would ensure that all staff were provided the training, she stated that it would be the Director of Nursing or CNA Coordinator (CNAC). The ADM could not provide documentation any inservices for staff prior to [DATE]. On [DATE] at 3:30 PM, an interview was conducted with the CNAC. When asked about training provided at the facility, the CNAC stated there is no training ever. The CNAC stated that an abuse training had been provided, and a fall training, but no others. The CNAC stated that there had not been a dementia or trauma informed care training provided to staff. 2. On [DATE], the files of 3 Nursing Assistants (NAs) were reviewed and revealed the following: a. NA 1 had a hire date listed as [DATE]. No orientation checklist was included in NA 1's employee file. b. NA 2 had a hire date listed as [DATE]. No orientation checklist was included in NA 2's employee file. c. NA 3 had a hire date listed as [DATE]. No orientation checklist was included in NA 3's employee file. d. NA 4 had a hire date listed as [DATE]. No orientation checklist was included in NA 4's employee file. The facility staff schedule for the week of [DATE] through [DATE] was reviewed. NA 1, NA 2, NA 3 and NA 4 were all scheduled and assigned a section of the facility to provide cares for residents during that week. On [DATE] at 9:55 AM, an interview was conducted with Nurse Assistant (NA) 2. NA 2 stated that he had worked at the facility for 2 months and he was working on getting his certificate. On [DATE] at 2:22 PM, an interview was conducted with NA 3. NA 3 stated that she had been employed at the facility for 5 months, but had never completed an orientation packet. NA 3 stated she asked the CNA Coordinator about it and was told, we never got around to doing it. NA 3 stated that she had not taken the test to become certified yet. NA 3 stated that she was training other NAs and Certified Nursing Assistants (CNAs) at the facility. On [DATE] at 11:45 AM, an interview was conducted with NA 4. NA 4 stated that she was a new hire and planned to work at the facility for 30 days and then the facility would start her certification class work. NA 4 stated that she would be obtaining her certification through a separate program. NA 4 stated that she trained for a few days with the staff at the facility and they showed her how to do everything. On [DATE] at 12:05 PM, an interview was conducted with the facility Administrator (ADM). The ADM stated that upon hire, all NAs and CNAs were supposed to be trained using a facility orientation checklist. The ADM provided the orientation checklist for NA 1, however the checklist was not complete. The ADM stated that it was the responsibility of the CNA Coordinator to complete the training, fill out the checklist, and return the checklist to the Business Office Manager. The ADM stated that she could not find an orientation checklist for NA 2 or NA 4. The facility CNA/NA Orientation Checklist was reviewed. The checklist included skills and tasks to be observed and/or completed, such as communication and interpersonal skills; demonstrate knowledge of resident's rights; protect residents' dignity; verbalize knowledge of signs and symptoms of abuse; procedures for responding to and reporting accidents and incidents care of cognitively impaired, verbally aggressive, and/or physically aggressive residents; reporting resident changes in condition, how to provide assistance with activities of daily living; how to perform transfers; how to perform skin care; fall prevention; promoting hydration; responding to resident requests for assistance; use of assistive devices; range of motion; infection control; and care of the deceased .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), schizophrenia, diabetes mellitus type II, dementia, essential hypertension, moderate intellectual disabilities, and malnutrition. Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Alzheimer's disease, diabetes mellitus type II, pseudobulbar effect, dementia, schizophrenia, depression, essential hypertension, and dementia. On 5/26/22, record review was completed for residents 3 and 22. On 3/15/22 at 5:30 AM, a Nurses Note for resident 3 revealed, CNA's (Certified Nursing Assistants) found male resident [resident 3] sitting on the couch (closest to the TV), naked and masturbating. CNA approached him and politely asked him to stop, and come with him to his room, to get dressed, and lay down on his bed. Resident got up and grabbed his walker. As he was walking around the other couch facing the TV; noticed a resident [resident 22] sleeping on that couch. He stopped stared at her for a brief moment, and proceeded to slap her on the top of her head. She woke after being hit, turned to face him, and just laughed. On 5/24/22 at 11:52 AM, a nursing assistant (NA) was interviewed. The NA stated that he was not aware of any abuse in the building. The NA stated that he had not been provided direction to observe any residents for abuse. On 5/24/22 at 12:03 PM, Certified Nursing Assistant (CNA) 4 was interviewed. CNA 4 stated that she had not had abuse training recently. CNA 4 stated that if she had been aware of abuse, she would have reported it. CNA 4 stated that she was not told about abuse and had no residents that she was required to monitor more frequently. On 5/24/22 at 12:10 PM, an interview was conducted with CNA 5. CNA 5 stated that she was not familiar with the residents. CNA 5 stated that she was not informed about abuse at the facility. CNA 5 stated that she was aware that resident 22 had swung her arms around other residents but no residents had been abusive. CNA 5 stated that she was told residents had hit each other, but it was not considered abuse. On 5/25/22 at 4:41 PM, the Administrator (ADM) was interviewed. The ADM stated that he was the abuse coordinator. The ADM stated that the facility had not completed an abuse report when resident 3 swatted resident 22 on the head. The ADM stated that he did not investigate further, and that resident 3 disliked resident 22 for no cognitive reason. The ADM stated that resident 3 intentionally hit resident 22 on the head, and therefore the interaction was abuse. The ADM stated that there were no injuries. The ADM did not create a Facility Reported Incident. [Cross refer to F609 and F610] Based on interview and record review, the facility did not ensure that 3 of 23 sample residents were free from abuse. Specifically, a resident was determined to have been verbally abused by a staff member. In addition, a resident hit another resident on the head. It should be noted that based on the victims' reactions in both of these cases, the deficiency was not cited at a harm level. Resident identifiers: 3, 12, and 22. Findings include: 1. Resident 12 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included Parkinson's disease, epilepsy, diabetes mellitus, multiple sclerosis, chronic viral hepatitis C, and anxiety disorder. On 5/22/22 at 2:05 PM, an interview was conducted with resident 12. When asked how staff had been treating him, he stated It wasn't [Certified Nursing Assistant (CNA) 2's] fault what happened, and that CNA 2 had been fired for how she had treated him. When asked to describe the incident, resident 12 stated that CNA 2 would yell at me all the time but from my point of view she was just clowning around. Resident 12 stated that one day, CNA 2 just told me to quit yelling. Resident 12 stated that CNA 2 was in a different room than he was, but CNA 2 yelled at him to shut up. Resident 12 stated that no profanities were used. When asked what his response was, resident 12 stated I shut up and went back to sleep. Resident 12 further stated that I needed to shut up, they said they could hear me all the way down to the offices. I was yelling because I am spoiled rotten here. When asked to describe CNA 2's demeanor with him on other days, resident 12 stated that its my loss that CNA 2 was fired because she would really pamper me. She always did a good job with me. When asked if he was ever afraid of CNA 2, resident 12 stated Hell no! Resident 12 stated that CNA 2 always made sure she knew what was going on, and passed it on to the next shift. She gave 100% to the job . I think they jumped the gun (with regard to firing her). When they told me they fired her, I thought they were joking around about that . Is there a chance they can bring her back? There was a misunderstanding there. I miss her, she took really good care of me. On 5/24/22, an interview was conducted with the Corporate Resource Dietitian (CRD). The CRD stated that she had witnessed the interaction between CNA 2 and resident 12, and that it was more than just teasing. The CRD stated that there were several F words used, and that the CNA was mean in the way she spoke to resident 12. On 5/22/22, resident 12's medical record was reviewed. On 7/1/21, an admission Minimum Data Set (MDS) was completed for resident 12. The MDS indicated that resident 12 had a Brief Interview for Mental Status score of 11, indicating moderately impaired cognition. The Facility Reported Incidents (FRIs) filed with the State Survey Agency (SSA) were reviewed and revealed the following: At around 7:30 AM on Monday 3/21/22, [CNA 2). got frustrated with [resident 12] . because he had been difficult through the weekend and he seemed to be starting in again on the same behaviour (sic). At that point she yelled at him using the F word saying that she wasn't going to put up with it that day and that he better F'ing stop it. [It should be noted that this FRI was not submitted until 3/22/22 at 4:57 PM). Review of the facility's investigation into the incident between CNA 2 and resident 12 revealed that the Administrator (ADM) interviewed the 2 witnesses who reported the incident to him, but did not include any other resident or staff interviews to determine if there were other victims or witnesses. The investigation revealed that CNA 2 was suspended that day pending the investigation. After the accusations were substantiated, the employee was terminated.

Based on interview and record review it was determined that the facility did not have an effective system to record the disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. Findings include: On 5/24/22 at 8:34 AM, observation was made of nurse 1 (N 1) preparing and passing medications to residents. N 1 was observed to obtain a narcotic for a resident. On 5/24/22 at 2:32 PM, observations were made of the narcotic record sheets at the nurses' carts. One resident's record for the month of May 2022, revealed an order for hydrocodone/APAP (acetaminophen) 7.5 mg (milligrams)-325 mg, one tablet by mouth every 6 hours as needed for pain. On the narcotic sheet, there was one administration on 5/1/22 that was crossed out without a second nurse's signature. There was no noted reason for the line through. The narcotic count was decreased by one tablet. A different resident's controlled drug record for oxycodone 5 mg tablet, take 1/2 tablet by mouth every 4 hours as needed for pain was observed. The medication was received on 4/10/22, and included 60 half-tablet doses. On 4/22/22, a medication was lined through at approximately 9:00 PM, without a notation as to why the medication was not administered and no second nurses' signature was provided. Between 4/22/22 and 4/24/22, medication counts were lined out and written over. The count decreased by at least one dose. There was no accounting for the missing narcotic. On 5/24/22 at 2:45 PM, nurse 1 was interviewed. N 1 stated that she did not know what happened to the missing medications. N 1 stated that the protocol for nurses is that whenever a nurse has to waste a medication that was not given for whatever reason, they were to sign with another nurse. N 1 stated that if a nurse wasted in the evening, when only one nurse was working, that nurse was to preserve the medication and waste with another nurse who arrived on shift. N 1 stated that no narcotics should have a line through them without a second nurses' signature. N 1 observed the narcotic record with the miscount. N 1 stated that the night nurse had been talked to previously about his ability to write legibly. On 5/24/22 at 3:30 PM, an interview was conducted with the Director of Nursing (DON). The DON observed the narcotic records and identified that a second nurses' initials should have counter-signed missing or wasted narcotic medications. The DON stated that nurses should not have wasted narcotics without a second nurse observing the unadministered medication. The DON identified that there was a miscount in the narcotic record and stated that the nurse would be reminded to print legibly. The DON stated that the nurses who had access to the missing narcotics would be tested for controlled substances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), schizophrenia, diabetes mellitus type II, dementia, essential hypertension, moderate intellectual disabilities, and malnutrition. Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Alzheimer's disease, diabetes mellitus type II, pseudobulbar effect, dementia, schizophrenia, depression, essential hypertension, and dementia. On 5/26/22, record review was completed for residents 3 and 22. On 3/15/22 at 5:30 AM, a Nurses Note for resident 3 revealed, CNA's (Certified Nursing Assistants) found male resident [resident 3] sitting on the couch (closest to the TV), naked and masturbating. CNA approached him and politely asked him to stop, and come with him to his room, to get dressed, and lay down on his bed. Resident got up and grabbed his walker. As he was walking around the other couch facing the TV; noticed a resident [resident 22] sleeping on that couch. He stopped stared at her for a brief moment, and proceeded to slap her on the top of her head. She woke after being hit, turned to face him, and just laughed. On 5/24/22 at 11:52 AM, a nursing assistant (NA) was interviewed. The NA stated that he was not aware of any abuse in the building. The NA stated that he had not been provided direction to observe any residents for abuse. On 5/24/22 at 12:03 PM, CNA 4 was interviewed. CNA 4 stated that she had not had abuse training recently. CNA 4 stated that if she had been aware of abuse, she would have reported it. CNA 4 stated that she was not told about abuse and had no residents that she was required to monitor more frequently. On 5/24/22 at 12:10 PM, an interview was conducted with CNA 5. CNA 5 stated that she was not familiar with the residents. CNA 5 stated that she was not informed about abuse at the facility. CNA 5 stated that she was aware that resident 22 had swung her arms around other residents but no residents had been abusive. CNA 5 stated that she was told residents had hit each other, but it was not considered abuse. On 5/25/22 at 4:41 PM, the Administrator (ADM) was interviewed. The ADM stated that he was the abuse coordinator. The ADM stated that the facility had not completed an abuse report when resident 3 swatted resident 22 on the head. The ADM stated that he did not investigate further, and that resident 3 disliked resident 22 for no cognitive reason. The ADM stated that resident 3 intentionally hit resident 22 on the head, and therefore was abuse. The ADM stated that there were no injuries. The ADM did not create a FRI. No five-day follow-up was created. The incident was not investigated. The ADM did not report the incident to Adult Protective Services (APS), the Ombudsman, or to Police. The ADM did not report the incident to Centers for Medicare and Medicaid Services (CMS). 5. Per review of the FRIs submitted to the SSA, the facility reported that on 2/17/22 at 5:30 PM, resident 9 yelled at resident 22. Resident 24 then yelled at resident 9, after which resident 24 called resident 9 retarded. Resident 9 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus type II, heart disease, borderline intellectual functioning, adult failure to thrive, depression, anxiety, and cataracts. Resident 24 was admitted to the facility on [DATE] and readmitted on [DATE] and on 4/25/22 with diagnoses that included neuropathy, respiratory failure, diabetes type II, hypertension, schizoaffective disorder, epilepsy, bipolar disorder, borderline personality disorder, chronic pain syndrome, and post-traumatic stress disorder (PTSD). On 5/25/22, a medical records review was completed. On 2/27/22 at 8:30 PM, a FRI was submitted to the SSA, approximately 10 days after the incident. [Cross refer to F600 and F610] Based on record review and interview it was determined that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency. Specifically, multiple entity reports of abuse allegations were not submitted to the State Survey Agency in a timely manner. Resident identifiers: 3, 9, 12, 14, 22, 24, 25, and 27. Findings include: 1. The Facility Reported Incidents (FRIs) filed with the State Survey Agency (SSA) were reviewed and revealed the following: At around 7:30 AM on Monday 3/21/22, [CNA 2). got frustrated with [resident 12] . because he had been difficult through the weekend and he seemed to be starting in again on the same behaviour (sic). At that point she yelled at him using the F word saying that she wasn't going to put up with it that day and that he better F'ing stop it. [It should be noted that this FRI was not submitted until 3/22/22 at 4:57 PM, approximately 33 hours after the incident occurred). Review of the facility's investigation into the incident between CNA 2 and resident 12 revealed that the Administrator (ADM) interviewed the 2 witnesses who reported the incident to him, but did not include any other resident or staff interviews to determine if there were other victims or witnesses. Also, the ADM did not follow up with resident 12 to determine if there were any lingering effects from the incident. The investigation revealed that CNA 2 was suspended that day pending the investigation. After the accusations were substantiated, the employee was terminated. 2. The FRIs filed with the SSA were reviewed and revealed the following: On 2/12/22 at 10:00 AM, [Resident 25] stated that he was standing by the door of the dining room door (sic) next to the nurses station. He reported that [resident 3] came up behind him and got him in a headlock and threw him over his shoulder and [resident 25] landed on his back. He said that he was able to fend off [resident 3] from there and things came to an end. He reported that the nurses were there but didn't react because it all happened so fast. I told him I would talk to the nurses to confirm and view the video tape of the incident. Initial investigation yielded no evidence that anything happened and is suspected to be one of his dilutions (sic) however further interviews and viewing of video tape will be completed. [It should be noted that this FRI was not submitted to the SSA until 2/27/22 at 8:30 PM.] Review of the facility's investigation into the incident between resident 25 and resident 3 revealed that the ADM interviewed 2 nurses that were on duty at the time of the incident, however it wasn't until 2 days after the alleged incident. In addition, the ADM did not speak to any residents to determine if there were other potential victims. Also, the ADM did not follow up with resident 25 to determine if there were any lingering effects from the alleged incident. 3. The FRIs filed with the SSA were reviewed and revealed the following: During breakfast on Tuesday March 1st, [resident 14] and [resident 27] were getting frustrated at each other. [Resident 14] went over to warm some hot chocolate and [resident 27] followed to warm her's as well. Upon finishing getting her hot chocolate warmed up, as [resident 14] was passing [resident 27] in her wheelchair she swatted at [resident 27] in a dismissive way but ended up connecting with [resident 27] with her open palm. This heightened the level of frustration and [resident 27] retaliated by swatting [resident 14] with an open palm on the shoulder. At that point, our nurses stepped in and split the two of them up to stop the escalation. [It should be noted that this FRI was not submitted to the SSA until 3/2/22 at 9:32 PM.]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), schizophrenia, diabetes mellitus type II, dementia, essential hypertension, moderate intellectual disabilities, and malnutrition. Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Alzheimer's disease, diabetes mellitus type II, pseudobulbar effect, dementia, schizophrenia, depression, essential hypertension, and dementia. On 5/26/22, record review was completed for residents 3 and 22. On 3/15/22 at 5:30 AM, a Nurses Note revealed, CNA's (Certified Nursing Assistants) found male resident [resident 3] sitting on the couch (closest to the TV), naked and masturbating. CNA approached him and politely asked him to stop, and come with him to his room, to get dressed, and lay down on his bed. Resident got up and grabbed his walker. As he was walking around the other couch (facing the TV; noticed a resident [resident 22] sleeping on that couch. He stopped stared at her for a brief moment, and proceeded to slap her on the top of her head. She woke after being hit, turned to face him, and just laughed. On 5/24/22 at 11:52 AM, a nursing assistant (NA) was interviewed. The NA stated that he was not aware of any abuse in the building. The NA stated that he had not been provided direction to observe any residents for abuse. On 5/24/22 at 12:03 PM, CNA 4 was interviewed. CNA 4 stated that she had not had abuse training recently. CNA 4 stated that if she had been aware of abuse, she would have reported it. CNA 4 stated that she was not told about abuse and had no residents that she was required to monitor more frequently. On 5/24/22 at 12:10 PM, an interview was conducted with CNA 5. CNA 5 stated that she was not familiar with the residents. CNA 5 stated that she was not informed about abuse at the facility. CNA 5 stated that she was aware that resident 22 had swung her arms around other residents but no residents had been abusive. CNA 5 stated that she was told residents had hit each other, but it was not considered abuse. On 5/25/22 at 4:41 PM, the Administrator (ADM) was interviewed. The ADM stated that he was the abuse coordinator. The ADM stated that the facility had not completed an abuse report when resident 3 swatted resident 22 on the head. The ADM stated that he did not investigate further, did not protect resident 22 and that resident 3 disliked resident 22 for no cognitive reason. The ADM stated that resident 3 intentionally hit resident 22 on the head, and therefore was abuse. The ADM stated that there were no injuries. The ADM did not create a Facility Reported Incident. No five-day follow-up was created. The incident was not investigated and resident 22 was not protected from any potential future abuse. The ADM did not report the incident to Adult Protective Services (APS), the Ombudsman, or to Police. The ADM did not report the incident to Centers for Medicare and Medicaid Services (CMS). Based on interview and record review it was determined that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility failed to have evidence that all alleged violations were thoroughly investigated. Resident identifiers: 3, 12, 22, 25, 27, and 82. Findings include: 1. The Facility Reported Incidents (FRIs) filed with the State Survey Agency (SSA) were reviewed and revealed the following: At around 7:30 AM on Monday 3/21/22, [CNA 2). got frustrated with [resident 12] . because he had been difficult through the weekend and he seemed to be starting in again on the same behaviour (sic). At that point she yelled at him using the F word saying that she wasn't going to put up with it that day and that he better F'ing stop it. [It should be noted that this FRI was not submitted until 3/22/22 at 4:57 PM, approximately 33 hours after the incident occurred). Review of the facility's investigation into the incident between CNA 2 and resident 12 revealed that the Administrator (ADM) interviewed the 2 witnesses who reported the incident to him, but did not include any other resident or staff interviews to determine if there were other victims or witnesses. Also, the ADM did not follow up with resident 12 to determine if there were any lingering effects from the incident. The investigation revealed that CNA 2 was suspended that day pending the investigation. After the accusations were substantiated, the employee was terminated. 2. The FRIs filed with the SSA were reviewed and revealed the following: On 2/12/22 at 10:00 AM, [Resident 25] stated that he was standing by the door of the dining room door (sic) next to the nurses station. He reported that [resident 3] came up behind him and got him in a headlock and threw him over his shoulder and [resident 25] landed on his back. He said that he was able to fend off [resident 3] from there and things came to an end. He reported that the nurses were there but didn't react because it all happened so fast. I told him I would talk to the nurses to confirm and view the video tape of the incident. Initial investigation yielded no evidence that anything happened and is suspected to be one of his dilutions (sic) however further interviews and viewing of video tape will be completed. [It should be noted that this FRI was not submitted to the SSA until 2/27/22 at 8:30 PM.] Review of the facility's investigation into the incident between resident 25 and resident 3 revealed that the ADM interviewed 2 nurses that were on duty at the time of the incident, however it wasn't until 2 days after the alleged incident. In addition, the ADM did not speak to any residents to determine if there were other potential victims. Also, the ADM did not follow up with resident 25 to determine if there were any lingering effects from the alleged incident. 3. The FRIs filed with the SSA were reviewed and revealed the following: At 3:00 AM on 4/21/22, Nursing staff walked into to (sic) the room of [resident 3], [resident 82] and an additional rooommate and found [resident 3] and [resident 82] in bed together pleasuring each other. Things seemed to be consentual (sic) for both of them. Because both [resident 3] and [resident 82] are cognitively impaired, they were separated and sent to their own beds. [It should be noted that this FRI was not submitted until 4/21/22 at 12:02 PM. In addition, the final investigation report was not submitted to the SSA until 5/24/22.] The final investigation submitted by the facility indicated that a staff member reported the incident, however the staff member's interview and name were not included in the report. In addition, the investigation did not include any other resident or staff interviews to determine if there were other victims or witnesses. 4. The FRIs filed with the SSA were reviewed and revealed the following: On 3/12/22 at 9:00 AM, [A resident] wasn't happy this morning and when [resident 3] . was talking loudly, [the resident] tossed a small plastic cup at [resident 3] hitting him in the chest and told him to shut up. Both parties are fine after interviews and the situation was resolved. Review of the SSA FRI database revealed that a 5 day final investigation report was not submitted until 5/27/22. 5. The FRIs filed with the SSA were reviewed and revealed the following: On 3/14/22 at 10:00 AM, [Resident 22] was picking up decoration (sic) off the table. [Resident 22] set it back on the table. [Resident 22] began hitting [resident 27] and [resident 27] began hitting her defending herself [resident 22] (sic). The final investigation submitted by the facility indicated that the ADM watched a video of the incident, but did not interview any staff or residents to determine if abuse had occurred or if there were other witnesses or possible victims.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined for 2 of 18 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, at the residents' option formulate an advance directive. Specifically, two residents did not have life-saving preferences accurately documented. Resident identifiers: 21 and 33. Findings include: 1. Resident 21 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included quadriplegia, muscle weakness, cauda equina syndrome, and anxiety disorder. On 12/16/19 resident 21's medical record was reviewed. Resident 21's Provider Order for Life Sustaining Treatment (POLST ) form stated, DNR - Do not attempt or continue any resustation (allow natural death). The code status on resident 21's electronic facesheet stated, Full code (attempt to resuscitate). On 12/16/19 at 12:07 PM, Licensed Practical Nurse (LPN) 1 was interviewed. When asked how she knows which residents are a full code and which are DNR, LPN 1 stated, It says on my screen (electronic medical record) on the resident's facesheet. LPN 1 verified resident 21's status was full code according to her computer. On 12/16/19 at 2:19 PM, resident 21 was interviewed. When asked about life sustaining measures, resident 21 stated, If they find me blue I want them to just leave me be. I don't want to wake up on a machine. On 12/17/19 at 1:22 PM, the Director of Nursing (DON) was interviewed. She stated, I keep everyone as a full code in the electronic record until we get the POLST. Then either the [resident advocate] or myself will update it. When the DON was shown the discrepancy between the resident's POLST and what was displayed to staff in the electronic record, she stated the electronic record was incorrect and needed to be updated. 2. Resident 33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included catatonic schizophrenia, type 2 diabetes, hypertension, and edema. On 12/16/19 resident 33's medical record was reviewed. Resident 33's POLST form stated, DNR - Do not attempt or continue any resustation (allow natural death). The code status on resident 33's electronic facesheet stated, Full code (attempt to resuscitate). On 12/16/19 at 12:07 PM, LPN 1 was interviewed. When asked how she knows which residents are a full code and which are DNR, LPN stated, It says on my screen (electronic medical record) on the resident's facesheet. LPN 1 verified resident 33's status was full code according to her computer. On 12/17/19 at 1:22 PM, the DON was interviewed. She stated, I keep everyone as a full code in the electronic record until we get the POLST. Then either [resident advocate] or myself will update it. When the DON was shown the discrepancy between the resident's POLST and what was displayed to staff in the electronic record, she stated the electronic record was incorrect and needed to be updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined for 1 of 18 sampled residents that the facility did not ensure the development and implementation of a comprehensive person-centered care plan including measurable objectives and timeframes to meet a resident's medical and nursing needs that were identified in the comprehensive assessment. Specifically, one resident's care plan did not address colostomy care. Resident identifier: 28. Findings include: Resident 28 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cerebrospinal fluid leak, unspecified intestinal obstruction, malignant neoplasm of rectum, and colostomy status. On 12/17/19, resident 28's medical record was reviewed. Resident 28's Care Plan did not have any focus areas, goals, or interventions regarding the treatment or care of his colostomy bag or stoma [note: a stoma is where the end of the bowel is brought to the outer surface of the abdomen to release waste into a bag]. On 12/17/19 at 12:06 PM, Certified Nurse's Assistant (CNA) 2 was interviewed. CNA 2 stated that regarding care for resident 28's ostomy bag, We change his ostomy bag about every two days. The nurses are the ones who will replace the wafer but we'll change the bag if it looks like it needs to be changed. On 12/17/19 at 12:17 PM, Licensed Practical Nurse (LPN) 1 was interviewed. LPN 1 stated that to ensure resident 28's colostomy was functioning properly, I know the aides check the BMs (bowel movements). The aides check it; it's not on our MAR/TAR (medical administration record and treatment administration record). On 12/17/19 at 1:08 PM, CNA 3 was interviewed. CNA 3 stated that staff cared for resident 28's ostomy bag when, We check it every couple times a shift. If its an old bag we'll tell the nurse and they'll change it. CNA 3 stated that staff knew the bag was old or needed changing, It's just known, like changing briefs. It's common sense. On 12/18/19 at 9:03 AM, the CNA Coordinator was interviewed regarding procedures and scheduled tasks regarding resident 28's colostomy. The CNA Coordinator stated We empty it when it's full, usually every shift. We change it when he showers, usually, or if it's falling off or if it's thick paste. We look at it every shift. We have the nurses change it though, the CNAs don't. We don't have any set procedures or schedule for it. On 12/18/19 at 10:32 AM, the Director of Nursing (DON) and Corporate Resource Nurse (CRN) were interviewed. When asked about resident 28's colostomy, the DON stated, It should be care planned. His catheter is care planned but I don't see any bowel care planning. There's no care plan for it and there are no orders for it. I'll need to add some orders for checking his colostomy bag. The CRN stated, Since we help him with it I would say yes, it should have been care planned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, that for 1 of 18 sampled residents, the facility failed to ensure that residents received proper treatment and assistive devices to maintain vision and hearing abilities. Specifically, one resident who is hard of hearing did not receive professional intervention. Resident identifier: 20. Findings include: Resident 20 was admitted to the facility on [DATE] with diagnoses which included unspecified symptoms and signs involving cognitive functions following other cerebrovascular disease, essential hypertension, diabetes type II, anemia, unspecified hearing loss, unspecified ear, major depressive disorder, hemiplegia and hemiparesis affecting left side, venous insufficiency, contracture of left wrist, and unspecified personality disorder. On 12/16/19 at 7:01 AM, resident 20 was observed in her room. Resident 20 was interviewed and had a difficult time hearing. Resident 20 could not understand conversation at a typical volume. On 12/18/19 a record review was completed of resident 20's electronic medical record. On 5/2/19 at 11:16 AM, an IDT (interdisciplinary team) event review revealed that .We are looking into getting her into a ear doctor because she doesn't hear that well. On 5/13/19, a quarterly Minimum Data Set (MDS) assessment for hearing was completed for resident 20. Resident 20 was assessed with minimal difficulty to hear. Resident 20 did not use a hearing aid or other hearing appliances. On 7/26/19 at 9:49 AM, a Physician's Progress Note revealed that resident 20 had hearing loss. On 9/25/19 at 1:40 PM, a Physician's Progress Note revealed that resident 20 had hearing loss. On 10/15/19, a quarterly MDS was completed for resident 20. Resident 20's ability to hear (with hearing aid or hearing appliances if normally used) was assessed at moderate difficulty. Resident 20 did not have a hearing aid or other hearing appliance. On 10/23/19, a care plan focus for resident 20 was revised that stated she has a communication problem r/t (related to) mental health problems, use of antidepressants, problems describing objects, and hearing impairment. This was initiated on 2/20/17, and the goal of maintaining current level of communication function through the review date. No new interventions were added to the care plan since 8/31/18. On 11/20/19 at 1:46 PM, a Physician's Progress Note revealed that resident 20 had hearing loss. On 12/16/19 at 3:32 PM, the Resident Advocate (RA) entered the following note: [Resident 20] has been set up with an audiologist from when she mentioned she has a hard time hearing. [Note: This was set up after survey interviews and occurred over 7 months after the initial IDT meeting minutes.] On 12/16/19 at 1:39 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that staff would keep notes during the IDT meetings, and the resident advocate might have been in charge of making appointments. The ADON stated that IDT meetings were held quarterly, and after admission. Each department would state cares and concerns for the resident. Hearing, eye glasses, dental and podiatry concerns were kind of a social services thing. On 12/16/19 at 1:42 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 20 had not been examined by an audiologist or had a hearing appointment since the IDT meeting in May, 2019. On 12/16/19 at 1:46 PM, an interview was conducted with the Administrator. The Administrator stated that resident 20 had not complained about her hearing to me so it hasn't interfered with her cares.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined for 1 of 18 residents that the facility did not establish and maintain and infection and prevention control program designed to provide and safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, facility staff did not follow clean technique when changing a resident's catheter tubing and bag. Resident identifier: 33. Findings include: Resident 33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included catatonic schizophrenia, type 2 diabetes, hypertension, and edema. On 12/17/19 at 8:00 AM, Licensed Practical Nurse (LPN) 1 was observed flushing resident 33's urinary catheter with sterile saline. LPN 1 removed the cap off the saline flush then attempted to unscrew the rubber urine drainage port. While rotating the port, the opened saline flush rubbed against the resident's pants and bed. LPN 1 removed the rubber tubing from the urine drainage port and placed the tubing on the resident's bed, not on a clean surface. LPN 1 affixed the saline flush to the urine drainage port without wiping the port or saline flush with an alcohol wipe. LPN 1 pushed the saline, removed the flush, then attached a second flush and pushed it as well. LPN 1 then picked the rubber catheter tubing up off the bed and reattached it to the urine drainage port without wiping the port or tubing with an alcohol wipe. On 12/17/19 at 8:15 AM, Certified Nurse's Assistant (CNA) 2 was observed replacing the catheter tubing. CNA 2 removed the new tubing from the package, removed the blue cap from the top of the tube, and laid it on the resident's bed, not on a clean surface. CNA 2 then removed the old tubing at the urine drainage port and dropped it in the garbage can. The CNA then picked up the new tubing from the resident's bed and attached it to the drainage port without wiping either with an alcohol wipe. On 12/17/19 at 9:21 AM, the director of Nursing (DON) and Assistant director of Nursing (ADON) were asked what their expectations are for a catheter flush and bag/tubing change. The DON stated she would have to review the facility's policy regarding catheter care. The DON later provided a copy of the facility policy on catheters. The policy contained no procedures for flushing a catheter or changing the bag and tubing. On 12/18/19 at 9:04 AM, the CNA Coordinator was interviewed regarding urinary catheter care. The CNA Coordinator stated, When we drain it we use alcohol wipes to make sure we clean the tips. The nurses replace the bags, not the CNAs. I haven't told my CNAs to do that. I can change a bag because I know how to do it, but as far as I know, the CNAs here don't change bags, that's a nursing job. On 12/18/19 at 9:22 AM, CNA 2 was interviewed regarding urinary catheter care. CNA 2 stated, I wasn't trained here, I just knew how to do it from my last job. On 12/18/19 at 9:37 AM, CNA 4 was interviewed regarding urinary catheter care. CNA 4 stated, The CNAs replace bags. I wasn't trained how to do it here, I learned how to do it in CNA school.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility did not ensure that each resident's environment was safe, clean and comfortable. Specifically, a sit-to-stand lift had debris, a window was broken, Findings include: On 12/15/19 at 8:27 AM, the following observations were made: a. Eight tables in the dining room had debris on them. b. There were red, brown and tan splashes on the dining room floor. c. There was a soiled rug in the dining room television area. d. The resident advocate placed a tray down on a dirty table to feed a resident e. An assistant in the dining room was sweeping the dining room of debris, and wiped off 2 dirty tables. On 12/16/19 between 8:15 and 8:40 AM, the following observations were made: a. A sit-to-stand lift had white and tan debris on it. b. The window in room [ROOM NUMBER] was cracked. c. The privacy curtains in room [ROOM NUMBER] and 12 had visible splashes that were dark in color. d. rooms [ROOM NUMBERS] had a door with a large gouged out area on it. e. The CNA (Certified Nursing Assistant's) charting computer outside room [ROOM NUMBER] had white and brown splashes and black streaks on it. f. Rooms 6, 12, 13, and 14 had debris on the floors. g. The hallway from the dining room to rooms 9/10 had gouges in the paint along the hallway. On 12/17/19 at 7:11 AM, the following observations were made: a. The window in room [ROOM NUMBER] continued cracked. b. The sit-to stand in the hallway with white and debris on it. c. The CNA computer in the hallway outside room [ROOM NUMBER] continued with splashes and streaks. On 12/18/19 at 9:06 AM, an interview was conducted with Dietary Staff (DS) 1. DS 1 stated that he was unaware if there were any cleaning checklists. DM 1 stated that he was unsure if he was supposed to clean the lifts or if that was a task of the CNAs. DS 1 stated that he knew he was supposed to clean bathrooms, under beds, handrails, and mirrors. On 12/18/19 at 9:10 AM, an interview was conducted with CNA 1. CNA 1 stated that she did not know who was responsible to clean the lifts, but she thought it was the responsibility of the night shift CNAs. On 12/18/19 at 9:15 AM, an observation was made with the Maintenance Director (MD). The MD stated that he had not been told about the broken window, and stated that the crack was on the inside. The MD stated that the cracked window was not brought to his attention. The MD stated that he would fix the window. The MD noted the gouges in the doors and along the hallways and stated that they would be repaired as soon as possible. On 12/18/19 at 9:22 AM, an interview was conducted with the CNA Coordinator. The CNA Coordinator stated that housekeeping was responsible to clean the CNA charting computers and the privacy curtains, and the CNAs were responsible to clean the lifts. The CNA Coordinator provided a cleaning checklist, that did not include cleaning lifts. The CNA Coordinator stated that she would add cleaning lifts to the checklist. On 12/18/19 at 9:30 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that the kitchen staff was scheduled to come in at 6:00 AM and after, and were responsible to clean the dining room before breakfast at 7:15. The DM stated the dish washing staff was responsible to tidy the room because it was a little bit messy every morning. The DM stated the room was utilized by the residents at night. The DM stated that the dishwasher did not arrive at work until 7:50 AM, and therefore hadn't cleaned the dining room before breakfast on Sunday. The DM stated that there was a checklist for cleaning and that it would be provided to staff.