**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined for 2 of 61 sampled residents, that the facility failed to ensure each resident had the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. Specifically, one resident representative was not informed in advance of starting an antidepressant medication and another resident representative was not informed in advance of a wanderguard being placed. Resident identifiers: 82 and 103.Findings included:1. Resident 82 was admitted to the facility on [DATE] with diagnoses which included severe vascular dementia, hypertension, attention and concentration deficit following cerebral infarction, depression, and cognitive communication deficit.Resident 82's medical record was reviewed 6/9/25 through 6/19/25.A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated resident 82's Cognitive Skills for Daily Decision Making was, Severely impaired-never/rarely made decisions.A nurse's note dated 10/12/24 at 1:13 PM indicated, New orders received from [behavioral health services] to start Lexapro [antidepressant medication] 5 mg [milligrams] QD [every day]. [Physician name redacted] agreed with recommendation.A physician order dated 1/8/25 at 3:54 PM indicated, Escitalopram Oxalate Oral Tablet 10 MG .Give 1 tablet by mouth one time a day for Depression.An interview was conducted on 6/18/25 at 3:15 PM with the Administrator. The Administrator stated resident 82's representative was her sister.An interview was conducted on 6/19/25 at 9:44 AM with the Regional Nurse Consultant (RNC). The RNC stated they were unable to find a consent notifying the resident representative before starting the Escitalopram. 2. Resident 103 was admitted to the facility on [DATE] with diagnoses which included atherosclerotic heart disease, essential hypertension, type 2 diabetes, bipolar disorder, muscle weakness, and difficulty in walking.Resident 103's medical record was reviewed on 6/9/25 through 6/19/25. According to a facility investigation, resident 103 eloped from the facility on 4/22/25 and was returned to the facility on 4/23/25.On 4/23/25 at 3:38 PM, an order was started to Check skin integrity around wanderguard on R [right] ankle every shift for Skin integrity. Beginning on the 4/23/25, nursing staff began to document in the Treatment Administration Record that this order was being completed every shift. On 4/23/2025, the intervention Wander guard to R ankle was initiated in Resident 103's care plan.No progress note was located in resident 103's medical record regarding when the wanderguard was placed. On 4/25/25, an informed consent for a wanderguard restraint was dated 4/25/25 and contained resident 103's signature, a facility representative's signature, and a note that stated verbal consent from her guardian [name redacted] obtained.On 4/25/25 at 8:05 PM, a progress note stated Resident signed her consent for the wanderguard today. UM [Unit Manager] manager called her State Guardian to inform her the need of it and to get a verbal. She is in agreement. Wander guard is on her right ankle.On 6/19/25 at 11:10 AM, an interview was conducted with the Administrator and the RNC. The Administrator stated that the wanderguard was placed on resident 103 on the day she returned to the facility after the elopement. The Administrator further stated that he was present when the wanderguard was placed on resident 103. The RNC stated that consent for the wanderguard should be given before the wanderguard was placed.

Based on interview and record review, it was determined, 1 of 61 sampled residents, the facility failed to keep residents free from abuse. Specifically, a Registered Nurse (RN) employee had a sexual relationship with a resident who resided in the facility. Resident identifier: 118Based on interview and record review, it was determined, 1 of 61 sampled residents, the facility failed to keep residents free from abuse. Specifically, a Registered Nurse (RN) employee had a sexual relationship with a resident who resided in the facility. Resident identifier: 118Findings included:On 3/28/25 at 12:22 PM, the facility reported that on 3/28/25 at 10:00 AM an investigator from the Division of Professional Licensing (DOPL) came into the facility on a complaint from resident 118. It was reported to DOPL that RN 3 had been sexually inappropriate with resident 118. On 3/28/25 at 11:00 AM, RN 3 was placed on leave from the facility while an investigation was conducted. The form titled 359, the final investigation, was submitted to the State Survey Agency (SSA) on 4/2/25. The form revealed the Administrator (Admin) interviewed RN 3. RN 3 stated that he had been having a consensual sexual relationship with resident 118. RN 3 stated that inappropriate messages and images were sent by both parties. RN 3 stated that there had been physical contact between him and resident 118. On 6/18/25 at 8:32 AM, an interview was conducted with the Admin. The Admin stated that he was notified about the abuse about one month after resident 118 discharged from the facility. The Admin stated that the DOPL investigator would not disclose a lot of information regarding the complaint or investigation. The Admin stated that RN 3 was suspended and then later terminated from the facility. The Admin stated that he interviewed RN 3 via telephone and RN 3 confirmed that he had been having a sexual relationship with resident 118 and that he should have let the facility know. On 6/18/25 at 9:21 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that staff should not have any type of relationship with residents. The RNC stated that even if a resident agreed to have a consensual relationship, it should not occur.On 6/18/25 at 9:28 AM, a follow-up interview was conducted with the Admin. The Admin stated he did not know about the relationship so he was unable to prevent the abuse. The Admin stated resident 118 consented to the relationship so it was not abuse. A review of the facility Resident Rights/Dignity Policy documented:Policy StatementResidents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.Policy Interpretation and ImplementationThe resident abuse, neglect and exploitation prevention program consists of a facility-widecommitment and resource allocation to support the following objectives:1. Protect residents from abuse, neglect, exploitation or misappropriation of property byanyone including, but not necessarily limited to:a. facility staff;b. other residents;c. consultants;d. volunteers;e. staff from other agencies;f. family members;g. legal representatives;h. friends;i. visitors; and/orj. any other individual.2. Develop and implement policies and protocols to prevent and identify:a. abuse or mistreatment of residents;b. neglect of residents; and/orc. theft, exploitation or misappropriation of resident property.3. Ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and high turnover rates.4. Conduct employee background checks and not knowingly employ or otherwise engage any individual who has:a. been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law;b. had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; orc. a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.6. Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.7. Implement measures to address factors that may lead to abusive situations, for example:a. adequately prepare staff for caregiving responsibilities;b. provide staff with opportunities to express challenges related to their job and work environment without reprimand or retaliation;c. instruct staff regarding appropriate ways to address interpersonal conflicts; andd. help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts.8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.9. Investigate and report any allegations within timeframes required by federal requirements.10. Protect residents from any further harm during investigations.11. Establish and implement a QAPI review and analysis of reports, allegations or findings of abuse, neglect mistreatment or misappropriation of property.12. Involve the resident council in monitoring and evaluating the facility's abuse prevention program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined for 2 out of 61 sampled residents, that the facility did not notify the resident of the discharge and the reasons for the move in writing and in a language and manner they understand; or send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman as soon as practicable or when a resident had not resided in the facility for 30 days. Specifically, the Ombudsman was not notified when one resident was discharged to the hospital and the ombudsman was not notified of a resident's discharge and the reasons why the resident left the facility. Resident identifiers: 54 and 113.Findings included:1. Resident 54 was admitted to the facility on [DATE] with diagnoses which included type 1 diabetes mellitus and end-stage renal disease. Resident 54's medical record was reviewed 6/9/25-6/19/25.On 3/15/24 at 2:45 AM, a nursing progress note documented, .Patient was handed off with report to EMS [emergency medical services] and resident left the facility at approx. [approximately] 0245 [2:45 AM] with no new complaints.On 4/1/24 at 10:22 AM, a nursing progress note documented, .[resident 54] was admitted to [local hospital] on Saturday .On 10/16/24 at 7:33 AM, a nursing progress note documented, Resident was found unresponsive at 0650 [6:50 AM] when aide went to take vitals, aide called for assistance, on assessment residents BG [blood glucose] was 29, skin was cold and clammy, presented w/ [with] labored breathing and thready pulse. EMS called immediately after injection was given resident remained unresponsive, at time of EMS arrival BG was at 41,Resident Transferred to [local hospital] .On 12/6/24 at 12:51 AM, a nursing progress note documented, Resident is still c/o [complaining of] SOB [shortness of breath] and difficulty breathing feels that breathing treatment did not help, and wants to be sent out for further evaluation, called the on call and they said to have her be sent out resident presents as non emergent, she is having her mom come and get her to take her to[local hospital] .On 6/17/25 at 11:05 AM, an interview was conducted with the Admissions Marketing Director (AMD). The AMD stated that he kept a log of all the residents that were discharged from the facility. The AMD stated that he notified the Ombudsman monthly regarding the residents that left the facility AMA (against medical advice) or discharged to the community. The AMD stated that he did not notify the Ombudsman when a resident was discharged to a hospital. On 6/18/25 at 9:11 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that the Ombudsman should be notified monthly of all residents that were discharged home, AMA, and hospital transfers. 2. Resident 113 was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia, major depressive disorder, generalized anxiety disorder, cutaneous abscess of left lower limb, muscle weakness, and difficulty in walking.Resident 113's medical record was reviewed 6/9/25 through 6/19/25.A Medication Administrative Note dated 3/21/25 at 9:04 PM indicated, Pt [patient] checked out at 1300 [1:00 PM] today, and has not yet returned.A Progress Note dated 3/27/25 at 2:39 PM indicated, [Resident 113] left the facility with a friend on 3/21 and has not returned. Attempts to contact him has been unsuccessful.On 6/19/25 at 9:47 AM, an interview was conducted with the Administrator (Admin). The Admin stated a relative came and signed resident 113 out and he did not return the next day. The Admin stated they called him on his phone, but they were unable to get a hold of him. The Admin stated that after a couple of days, resident 113 came back to the facility to get some of his items and told them that he would not be returning and then left again. The Admin stated he did not provide resident 113 with an AMA form or discharge instructions because resident 113 was in a rush. The Admin stated resident 113 had been unhappy about his share of cost and kept talking about discharging.On 6/19/25 at 10:01 AM, an interview was conducted with the AMD. The AMD stated resident 113's friend came to sign him out LOA (leave of absence) and he decided not to come back. The AMD stated he would consider that leaving AMA because they expected him to come back. The AMD stated when he asked resident 113 about a discharge plan during his stay, resident 113 told him multiple times that he was fine and did not have anywhere else to go.On 6/19/25 at 10:43 AM, a concurrent interview was conducted with the Admin and the RNC. The Admin stated if a resident eloped they would notify the doctor, family, and the police. The RNC stated if a resident signed themselves out on an LOA they should try to call and contact them if they did not return when they were expected and that if they could not get a hold of them they would call in a wellness check with law enforcement. The Admin stated if the resident stated they were coming back the day they signed out that they would start to get concerned if they were not back by that same evening and start calling.On 6/19/25 at 11:38 AM, an interview was conducted with the Director of Nursing (DON) DON 2. DON 2 stated if a resident was approved for LOA the resident would indicate how long they intended to be gone and if it went over that time, she would start to call the resident or family. DON 2 stated she would notify the police if the resident or family did not answer those calls.On 6/19/25 at 1:12 PM a follow-up interview was conducted with the Admin. The Admin stated the reason police were not called was because he signed out with someone and it was their responsibility to keep an eye on him. The Admin stated he did not think he contacted the Ombudsman about resident 113 leaving and not returning to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined for 1 of 61 sampled residents, that the facility failed to ensure the assessment accurately reflected the resident's status. Specifically, a diagnosis of depression was not included on the assessment. Resident identifier: 82.Findings included:Resident 82 was admitted to the facility on [DATE] with diagnoses which included severe vascular dementia, hypertension, attention and concentration deficit following cerebral infarction, depression, and cognitive communication deficit.Resident 82's medical record was reviewed 6/9/25 through 6/19/25.A Psych (psychiatric) Follow Up note dated 10/4/24 at 6:00 AM indicated, .suggest Lexapro 5mg [milligrams] daily for depression and anxiety A Nursing note dated 10/12/24 at 1:13 PM indicated, New orders received from [mental health services] to start Lexapro [antidepressant medication] 5 mg QD [every day]. [Physician name redacted] agreed with recommendation.A Psych Follow Up note dated 10/18/24 at 6:30 AM indicated, .Endorses depression, poor appetite, no interest in ADL's [activities of daily living]. She is tolerating the lexapro 5mg well.A Psych GDR (Gradual Dose Reduction) note dated 11/15/24 at 8:15 AM indicated, .Escitalopram Oxalate [antidepressant medication] Tablet 5 MG Give 1 tablet by mouth one time a day for Depression .A physician order dated 1/8/25 at 3:54 PM indicated, Escitalopram Oxalate Oral Tablet 10 MG .Give 1 tablet by mouth one time a day for Depression.A review of resident 82's medical diagnoses list did not include depression.A Quarterly Minimum Data Set (MDS) dated [DATE] did not include a diagnosis of depression.On 6/18/25 at 9:42 AM, an interview was conducted with Registered Nurse (RN) 6. RN 6 stated they were not sure if resident 82 had depression. RN 6 reviewed resident 82's physician orders and stated she had escitalopram ordered for depression.On 6/18/25 at 12:55 PM, an interview was conducted with RN 7. RN 7 stated resident 82 did not have depression.On 6/18/25 at 1:19 PM, an interview was conducted with the Social Service Worker (SSW). The SSW stated resident 82's face sheet did not indicate she had depression.On 6/18/25 at 3:10 PM, an interview was conducted with the Director of Nursing (DON) 2. The DON 2 stated resident 82 was diagnosed with depression in February of 2025 but it did not get updated in the medical chart. The DON 2 stated the MDS should have been updated with the diagnosis of depression.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, for 1 of 61 sampled residents, the facility did not provide care and services to maintain or improve a resident's ability to carry out the activities of daily living. Specifically, a resident's bed was positioned against a wall so that his inoperable hand was facing his environment, diminishing his abilities in activities of daily living. Resident identifier: 67.Findings included:Resident 67 was admitted on [DATE] with diagnoses which included hemiplegia, cerebral infarction, contracture left elbow, memory deficit, major depressive disorder, contracture left knee, and mood disorder.On 6/9/25 at 1:08 PM, an observation was made of resident 67 lying slumped down in bed with his head of bed elevated to 90 degrees, shirt pulled up and blankets partially covering his lower extremities. Resident 67's legs were bare, knees were bent and lying sideways in the bed with feet against the footboard and resident 67's upper body positioned approximately at midpoint in his bed so that he was not sitting upright in bed. Resident 67 was lying with the right side of his body against the wall and hemiplegic left side of his body facing his environment. Resident 67's water mug was placed on the bedside table out of reach and an over the bed table with a water cup was placed on the left side of the bed out of reach. Resident 67's food was delivered and resident was observed immediately before and after the lunch tray was delivered. Resident 67 was found to be in the same slumped down position after his tray was delivered as he was before his tray was delivered. Resident 67 was not repositioned in bed when his meal was delivered but the bedside table was placed half over resident 67's bed on his left side. Resident 67 was able to reach his water cup and tray with his right hand, reaching cross body.On 6/9/25 at 1:53 PM, an interview was conducted with Certified Nursing Assistant (CNA) 5. CNA 5 stated that resident 67 was able to feed himself if he was sitting up in bed. CNA 5 stated that resident 67 refused to go to the dining room for meals and sometimes received help from a CNA to eat because he was able to feed himself.On 6/9/25 at 2:11 PM, an additional observation was made of resident 67. Resident 67 was observed to have his head of bed upright at 90 degrees and was slid down in bed in the same position as during lunch. Resident 67 stated he could not straighten his left leg but did prefer to sit up in bed.On 6/11/25 at 01:19 PM, an observation and interview were conducted with resident 67. Resident 67 was observed with lunch and was able to eat ice cream with his right hand with a spoon, reaching cross body to his tray placed on his left side halfway over the bed. Resident 67 was upright at an approximately 60 degree angle and was sitting in the middle of the bed and not against the wall. Resident 67 stated he would like to have his bed position changed so his active arm was not against the wall and he was able to access his environment. Resident 67 stated the staff put his head of bed up when he ate and sometimes repositioned him in bed to sit up.On 6/12/25 at 8:45 AM, an observation was made of resident 67 lying in the center of the bed, at a 60 degree angle during breakfast and was able to reach his food and water to eat with his right hand. Resident 67 was able to demonstrate he was able to pull his body and roll to the left side somewhat but was not able to reposition himself in bed. Resident 67's medical record was reviewed 6/9/25 though 6/19/25.On 06/17/25 at 11:15 AM, resident 67's minimum data set (MDS) for 4/30/25 was reviewed and stated that Resident 67 was able to roll left and right with substantial or maximal assist. Resident 67 was dependent with moving from sitting to lying and lying to sitting in bed. Resident 67's care plan dated 7/15/21, revealed resident 67 required up to extensive assistance by staff for turning and repositioning.On 6/18/25 at 9:15 AM, an interview and observation was made of resident 67. Resident 67 was observed to be positioned at the lower portion of his bed with the head of bed at approximately a 75 degree angle. Resident 67 stated he was not uncomfortable and did not mind the position he was in. Resident 67 was not positioned against the wall and he had eaten all of his breakfast but stated he had to reach across his bed to eat or drink and felt it would be easier if his good arm was not positioned next to the wall.On 6/18/25 at 9:23 AM, an interview was conducted with Unit Manager (UM) 1 and Certified Medication Aide (CMA) 1. UM 1 stated resident 67 was previously on the 300 hall with the right side of his body positioned against the wall. UM 1 stated he believed resident 67 preferred his current positioning. CMA 1 stated the protocol for tray delivery was to reposition resident 67 for meals, sitting him up in bed with the head of bed elevated and the over bed table placed in front of resident 67 on his left side. CMA 1 stated resident 67 moved around in bed and slid down on his own.On 6/18/25 at 9:28 AM, an interview was conducted with the Certified Occupational Therapy Assistant (COTA) who stated she treated resident 67 in April 2025 but had not considered the positioning of resident 67's dominant side against the wall and whether the dominant side should be available to the environment. The COTA stated resident 67 did not reposition himself independently and required assistance for bed mobility to sit upright in bed but may be able to scoot himself down in bed if he wanted.On 6/18/25 at 11:54 AM, an interview was conducted with UM 1. UM 1 stated he talked with the Social Service Worker (SSW) about whether resident 67 wanted his right arm against the wall when he was moved into his room on the 500 hall and was told the bed positioning was not discussed at the time of the room move. UM 1 stated he and the SSW talked with resident 67 about whether he wanted to have his bed positioning changed so resident 67's dominant side could access his environment more freely. UM 1 stated resident 67 stated he did want that change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, for 1 out of 61 sampled residents, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and resident's choices. Specifically, a resident's diabetes was not managed with required documentation, timely referral to outside services or diet management according to physician's orders and resident's choice. Resident identifier: 36.Findings included: Resident 36 was re-admitted on [DATE] with diagnoses of hemiplegia/hemiparesis, chronic respiratory failure, morbid obesity, major depressive disorder, type 1 diabetes, epilepsy and generalized anxiety disorder.On 6/12/25 at 8:07 AM, an interview was conducted with resident 36. Resident 36 stated he was not doing so great. Resident 36 stated he had a reminder on his amazon echo in the evening on 6/11/25, to take his blood glucose level which was reading Hi (high) on his continuous monitor, indicating his blood glucose level was over 400 milligrams per deciliter (mg/dL). Resident 36 stated he called for the graveyard nurse, Licensed Practical Nurse (LPN) 1, to check his blood glucose level using the facility's glucometer. Resident 36 stated LPN 1 tested his glucose level at about 10:30 PM and his blood glucose level was over 400 mg/dL. Resident 36 stated he did not recall the specific results. Resident 36 stated he asked LPN 1 to contact the Physician's Assistant (PA) to get an order for insulin to reduce his glucose level. Resident 36 stated LPN 1 said it was too late to call and refused to contact the PA. Resident 36 stated LPN 1 suggested resident 36 was eating snacks after dinner which accounted for the high blood glucose results. Resident 36 stated he did not eat snacks after dinner and reported that the meals he received from the facility were very high in carbohydrates. Resident 36 stated he wanted lower carbohydrate food as he had type 1 diabetes and that it was hard for him to keep his blood glucose level low like they should be especially considering he was bed bound and didn't get much exercise. Resident 36 stated he did not have an as needed (PRN) order for insulin so he did not receive an insulin shot through the night and stated he was still high in the morning. Resident 36 stated he asked LPN 2 to check his blood sugar this morning 6/12/25 at about 7:30 AM due to his continuous monitor still reading Hi. At 8:10 AM, resident 36's Freestyle Libre 3 monitor was observed to read Hi.On 6/12/25 at 1:30 PM, an observation was made of resident 36's lunch meal which consisted of ham, corn, scalloped potatoes, a roll and bread pudding with caramel. Resident 36 did not have fruit instead of dessert as the meal ticket stated and he stated he would prefer lower carbohydrate food options.On 6/12/25 at 8:27 AM, an interview was conducted with resident 36's family member. The family member asked resident 36 if he was still alive. Resident 36 told the family member about the Hi blood glucose reading on the continuous monitor and that the facility's monitor read 389 mg/dL. The family member stated resident 36's high glucose had been going on for a long time. Resident 36's family member stated resident 36 was a type 1 diabetic and the facility did not allow insulin pumps. Resident 36's family member stated resident 36's glycated hemoglobin (A1C) was 6.2 prior to admission to the facility but had been 8.1 or higher and was routinely above 9 since admission. Resident 36's family member complained that resident 36 was given a flat amount of insulin before meals, regardless of the carbohydrates in the meal. Resident 36's family member stated his glucose level was 393 initially then 400 when tested later in the night on 6/11/25. The family member stated that resident 36 should have an insulin shot if blood glucose levels were higher than 250.On 6/12/25 at 10:08 AM, a phone interview was conducted with LPN 1. LPN 1 stated that he did not contact the PA as resident 36 requested since there was no order to notify the PA of a high blood glucose level. LPN 1 stated he would generally notify the PA for guidance if the glucose level was unusually high for a resident or there was an order to do so. LPN 1 stated the facility had two after hours providers to contact in an emergency. LPN 1 stated he took blood glucose levels if asked by a resident and usually documented it in the electronic medical record and a progress note if the levels were high, above 400. LPN 1 stated resident 36's continuous monitor read Hi but the facility's glucose monitor read resident 36's glucose level in the 200's. LPN 1 stated he did not recall what the specific number was on the glucometer and stated he did not document the results. LPN 1 stated he did not know how resident 36's continual glucose monitoring system worked or if there were sometimes different readings than the facility glucometer. LPN 1 stated the night shift calibrated the facility glucometers weekly and documented the results in the narcotics binder. LPN 1 stated that, to his knowledge, the facility glucometer was working and accurate. LPN 1 stated he checked Resident 36's glucose level around midnight and again about 2:30 AM. LPN 1 stated he did not know why he checked it again at 2:30 AM when the glucose was normal for resident 36 at 12:30 AM.Resident 36's medical record was reviewed 6/12/25 through 6/19/25.Resident 36's laboratory Hemoglobin A1C results were as follows: a. On 2/18/25 was 8.9, reference rate <5.7 b. On 5/23/25 was 9.8, reference rate <5.7On 6/12/25 at 8:52 AM, documentation showed the blood glucose level was still high. The following were documented levels: a. On 6/11/025 at 12:42 PM 272.0 mg/dL b. On 6/11/25 at 4:20 PM 264.0 mg/dL c. On 6/12/25 at 8:52 AM 397.0 mg/dL[Licensor note: no blood glucose level was documented in the evening on 6/11/25 by LPN 1].On 6/12/25 at 10:40 AM, an interview was conducted with LPN 2. LPN 2 stated the glucometers were calibrated weekly by the graveyard shift nurse and the calibration log was kept in the narcotic binder.The facility's 500 hall glucometer calibration and quality control tracking sheet was reviewed. The following was observed: a. 4/24/25 at 6:30 AM, low control: 48, high control: 195 b. 5/4/25 at 9:45 AM, low control: 48, high control: 185 c. 5/17/25 at 4:40 PM, low control: 42, high control: 187 d. 6/1/25 at 1:00 AM, low control: 53, high control: 214 e. 6/4/25 at 11:00 PM, low control: 53, high control: 210On 6/12/25 at 10:46 AM, an observation was made of resident 36's continuous glucose monitor which read 372. The history on the continuous monitor revealed resident 36 had glucose level above 350 mg/dL (top of graph) on the monitor's line graph starting about 5:00 PM on 6/11/25, continuing until midnight when the data ended.On 6/12/25 at 11:00 AM, resident 36's progress notes were reviewed and there was no documentation from LPN 1 from 6/11/25 through 6/12/25.On 6/12/25 at 11:05 AM, resident 36's blood glucose level continuous monitor was at 394.On 6/18/25 at 10:50 AM, LPN 2 stated the facility did not have any standing protocols or instructions for contacting the physician when blood glucose levels were high. LPN 2 stated that if she observed resident 36's blood glucose level was close to 400 she would call the doctor and typically write a progress note. LPN 2 stated she typically contacted the doctor when a person was over 400 which she considered best practice. LPN 2 stated that whenever a resident's blood glucose was taken it was documented in the electronic medical record.On 6/18/25 at 11:54 AM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated they were working on a facility wide change to have standing protocol for notifying the physician whenever patients had high blood glucose levels. UM 1 stated this would be typically above 400.On 6/18/25 at 12:40 PM, an interview was conducted with the Director of Nursing (DON) 2. DON 2 stated there were no standing orders and nurses used their judgement for when to contact the physician related to unusual blood sugar level results. DON 2 stated diabetic residents should have orders of when to notify the physician for their blood glucose. DON 2 stated the range was usually to notify if under 60 or over 400.On 6/18/25 at 1:20 PM, an interview was conducted with resident 36's Medical Doctor (MD). The MD stated that when blood glucose was over 400 then typically the nurse should notify the doctor. The MD stated he had frequently been contacted about glucose levels and that it would be unusual for a diabetic resident to not be on a sliding scale. The MD stated that if resident 36 was above 450 or 500 then he would expect the nurse to call the doctor. The MD stated that low blood glucose was a bigger concern than high glucose levels but the A1C target was below 8.5. The MD stated that A1C above 8.5 was considered under treated diabetes. The MD stated that he did not know if resident 36 had a PRN insulin order for when glucose levels were high but stated a PRN order would help when resident 36's level was high. The MD stated resident 36's last A1C was at 12.On 6/18/25 at 1:59 PM, a follow-up interview was conducted with UM 1. UM 1 stated he received a referral from the PA on 5/27/25 for resident 36 to be evaluated by a preferred endocrinologist. UM 1 stated he had been the UM for a couple months and was unaware of previous endocrinology referrals. UM 1 stated a nurse with the local endocrinology clinic assessed resident 36 on 6/9/25 and resident 36 had an appointment with the endocrinologist on 7/1/25. On 6/19/25 at 12:01 PM, an interview was conducted with the Dietary Manager (DM). The DM stated all information about a resident's diet was at the bottom of the production sheet. The DM stated for Controlled Carbohydrate Diet (CCHO) diet, the dietary staff would send sugar free juice. The DM stated if the resident was on a renal diet, no tomato and other high potassium foods would be served. The DM stated residents were served foods listed on the menu. The DM stated the system automatically eliminated items that were not on the therapeutic diet. The DM stated he was not sure how many carbohydrates were served per meal for CCHO diets. The DM stated resident 36 was on a CCHO diet with no dessert but fruit was okay. The DM stated resident 36 had a blond brownie on the meal ticket for dinner at the time of the interview. The DM stated the planned dessert could not be removed from the production ticket so the dietary staff rely on the notes on the production ticket to adjust the foods delivered to the resident.On 6/19/25 at 12:20 PM, an interview was conducted with the Registered Dietitian (RD). The RD stated that a CCHO diet should be between 225 to 250 grams of carbohydrates per day, which was according to CCHO diet guidelines. The RD stated that residents who were not supposed to get a dessert should have it left off their tray and a substitute offered. The RD stated the management of the meals, meal computer system, meal cards, and meal prep is left up to the DM. The RD stated that she was not aware that resident 36 desired to have lower carbohydrate meals. The RD stated if a resident requested that, then the facility should provide what was requested.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, for 2 out of 61 sampled residents, the facility did not ensure that residents were offered a therapeutic diet when the therapeutic diet was ordered. Specifically, a resident on a diabetic diet was not provided a low carbohydrate option. In addition, a resident complained of not being provided a renal diet. Resident identifier: 36 and 79. Findings included: 1. On 6/12/25 at 8:07 AM, an interview was conducted with resident 36. Resident 36 stated he was not doing so great. Resident 36 stated he had a reminder on his amazon echo in the evening on 6/11/25, to take his blood glucose level which was reading Hi (high) on his continuous monitor, indicating his blood glucose level was over 400 milligrams per deciliter (mg/dL). On 6/12/25 at 8:27 AM, an interview was conducted with resident 36's family member. The family member asked resident 36 if he was still alive. Resident 36 told the family member about the Hi blood glucose reading on the continuous monitor and that the facility's monitor read 389 mg/dL. The family member stated resident 36's high glucose had been going on for a long time. Resident 36's family member stated resident 36 was a type 1 diabetic and complained that Resident 36 was given a flat amount of insulin before meals, regardless of the carbohydrates in the meal. The family member stated they had requested low carbohydrate food options but resident 36 was usually given a high carbohydrate meal. On 6/12/25 at 1:30 PM, an observation was made of resident 36's lunch meal. The meal was ham, corn, scalloped potatoes, a roll and bread pudding with caramel sauce on top. Resident 36 did not have fruit instead of dessert as the meal ticket stated. Resident 36 stated he would prefer lower carbohydrate food options. Resident 36's medical record was reviewed 6/9/25-6/19/25. Resident 36's diet order was carbohydrate controlled. On 3/19/2025 at 2:17 PM, the interdisciplinary team (IDT), met with resident 36 and a family member. The IDT note stated they discussed resident 36's diabetes and adjustments that were needed to his insulin and diet. On 6/19/25 at 12:01 PM, an interview was conducted with the Dietary Manager (DM). The DM stated all information about a resident's diet was at the bottom of the production sheet. The DM stated for Controlled Carbohydrate Diet (CCHO) diet, the dietary staff will send sugar free juice. The DM stated if the resident was on a renal diet, no tomato and other high potassium foods would be served. The DM stated residents were served foods listed on the menu. The DM stated the dining computer software automatically eliminated items that were not on the therapeutic diet. The DM stated he was not sure how many carbohydrates were served per meal for CCHO diets. The DM stated resident 36 was on a CCHO diet with no dessert but fruit was okay. The DM stated resident 36 had a blond brownie on the meal ticket for dinner at the time of the interview. The DM stated the planned dessert could not be removed from the production ticket so the dietary staff relied on the notes on the production ticket to adjust the foods delivered to the resident. On 6/19/25 at 12:20 PM, an interview was conducted with the Registered Dietitian (RD).The RD stated that a CCHO diet should be between 225 to 250 grams of carbohydrates per day, which was according to CCHO diet guidelines. The RD stated that residents who were not supposed to get a dessert should have it left off their tray and a substitute offered. The RD stated the management of the meals, meal computer system, meal cards, and meal prep was left up to the DM. The RD stated that she was not aware that resident 36 desired to have lower carbohydrate meals. The RD stated if a resident requested that, then she would evaluate the resident. 2. Resident 79 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included end stage renal disease with dialysis, gastroparesis, and type 2 diabetes mellitus. On 6/9/25 at 10:18 AM, an interview was conducted with resident 79. Resident 79 stated the facility did not provide a renal diet. Resident 79 stated the facility served him beans, high potassium foods, like lots of bananas. Resident 79 stated the food was not good, there was no seasoning and it was usually cold. Resident 79 stated he had talked to the head cook but nothing had changed. Resident 79's medical record was reviewed 6/9/25 through 6/19/25. A physician's order dated 4/20/25 revealed a renal/diabetic diet with regular texture, thin liquids, double protein portions and low potassium diet. A form titled Nutritional Data Collection and assessment dated [DATE] revealed a renal/diabetic diet. The facility provided a form titled Production Sheet for the meals. According to the form on Tuesday Day 10 for lunch residents with renal diets were served a #12 scoop of mashed potatoes. On 6/19/25 at 12:01 PM, an interview was conducted with the DM. The DM stated if a resident wanted a more strict diet, then the RD would evaluate them. On 6/19/25 at 12:24 PM, an interview was conducted with the RD. The RD stated if a resident was on a renal diet, then the computer system would take out the foods the resident should not be eating. The RD stated she was not aware of concerns with the renal diets. The RD stated she had not visited resident 79 and asked about dietary needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, it was determined that for 1 of 61 sampled residents, the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, a resident did not have an Invega injection available when it was scheduled to be administered. Resident identifiers: 59.Findings included:Resident 59 was admitted to the facility on [DATE] with diagnosis which included severe dementia with agitation, paranoid schizophrenia, type 2 diabetes, generalized anxiety disorder, delusional disorders, insomnia, schizoaffective disorder, and essential hypertension.Resident 59's medical record was reviewed on 6/9/25 through 6/19/25.On 4/10/25, a 117 milligram (mg) Invega intramuscular injection was scheduled for administration. This order, which was started on 2/6/25 and discontinued on 4/14/25, was scheduled to be administrated every 21 days. On 4/10/25 at 4:21 PM, a Medication Administration Note stated that the ordered Invega injection was not administered because Injection has not arrived, will administer it when it does arrive within the facility. According to the Medication Administration Record (MAR) a 117 mg Invega intramuscular injection was administered on 4/15/25. This order, which was started on 4/15/25 and discontinued on 5/7/25, was scheduled to be administered every 21 days. On 5/6/25, a 117 mg Invega intramuscular injection was scheduled for administration. On 5/6/25, it was documented in the MAR that the Invega injection was not administered, citing chart code 9, defined as Other/See Nurse Notes. No note could be found in resident 59's medical record providing a reason why the medication was not administered on 5/6/25. On 5/8/25, a 117 milligram (mg) Invega intramuscular injection was scheduled for administration. This order was started on 5/8/25 and ended on 5/9/25.On 5/8/25 at 1:52 PM, a Medication Administration Note stated that the ordered Invega injection was not administered because Patient refused multiple times today. On 5/9/25 an order was placed to administer a 234mg Invega intramuscular injection every 28 days starting 5/12/25. According to the MAR the medication was administered as scheduled. On 6/1/25, an order was started to call the pharmacy every 25 days and order the Invega medication. It was documented in the MAR that the Invega medication was ordered on 6/1/25. On 6/9/25, a 234mg Invega intramuscular injection was scheduled for administration. On 6/9/25 at 3:35 PM, a Progress Note stated that the Invega injection was currently unavailable and the pharmacy was called to reorder the medication. On 6/10/25, it was documented in the MAR that a 234mg Invega intramuscular injection was administered. On 06/19/25 at 10:08 AM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated that the Invega injection was unavailable for administration due to issues with insurance coverage. UM 1 stated that the dosage and administration schedule for the Invega injection had been adjusted in an effort to accommodate insurance requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for 2 of 61 sampled residents, the facility did not arrange services with an outside agency in a timely manner. Specifically, a resident that needed dental services did not have those services scheduled, and a resident did not have an endocrinology appointment scheduled after a referral from the physician. Resident identifiers: 36 and 64. Findings included: 1. Resident 64 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, schizoaffective disorder, adult failure to thrive, dysphagia, dementia, and morbid obesity. On 6/9/25 at 11:00 AM, an interview was conducted with resident 64 who stated she had seen a dentist in 2024 and was told she needed to see an outside dentist for further treatment. Resident 64 stated she had not yet seen an outside dentist. Resident 64's medical records were reviewed between 6/9/25 and 6/19/25. A physician order dated 8/24/24 revealed, May have dental, vision & eye health, hearing, wound and podiatry consults as needed. A review of resident 64's documents revealed a dental visit note dated 9/25/24 with dental provider notes that stated the following, Facility visit in room for exam. Oral cancer screening complete IO/EO-WNL [Intraoral/Extraoral-Within Normal Limits]. Patient will need to be referred for fillings on teeth #4-6, 9-11. Decay is causing her to cut her lip.-[Dentist initials]. Resident 64's care plan dated 9/4/24 revealed a focus area, [resident 64] has oral/dental health r/t [related to] poor oral hygiene. The goal was, The resident will be free of infection, pain or bleeding in the oral cavity by review date. Interventions included, Coordinate arrangements for dental care, transportation as needed/as ordered. On 6/17/25 at 10:00 AM, an interview was conducted with Registered Nurse (RN) 1 who stated the Unit Manager (UM) or the Nurse were responsible to review the resident's notes after a provider visit. RN 1 stated if a follow-up was recommended, the nurse would submit a request transportation and enter an order for the scheduled appointment. RN 1 stated the entered order would alert nursing staff the day before the follow-up. RN 1 stated evening nurse reminded the resident the night before the appointment and put a reminder on the resident's door. RN 1 stated the process had recently changed and recommended the previous UM be interviewed. On 6/17/25 at 10:30 AM, an interview was conducted with the Respiratory Lead (RL) who stated she used to be the UM on the resident's hallway. The RL stated if a resident returned from an appointment with a follow-up appointment, she would put a physician's order for the appointment in the resident's orders, and would put in a request slip for transportation. The RL stated they would then coordinate with transportation and the schedule to ensure they did not have double rides on that day. The RL stated if a referral was needed, she would complete the referral and write down the information so the resident would know the referral had been completed and the appointment had been made. The RL stated if resident 64 did not want to go to an appointment she would call and cancel. The RL stated she did not remember what happened with resident 64 and her dental appointments. The RL stated another staff member was setting up resident 64's dental appointments. The RL stated she was unsure if resident 64's insurance covered visits with an outside dental provider. The RL stated that normally, a progress note was entered into the resident's medical record when an appointment was made or canceled. The RL stated she put notes in resident 64's progress notes for appointments she was responsible for scheduling. The RL stated she switched to a new position a few months ago. The RL stated she no longer knew what the process was for scheduling transportation or getting documents to medical records to be put into a resident's medical record. On 6/19/25 at 7:22 AM, an interview was conducted with the Regional Nurse Consultant (RNC) who stated she looked at resident 64's previous medical records and was unable to find any documentation stating that resident 64 had refused dental appointments or canceled them, and there was no information about scheduling or rescheduling the dental appointment. 2. Resident 36 was re-admitted on [DATE] with diagnoses of hemiplegia/hemiparesis, chronic respiratory failure, morbid obesity, major depressive disorder, type 1 diabetes, epilepsy, generalized anxiety disorder. On 6/18/25 at 1:20 PM, an interview was conducted with resident 36's medical doctor (MD). The MD stated that he did not know if resident 36 had a PRN (as needed) insulin order for when glucose levels were high but stated a PRN order would help when resident 36's level was high. The MD stated that resident 36's family member requested a specific endocrinologist and a referral was made but there was some back and forth on scheduling with the endocrinologist. The MD stated resident 36's last A1C (glycated hemoglobin) was at 12. On 6/18/25 at 1:59 PM, an interview was conducted with UM 1. UM 1 stated the physician's assistant (PA) referred resident 36 to a preferred endocrinologist about 2 weeks ago. The referral was made on 5/27/25. UM 1 stated he was the unit manager for a couple months and was unaware of previous endocrinology referrals. UM 1 stated a nurse for the endocrinologist assessed resident 36 on 6/9/25 and resident 36 had an endocrinology appointment 7/1/25. Resident 36's medical record was reviewed 6/12/25 through 6/19/25. Resident 36's laboratory Hemoglobin A1c results were as follows: a. On 2/18/25 was 8.9, reference rate <5.7 b. On 5/23/25 was 9.8, reference rate <5.7Endocrinologist referrals a. On 12/26/24, a follow up PA report stated resident 36 may benefit from an outpatient endocrinology referral. b. On 2/12/25, a follow up MD report documented an endocrinology referral in resident 36's assessment and plan. This was signed by the MD on 2/21/25. c. On 3/17/25, a follow up PA report documented an endocrinology referral in resident 36's assessment and plan. d. On 3/19/2025 at 2:17 PM, the interdisciplinary team (IDT) care plan conference, attended by the social services worker (SSW), unit manager (UM 2) who was the 500 hall unit manager at this time, stated they discussed resident 36's diabetes and making adjustments to his insulin and diet and that the PA and the family member wanted him to see the endocrinologist. e. On 5/27/2025 at 14:56 PM, a progress note stated to notify the provider if low blood sugar occurs, and refer resident 36 to an endocrinologist for diabetes mellitus. f. On 6/11/2025 at 11:43 AM, a progress note stated that resident 36 was referred to an endocrinologist. On 6/9/25, resident 36 had his first assessment in the facility by a nurse for the endocrinologist. On 6/19/25, an interview with the SSW was conducted. The SSW was present at the IDT meeting on 3/19/25 and stated that resident 36's family member wanted him to see the endocrinologist. The SSW did not know if an endocrinology referral or attempt to set up an appointment was made after the IDT meeting. The SSW confirmed that UM 2 was present in the IDT meeting and was the person responsible to set up appointments with outside providers. UM 2 was not available for an interview during the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined for 2 of 61 sampled residents, that the facility failed to maintain medical records on each resident that was complete, accurately documented, readily accessible, and systematically organized; and failed to ensure the medical record contained the results of any preadmission screening and resident review evaluations and determinations conducted by the State; and physician, nurse, and other licensed professionals progress notes. Specifically, one resident had an updated Pre-admission Screening/Resident Review (PASRR) that was not located in the medical record and one resident had no documentation regarding an elopement. Resident identifiers: 82 and 103.Findings included:1. Resident 82 was admitted to the facility on [DATE] with diagnoses which included severe vascular dementia, hypertension, attention and concentration deficit following cerebral infarction, depression, and cognitive communication deficit.Resident 82's medical record was reviewed 6/9/25 through 6/19/25.A PASRR dated 1/3/24 did not indicate resident 82 had a diagnosis of depression.A Psych (Psychiatric) Follow Up note dated 10/4/24 at 6:00 AM indicated, .suggest Lexapro 5mg [milligrams] daily for depression and anxiety A Nursing note dated 10/12/24 at 1:13 PM indicated, New orders received from [mental health services] to start Lexapro [antidepressant medication] 5 mg QD [every day]. [Physician name redacted] agreed with recommendation.A Psych (psychiatric) Follow Up note dated 10/18/24 at 6:30 AM indicated, .Endorses depression, poor appetite, no interest in ADL's [activities of daily living]. She is tolerating the lexapro 5mg well.A Psych GDR (Gradual Dose Reduction) note dated 11/15/24 at 8:15 AM indicated, .Escitalopram Oxalate [antidepressant medication] Tablet 5 MG Give 1 tablet by mouth one time a day for Depression .On 6/18/25 at 1:19 PM, an interview was conducted with the Social Service Worker (SSW). The SSW stated a new PASRR would be completed if a resident had a new diagnoses added. The SSW stated that she probably had an old email that indicated she notified the PASRR evaluator when resident 82 was diagnosed with depression.On 6/18/25 at 3:10 PM, an interview was conducted with the Director of Nursing (DON) 2. DON 2 stated resident 82 was diagnosed with depression in February of 2025 but it did not get updated in the medical chart. DON 2 stated the PASRR should be updated with the new depression diagnosis.On 6/18/25 at 3:26 PM, an email was received from the SSW that indicated resident 82 was screened out on 1/9/25 for Depression due to Dementia.On 6/19/25 at 9:44 AM, a follow-up interview was conducted with the SSW. The SSW stated she updated resident 82's PASRR and uploaded the document to the medical record. 2. Resident 103 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, atherosclerotic heart disease, essential hypertension, type 2 diabetes, bipolar disorder, muscle weakness, and difficulty in walking.Resident 103's medical record was reviewed on 6/9/25 through 6/19/25. The facility reported that resident 103 eloped from the facility on 4/22/25. No documentation of this elopement was located in resident 103's medical record.On 6/19/25 at 11:10 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that any change of condition would require documentation in the progress notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a safe and sanitary environment to prevent the potential transmission of communicable diseases and infections for 1 out of 61 sampled residents. Specifically, staff were not wearing Enhanced Barrier Precautions (EBP) for a resident with chronic wounds and a tube feed when caring for the resident and the tube feed was not capped when not in use. Resident identifier: 90.Findings included:Resident 90 was admitted to the facility on [DATE] with diagnoses which included, pressure ulcer of sacral region stage 4, adult failure to thrive, and unspecified severe protein-calorie malnutrition.On 6/9/25 at 10:58 AM, an interview was conducted with resident 90. Resident 90 stated that his tube feed was continuous, but was stopped and disconnected when he went outside the facility to smoke. Resident 90 stated that staff wore gloves when changing him, but not gowns. On 6/9/25 at 1:03 PM, an observation was made of resident 90's tube feed. Resident 90 was disconnected from the tube feed and the end of the tube was not capped and was open to air. On 6/9/25 at 1:18 PM, an observation was made of Registered Nurse (RN) 1 reconnecting resident 90's tube feed. RN 1 was observed without wearing a gown.On 6/11/25 at 12:41 PM, an observation was made of resident 90 in the hoyer lift in his room. Certified Nursing Assistant (CNA) 1 was observed to change resident 90's bed linens without wearing a gown. On 6/17/25 at 8:02 AM, an observation was made of CNA 2. CNA 2 changed resident 90's brief without wearing a gown. On 6/17/25 at 6:31 AM, an interview was conducted with RN 2. RN 2 stated that resident 90 had a tube feed and wounds. RN 2 stated that resident 90 was on EBP which meant that gloves and gowns needed to be worn while providing care. RN 2 stated that when resident 90 was disconnected from his tube feed the end should be covered with a cap and not left open. On 6/17/25 at 6:47 AM, an interview was conducted with RN 1. RN 1 stated that resident 90 had contact precautions because of the feeding tube. RN 1 stated if resident 90 had to be disconnected from the feeding tube the nurse should put the cap on the end of the tube.On 6/17/25 at 8:02 AM, an interview was conducted with CNA 2. CNA 2 stated that she wore gloves when caring for resident 90 and did not know if she needed to wear a gown. On 6/18/25 at 9:15 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that when a resident needed their tube feed disconnected, staff flushed the tube and then capped it. The RNC stated that EBP should be used for all residents with tube feeds, chronic wounds, or catheters. The RNC stated that staff identified residents requiring EBP by a magnet with the number 6 hanging on the door frame and by reviewing the doctor's orders. The RNC stated bins outside the resident's door provided gowns and masks for staff, and gowns were required whenever staff had direct contact with the resident.

Based on interview and observation, the facility did not treat residents with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, residents dining in the dining room were served beverages in Styrofoam cups and prepackaged juice cups. Findings included: On 6/9/25 at 11:55 AM, an observation was made of residents in the dining room for the lunch meal. Staff members were passing out beverages as residents entered the dining room and took their seats. Juices were being served in 4 ounce (oz), foil-covered cups and 4 oz. cartons, chocolate milk was served in a carton, white milk and water was being served in a Styrofoam cup. Coffee and tea were being served in a coffee cup. On 6/9/25 at 12:00 PM, an observation was made of resident 2 sitting at the dining table with 2 cartons of chocolate milk, 2 cartons of orange juice, 2 containers of red juice, a Styrofoam cup with a brown liquid in it and a coffee cup with a brown liquid in it. On 6/10/25 at 8:18 AM, an observation was made of the dining room during the breakfast meal. Staff members were passing beverages as residents entered the dining room and took their seats. Milk and water were being served in Styrofoam cups. Juices were being served in 4 oz. cartons and foil covered cups, coffee and tea was being served in coffee cups, chocolate milk was served in cartons. On 6/12/25 at 8:32 AM, an observation was made of the 200 hallway lunch service. There were strawberries served in a disposable container on the trays. On 6/18/25 at 11:55 AM, an interview was conducted with the Dietary Manager (DM) who stated the mugs in the dining room were used for hot drinks. The DM stated the Styrofoam cups were being used in the dining room because several cups had gone missing and it took several weeks for those to arrive once they are ordered. The DM stated they had some cups, but not enough for everyone.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for 3 out of 61 sampled residents, the facility did not ensure that all alleged violations involving abuse and neglect were reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, notification to the SSA and APS was not done when a resident eloped from the facility and another resident alleged that a Certified Nursing Assistant (CNA) put their fingers into her private parts. Additionally, a resident eloped from the facility and APS was not notified. Resident identifiers: 64, 113, and 115.Findings included:1. Resident 115 was admitted to the facility on [DATE] with diagnoses which included, unspecified focal traumatic brain injury, cognitive communication deficit, and vascular dementia.Resident 115's medical record was reviewed 6/9/25-6/19/25.On 3/31/24 at 8:53 PM, an alert note documented, At 1715 [5:15 PM], Medicare CNA answered a phone call from a person living in the area stating he saw a resident leave the facility. CNA looked outside for the resident and got in her vehicle and went down two blocks and the resident was walking on the sidewalk at 1718 [5:18 PM]. CNA safely helped the resident into her vehicle and brought the resident back to the facility. CNA notified DON [Director of Nursing] of Elopement . On 6/19/25 at 11:02 AM, an interview was conducted with the Administrator (Admin). The Admin stated that resident 115 had been in the facility for a while and was a wander risk. The Admin stated that resident 115 was spotted walking down the street by a member of the community and was brought back into the facility and placed on a 1:1 (one to one). The Admin stated that he was unsure if he contacted APS about the elopement and would look to see if he had.It should be noted that no further documentation was submitted regarding APS notification. 2. Resident 113 was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia, major depressive disorder, generalized anxiety disorder, cutaneous abscess of left lower limb, muscle weakness, and difficulty in walking. Resident 113's medical record was reviewed 6/9/25 through 6/19/25. A Medication Administrative Note dated 3/21/25 at 9:04 PM indicated, Pt [patient] checked out at 1300 [1:00 PM] today, and has not yet returned. A Medication Administrative Note dated 3/22/25 at 1:01 AM indicated, As of 3/22/25 @0101 [at 1:01 AM], patient has not yet returned to the facility. A Medication Administrative Note dated 3/22/25 at 6:23 AM indicated, resident is LOA [leave of absence]. A Progress Note dated 3/22/25 at 6:04 PM indicated, Resident continues to be LOA throughout shift. Residents phone called with no answer. Management aware. A Medication Administrative Note dated 3/25/25 at 7:45 PM indicated, resident has not returned to the facility. A Medication Administrative Note dated 3/26/25 at 8:29 AM indicated, pt is away. A Progress Note dated 3/27/25 at 2:39 PM indicated, [Resident 113] left the facility with a friend on 3/21 and has not returned. Attempts to contact him has been unsuccessful. A Social Services Quarterly & Annual Note dated 1/15/25 at 10:26 AM indicated, [Resident 113] has appeared to become more confused. He is pleasant and enjoys socializing. [Resident 113] has outside support. He has been approved for long term care and participates well in his care plan. A provider Progress Note dated 1/23/25 indicated, .he would like to think about discharging the facility he states. will have the discharge planner and others help w [with]/ this. will need to recheck BIMS [Brief Interview for Mental Status] to ensure able to make this decision for himself . On 6/19/25 at 9:47 AM, an interview was conducted with the Admin. The Admin stated a relative came and signed resident 113 out and he did not return the next day. The Admin stated he was not sure if resident 113 needed someone to sign him out. The Admin stated they called him on his phone, but they were unable to get a hold of him. The Admin stated that after a couple of days, resident 113 came back to the facility to get some of his items and told them that he would not be returning and then left again. The Admin stated he did not provide resident 113 with an AMA (leaving against medical advice) form or discharge instructions because resident 113 was in a rush. The Admin stated resident 113 had a BIMS of 10 (a BIMS of 10 indicated a moderate cognitive impairment) and was alert and oriented x3 (times 3). The Admin stated resident 113 had been unhappy about his share of cost and kept talking about discharging. The Admin stated it had not crossed his mind to call law enforcement. The Admin stated if a resident had a BIMS that was a 12 or higher, they could sign themselves out, but other circumstances were taken into consideration and the Director of Nursing would be consulted to make that decision. On 6/19/25 at 10:01 AM, an interview was conducted with the Admissions Marketing Director (AMD). The AMD stated resident 113's friend came to sign him out LOA and he decided not to come back. The AMD stated he would consider that leaving AMA because they expected him to come back. The AMD stated when he asked resident 113 about a discharge plan during his stay, resident 113 told him multiple times that he was fine and did not have anywhere else to go. On 6/19/25 at 10:43 AM, a concurrent interview was conducted with the Admin and the RNC. The Admin stated if a resident eloped they would notify the doctor, family, and the police. The RNC stated if a resident signed themselves out on an LOA they should try to call and contact them if they did not return when they were expected and that if they could not get a hold of them they would call in a wellness check with law enforcement. The Admin stated if the resident stated they were coming back the day they signed out that they would start to get concerned if they were not back by that same evening and start calling. On 6/19/25 at 11:38 AM, an interview was conducted with DON 2. DON 2 stated if a resident was approved for LOA the resident would indicate how long they intended to be gone and if it went over that time, she would start to call the resident or family. DON 2 stated she would notify the police if the resident or family did not answer those calls. On 6/19/25 at 1:12 PM a follow-up interview was conducted with the Admin. The Admin stated the reason police were not called was because he signed out with someone and it was their responsibility to keep an eye on him. The Admin stated he did not think he contacted the Ombudsman about resident 113 leaving and not returning to the facility. It should be noted that no further documentation was provided regarding resident 113's elopement. 3. Resident 64 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, schizoaffective disorder, chronic respiratory disease, dementia, and morbid obesity. On 6/9/25 at 10:40 AM, an interview was conducted with resident 64 who stated that while receiving cares approximately one month ago, a CNA had inserted her fingers into her private parts and then bragged about it. Resident 64 stated she told the director of the CNA's about the incident. Resident 64 stated she did not know the name of the CNA, but that the CNA was still providing cares for her. Resident 64 stated the incident made her feel awful and that nobody aided her when the incident happened. On 6/18/25 at 9:38 AM, an interview was conducted with the CNA Coordinator who stated resident 64 briefly mentioned the incident to her. The CNA Coordinator stated if the DON and the Admin were busy they asked her to talk to the resident. The CNA Coordinator stated she did not remember who the CNA involved was, but that she ended up changing resident 64's brief and bed and wanted to talk with the DON and administrator about it. Later in the interview, the CNA Coordinator stated she believed the CNA involved was CNA 3. The CNA Coordinator stated CNA 3 no longer worked with resident 64. The CNA Coordinator stated resident 64 told her that CNA 3 was wiping her too aggressively and put her finger in her anus. The CNA Coordinator stated resident 64 no longer wanted CNA 3 to work with her and that CNA 3 hurt her. The CNA Coordinator stated the way that scheduling worked was that if CNA 3 was scheduled on that hallway, she would just switch residents with another CNA that was working on the same hallway so she was not working with resident 64. The CNA Coordinator stated the schedulers try not to schedule CNAs on hallways where there are residents that prefer not to work with them but sometimes they forget. The CNA Coordinator stated that she spoke with the DON specifically about the particular situation but she did not know if the DON spoke with resident 64 or told the administrator about the situation. The CNA Coordinator stated she did not know if the incident was investigated. The CNA Coordinator stated she did not talk to CNA 3 about the incident or ask her what happened. The CNA Coordinator stated she felt that those conversations should come from the DON or administrator. On 6/18/25 at 9:19 AM, an interview was conducted with CNA 4 who stated some categories of resident abuse were psychological, physical, and sexual. CNA 4 stated some symptoms of abuse to watch for could be a change in resident behavior, the resident being withdrawn, bruises, a resident refusing cares or not wanting cares from a certain person. CNA 4 stated his role in preventing resident abuse included answering resident call lights quickly, being aware of changes in resident's behavior, reporting immediately to a nurse if he became aware of something, or reporting to the administrator who is the abuse coordinator immediately. On 6/18/25 at 10:06 AM, an interview was conducted with Registered Nurse (RN) 4 who stated resident 64 did not like to have male aides in her room. RN 4 also stated she was not aware of resident 64 not wanting to work with any specific CNAs or making any allegations of abuse. On 6/18/25 at 10:08 AM, an interview was conducted with RN 1 who stated resident 64 had not made any allegations of inappropriate touching by CNAs. An attempt was made to contact DON 1, but the call was not returned. On 6/18/25 at 2:30 PM, an interview was conducted with the Admin who stated he was not made aware of resident 64's allegations until earlier in the day. The Admin stated he was aware of a prior complaint about a month ago by resident 64 that a CNA was not cleaning her well enough. The Admin stated he self-reported to the state agency the allegations that resident 64 made about the incident a month ago, and had begun an investigation. The Admin stated the CNA involved had been suspended until the investigation had been completed. The Admin stated he had spoken with the DON 1 who told him she did not remember resident 64's allegations. The Admin stated his process as the abuse coordinator was to educate all staff to report any abuse immediately. The Admin stated if the allegation was about staff, the staff member would be suspended immediately pending the investigation. The Admin stated he would interview the resident, interview other residents for other claims or complaints, and interview other staff members to collect more information. If there were additional complaints, the Admin stated the employee would be terminated. The Admin stated if there were no other concerns, the employee would be re-educated. The Admin stated when there was an allegation of abuse, the physician would be notified, the responsible party or family member, and based on the allegation, the police, adult protective services, and the ombudsman. The Admin stated there was a 2 hour time frame for initial reporting of abuse, and 5 days to submit the investigation report. The Admin stated that it was not reported to the state and that he was not aware that it was an abuse allegation until earlier in the day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined for 4 of 61 sampled residents, that the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable. Specifically, three resident's eye drops and one resident's insulin were expired. Resident identifiers: 31, 44, 106, and 107. Findings included: On [DATE] at 8:17 AM, an observation and interview were conducted with Registered Nurse (RN) 7. RN 7 was observed to pull Ketotifen Fumarate eye drops out of the Long Term [NAME] Medication Cart. The eye drops were labeled with an open date of 4/11. RN 7 stated eye drops were good for 28 days after they were opened and that the eye drops were expired. At 8:39 AM, RN 7 was observed to administer the Ketotifen Fumarate eye drops into resident 31's eyes. At 10:41 AM, RN 7 stated they talked with the nurse manager and the eye drops expired 30 days after they were opened. RN 7 stated they got rid of the eye drops and ordered more. On [DATE] at 1:18 PM, an observation and interview were conducted with Licensed Practical Nurse (LPN) 2. An opened bottle of Latanoprost Ophthalmic Solution 0.05% eye drops, labeled with resident 44's name, were located in the 400 Hall Medication Cart. There was no opened date labeled on the eye drops. LPN 2 stated there was supposed to be an open date written on the eye drops and that it should be discarded because it could be expired. Resident 44 had a physician order dated [DATE] at 1:13 PM which indicated, Latanoprost Ophthalmic Solution 0.005% (Latanoprost) Instill 1 drop in both eyes at bedtime for dry eye Instill 1 drop OU [both eyes] QHS [every night at bedtime]. A Medication Administration Record dated [DATE]-[DATE] indicated resident 44 was administered 1 drop of Latanoprost Ophthalmic Solution 0.005% (Latanoprost) in both eyes at bedtime from [DATE] through [DATE]. On [DATE] at 1:36 PM, an observation and interview were conducted with LPN 2. Located inside the 500 Hall Medication Cart was a used medication pen of Insulin Aspart for resident 107 with an open date labeled [DATE]. LPN 2 stated the Insulin Aspart pen expired on [DATE]. An open bottle of Olopatadine Hcl (hydrochloride) 0.2% eye drops for resident 106 with no open date was also located in this medication cart. LPN 2 stated all eye drops expire 28 days after opening. Resident 107 had a physician order dated [DATE] at 4:41 PM which indicated, Insulin Aspart Subcutaneous Solution Pen-injector 100 UNIT/ML [milliliters] (Insulin Aspart) Inject subcutaneously four times a day related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. A Medication Administration Record dated [DATE]-[DATE] indicated resident 107 was administered Insulin Aspart Subcutaneous Solution Pen-injector six times prior to [DATE]. Resident 106 had a physician order dated [DATE] at 5:20 PM which indicated, Pataday Ophthalmic Solution 0.2% (Olopatadine Hcl) Instill 1 drop in right eye in the morning for itching and redness. On [DATE] at 1:50 PM, an observation and interview were conducted with RN 2. Three over the counter artificial tears and 1 bottle of Systane eye drops were located inside the Medicare Odd Medication Cart. All four eye drops were opened and they were not labeled with open dates. RN 2 stated they only go by the expiration date on the box, even if it was opened. RN 2 stated the opened Systane eye drops would expire on 2/27, which was observed to be the manufacturer's expiration date on the bottle. On [DATE] at 1:35 PM, an interview was conducted with the Director of Nursing (DON) 2. DON 2 stated all opened eye drops, including over the counter, were good for 28 days. DON 2 stated insulin expired 28 days after being opened and should have been discarded.

Based on observation, interview and record review the facility did not ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Specifically, sanitizer solution was not measuring on the testing strips, there were soiled areas in the kitchen and spices were left open to air. Findings included:1. On 6/9/25 at 9:23 AM, an initial kitchen tour was conducted. The following was observed: a. The area behind the steamer had a white substance splattered on it, debris and grease splatter. The table it is sitting on is rusty, has a white splatter on the legs and the bottom shelf. b. The area under the storage shelves and under the storage carts in the dish room were soiled. The floor had a white substance on it. 2. On 6/18/25 at 11:54 AM, an observation was made of the Registered Dietitian (RD) in the kitchen without a hairnet, in the food preparation area. 3. On 6/19/25 at 11:19 AM, a follow-up tour of the kitchen was conducted. The following was observed: a. The sanitizer solution in the cooking area was tested. The test strip turned blue. Using the test strip comparing it to test strip container revealed there was no blue color to determine parts per million (PPM) of the quats sanitizer solution. The highest was 400 PPM of quats sanitizer solution which was the color was green. The preparation area sanitizer solution was tested and the strip turned blue. According to the label on the sanitizer it should be testing at 150 to 400 PPM. An observation was made of sanitizer solution container. The container revealed it was a quats sanitizer and needed to be 150-400 PPM for food surfaces. An interview was immediately conducted with the Dietary Manager (DM). The DM stated the sanitizers were just changed because the solution was warm. The DM stated the blue color meant it was 400 PPM. The DM confirmed there was no blue color on the sanitizer strips check. b. There were plastic drawers with serving utensils that was soiled. c. Behind the steamer there was debris and black substance. d. There was white substance on the floor under the preparation sinks. e. There was tape on the ceiling above the preparation sink. f. There were 4 large bins labeled powdered milk, sugar, flour and oatmeal. The bins were soiled around the tops that opened. g. Spices labeled cajun and thyme leaves were open to air. h. The steamer was broken and not available for use. On 6/29/25 at 12:01 PM, an interview was conducted with the DM. The DM stated the steamer had been broken for about a year. The DM stated the steamer was used for vegetables, pork ribs and mashed potatoes. The DM stated staff had to boil everything which took longer. The DM stated it was hard to get the same results with boiling foods over steaming. The DM stated every 2 weeks staff cleaned behind the steamer, stove and grill. The DM stated floors were cleaned daily. The DM stated the white containers were cleaned daily after the cook finished tray line and cleaning up. The DM stated the drawers with scoops should be cleaned weekly.

Based on observation, interview, and record review the facility did not ensure that policies were established and implemented to ensure that identified deficiencies were corrected. Specifically, areas of immediate jeopardy (IJ) were identified and not identified through the Quality Assurance and Performance (QAPI) process. In addition, multiple areas of non compliance were cited on the previous survey and again during the current recertification survey. Findings included:1. Based on observation, interview, and record review it was determined, for 12 out of 61 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, hot water temperatures in resident rooms throughout the facility were observed to range in temperatures from 121.7-145.5 degrees Fahrenheit. The deficient practice identified, in regards to the hot water, was found to have occurred at an Immediate Jeopardy level. In addition, residents who were assessed as requiring supervision while smoking were observed smoking unsupervised, a resident was not evaluated for smoking and was observed smoking, and residents with a history of wandering eloped from the facility without staff knowing. Resident Identifiers: 3, 5, 21, 24, 25, 32, 48, 66, 71, 72, 73, 87, 100, 103, 110, 113, 115, 119, 418, 421, 424 A review of the facility's weekly water temperature logs from 5/9/25-6/2/25 revealed: a. On 5/9/25 the hottest water temperature recorded was 98 degrees Fahrenheit. b. On 5/15/25 the hottest water temperature recorded was 93 degrees Fahrenheit. c. On 5/23/25 the hottest water temperature recorded was 88 degrees Fahrenheit. d. On 5/27/25 the hottest water temperature recorded was 95 degrees Fahrenheit. e. On 6/2/25 the hottest water temperature recorded was 98 degrees Fahrenheit.A review of the facility QAPI plan dated 10/18/24 regarding supervised smoking revealed: a. The facility was not following its policy regarding supervised smoking b. Actions taken were to post signs specifically noting residents that were required to use assistive devices while smoking c. Audits were performed of the smoking area to ensure the smoking policy and procedures were being followed (staff supervising smoking, protective/safety equipment available and used appropriately)[Note: After the QAPI identified concerns with smoking, there were no updated lists of residents who required supervision, residents were not assessed for safety of smoking, residents who were assessed as requiring supervision while smoking were observed smoking independently during the survey.]A review of the facility QAPI plan dated 3/31/24 regarding resident elopements revealed: a. The Director of Nursing (DON) would review residents who were elopement risks to ensure appropriate interventions were in place b. Doors were checked to ensure that they were functioning properly c. Residents with adult electronic monitoring safety devices were checked daily to ensure the device was in place and functioning[Note: After the QAPI identified concerns with elopement, there was an elopement as recent as 4/22/25.][Cross refer to F689]2. There were repeat deficiencies from the survey on 1/25/24 that were recited on the current survey. Those regulations included F689, F609, F755, F761 and F880. On 6/19/25 at 1:12 PM, an interview was conducted with the Administrator (Admin). The Admin stated that QAPI was held monthly. The Admin stated that based off of concerns from residents, complaints, negative trends, or something that was consistently happening an action plan would be put in place. The Admin stated that the facility had done action plans for supervised smoking and elopements. The Admin stated that the facility had not identified hot water concerns. The Admin stated that any concerns for action plans were adjusted and then reviewed the following month.

Based on observation, interview and record review it was determined the facility did not provide or obtain laboratory services to meet the needs of its residents. If the facility provided its own laboratory services, the services must meet the applicable requirement for laboratories. Specifically, facility glucometers were not being calibrated according to the manual. Findings included:1. The facility's 500 hall glucometer calibration and quality control tracking sheet was reviewed. The glucometer was calibrated on 4/24/25 at 6:30 AM, 5/4/25 at 9:45 AM, 5/17/25 at 4:40 PM, 6/1/25 at 1:00 AM, and 6/4/25 at 11:00 PM. On 6/12/25 at 10:08 AM, a phone interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the night shift calibrated the facility glucometers weekly and documented the results in the narcotics binder. LPN 1 stated that, to his knowledge, the facility glucometer was working and accurate. On 6/12/25 at 10:40 AM, an interview was conducted with LPN 2. LPN 2 stated the glucometers were calibrated weekly by the graveyard shift nurse and the calibration log was kept in the narcotic binder. 2. On 6/12/25 at 10:38 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated Certified Nursing Assistants (CNA's) could be passed off to check glucose levels of residents, but he personally liked to do his own blood sugar checks. RN 2 stated that his medication cart had two glucometers to test resident's glucose levels. RN 2 stated that the glucometers in the facility were not required to be calibrated. RN 2 stated that the weekend manager was the one that signed the log when calibration was done.The medication cart for the 100/200 hall way odd side had a glucometer calibration log with the dates 4/24/25, 5/4/25, and 5/17/25. On 6/12/25 at 10:51 AM, an interview was conducted with RN 4. RN 4 stated that the nursing night shift performed calibration for the glucometers. RN 4 stated that she was unsure how often this was performed. RN 4 stated that she was unsure where the calibration log was kept and was unable to locate one on her medication cart for the 100/200 hallway even side. On 6/12/25 at 11:36 AM, an interview was conducted with the Director of Nursing (DON) 1. DON 1 stated that CNA's were not able to perform blood sugar checks because they had not been passed off. 3. On 6/12/25 at 10:30 AM, the 300 and 400 hallway glucometer calibration form was reviewed calibration was done 4/24/25, 5/4/25 at 10:30 AM, 5/9/25 at 4:45 PM, 5/17/25 at 4:45 PM, 5/30/25 at 11:30 PM, and 6/5/25 at 2:00 AM. On 6/12/25 at 10:40 AM, an interview was conducted with Certified Medication Aide (CMA) 1. CMA 1 stated medication aides were able to obtain blood glucose levels. CMA 1 stated that calibrations were done during the night shift weekly. On 6/12/25 at 10:45 AM, an interview was conducted with CMA 2. CMA 2 stated glucometers were calibrated weekly during the night shift. On 6/18/25 at 12:40 PM, an interview was conducted with the Regional Nurse Consultant (RNC) and DON 2. The RNC stated according to the manufacturer requirements glucometers needed to be calibrated weekly. The RNC stated they were not being calibrated according to the manufacturer instructions. The glucometer manual revealed controlled solution testing should be done when using the meter the first time, once per week to ensure the meter and test strips were working properly, using a new bottle of testing strips, or if it was suspected the testing strips and meter were not working properly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, for 1 out of 26 sampled residents, notification to the SSA and APS was not done when a resident with cognitive impairment eloped from the facility. Resident identifier: 7. Findings included: Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included focal traumatic brain injury without loss of consciousness, schizoaffective disorder, vascular dementia, hemiplegia and hemiparesis following cerebral infarction affection left non dominant side, history of falling, need for assistance with personal care, anxiety disorder, and personal history of traumatic brain injury. Resident 7's medical record was reviewed on 1/24/24. A Wander Risk dated 10/8/23, documented that resident 7 was at risk for wandering/elopement with a score of 14. A score of 9 or greater would indicate resident 7 was at risk for wandering/elopement. An admission Minimum Data Set assessment dated [DATE], documented that resident 7 had a Brief Interview for Mental Status (BIMS) score of 6. A BIMS score of 0 to 7 indicated severe cognitive impairment. On 10/23/23 at 12:15 AM, an Alert Note documented Note Text: This nurse answered the phone around 2205 [10:05 PM] the [name removed] Police called to inquire if this resident was living at this facility. This nurse said yes. The officer stated they picked up the resident around 2700S and 1300E. The officer stated, resident seemed confused and didn't know where she was going or what she was doing there. EMS [Emergency Medical Services] was called and checked out the resident to see if she was physically and mentally okay to return to the facility. The resident returned with the police officer at 2237 [10:37 PM]. Resident was helped to room. After the resident was toileted and ready for bed she was started on every 15 minute check. At this time the resident is sleeping in her bed. Call light and water within reach. [Note: The last note prior to resident 7 eloping was dated 10/21/23 at 10:22 AM.] On 10/24/23 at 7:53 PM, a Nursing Note documented Note Text: Resident denies pain r/t [related to] elopement fall from two days ago. Resident's wanderguard to R [right] ankle in place this shift. [Note: Resident 7's wander guard was not reinstated until after the elopement on 10/23/23.] A physician's order dated 10/29/23, documented Ensure residents wander guard is functioning and test with verichip machine q [every] noc [night] shift every night shift every Sun [Sunday] for Wander guard functioning. On 1/25/24 at 9:40 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 7 on occasion would be exit seeking. LPN 1 stated that once resident 7 got within a certain amount of feet of the door the wander guard alarmed. LPN 1 stated that he knew resident 7's wander guard was working because she took LPN 1 to the door last night. LPN 1 stated that resident 7 had eloped and LPN 1 thought it was in October 2023. LPN 1 stated he did not know the details of the elopement but people were coming and going from the facility and resident 7 went out the door. On 1/25/24 at 9:42 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that some residents were authorized to go in and out of the facility for smoking and the residents would come and go in groups. RN 2 stated the residents had to sign out to go out front to smoke. RN 2 stated that she thought resident 7's elopement had something to do with the wander guard. On 1/25/24 at 10:26 AM, an interview was conducted with the Wound Nurse (WN). The WN stated that resident 7 would exit seek a lot and the exit seeking would come and go. The WN stated the staff would focus on resident 7 a lot. The WN stated that resident 7 should have a wander guard on at all times. The WN stated the physician's order for the identification bracelet was for identification purposes only and was not a wander guard. The WN stated that he was not sure if resident 7 would be able to tell anyone who she was or where she lived. On 1/25/24 at 11:37 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that when resident 7 eloped in October 2023, the facility got a call from the police department asking if resident 7 lived at the facility. The DON stated that EMS did an evaluation to make sure resident 7 was safe. The DON stated that she was not sure if the evaluation was done at the facility or the police department. The DON stated when resident 7 came back to the facility the nurse interviewed resident 7 and resident 7 just shrugged her shoulders when asked where she went. The DON stated that facility staff notified the Unit Manager, DON, and the provider. The DON stated the family was called the next morning because it was late at night and the family stated that resident 7 had been calling them. The DON stated that resident 7 had recently been blue sheeted at the hospital and the wander guard was removed. The DON stated that she was not sure if the wander guard was put back on resident 7 when she readmitted to the facility. The DON stated that she was unsure on how resident 7 got out of the facility. The DON stated that the staff try to get resident 7 in activities as much as they can and get her involved. The DON stated that sometimes resident 7 would say she wanted to see her family and that was the key indicator that something was happening with resident 7. The DON stated that the elopement in October 2023 should have been reported to the State Survey Agency. The DON stated that the Administrator (Admin) was the abuse coordinator. The DON stated there was a discussion back and forth as to resident 7 not being harmed and reporting but she did not agree with the decision. On 1/25/24 at 12:17 PM, an interview was conducted with the Admin. The Admin stated that he spoke with the facility cooperate team and resident 7 had no harm while out of the facility and resident 7 was not out of the facility for a long time so there was no need to report. The Admin stated that abuse should be reported in two hours from when staff became aware. The Admin stated that resident 7 left the facility and staff were notified by the police that someone had picked resident 7 up. The Admin stated that no one at the facility had identified resident 7 was missing. The Admin stated that staff assessed resident 7 for harm or anything that may have happened to her. The Admin stated that no injuries were assessed. The Admin stated the Medical Director assessed resident 7 during the next rounds. The Admin stated there was another door where the mag lock had malfunctioned and that was how resident 7 got out of the facility. On 1/25/24 at 2:18 PM, a follow-up interview was conducted with the DON. The DON stated that the Certified Nursing Assistants rounded on the residents three to four times a shift and the nurses had three windows for medication pass times that they would lay eyes on the residents. The DON further stated that the staff assisted resident with meals and that was another opportunity to lay eyes on residents. The DON stated that resident 7 self reported the she had fallen when she eloped on 10/23/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility did not develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care, and be developed within 48 hours of the resident's admission. Specifically, for 1 out of 26 sampled residents, a resident's baseline care plan was developed four days after the resident admitted to the facility. Resident identifier: 143. Resident 143 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included benign neoplasm of meninges, pressure ulcer of left buttock stage 4, and cognitive communication deficit. Resident 143's medical record was reviewed on 1/23/24. A care plan Focus initiated on 5/2/23, documented [Resident 143] has skin graft donor sites to bilateral thighs on admission to the facility. The interventions included, Wound care per orders. A care plan Focus initiated on 5/2/23, documented Code status: DNR [Do Not Resuscitate]. The interventions included, DNR. A care plan Focus initiated on 5/2/23, documented The resident prefers to be addressed as [name removed]. The intervention included, Address resident by preferred name: [name removed]. A care plan Focus initiated on 5/2/23, documented [Resident 143] has a surgical incision to his head on admission. The intervention included, Keep area OTA [open to air]. Report and [sic] changes in condition to MD [Medical Director]. A care plan Focus initiated on 5/2/23, documented [Resident 143] has an ADL [activities of daily living] self-care performance deficit. The interventions initiated on 5/2/23, included: a. Bathing/Showering: The resident is up to totally dependent on (1) staff to provide bath/shower and as necessary. b. Bed Mobility: The resident requires extensive assistance by up to (2) staff to turn and reposition in bed. c. Dressing: The resident requires extensive assistance by up to (1) staff to dress. d. Eating: The resident requires set up assist of (1) staff for eating. e. Personal Hygiene/Oral Care: The resident requires up to extensive assist of (1) staff for personal hygiene and oral care. f. Toilet use: The resident requires extensive assist of up to (2) staff for toilet use. g. Transfer: The resident requires extensive assistance of up to (2) staff for transferring. A care plan Focus initiated on 5/2/23, documented [Resident 143] has a communication problem: cognitive communication deficit. The interventions initiated on 5/2/23, included: a. Anticipate and meet needs. b. COMMUNICATION: Allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, face when speaking, make eye contact, turn off TV/radio to reduce environmental noise, ask yes/no questions if appropriate, use simple, brief, consistent words/cues, use alternative communication tools as needed. A care plan Focus initiated on 5/2/23, documented [Resident 143] wishes to be discharged home with his son in [name removed] following his rehab [rehabilitation] stay. The intervention included, Make arrangements with required community resources to support independence post-discharge (home care, PT [physical therapy], OT [occupational therapy], MD). A care plan Focus initiated on 5/2/23, documented [Resident 143] has hypertension (HTN). The interventions initiated on 5/2/23, included: a. Avoid taking the blood pressure reading after physical activity or emotion distress. b. Give anti hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness. A care plan Focus initiated on 5/2/23, documented [Resident 143] has hyperglycemia. The intervention included, Give medications as ordered. A care plan Focus initiated on 5/2/23, documented [Resident 143] is at risk for falls r/t [related to] impaired mobility. The interventions initiated on 5/2/23, included: a. Anticipate and meet the resident's needs. b. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. c. Ensure commonly used items (ice water, glasses if applicable, call light, phone, remote) are within reach of resident prior to leaving room. A care plan Focus initiated on 5/2/23, documented [Resident 143] is on anticoagulant therapy (lovenox) r/t Post surgical. The interventions initiated on 5/2/23, included: a. Administer anticoagulant medications as ordered by physician. Monitor for side effects and effectiveness every shift. b. Monitor, document, and report as needed adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising , blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. A care plan Focus initiated on 5/2/23, documented [Resident 143] has an alteration in neurological status s/p [status post] bifrontal craniotimy with resection of meningiomas. The interventions initiated on 5/2/23, included: a. Cueing, reorientation as needed. b. Give medications as ordered. Observe and document for side effects and effectiveness. A care plan Focus initiated on 5/2/23, documented NUTRITION: [Resident 143] has increased nutrient needs RT [related to] healing AEB [as evidenced by] pressure sore. Risk for malnutrition r/t recent hospitalization s/p surgical resection of recurrent meninges, cognitive deficits following surgery. The intervention included, RD [Registered Dietician] to evaluate and make diet change recommendations PRN [as needed]. A care plan Focus initiated on 5/2/23, documented [Resident 143] has pain r/t s/p bifrontal craniotomy with meningioma resection x3. The interventions initiated on 5/2/23, included: a. Administer analgesia as per orders. Give half hour before treatments or care. b. Evaluate the effectiveness of pain interventions every shift. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. A care plan Focus initiated on 5/2/23, documented [Resident 143] has potential for impairment to skin integrity r/t impaired mobility, impaired cognition, incontinence. The intervention included, Keep skin clean and dry. Use lotion on dry skin. A care plan Focus initiated on 5/2/23, documented [Resident 143] has bladder and bowel incontinence r/t impaired mobility, impaired cognition. The interventions initiated on 5/2/23, included: a. Barrier cream to peri area with each brief change. b. Clean peri-area with each incontinence episode. A care plan Focus initiated on 5/2/23, documented [Resident 143] has impaired visual function. The interventions initiated on 5/2/23, included: a. Ensure appropriate visual aids (glasses) are available to support resident's participation in activities. b. Prescription Glasses. On 1/24/24 at 9:08 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that a Registered Nurse (RN) and Unit Manager (UM) were responsible for the baseline care plans. On 1/24/24 at 11:30 AM, an interview was conducted with RN 3. RN 3 stated the UM would keep the resident care plans up to date and the UM would take suggestions from the floor staff regarding interventions. On 1/24/24 at 1:20 PM, an interview was conducted with UM 1. UM 1 stated that she did the initial base line care plans for new residents. UM 1 stated the initial care plan included ADLs, falls, pain, etc. and the initial care plan needed to be completed within three days of admission to the facility. On 1/25/24 at 11:24 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the UM would do the baseline care plans and they should be completed within 48 hours of admission to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan consistent with the resident rights that included measurable objectives and timeframe's to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. Specifically, for 1 out of 26 sampled residents, the resident's Care Area Assessment (CAA) Summary of the admission Minimum Data Set (MDS) assessment triggered a care plan for pressure ulcer/injury and the care plan was not developed until 5/8/23, after the resident developed a pressure ulcer/injury. Resident identifier: 143. Findings included: Resident 143 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included benign neoplasm of meninges, pressure ulcer of left buttock stage 4, and cognitive communication deficit. Resident 143's medical record was reviewed on 1/23/24. On 4/28/23 at 1:54 PM, a Nursing Note documented Note Text: . alert and oriented x3-4 [person, place, time, and event] but slow at times to respond to commands, . is incontinent of bowel and bladder most times, will at times ask to use the restroom. Uses a walker for locomotion and is a standby transfer with 1-2 staff members. Known skin issues on scalp from surgical incision (closed with sutures) and 2 skin grafts areas on left thigh that are open to air, and an additional skin graft site on his right thigh that is covered with dressing. Trace generalized edema noted, no pitting edema noted. A Braden Scale for Predicting Pressure Sore Risk dated 5/1/23, documented that resident 143 was at Moderate Risk for pressure sores with a score of 13. A score of 13 to 14 would indicate a Moderate Risk. An admission MDS assessment dated [DATE], documented that resident 143 had a Brief Interview for Mental Status (BIMS) score of 14. A BIMS score of 13 to 15 would suggest intact cognition. The CAA Summary of the MDS assessment triggered a care plan for Pressure Ulcer/Injury. [Note: A care plan addressing pressure ulcers was not developed until 5/8/23, after resident 143 developed a pressure ulcer.] A care plan Focus addressing wounds initiated on 5/2/23, documented [Resident 143] has skin graft donor sites to bilateral thighs on admission to the facility. The interventions included, Wound care per orders. A care plan Focus initiated on 5/8/23, [Resident 143] has a wound to his L [left] inner upper buttock. The interventions included: [Note: The care plan Focus was initiated after resident 143 developed a pressure ulcer/injury.] a. Low air loss mattress with pump to bed. Date Initiated: 5/8/23. b. Wound care as ordered by Nurse Practitioner (NP) and Medical Director (MD). Date Initiated: 5/8/23. c. Encourage and assist resident 143 with turning, repositioning, and offloading every two hours or as much as he will allow or tolerate. Date Initiated: 5/11/23. d. Float resident 143's heels off the bed or apply foam heel protectors when he was in bed. Date Initiated: 5/25/23. e. Wound healing supplements as ordered by Registered Dietician, NP, and MD. Date Initiated: 5/25/23. On 1/24/24 at 9:08 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that a Registered Nurse (RN) and Unit Manager (UM) were responsible for the baseline care plans. On 1/24/24 at 11:30 AM, an interview was conducted with RN 3. RN 3 stated the UM would keep the resident care plans up to date and the UM would take suggestions from the floor staff regarding interventions. On 1/24/24 at 1:20 PM, an interview was conducted with UM 1. UM 1 stated that she did the initial base line care plans for new residents. UM 1 stated the initial care plan included activities of daily living, falls, pain, etc. and the initial care plan needed to be completed within three days of admission to the facility. On 1/25/24 at 10:22 AM, a follow up interview was conducted with the Wound Nurse (WN). The WN stated if the resident was at moderate risk for pressure ulcers and moved well he probably would not have developed a care plan for pressure ulcer prevention. The WN stated the baseline care plan addressed skin. On 1/25/24 at 11:24 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that once staff were aware of skin issues they should care plan so they can relay shift to shift. The DON stated if the resident upon admission were a moderate or at risk for pressure ulcers, the resident would get an air mattress or therapy would be involved more. The DON stated the UM would do the baseline care plans and they should be completed within 48 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents. Specifically, for 1 out of 26 sampled residents, a resident with cognitive impairment eloped from the facility on two separate occasions. Resident identifier: 7. Findings included: Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included focal traumatic brain injury without loss of consciousness, schizoaffective disorder, vascular dementia, hemiplegia and hemiparesis following cerebral infarction affection left non dominant side, history of falling, need for assistance with personal care, anxiety disorder, and personal history of traumatic brain injury. Resident 7's medical record was reviewed on 1/24/24. A care plan Focus initiated on 6/19/2020, documented [Resident 7] is an elopement risk/wanderer. The Focus was revised on 4/18/23. The interventions included, but were not limited to: a. Monitor location as necessary. Initiated on 6/19/20, and revised on 10/1/21. b. RESOLVED: Elopement Prevention Device: Check expiration date and function weekly. Initiated on 6/19/20. Intervention was revised and resolved on 4/25/23. c. Check placement and function per Treatment Administration Record. Initiated on 8/25/20, and revised on 7/17/23. d. Assess for fall risk. Initiated on 6/30/21, and revised on 7/1/21. e. Residents skin under the wanderguard will be checked. Initiated on 3/30/21, and revised on 7/17/23. f. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Initiated on 3/30/22, and revised on 10/23/23. g. CANCELED: Elopement Prevention Device: Verify placement every shift. Initiated on 6/19/20. The intervention was revised on 9/14/23, and canceled on 9/13/23. An additional care plan Focus initiated on 6/22/21, documented RESOLVED: Resident is an elopement risk without exit seeking behaviors. [Resident 7] is very impressionable and would leave with a friend or family member. The Focus was revised and resolved on 4/18/23. The interventions included: a. RESOLVED: Document wandering behavior and attempted diversional interventions in electronic medical record as needed if resident is exhibiting exit seeking behaviors. Initiated on 6/22/21. The intervention was revised and resolved on 4/18/23. b. RESOLVED: The resident will be placed closer to the nurses station for constant monitoring. Initiated on 6/22/21. The intervention was revised and resolved on 4/18/23. c. RESOLVED: Will reach out to family members and ask if they can come and sit with the patient if exhibiting exit seeking behaviors. Initiated on 6/30/21. The intervention was revised and resolved on 4/18/23. d. RESOLVED: Identification bracelet placed to right wrist. Initiated on 7/19/21. The intervention was revised and resolved on 4/17/23. e. RESOLVED: Wander Guard in place to alert staff of exit seeking. Initiated on 4/17/23. The care plan intervention was revised and resolved on 4/18/23. A quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 7 had a Brief Interview for Mental Status (BIMS) score of 9. A BIMS score of 8 to 12 indicated moderate impairment. A physician's order dated 6/2/22, documented Monitor residents wander guard placement every shift every shift for Wander guard placement for elopement. A physician's order dated 3/27/23, documented Ensure wander guard alarms are working properly; Take resident to the door and ensure it alarms every day shift every Mon [Monday] for Wander guard alarm properly working. A Wander Risk dated 3/30/23, documented that resident 7 was at risk for wandering/elopement with a score of 12. A score of 9 or greater would indicate the resident was at risk for wandering/elopement. On 4/16/23 at 11:14 PM, a Nursing Note documented Incorrect Documentation - Note Text: Resident exited building premises from emergency side door exits. Resident was seen and stopped by police who then returned her to the facility. Resident was returned to room and has been under continuous supervision. Father and Mother of resident were notified along with on call administrator and on call provider. Skin check has been performed with no abnormal findings. On 4/16/23 at 11:15 PM, a Nursing Note documented Late Entry: Note Text: Resident returned to facility at around 2000 [8:00 PM]. Skin check was performed, no injuries were found. Resident was quiet and cooperative upon arrival. The exhibit 358 form submitted to the State Survey Agency was reviewed. The form revealed resident 7 left the building around 7:20 PM, and walked to 2700 South before being found by police around 8:30 PM. The police then returned resident 7 to the facility. The exhibit 359 form submitted to the Stated Survey Agency was reviewed. The form revealed resident 7 had previously been care planned to wear a wander guard. Records show that resident had previously tried to leave the building. Resident 7 was found to have wander guard in place upon return and during our investigation it was determined that resident 7 followed another community member out the door. On 9/13/23 at 6:18 PM, a Nursing Note documented Note Text: [Resident 7] reports to me that she is suicidal and has a plan with the privacy curtain in her room. She will not expound any further of her plan with the privacy curtain. [Resident 7] reports that she has been having voices in her head to hurt others and to hurt herself. She has been angry and tearful. [Resident 7] will not agree to not harm herself tonight and states that she does not want treatment. It was explained to her that if she could not promise that she would not harm herself that we would need to send he out to the hospital for treatment. [Name of doctor removed] and [name removed], NP [Nurse Practitioner] was notified of the conversation and new order was received to send her to [name of hospital removed] for eval [evaluation] and treat [treatment]. [Note: All physician orders were discontinued including the wander guard when resident 7 was discharged to the hospital.] On 9/20/23 at 3:09 PM, a Nursing Note documented Note Text: Received a call from [name removed] hospital that they received our long term patient, [resident 7], last night and that she would be there under observation for SI [suicidal ideation]. Confirmed with [name removed] hospital that it would be a short term psyche [psychiatric] stay and then she would be returning to our facility for long term care. On 10/4/23 at 11:50 AM, a Nursing Note documented Note Text: new resident readmitted to this unit same bed of 301-B with same DX [diagnoses] of Schizoaffective disorder, Type depressive vascular dementia with mood disruptive behav [behavior], Brain iNjury, ANxiety,, resident is A/O [alert and oriented] to herself only, according to report fro [sic] nurse to nurse, resident not having suicidal ideation, and is calm and cooperative, no Hallucinations, resident let us did [sic] her physical assessment, skin is intact, resident denied pain or HX [history] of pain, resident is confused and walked outside her room to wander in the halls, resident is not able to remembered [sic] to use her call light, staff was educated to unticipated [sic] to her needs due to HX of bladder inc. [incontinence] resident appetite was good. A Wander Risk dated 10/8/23, documented that resident 7 was at risk for wandering/elopement with a score of 14. A score of 9 or greater would indicate resident 7 was at risk for wandering/elopement. An admission MDS assessment dated [DATE], documented that resident 7 had a BIMS score of 6. A BIMS score of 0 to 7 indicated severe cognitive impairment. On 10/23/23 at 12:15 AM, an Alert Note documented Note Text: This nurse answered the phone around 2205 [10:05 PM] the [name removed] Police called to inquire if this resident was living at this facility. This nurse said yes. The officer stated they picked up the resident around 2700S and 1300E. The officer stated, resident seemed confused and didn't know where she was going or what she was doing there. EMS [Emergency Medical Services] was called and checked out the resident to see if she was physically and mentally okay to return to the facility. The resident returned with the police officer at 2237 [10:37 PM]. Resident was helped to room. After the resident was toileted and ready for bed she was started on every 15 minute check. At this time the resident is sleeping in her bed. Call light and water within reach. [Note: The last note prior to resident 7 eloping was dated 10/21/23 at 10:22 AM.] On 10/24/23 at 7:53 PM, a Nursing Note documented Note Text: Resident denies pain r/t [related to] elopement fall from two days ago. Resident's wanderguard to R [right] ankle in place this shift. [Note: Resident 7's wander guard was not reinstated until after the elopement on 10/23/23.] A physician's order dated 10/29/23, documented Ensure residents wander guard is functioning and test with verichip machine q [every] noc [night] shift every night shift every Sun [Sunday] for Wander guard functioning. On 1/25/24 at 9:40 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 7 on occasion would be exit seeking. LPN 1 stated that once resident 7 got within a certain amount of feet of the door the wander guard alarmed. LPN 1 stated that he knew resident 7's wander guard was working because she took LPN 1 to the door last night. LPN 1 stated that resident 7 had eloped and LPN 1 thought it was in October 2023. LPN 1 stated he did not know the details of the elopement but people were coming and going from the facility and resident 7 went out the door. On 1/25/24 at 9:42 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that some residents were authorized to go in and out of the facility for smoking and the residents would come and go in groups. RN 2 stated the residents had to sign out to go out front to smoke. RN 2 stated that she thought resident 7's elopement had something to do with the wander guard. On 1/25/24 at 10:26 AM, an interview was conducted with the Wound Nurse (WN). The WN stated that resident 7 would exit seek a lot and the exit seeking would come and go. The WN stated the staff would focus on resident 7 a lot. The WN stated that resident 7 should have a wander guard on at all times. The WN stated the physician's order for the identification bracelet was for identification purposes only and was not a wander guard. The WN stated that he was not sure if resident 7 would be able to tell anyone who she was or where she lived. [Note: Resident 7's elopement in April 2023, was reported to the WN. The WN did not remember resident 7's elopement in April 2023.] On 1/25/24 at 11:37 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that when resident 7 eloped in October 2023, the facility got a call from the police department asking if resident 7 lived at the facility. The DON stated that EMS did an evaluation to make sure resident 7 was safe. The DON stated that she was not sure if the evaluation was done at the facility or the police department. The DON stated when resident 7 came back to the facility the nurse interviewed resident 7 and resident 7 just shrugged her shoulders when asked where she went. The DON stated that facility staff notified the Unit Manager, DON, and the provider. The DON stated the family was called the next morning because it was late at night and the family stated that resident 7 had been calling them. The DON stated that resident 7 had recently been blue sheeted at the hospital and the wander guard was removed. The DON stated that she was not sure if the wander guard was put back on resident 7 when she readmitted to the facility. The DON stated that she was unsure on how resident 7 got out of the facility. The DON stated that the staff try to get resident 7 in activities as much as they can and get her involved. The DON stated that sometimes resident 7 would say she wanted to see her family and that was the key indicator that something was happening with resident 7. The DON stated that the elopement in October 2023 should have been reported to the State Survey Agency. The DON stated that the Administrator (Admin) was the abuse coordinator. The DON stated there was a discussion back and forth as to resident 7 not being harmed and reporting but she did not agree with the decision. On 1/25/24 at 12:17 PM, an interview was conducted with the Admin. The Admin stated that he spoke with the facility cooperate team and resident 7 had no harm while out of the facility and resident 7 was not out of the facility for a long time so there was no need to report. The Admin stated that abuse should be reported in two hours from when staff became aware. The Admin stated that resident 7 left the facility and staff were notified by the police that someone had picked resident 7 up. The Admin stated that no one at the facility had identified resident 7 was missing. The Admin stated that staff assessed resident 7 for harm or anything that may have happened to her. The Admin stated that no injuries were assessed. The Admin stated the Medical Director assessed resident 7 during the next rounds. The Admin stated there was another door where the mag lock had malfunctioned and that was how resident 7 got out of the facility. On 1/25/24 at 2:18 PM, a follow-up interview was conducted with the DON. The DON stated that the Certified Nursing Assistants rounded on the residents three to four times a shift and the nurses had three windows for medication pass times that they would lay eyes on the residents. The DON further stated that the staff assisted resident with meals and that was another opportunity to lay eyes on residents. The DON stated that resident 7 self reported the she had fallen when she eloped on 10/23/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, for 2 out of 26 sampled residents, medications were not administered as ordered by the physician due to the medications not being available by the pharmacy. One resident was not administered their mood disturbance medication, anti-tremor medication, and a medication for sleep. In addition, a resident was not administered their blood thinning medication to prevent blood clots and an antibiotic that was used to treat a wound infection. Resident Identifiers: 7 and 143. Findings Included: 1. Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included focal traumatic brain injury without loss of consciousness, schizoaffective disorder, vascular dementia, hemiplegia and hemiparesis following cerebral infarction affection left non dominant side, history of falling, need for assistance with personal care, anxiety disorder, and personal history of traumatic brain injury. Resident 7's medical record was reviewed on 1/24/24. On 10/8/23 at 7:38 PM, an Orders - Administration Note documented Note Text: Valproic Acid Oral Solution 250 MG [milligrams]/5ML [milliliters] Give 20 ml by mouth two times a day related to VASCULAR DEMENTIA, MODERATE, WITH MOOD DISTURBANCE pharmacy pending On 11/6/23 at 7:40 AM, an Orders - Administration Note documented Note Text: Valproic Acid Oral Solution 250 MG/5ML Give 20 ml by mouth two times a day related to VASCULAR DEMENTIA, MODERATE, WITH MOOD DISTURBANCE Medication unavailable. On order from pharmacy. On 12/21/23 at 6:51 AM, an Orders - Administration Note documented Note Text: Benztropine Mesylate Oral Tablet 0.5 MG Give 0.5 mg by mouth two times a day for EPS [extrapyramidal symptoms] reorder from pharmacy. On 12/21/23 at 6:59 PM, an Orders - Administration Note documented Note Text: Benztropine Mesylate Oral Tablet 0.5 MG Give 0.5 mg by mouth two times a day for EPS Waiting for medication from pharmacy. Not given. On 12/21/23 at 7:00 PM, an Orders - Administration Note documented Note Text: TraZODone HCl [hydrochloride] Tablet 100 MG Give 1 tablet by mouth one time a day related to INSOMNIA, UNSPECIFIED Waiting for medication from the pharmacy. 2. Resident 143 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included benign neoplasm of meninges, pressure ulcer of left buttock stage 4, and cognitive communication deficit. Resident 143's medical record was reviewed on 1/23/24. On 5/8/23 at 10:17 PM, an Orders -Administration documented Note Text: Heparin Sodium (Porcine Injection Solution 5000 UNIT/ML Inject 5000 unit subcutaneously three times a day for thrombosis prophylaxis Pharmacy Pending. On 5/16/23 at 8:27 PM, an Orders - Administration Note documented Note Text: Doxycycline Hyclate Oral Tablet 100 MG Give 1 tablet by mouth two times a day for infection for 15 Days pending delivery. On 1/25/24 at 9:36 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated when reordering a medication it would depend on the medication. LPN 1 stated that when he saw the medication card getting low he would reorder the medication thorough the electronic medical record. LPN 1 stated if the medication was a narcotic he would print the script and have the doctor sign the script prior to sending it to the pharmacy for a refill. LPN 1 stated that he would do the same process for Hospice medications. LPN 1 stated the facility had an emergency medication system. LPN 1 stated that he had not used the emergency medication system that much but when he did the medication he needed was in there. LPN 1 stated the facility did have problems in the past with the pharmacy delivering but they gave the pharmacy an ultimatum. LPN 1 further stated the facility had recently switched pharmacies. On 1/25/24 at 11:24 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that antibiotics should be in the emergency medication system. The DON stated that within the resident electronic medical record there was a reorder button for medications that communicated with the pharmacy. The DON stated the pharmacy got orders through the electronic medical record and when the pharmacy received the orders they should deliver the medications. The DON stated the nurses should call the pharmacy if the medication was urgent. The DON stated that once the staff got an antibiotic order they had four hours to administer the medication. The DON stated there had been talks with the pharmacy regarding the delivery of medications.

Based on observation and interview, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, staff members were observed to touch the resident's medications and the inside of the medication cups with bare hands during medication administration. Resident identifier: 9. Findings included: On 1/24/24 at 8:26 AM, an observation was made of Registered Nurse (RN) 3 during medication administration. RN 3 grabbed a medication cup on the base of the cup, she then placed it on the medication cart and then grabbed it again placing a bare right hand finger inside of the medication cup. On 1/24/24 at 8:28 AM, an observation was made of RN 3. RN 3 took a medication bottle from the medication cart, she opened the bottle and shook the pill bottle until a pill was near the edge of the bottle. RN 3 took a bare right hand finger and touched the medication, placing it into the bottle lid and then placing the medication into the medication cup. No hand hygiene was observed prior to touching the medications. RN 3 was observed to administer the medications to resident 9. On 1/24/24 at 12:55 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that during medication administration staff were not allowed to touch medications with their hands, and should sanitize frequently. The DON stated that when a medication was in a pill bottle, staff should pour the medication into the pill bottle cap and then put into the medication cup. The DON stated that when handling the medication cup, staff should only touch the bottom or the sides of the cup, an area where the resident would not be putting their mouths, this was done to prevent the transmission of infection. The DON stated that the facility had an at risk population that was immunocompromised and staff should try to prevent the spread of infection. On 1/24/24 at 1:31 PM, an interview was conducted with a Licensed Practical Nurse (LPN) 1. LPN 1 stated that when administering medications to residents there should never be any skin contact with the pill. LPN 1 stated that one should avoid touching the medication cup on any area where the resident would put their mouth. When handling medication cups the only area the nurses should touch was around the base of the cup and should not touch the lip or the inside of the medication cup. LPN 1 stated that when removing a pill from a pill bottle best practice would include pouring the pill into the cap of the pill bottle and then pour the medication into the medication cup. LPN 1 stated that touching the medications or inside of the medication cup with bare hands could spread infection. LPN 1 stated that staff should never touch the actual pill, but if they did need to staff should first do hand hygiene and then put gloves on before touching the medication.

Based on observation and interview, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable. In addition, the facility did not ensure that all drugs and biologicals were stored under proper temperature controls. Specifically, opened insulin vials were not labeled with open dates and the insulin vials were in the medication cart available for resident use. In addition, the medication refrigerator was found to have low temperatures not compatible with medication storage and a pill was observed on the floor in the hallway accessible to residents. Findings included: 1. On 1/24/24 at 8:17 AM, an observation was conducted of Registered Nurse (RN) 1 performing medication pass to residents. An observation of RN 1's medication cart was made. The insulin Lispro glass via was observed and was open for administration and was not labeled with an open date. RN 1 was immediately interviewed. RN 1 stated that the medication did not have an expiration date located on the bottle and was unsure why it was not labeled. RN 1 stated that insulin vials were to be dated as soon as it had been opened. RN 1 stated that there was no way to prove how long it had been opened and if it had been used with the sealed lid missing. RN 1 stated that if there was a question of when an insulin bottle was opened and there was not a date located on the insulin, she would throw the bottle away and obtain a new one and date it with the open date. 2. On 1/24/24 at 9:31 AM, an observation was made of the medication fridge in the medication storage room. The temperature of the medication fridge was observed at 32 degrees F (Fahrenheit). The medication fridge contained insulin injector pens, and resident antibiotics. The January 2024 Fridge Temperature Log was reviewed and it documented Temperature to be 34-38 degrees F. On 1/24/24 at 12:55 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the nurses should label the insulin with the open date when they were first used. The DON stated that if insulin was open and a date was not written on it, staff were expected to dispose of it and order a new one. The DON stated that the medication fridge temperatures should be checked each day by the evening shift nurses. On 1/25/24 at 9:39 AM, a second observation was made of the medication fridge in the medication storage room. The temperature of the medication fridge was observed at 32 degrees F. An interview was conducted with RN 2. RN 2 stated that there were specific parameters for the fridge temperature to ensure the medications were viable to use. RN 2 stated that there were antibiotics and vaccines that must maintain a certain temperature to remain effective. 3. On 1/25/24 at 9:50 AM, an observation was conducted of the nursed station on the 400 hallway. A white medication pill was observed on the floor near the nurses station. Throughout the observation residents were observed wandering the hallway near the pill. There was a facility dog wandering the hallway near the pill. On 1/25/24 at 10:56 AM, the Medication Technician (MT) was observed to park the medication cart next to the nurses station and the pill was underneath the medication cart. The pill was picked up my staff for one hour and six minutes. On 1/25/24 at 10:59 AM, an interview was conducted with the MT. The MT stated if she saw a pill on the floor she would have reported it to the nurse. The MT stated that she saw the surveyors looking at the pill near the nurses station. On 1/25/24 at 11:00 AM, an interview was conducted with RN 4. RN 4 stated if a pill was on the floor she would put the pill in the sharps container. RN 4 stated it would be to difficult to figure out what the pill was and who it belonged to.

2. On 1/24/24 at 9:31 AM, an observation of the resident refrigerator behind the nurses station was conducted. The resident refrigerator had two unlabeled plastic containers with food. Additionally, there was an unlabeled soft sided lunch box that contained a salad and other unlabeled food items. The freezer had a brown sticky substance in the back corner. A box of ice cream bars and ice packs were stuck to the brown sticky substance in the freezer. On 1/24/24 at 9:33 AM, an interview was conducted with the Medication Technician (MT). The MT stated that the resident fridge was for resident food only and that all food should be labeled with the residents name. The MT stated that staff were not allowed to place their personal food in the resident food fridge. The MT stated that she did not know who the plastic container and lunch box belonged to, but did not think they belonged to a resident. A document on the outside of the resident fridge stated,Attention staff: this fridge is for resident use only any personal food items left in this fridge will be thrown away. Any employee food must be placed in the employee fridge, located in the employee break room. Thank you, Management. On 1/24/24 at 12:55 PM, an interview was conducted with the Director Of Nursing (DON). The DON stated that the resident fridge should be checked everyday for the temperature and cleanliness. She stated that the employees have there own fridge in the employee break room, and should not place personal food in the resident fridge. The DON stated that staff did have their lunch in the resident fridge and that it should have been in the employee fridge. On 1/25/24 at 2:01 PM, an interview was conducted with DM. The DM stated that a staff member would clean the resident fridge behind the nurses station daily, he was unaware of the brown sticky substance in the fridge. The DM stated he would have it cleaned immediately. The DM stated that staff should not keep their food in the resident fridge, they have a fridge in the employee break room. Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in freezer were open to air and the resident refrigerator was unclean and contained unlabeled and undated food items. Findings included: 1. On 1/22/24 at 8:15 AM, an initial walk-through was conducted in the kitchen. In the walk-in freezer, a box of frozen sausage patties was open to air and a box of frozen biscuits was open to air. On 1/25/24 at 9:59 AM, a second walk-through was conducted in the kitchen. In the walk-in freezer, a box of beef patties was open to air, a box of frozen sausage patties was open to air, a box of frozen biscuits was open to air, a box of peanut butter cookie dough was open to air, and a box of sugar cookie dough was open to air. On 1/25/24 at 10:28 AM, an interview was conducted with the Dietary Manager (DM). The DM stated when a food item was removed from the freezer, there was very little, if any, of the food product left so the few that were left would be thrown away. The DM stated if there was enough food items that it could be used for another meal, it was returned to the freezer. The DM stated that all food items should be sealed before returning to the freezer, even if the food item was inside a box.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 2 of 51 sample residents, that the facility did not treat each resident with respect, dignity and care, in a manner and in an environment that promoted maintenance and enhancement of his or her quality of life. Specifically, residents were observed to have urine soaked beds. Resident identifiers: 58 and 82. Findings included: 1. Resident 82 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy (CP), chronic myeloid leukemia, schizoaffective disorder, post-traumatic stress disorder (PTSD) and major depressive disorder. On 3/14/22 at 10:08 AM, an interview was conducted with resident 82. Resident 82 stated staff changed his brief before bed the pervious night and then again just now. An observation was made of resident 82's bed. Resident 82's bed was observed to be saturated with urine and had a strong urine odor. Resident 82 stated his bed was saturated with urine and smelled. Resident 82 stated he was not checked on last night and his brief was not changed during the night. On 3/17/22 at 3:05 PM, a follow up interview was conducted with resident 82. Resident 82 stated on Sunday (3/13/22), the night staff did not change his brief until Monday morning. Resident 82 stated that staff usually used 2 briefs on him because they absorbed more. Resident 82 stated that he was able to use a urinal. Resident 82's medical record was reviewed on 3/17/22. A quarterly Minimum Data Set (MDS) dated [DATE] revealed resident 82 required extensive 2 person assistance with bed mobility and 2 plus person extensive assistance with toileting. According to the MDS, resident 82 was not receiving a toileting program and was frequently incontinent of bowel and bladder. Resident 82 had a Brief Interview of Mental Status (BIMS) score of 15 which revealed resident 82 was cognitively intact. A care plan for resident 82 dated 9/2/21 revealed B & B [Bowel and Bladder] [resident 82] has bowel and bladder incontinence r/t [related to] Impaired Mobility and activity intolerance. The goal developed was The resident will remain free from skin breakdown due to incontinence and brief use through the review date 9/2/21. The interventions developed were Ensure the resident has an unobstructed path to the bathroom and Resident uses Briefs for dignity and Clean peri-area with each incontinence episode. An additional care plan for resident 82 dated 11/9/21 revealed Resident is resistive to cares. The goal was The resident will cooperate with care through the next review date. Interventions developed were Allow the resident to make decisions about treatment regime, to provide sense of control and Provide resident with opportunities for choice during care provision and Risk vs (verses) benefit for refusal of cares. Resident was also educated. A task section titled activities of daily living (ADLs) which was completed by the facility Certified Nursing Assistants (CNAs) revealed that resident 82's brief was changed on 3/13/22 at 4:41 PM, 7:33 PM, and 7:34 PM. There was no documentation that resident 82's brief was changed on 3/14/22. There was no documentation that resident 82 refused to have his brief changed. On 3/16/22 at 1:26 AM, an observation was made of CNA 15. CNA 15 was observed to enter resident 82's room. CNA 15 was observed to assist resident 82's roommate. At 1:32 AM, CNA 15 was observed to tell resident 82 she was going to check his brief. Two nurses were observed to enter resident 82's room and asked CNA 15 if she needed assistance. CNA 15 stated no she was doing fine and asked if the call light was alarming. They said no but just wanted to check in with her. At 1:37 AM, CNA 15 was interviewed. CNA 15 stated that she had just finished changing resident 82's brief alone. CNA 15 stated that she was able to change resident 82's brief by herself. CNA 15 stated that resident 82 was incontinent of bowel and bladder. CNA 15 stated resident 82 was soaked and staff had to constantly check on him because he was a heavy wetter. CNA 15 stated she was not aware of any residents on a toileting program during the night time but there might be some during the day. On 3/17/22 at 3:49 PM, an interview was conducted with the Director of Nursing (DON). The DON stated there was not a specific time for staff to check residents but she hoped that staff did rounds every 2 hours but no longer than every 3 hours. On 3/17/22 at 10:56 AM, an interview was conducted with CNA 14. CNA 14 stated that staff asked residents who were able to verbalize if they needed to use the restroom and assisted the resident if they needed assistance. CNA 14 stated there should be different documentation for a resident with a retraining program verses one without but she was not aware of any residents on a retraining program. 2. Resident 58 was admitted to the facility on [DATE] with diagnoses which included coronary artery disease, hypertension, diabetes, depression, and post-traumatic stress disorder. On 3/14/22 at 12:30 PM, an interview was conducted with resident 58. Resident 58 stated that the staff did not respond when he pressed his call light. Resident 58 stated that he had bladder and bowel accidents waiting for staff to answer his call light. Resident 58's bed was observed to be saturated with urine and there was a strong urine odor. Resident 58 stated that he was currently wet and had not been changed since yesterday. Resident 58's medical record was reviewed on 3/16/22. A quarterly MDS dated [DATE] revealed resident 58 required one person extensive assistance with toileting and bed mobility. The MDS further revealed that resident 58 was frequently incontinent of bladder which meant 7 or more episodes of incontinence and at least 1 episode of continence during a 7 day look back period of time. The MDS revealed that resident 58 was not on a toileting program and required 1 person physical assist for bed mobility and toileting. Resident 58's Brief Interview of Mental Status (BIMS) score was a 14 which indicated resident 58 was cognitively intact. On 3/16/22 at 12:52 AM, resident 58 was lying in bed with the television on. At 1:11 AM, an observation was made of CNA 15 going into resident 58's room. CNA 15 was observed to get a brief and enter resident 58's side of the room behind the curtain. At 1:24 AM, CNA 15 was interviewed. CNA 15 stated that she checked resident 58 and he was wet so she changed his brief. CNA 15 stated that urine had not soaked through the brief. CNA 15 stated that resident 58 was able to turn and reposition so she was able to change him by herself. On 3/17/22 at 10:53 AM, an interview was conducted with CNA 14. CNA 14 stated that resident 58 was incontinent of bowel and bladder. CNA 14 stated that resident 58 needed to be checked every 2 hours at least for possible incontinence. CNA 14 stated that resident 58 was able to use his call light and called when he needed to be changed. CNA 14 stated that resident 58 sometimes used a urinal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews it was determined, for 1 of 51 sample residents, that the facility failed to assure Pre-admission Screening and Resident Review (PASARR) screening was accurately completed. Resident identifiers: 16. Findings include: Resident 16 was admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder, other stimulant abuse, chronic obstructive pulmonary disease, and right foot drop. On 3/21/2022 at 1:15 PM, a record review was conducted of Resident 16's electronic health record. No PASARR screening was found. On 3/21/2022 at 4:06 PM, an interview was conducted with the facility's Director of Mental Health Services/Master's of Social Work (MSW). MSW stated there was not a PASARR completed. MSW stated the resident was private pay and she was not aware that a PASARR needed to be completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 51 sample residents, that the facility did not develop a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care. Specifically, a resident had wounds identified on their admission assessment and the baseline care plan did not address the skin condition or wound care treatment. Resident identifier: 198. Findings included: Resident 198 was admitted to the facility on [DATE] with diagnoses of fracture of right humerus, ground level fall, alcohol dependence, type 2 diabetes mellitus, chronic obstructive pulmonary disease, cellulitis of left lower limb, hypertension, hyperlipidemia, hypothyroidism, sleep apnea, dorsalgia, major depressive disorder, anxiety disorder, gastro-esophageal reflux disease, and chronic pain. On 3/14/22 at 1:18 PM, an interview was conducted with resident 198. Resident 198 stated that he had open wounds on the bottom of both feet, and that he had neuropathy. Resident 198 stated that he did not have any wound care for his feet, no dressing changes, no creams or ointments. Resident 198 stated that the wounds were located on the heels and big toes, and would bleed a little bit. Resident 198 stated that he did not think that the facility staff knew about the wounds. On 3/15/22 resident 198's medical records were reviewed. On 3/12/22 at 1:50 PM, resident 198's Brief Interview for Mental Status (BIMS) assessment documented a score of 12 which would indicate that the resident had a moderate cognitive impairment. Resident 198's skin assessments were reviewed and revealed the following: a. On 3/9/22 at 1:50 PM, the admission Evaluation documented edema on right and left lower extremity. Skin issues were documented as present with skin breaks documented on the right toe, sacrum and sores on left and right heel. b. On 3/9/22 at 2:50 PM, the Braden scale for Predicting Pressure Sore Risk documented a score of 21, which would indicate that the resident was at risk. c. On 3/16/22 at 1:50 PM, the skin and wound assessment document no wounds, the condition was normal, the elasticity was good, skin color was normal for ethnic group, temperature warm (normal), and moisture was normal. Review of resident 198's physician orders revealed no treatment or wound care orders. Review of resident 198's progress notes revealed the following: a. On 3/9/2022 at 5:19 PM, the note documented, .has wounds on both feet and bruising on his R [right] arm. b. On 3/10/2022 at 10:35 AM, the physician/provider note documented, Skin: inspection: no rashes, lesions, normal coloring and complexion, warm and dry. Skin is clean, dry and intact. c. On 3/14/2022 at 6:28 AM, the physician/provider note documented, Skin: inspection: no rashes, lesions, normal coloring and complexion. Review of resident 198's care plan revealed a focus area of had the potential for impairment to skin integrity. The care plan was initiated on 3/10/22. The goal identified was that the resident will maintain or develop clean and intact skin by the review date. Interventions identified were to encourage good nutrition and hydration in order to promote healthier skin. There was no care plan regarding resident 198's open wounds on his feet. On 3/17/22 at 9:23 AM, an interview was conducted with Registered Nurse (RN) 11. RN 11 stated that he had sores identified on his feet when he was admitted , but he did not have any treatments ordered for them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, for 1 of 51 sample residents, that the facility did not ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene. Specifically, a resident was not provided showers according to their schedule. Resident identifier: 36. Findings included: Resident 36 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included congestive heart failure (CHF), chronic respiratory failure with hypoxia, muscle weakness and major depressive disorder. On 3/14/22 at 1:43 PM, an interview was conducted with resident 36. Resident 36 stated she would like to be showered 3 to 4 times per week. Resident 36 stated she was showered one to two times per week. Resident 36 stated she was showered a few days ago because she went a long time without a bed bath. Resident 36's roommate stated that resident 36's hair was matted and it was not healthy to go that long without a shower. Resident 36 was observed to have matted hair and both eyes had cream colored discharge that was dried to her eyelash's and eye lids. Resident 36 was observed to have long fingernails with a brown substance under them. Resident 36 stated she did not want her fingernails cut short, but did not want them dirty. Resident 36 stated she wanted to have her fingernails cleaned. Resident 36's medical record was reviewed on 3/27/22. A quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 82 was totally dependent requiring two or more person physical assist with bathing. The MDS further revealed that resident 82 required extensive two plus persons physical assist for personal hygiene. A care plan dated 5/3/21 and revised on 7/20/21 revealed that [Resident 36] has an ADL self-care performance deficit r/t (related to) CHF and COPD (chronic obstructive pulmonary disease). The goal was The resident will maintain current level of ADL function through the review date. The interventions included bathing/showering: the resident is up to extensive assist of (2) staff to provide bath/shower and as necessary and Personal Hygiene/Oral Care: The resident requires up to extensive assist of (1) staff for personal hygiene and oral care. According to the ADL tasks section for bathing, resident 36 was bathed 2/17/22, 2/19/22, 2/22/22, 2/24/22, 3/3/22, 3/10/22 and 3/15/22. CNAs documented that resident 36 had being totally dependent on staff for showering on all the listed dates except 2/19/22, where resident 36 required physical help in part of bathing activity. Resident 36 refused to be showered on 3/8/22. According to the form, bathing was defined as How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower. There was no other documentation that resident 36 was bathed. On 3/17/22 at 11:22 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that she worked morning shift and resident 36 was scheduled for afternoon showers. CNA 2 stated she had not heard anything about showering and had not noticed anything with resident 36's eyes. CNA 2 stated that resident 36 asked one time to have her fingernails cut. CNA 2 stated resident 36 allowed for her nails to be cleaned. CNA 2 stated that nail care was done when fingernails were dirty and during showers. On 3/17/22 at 11:12 AM, an interview was conducted with CNA 1. CNA 1 stated that the computer notified CNAs which residents were to receive showers each day. CNA 1 stated there were shower sheets completed after the shower and the CNA gave them to the nurse. CNA 1 stated that not applicable should not be marked for showers. CNA 1 stated if a resident refused three times then the nurse was notified. CNA 1 stated if a resident refused three times then a form was signed by the CNA and nurse. On 3/17/22 at 2:54 PM, an interivew was conducted with CNA 20. CNA 20 stated she worked for an agency but had worked at the facility for a little over a year. CNA 20 stated the showers were scheduled in the computer system. CNA 20 stated she looked at the showers to be given at beginning of the shift. CNA 20 stated she notified the residents of their shower day and asked what time they wanted a shower when she completed vital signs. CNA 20 stated if a resident refused she notified the nurse and looked to see how long it had been since they were showered. CNA 20 stated if it had been a while, she went back to the resident and offered a bed bath. CNA 20 stated that resident 36 had not refused showers when she worked. CNA 20 stated that resident 36 preferred a women CNA to shower her. On 3/17/22 at 4:27 PM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated that residents were scheduled showers 3 days per week based on their preferences. UM 1 stated that the CNAs document under the tasks section in the medical record. UM 1 stated if a resident refused, the CNAs were required to ask 3 times before they documented refused. UM 1 stated there was also a book at the nurses station with a form to complete if a resident refused or if the shower was completed. UM 1 stated the form had a notification section regarding skin issues that the nurses had to sign off on. UM 1 stated the facility had a lot of agency staff in the building and she tried to educate them as they came on shift. UM 1 stated agency CNAs might not know the full process of it. UM 1 stated there was a binder at the nurses station that had every step of what needed to be completed during their shift for CNAs to follow. UM 1 stated she did not know what not applicable meant for showers. UM 1 stated that resident 36 refused cares a lot but did not have additional information. On 3/17/22 at 3:29 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that showers were scheduled 3 times per week. The DON stated that shower times were in the electronic charting system. The DON stated if a resident refused, the CNA notified the nurse and the nurse talked to the resident. The DON stated the problem was frustrating because there were agency CNAs that have been asked not to come back because they were not charting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 51 sample residents, that the facility did not ensure residents received proper treatment and care to maintain good foot health. Specifically, staff did not review the podiatrist's recommendations in a timely manner, resulting in the delay of proper treatment of a resident's foot issues. Resident identifier: 76. Findings included: Resident 76 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included multiple sclerosis, morbid obesity, paraplegia, cognitive communication deficit, limitation of activities due to disability, schizoaffective disorder, bipolar type, major depressive disorder, muscle weakness, pain in unspecified limb and borderline personality disorder. On 3/21/22 at 3:29 PM, an interview was conducted with unit manager (UM) 2. UM 2 stated the latest podiatry visit note for resident 76 was not in the electronic health record (EHR) but she would provide a copy for review. On 3/21/22 at 5:57 PM, a podiatry note dated 3/9/22 for resident 76 was reviewed. The record showed that resident 76 was seen by the podiatrist on 3/9/22 and a recommendation was made for a topical anti-fungal for the presence of tinea pedis. The record indicated the podiatry visit note was signed and reviewed by facility staff on 3/21/22 at 5:38 pm. [Note: Record review showed a recommendation from the podiatrist was made on 3/9/22 but the recommendation was not reviewed by facility staff until 3/21/22, indicating a 12-day delay in treatment.]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined, for 2 of 51 sample residents, that the facility did not ensure that residents with limited range of motion received appropriate treatment and services to increase and/or prevent further decrease in range of motion. In addition, the facility did not ensure that residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence. Specifically, a resident with limited range of motion did not have a splint that was recommended by Occupational Therapy. In addition, a resident was not provided bilateral positioning bars so she was able to reposition herself. Resident identifiers: 23 and 48. Findings included: 1. Resident 23 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy, paralytic syndrome, age-related osteoporosis, difficulty in walking, mood disorder, cognitive communication deficit, and muscle weakness. On 3/15/22 at 10:49 AM, an observation was made of resident 23. Resident 23 was observed to be transferring from her wheelchair to her bed with a staff member. Resident 23 was observed to not be using her left hand during the transfer. Resident 23's left wrist was observed to be bent and fingers were bent into a C shape. Resident 23 was not wearing any splints or wraps on her left hand or wrist. Resident 23's medical record was reviewed on 3/21/22. A quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 23 had functional limited range of motion to both her upper and lower extremities on both sides. A care plan dated 7/27/21 revealed that resident 23 had a left wrist contracture. One of the goals was that resident 23 was to remain free of complications related to immobility, thrombus formation, skin breakdown, and fall related injury through the next review date. The interventions developed were to assist resident with television remote control, bed rail to assist with bed mobility, the resident uses a motorized wheel chair, provide gentle range of motion as tolerated with (sic) daily and remind resident to get out of bed slowly when transferring from the bed to the chair. Another intervention sometimes [resident 23] request to have trash liner tied to the door handle to give her easy access to open the door please respect her choice and restorative nursing assistant (RNA) to provide passive range of motion. The care plan did not list Occupational Therapy (OT) or a splint/brace as interventions for resident 23's limited range of motion. The OT Discharge Summary for dates of service from 7/7/21 through 7/15/21 was reviewed and revealed the following: a. 7/15/21: STG [short term goal] . discontinued on 7/15/21. Pt [patient] will be able to tolerate resting hand splint for 4 hours on 4 hours off to improve ROM [range of motion] of L [left] digits 4 and 5 for BADLs [basic activities of daily living]. Baseline (7/7/21) pt able to tolerate splint for one hour. Previous (7/7/21) pt able to tolerate splint for one hour. Discharge (7/15/21) pt tolerates splint [less than] 2 hrs hours. b. 7/15/21: Discharge Recommendations: splint/brace. On 3/21/22 at 1:26 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 23 currently did not have a splint/brace for her left wrist contracture. On 3/21/22 at 11:39 AM, an interview was conducted with the Director of Therapy (DT). The DT stated that resident 23 had limited range of motion to her left hand and wrist. The DT further stated that resident 23 had a splint that was ordered and fitted by OT, but the splint had since disappeared. The DT stated he was in the process of ordering another splint for resident 23. On 3/21/22 at 1:36 PM, a follow up interview was conducted with the DT. The DT stated he was unsure if a splint for resident 23 had been ordered. The DT stated he did not know when the initial splint was ordered, but stated his records showed that when resident 23 was discharged from OT in July 2021, she had a splint. The DT stated he did not know how long the splint/brace had been missing. The DT stated he was working to get resident 23 back on therapy services. The DT was unable to provide information that a new splint/brace had been ordered. 2. Resident 48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included multiple sclerosis, type 2 diabetes mellitus with diabetic polyneuropathy, difficulty in walking, stiffness of unspecified joint, obesity, arthrodesis, and muscle weakness. On 3/14/22 at 11:26 AM, an interview was conducted with resident 48. Resident 48 stated her current bed had one low side rail on her right side. Resident 48 stated the rail was too low for her to reposition independently. Resident 48 stated the staff repositioned her from side to side by rotating her at the hips. Resident 48 stated she was unable to reposition herself with out a positioning rail on the sides of her bed. Resident 48 stated with her previous bed she was able to have positioning rails on both sides that were high enough for her to reach them. Resident 48 stated with the positioning rails she was able to roll side to side independently. Resident 48 stated her previous bed broke which was why she had to switch beds. On 3/21/22 at 10:45 AM, a follow up interview was conducted with resident 48. Resident 48 stated her positioning rails fit on her previous bed which had a larger frame. Resident 48 stated her positioning rails did not fit on the bed she currently had. Resident 48 stated she had a side rail on the right side but because the mattress was larger than the frame, she was unable to have a side rail on the left side of the bed. Resident 48 stated she thought her previous bed broke a couple of weeks ago. Resident 48 stated she wanted a different bed that her positioning rails fit on. Resident 48 stated she can move independently with her positioning rails but because the side rail on her current bed was too short, staff have to reposition her. Resident 48 stated she was unsure what was decided about her bed. Resident 48 stated she had ongoing discussions with the nurse, the maintenance man, and the Administrator regarding the side rails. A single positioning rail was observed on the floor in resident 48's room. Resident 48 stated the positioning rail on the floor was from her previous bed. Resident 48's medical record was reviewed on 3/22/22. A quarterly MDS dated [DATE] revealed that resident 48 Brief Interview of Mental Status score of 15 which revealed resident 48 was cognitively intact. A physician's order dated 9/24/18 revealed bilateral grab bars. Resident 48's care plan dated 4/6/21 revealed bilateral grab bars to bed to assist with mobility and Pt is resistive to cares of not showering, refusal to shave facial hair, pt chooses to stay in bed, turn q [every] 2 hours. The goal developed was [resident 23] will have no issues with BIL [bilateral] grab bars to her bed through the review date. Interventions included a risk verses benefits was signed by the resident regarding the grab bars and risk verses benefits in place for refusal of every 2 hour turning. On 3/21/22 at 11:02 AM, and interview was conducted with Certified Nursing Assistant (CNA) 11. CNA 11 stated resident 48's bed broke in January or February 2022. CNA 11 stated he had noticed a difference with positioning, stated resident 48 was able to position better with the positioning rails on her old bed. On 3/21/22 at 11:10 AM, an interview was conducted with unit manager (UM) 1. UM 1 stated she was not aware that resident 48's previous bed had broken; she stated she was unsure if there was a plan to replace resident 48's current bed. On 3/21/22 at 11:19 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the maintenance man quit the week prior. The DON stated she was unable to find any maintenance work orders for a broken bed for resident 48. The DON stated she ordered new beds and was unaware resident 48 needed a new bed. On 3/21/22 at 11:28 AM, an interview was conducted with the Administrator. The Administrator stated he was unaware that resident 48's bed had broken. The Administrator stated he had been doing most of the maintenance and most likely there were no logs of what had been done. The Administrator stated if he had been told about the bed, he probably would have switched out the broken bed for a different one. The Administrator stated the restorative department was responsible to ensure all residents had the mobility devices they needed. The Administrator stated an audit was recently conducted to verify the mobility devices for all residents were in place as needed. The Administrator stated that somehow resident 48 was missed. On 3/21/22 at 12:00 PM, the Administrator was observed removing the positioning rail from resident 48's room. The Administrator stated he put a side rail on the left side of resident 48's bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews it was determined that, for 2 of 51 sampled residents, the facility did not ensure that the resident environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, one resident was observed smoking without protective equipment that he was assessed to need. In addition, another resident was observed smoking and did not have a smoking assessment. Resident identifier: 5 and 38. Findings include: 1. Resident 5 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, type 2 diabetes mellitus, schizophrenia, obesity, hypothyroidism, and hypertension. On 3/14/22 at 11:38 AM, an interview was conducted with Resident 5. Resident 5 stated staff had him sign a paper about smoking a few weeks back and all residents were on a schedule now. Resident 5 stated that he only got to go out when staff said he could. On 3/15/22 at 10:00 AM, an observation was made of resident 5, Resident 5 was observed to be smoking outside the 300 hall on the patio with a staff member. Resident 5 was not observed to be wearing a smoking apron or using other safety equipment while smoking. Resident 5's medical record was reviewed on 3/21/22. A quarterly Minim Data Set (MDS) dated [DATE] a Brief Interview for Mental Status (BIMS) score of 11 which indicated resident had moderate cognitive impairment. Resident 5's smoking assessment dated [DATE] revealed that he was smoking 0 cigarettes a day, indicating he was not a smoker. Resident 5's previous assessments, dated 10/16/21, 7/16/21, and 4/16/21, revealed that resident 5 had the ability to light his own cigarette, no dexterity problems, no cognitive loss, no visual deficits, was able to retrieve a cigarette if it was dropped and was able to demonstrate the ability to hold a cigarette, but that the resident required a smoking apron while smoking. A care plan dated 12/16/21 revealed resident 5 was a smoker, needed supervision and needed to wear an apron. The goal was resident 5 would not suffer injury, would not smoke without supervision and would follow all facility smoking rules. Some of the interventions included to store smoking materials at nurses station; instructed on policies regarding risks and hazards; observed for burns; provided protective gear; and reviewed facility smoking policy. 2. Resident 38 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia, schizoaffective disorder, type 2 diabetes mellitus, and obstructive sleep apnea. On 3/14/22 at 11:49 AM, an interview was conducted with Resident 38. Resident 38 stated You heard it already from my roommate [Resident 5]. Resident 38 further stated that the new policy was not right and he had right and I'll smoke when I like! On 3/15/22 an observation was made of resident 38 smoking outside the 300 hall on the patio with a staff member. Resident 38 was not observed to be wearing or using safety equipment. Resident 38's medical record was reviewed on 3/21/22. A quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated resident was cognitively intact. An additional MDS dated [DATE] revealed in the Care Area Assessment that the Nature of Problem/Condition was He is a smoker. Resident 38's care plans were reviewed. There were no care plans regarding resident 38 being a smoker located in the medical record. Resident 38's had a smoking assessment dated [DATE] which indicated he smoked 0 cigarettes per day, needed no further assessment and was he was not identified as a smoker. On 3/14/2021 the facility provided a list of residents who smoked cigarettes. Resident 5 and Resident 38 were on the list. On 3/17/22 the Administrator (ADM) provided copies of a letter, dated 2/25/22, that had been sent to all of the facility's residents who smoked. The letter was addressed to the resident, their friends, family, and visitors. In the letter it stated, In the coming days, facility staff will be approaching residents who smoke, and asking the residents to turn over all smoking materials to staff. We would also ask that if you bring cigarettes/lighter to our residents, please do not give them to the residents. Please give all cigarettes/smoking materials directly to the staff. Facility staff will distribute the cigarettes and will safely supervise all the residents at the same smoking times. The letters were signed by the ADM, had the residents' names handwritten on the top of the letter, and were individually signed by Resident 38 and Resident 5. On 3/14/22 at 1:29 PM, an interview was conducted with Registered Nurse (RN) 6. RN 6 stated that residents were allowed to smoke at the facility, but a smoking schedule was followed. RN 6 obtained a physical copy of the smoking schedule and stated that We just recently changed to this schedule. The residents don't like it, but it means everyone can smoke at least. The smoking schedule provided designated smoking times at 10:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM. On 3/15/22 at 11:18 AM, an interview was conducted with the facility's Social Service Worker (SSW) 1. SSW 1 stated residents were only allowed to smoke when supervised. SSW 1 stated the supervised smoking was a new change and some resident did not like it but it was better with the new policy. On 3/15/22 at 1:16 PM, an interview was conducted with Certified Nursing Assistant (CNA) 7. CNA 7 stated that staff had to be present for smoking. CNA 7 stated there was a schedule and nobody goes out without supervision. On 3/17/22 at 11:00 AM, an interview was conducted with CNA 14. CNA 14 stated that there were new smoking times because of how many smokers the facility had. CNA 14 stated the smoking times were 10:00 AM, 1:00 PM, 5:00 PM and 7 PM. CNA 14 stated that there were a lot of residents so it was divided into 2 smoking session for each smoking time. CNA 14 stated residents did not like the new policy but some residents did. CNA 14 stated staff were trying to work it so everyone was okay with it. CNA 14 stated residents were able to smoke independently before the policy change. CNA 14 stated some of the residents were selling their cigarettes to other residents that needed supervision. On 3/16/22 at 8:24 AM, an interview was conducted with the ADM. The ADM stated that staff were taking the residents out in smaller groups to prevent resident to resident altercations. The ADM stated that the new smoking times were 10:00 AM, 1:00 PM, 5:00 PM and 9:00 PM. The ADM stated education was provided to everyone on 2/25/22. The ADM stated he had asked all residents to turn over their smoking materials to the nurses. The ADM stated if there was a lighter or cigarettes, residents needed to give them to the staff. The ADM stated that residents tried to smoke in their rooms previously, so the staff just decided to do supervision with everyone. The ADM stated there were open smoking times and it became an issue with smoking. The ADM stated facility staff did regular safety sweeps because other residents had brought in weapons and smoking equipment. The ADM stated a lot of residents were admitted from home and had drugs and other things that were not allowed. The ADM stated We bootlegged the policy because it didn't work for me. The ADM stated the smoking policy was modified for the residents. On 3/15/22 a copy of the facility's smoking policy was reviewed. The policy stated Residents who smoke will be supervised by staff members while smoking. Smoking will occur at designated smoking times. On 3/22/2022 the facility submitted additional information. Corporate Resource Nurse (CRN) submitted documentation that stated - . upon review it was determined that [Resident 38] does not smoke. Upon interview of the DON [Director of Nursing] it was determined that he was listed in error on our current smoker list. Confirmed with additional interview of Unit Manager (UM). Per UM he doesn't smoke but does have a previous history of smoking. UM interviewed [Resident 38] and he confirmed he hasn't smoked in a long time and no longer smokes. Smoking assessment and care plan would not be needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 2 of 51 sample residents, that the facility did not ensure based on resident's comprehensive assessment, that a resident who was incontinent received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, a resident was evaluated to be a good candidate for a bladder retraining program and the resident was not provided the program. In addition, the resident and another resident were observed to be in urine soaked beds. Resident identifiers: 58 and 82. Findings included: 1. Resident 82 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy (CP), chronic myeloid leukemia, schizoaffective disorder, post-traumatic stress disorder (PTSD) and major depressive disorder. On 3/14/22 at 10:08 AM, an interview was conducted with resident 82. Resident 82 stated staff changed his brief before bed the pervious night and then just now. An observation was made of resident 82's bed. Resident 82's bed was observed to be saturated with urine with a strong urine odor. Resident 82 stated his bed was saturated with urine and smelled. Resident 82 stated he was not checked on last night and his brief was not changed during the night. On 3/17/22 at 3:05 PM, a follow up interview was conducted with resident 82. Resident 82 stated on Sunday (3/13/22), night staff did not change his brief until Monday morning. Resident 82 stated that staff usually used 2 briefs on him so that it absorbed more. Resident 82 stated that he was able to use a urinal. Resident 82's medical record was reviewed on 3/17/22. A quarterly Minimum Data Set (MDS) dated [DATE] revealed resident 82 required extensive 2 person assistance with bed mobility and 2 plus person extensive assistance with toileting. According to the MDS, resident 82 was not receiving a toileting program and was frequently incontinent of bowel and bladder. Resident 82 had a Brief Interview of Mental Status (BIMS) score of 15 which revealed resident 82 was cognitively intact. A bowel and bladder evaluation dated 3/1/22 revealed resident 82 was a good candidate for retraining. A care plan for resident 82 dated 9/2/21 revealed B & B [Bowel and Bladder] [resident 82] has bowel and bladder incontinence r/t [related to] Impaired Mobility and activity intolerance. The goal developed was The resident will remain free from skin breakdown due to incontinence and brief use through the review date 9/2/21. The interventions developed were Ensure the resident has an unobstructed path to the bathroom and Resident uses Briefs for dignity and Clean peri-area with each incontinence episode. An additional care plan for resident 82 dated 8/26/21 revealed ADLs [activities of daily living] [resident 82] has an ADL self-care performance deficit r/t CP. The goal was The resident will improve current level of function through the review date. An intervention included Toilet use: The resident requires up to extensive assist of (2) staff for toilet use. An additional care plan for resident 82 dated 11/9/21 revealed Resident is resistive to cares. The goal was The resident will cooperate with care through the next review date. Interventions developed were Allow the resident to make decisions about treatment regime, to provide sense of control and Provide resident with opportunities for choice during care provision and Risk vs (verses) benefit for refusal of cares. Resident was also educated. A task section titled activities of daily living (ADLs) which was completed by the facility certified nursing assistants (CNAs) revealed that resident 82's brief was changed on 3/13/22 at 4:41 PM, 7:33 PM, and 7:34 PM. There was no documentation that resident 82's brief was changed on 3/14/22. There was no documentation that resident 82 refused to have his brief changed. On 3/16/22 at 1:26 AM, an observation was made of CNA 15. CNA 15 was observed to enter resident 82's room. CNA 15 was observed to assist resident 82's roommate. At 1:32 AM, CNA 15 was observed to tell resident 82 she was going to check his brief. Two nurses were observed to enter resident 82's room and asked CNA 15 if she needed assistance. CNA 15 stated no she was doing fine and asked if the call light was alarming. They said no but just wanted to check in with her. At 1:37 AM, CNA 15 was interviewed. CNA 15 stated that she had just finished changing resident 82's brief alone. CNA 15 stated that she was able to change resident 82's brief by herself. CNA 15 stated that resident 82 was incontinent of bowel and bladder. CNA 15 stated resident 82 was soaked and the staff had to constantly check on him because he was a heavy wetter. CNA 15 stated she was not aware of any residents on a toileting program during the night time but there might be some during the day. On 3/17/22 at 3:49 PM, an interview was conducted with the Director of Nursing (DON). The DON stated she was not sure what was on the bowel and bladder evaluation. The DON stated that bowel and bladder retraining program would consist of more frequent checks. The DON was asked to define more frequent checks and the DON stated there was not a specific time and she hoped that staff did rounds every 2 hours but no longer than every 3 hours. On 3/17/22 at 4:54 PM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated there were no residents on a bowel and bladder retraining program. UM 1 stated that the MDS coordinator completed the evaluations and let the UM' know if something needed to be implemented. UM 1 stated she was not aware that resident 82 was evaluated as a good candidate for bowel and bladder retraining. On 3/17/22 at 10:56 AM, an interview was conducted with CNA 14. CNA 14 stated that staff asked residents who were able to verbalize if they needed to use the restroom and assisted the resident if they needed assistance. CNA 14 stated there should be different documentation for a resident with a retraining program verses one without but she was not aware of any residents on a retraining program. 2. Resident 58 was admitted to the facility on [DATE] with diagnoses which included coronary artery disease, hypertension, diabetes, depression, and post-traumatic stress disorder. On 3/14/22 at 12:30 PM, an interview was conducted with resident 58. Resident 58 stated that the staff did not respond when he pressed his call light for help. Resident 58 stated that he had bladder and bowel accidents waiting for staff to answer his call light. Resident 58's bed was observed to be saturated with urine and had a strong urine odor. Resident 58 stated that he was currently wet and had not been changed since yesterday. Resident 58's medical record was reviewed on 3/16/22. A quarterly MDS dated [DATE] revealed resident 58 required one person extensive assistance with toileting and bed mobility. The MDS further revealed that resident 58 was frequently incontinent of bladder which meant 7 or more episodes of incontinence and at least 1 episode of continence during a 7 day look back period of time. The MDS revealed that resident 58 was not on a toileting program and required 1 person physical assist for bed mobility and toileting. Resident 58's BIMS score was a 14 which indiciated resident 58 was cognitively intact. There was no documentation that resident 58 was assessed for a toileting program. On 3/16/22 at 12:52 AM, resident 58 was observed lying in bed with the television on. At 1:11 AM, an observation was made of CNA 15 entering resident 58's room. CNA 15 was observed to get a brief and enter resident 58's side of the room behind the curtain. At 1:24 AM, CNA 15 was interviewed. CNA 15 stated that she checked resident 58's brief and he was wet so she changed him. CNA 15 stated that urine had not soaked through the brief. CNA 15 stated that resident 58 was able to turn and reposition so she was able to change him by herself. On 3/17/22 at 10:53 AM, an interview was conducted with CNA 14. CNA 14 stated that resident 58 was incontinent of bowel and bladder. CNA 14 stated that resident 58 needed to be checked every 2 hours at least for possible incontinence. CNA 14 stated that resident 58 was able to use his call light and call when he needed to be changed. CNA 14 stated that resident 58 used a urinal sometimes. CNA 14 stated that resident 58 was not on a bladder retraining program. The facility provided a Quality of Care Incontinence policy and guidelines for implementation. The purpose was To provide care and services to support residents in the management of urinary incontinence. Guidelines included the following: 1. Upon admission, the resident will be assessed to determine continence status, taking into consideration the resident's history, functional status and cognitive ability to understand. 2. As part of the initial and ongoing assessment, the nursing staff and physician will screen for information related to urinary continence. 3. Assessment shall consider: a. History of bladder functioning, including status continence; b. History of urinary incontinence, including onset, duration and characteristic; c. Presence of symptoms associated with incontinence, such as dysuria, polyuria, hesitancy; d. Functional and cognitive capabilities; e. Impact of medication regimen. 4. The staff and physician will identify individuals with complications of existing incontinence, or who are at risk for such complications . 5. The facility will consider various modifiable factors when determining ways to assist the resident to achieve his/her highest practicable level of functioning related to bladder continence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not establish an infection prevention and control program that included an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 1 of 51 sample residents. Specifically, a resident was receiving an antibiotic prophylactically, with no indication for use or periodic review of the necessity of the antibiotic. Resident identifier: 4. Findings include: Resident 4 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included diabetes mellitus, protein calorie malnutrition, and schizoaffective disorder. Resident 4's medical record was reviewed on 3/15/22. Resident 4's physician orders and Medication Administration Record (MAR) for March 2022 were reviewed. The orders and MAR indicated that resident 4 had been receiving Doxycycline Hyclate 100 milligrams twice daily since 7/25/17. The diagnosis listed for the antibiotic medication was prophylaxis. On 2/24/22, the resident's physician assessed resident 4. The physician progress note for this date indicated that the resident was on prophylactic doxycycline, but did not indicate the justification for the long term use of the antibiotic. Resident 4's pharmacy consultant reports were reviewed. For the months of December 2021 through February 2022, the pharmacist did not identify the long term use of an antibiotic for the physician to address. On 3/21/22 at 6:00 PM, an interview was conducted with Regional Nurse Consultant (RNC) 1 and Unit Manager (UM) 3. UM 3 stated that she thought resident 4 was receiving a prophylactic antibiotic medication because of chronic wounds, but was not sure. UM 3 stated that the only way to know if the resident was receiving the correct antibiotic was to do a wound culture if there was a current infection. RNC 1 and UM 3 stated that they did not know the procedure for reviewing antibiotics to ensure they were not overused. The facility's Antibiotic Stewardship policy and procedure was reviewed, and indicated the following: POLICY: . The Antibiotic Stewardship program will monitor antibiotic use and related resident outcomes to optimize the treatment of infections while reducing the adverse events associated with antibiotic use and to reduce antibiotic resistance. The program will validate that antibiotics are prescribed for the correct indication, the correct dose, the correct route, and the correct duration. GUIDELINES: .2. The facility will develop protocols to describe how the program will be implemented and how antibiotic use will be monitored. 3. Use of antibiotics will be based on recommendations from appropriate national, professional organizations. 4. The Antibiotic Stewardship program will be reviewed annually and revised as necessary. 7. Physician orders for antibiotics will include the name of the antibiotic, the dose, the route, the frequency, the indication for use and the duration. 10. During monthly medication regimen review, a consultant pharmacist will review antibiotic regimens for any irregularities. The policy and procedure did not address the process, if any, for using antibiotic medications prophylactically.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 51 sample resident, that the facility did not follow the Centers for Disease Control and Prevention (CDC) and Advisory Committee on Immunization Practices (ACIP) guidelines to offer pneumococcal immunizations. Specifically, a resident had no record of receiving the pneumococcal vaccine per CDC and ACIP guidelines. Resident Identifier: 196 Findings include: Resident 196 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, paranoid schizophrenia, hyperlipidemia, and encounter for immunization. On 3/21/22, Resident 196's medical record was reviewed. Resident 196's immunization history revealed that he consented to receive the pneumococcal vaccine on 2/11/2020. There was no documentation found in the medical record that the pneumococcal vaccine was administered. On 3/21/22 an interview was conducted with Unit Manager (UM) 3. UM 3 stated We normally always have a copy of the administration of a vaccine uploaded, along with the consent like he has here, but it looks like we don't have a copy of the actual vaccine being administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined, for 1 of 51 sample residents, that the facility did not have each bed with ceiling suspended curtains, which extended around the bed to provide total visual privacy in combination with adjacent walls and curtains. Specifically, the curtains in a resident's room did not have the ability to close all the way, leaving the resident to not have full visual privacy. Resident identifier: 62 Findings include 1. Resident 62 was initially admitted to the facility on [DATE] and again on 8/6/21 with diagnoses that included atherosclerotic heart disease, epilepsy, asthma, major depressive disorder, muscle weakness, generalized anxiety disorder, and muscle weakness. On 3/21/22 at 10:20 AM, an observation was made in resident 62's room. It was observed that resident 62 shared a room with another resident. It was observed that the privacy curtain was unable to close completely, leaving approximately a 1-foot gap of open space near the entrance of the room. It was observed that the roommate, along with anyone walking into the room, could visually see into resident 62's personal space due to the privacy curtain not having the ability to completely close. On 3/21/22 at 10:22 AM, an interview with resident 62 was conducted. Resident 62 stated that his privacy curtains did not completely close. Resident 62 stated that he was able to see his roommate's side of the room due to his curtains not completely closing. Resident 62 stated that he wished his curtains were able to completely close. On 3/21/22 at 10:45 AM, a record review of the facility's maintenance log was conducted. It was revealed that the privacy curtains in resident 62's room were not on the list of items to be fixed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 5 of 51 sample residents, that residents were not able to make choices about aspects of their life in the facility that were significant to residents. Specifically, the facility did not allow residents to smoke independently after being evaluated. In addition, a resident requested coffee and was not provided it. Resident identifiers: 47, 51, 52, 59 and 196. Findings include: 1. Resident 47 was admitted to the facility on [DATE] with diagnoses which included schizophrenia, post-traumatic stress disorder, polyneuropathy, unspecified asthma, and generalized anxiety disorder. On 3/14/22 at 11:15 AM, an interview was conducted with resident 47. Resident 47 stated that she wished that the facility .would let me smoke when I like. Resident 47 further explained They took away our cigarettes and lighters which I can understand, but they can't be taking away our smoking times. We have rights you know. Resident 47's medical record was reviewed on 3/15/22. A quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 12 which revealed resident had moderate cognitive impairment. Resident 47's smoking assessments dated 3/9/22, 1/16/22, and 10/16/22 assessed resident 47 with the ability to light her own cigarette, not needing adaptive equipment, no dexterity problems, no cognitive loss, no visual deficits, able to retrieve a cigarette if it was dropped and able to demonstrate the ability to hold a cigarette. 2. Resident 52 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, bipolar disorder, insomnia, and chronic obstructive pulmonary disease. On 3/14/22 at 11:25 AM, an interview was conducted with resident 52. Resident 52 stated that the facility .is always changing the rules on us. I used to smoke outside by myself, most of my life really, and now I have to wait for the whole team to go with me. It ain't right. Resident 52's medical record was reviewed on 3/22/22. A quarterly MDS dated [DATE] revealed a BIMS of 15 which revealed resident 52 was cognitively intact. Resident 52's smoking assessments from 3/9/22 and 4/14/21 recorded that resident 52 had the ability to light his own cigarette, not needing adaptive equipment, no dexterity problems, no cognitive loss, no visual deficits, able to retrieve a cigarette if it was dropped and able to demonstrate the ability to hold a cigarette. 3. Resident 59 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, schizoaffective disorder, chronic venous hypertension, panic disorder, and unilateral primary osteoarthritis, left knee. On 3/14/22 at 11:25 AM, an interview was conducted with Resident 59. Resident 59 stated that This facility is doing their best, but they need more help. For instance, we can't go smoke like we used to anymore. They took away my pack of cigarettes and now we have to wait to go out. Resident 59's medical record was reviewed on 3/22/22. Resident 59's smoking assessments from 2/22/22 and 11/2/21 indicate that resident 59 had the ability to light his own cigarette, not needing adaptive equipment, no dexterity problems, no cognitive loss, no visual deficits, able to retrieve a cigarette if it was dropped and able to demonstrate the ability to hold a cigarette. A quarterly MDS dated [DATE] revealed a BIMS of 15 which revealed resident 59 was cognitively intact. 4. Resident 51 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included falls, major depressive disorder, severe protein-calorie malnutrition, and Methicillin-resistant Staphylococcus aureus. On 3/14/22 at 12:30 PM, an interview was conducted with resident 51. Resident 51 stated that the smoking rules were stupid. Resident 51 stated that he liked to go out to smoke with his roommate but they were scheduled at different times. Resident 51 stated that he helped his roommate with smoking. Resident 51's medical record was reviewed on 3/17/22. A quarterly MDS dated [DATE] revealed resident 51 had a BIMS score of 15 which indicated resident 51 was cognitively intact. A care plan dated 10/14/21 and revised 3/15/22 revealed, [Resident 51] is a smoker. The goal was [Resident 51] will not smoke without supervision through the review date. Interventions included Cigarettes (or other smoking materials) and lighter are required to be stored at the nurse's station, Instruct resident about the facility policy on smoking: locations, times, safety concerns and The facilities smoking policy was reviewed and accepted by the resident and /or resident family. A smoking screen dated 3/9/22 revealed that resident 51 smoked 2 to 5 times per day, resident did not have cognitive loss, resident was able to demonstrate a safe technique for extinguishing matches/lighters and dispose of ash safety, resident was able to retrieve a cigarette if dropped, and resident was able to light own cigarette. The screen revealed that resident was non-compliant in the past with the smoking policy and had a history of smoking in non-designated smoking areas. On 3/17/22 the Administrator (ADM) provided copies of a letter, dated 2/25/22, that had been sent to all of the facility's residents who smoked. The letter was addressed to the resident, their friends, family, and visitors. In the letter it stated, In the coming days, facility staff will be approaching residents who smoke, and asking the residents to turn over all smoking materials to staff. We would also ask that if you bring cigarettes/lighter to our residents, please do not give them to the residents. Please give all cigarettes/smoking materials directly to the staff. Facility staff will distribute the cigarettes and will safely supervise all the residents at the same smoking times. The letter was signed by the ADM and the resident. There were letters addressed to resident 47, 52, 59 and 51. On 3/14/22 at 1:29 PM, an interview was conducted with Registered Nurse (RN) 6. RN 6 stated that residents were allowed to smoke at the facility, but a smoking schedule was followed. RN 6 obtained a physical copy of the smoking schedule and stated that We just recently changed to this schedule. The residents don't like it, but it means everyone can smoke at least. The smoking schedule provided designated smoking times at 10:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM. On 3/15/22 at 11:18 AM, an interview was conducted with the facility's Social Service Worker (SSW) 1. SSW 1 stated residents were only allowed to smoke when supervised. SSW 1 stated the supervised smoking was a new change and some resident did not like it but it was better with the new policy. On 3/15/22 at 1:16 PM, an interview was conducted with Certified Nursing Assistant (CNA) 7. CNA 7 stated that staff had to be present for smoking. CNA 7 stated there was a schedule and nobody goes out without supervision. On 3/17/22 at 11:00 AM, an interview was conducted with CNA 14. CNA 14 stated that there were new smoking times because of how many smokers the facility had. CNA 14 stated the smoking times were 10:00 AM, 1:00 PM, 5:00 PM and 7 PM. CNA 14 stated that there were a lot of residents so it was divided into 2 smoking session for each smoking time. CNA 14 stated residents did not like the new policy but some residents did. CNA 14 stated staff were trying to work it so everyone was okay with it. CNA 14 stated residents were able to smoke independently before the policy change. CNA 14 stated some of the residents were selling their cigarettes to other residents that needed supervision. On 3/16/22 at 8:24 AM, an interview was conducted with the ADM. The ADM stated that staff were taking the residents out in smaller groups to prevent resident to resident altercations. The ADM stated that the new smoking times were 10:00 AM, 1:00 PM, 5:00 PM and 9:00 PM. The ADM stated education was provided to everyone on 2/25/22. The ADM stated he had asked all residents to turn over their smoking materials to the nurses. The ADM stated if there was a lighter or cigarettes, residents needed to give them to the staff. The ADM stated that residents tried to smoke in their rooms previously, so the staff just decided to do supervision with everyone. The ADM stated there were open smoking times and it became an issue with smoking. The ADM stated facility staff did regular safety sweeps because other residents had brought in weapons and smoking equipment. The ADM stated a lot of residents were admitted from home and had drugs and other things that were not allowed. The ADM stated We bootlegged the policy because it didn't work for me. The ADM stated the smoking policy was modified for the residents. On 3/15/22 a copy of the facility's smoking policy was reviewed. The policy stated Residents who smoke will be supervised by staff members while smoking. Smoking will occur at designated smoking times. 5. Resident 196 was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia, unspecified psychosis, insomnia, lack of expected normal physiological development in childhood, type 2 diabetes mellitus, hypertension, and hyperlipidemia. On 3/14/22 at 7:50 AM, an observation was made of resident 196 at the front nurse's station. Resident 196 asked CNA 18 for 2 cups of coffee. CNA 18 was observed to tell resident 196 no and that she was only giving out 1 cup today. Resident 196 again asked for coffee. On 3/14/22 at 11:55 AM, resident 196 was observed seated in the main dining room drinking a cup of coffee. Review of resident 196's Annual MDS Assessment on 2/14/22 documented under functional status that the resident was a one person physical assist with supervision for eating and drinking. Review of resident 196's diet orders revealed Consistent Carbohydrate (CCD) diet, regular texture, and thin consistency. The order was initiated on 2/11/2020. On 3/21/22 at 8:10 AM, an interview was conducted with CNA 11. CNA 11 stated that residents who requested multiple cups of coffee or beverages would be provided the requested beverage. CNA 11 stated that it was the resident's right to have as many cups of coffee as they wanted. On 3/21/22 at 9:08 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 196 was able to drink coffee independently. The DON stated that resident 196 would drink it all day long and then would not eat. The DON stated that the staff tried to pace resident 196 with his fluid intake so he would eat. The DON stated that staff should not have told him no to his request for two cups of coffee, but should have reminded him as to why he could only have one at a time. The DON stated that the staff should provide the multiple beverages if the resident still requested them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review it was determined, for 4 of 51 sample residents, that the facility did not immediately consult with the resident's physician when residents experienced a significant change in physical, mental, or psychosocial status. Specifically, the physician was not notified for 8 days of a resident's worsening wound condition and the physician was not notified when a resident experienced low blood glucose levels. In addition, the physician was not notified a resident was screaming out in pain during the night and the physician was not notified a open wounds on a resident's foot. Resident identifier: 4, 76, 194 and 198. Findings included: 1. Resident 76 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included multiple sclerosis, morbid obesity, paraplegia, unspecified, cognitive communication deficit, limitation of activities due to disability, schizoaffective disorder, bipolar type, major depressive disorder, muscle weakness, pain in unspecified limb, and borderline personality disorder. On 3/15/22 at 10:11 AM, an interview was conducted with resident 76. Resident 76 stated she had to go the hospital and have surgery for a wound. Resident 76 was unable to recall why she had to have surgery but stated she currently had a wound vacuum-assisted closure (VAC). Resident 76's medical record was reviewed on 3/14/22. A review of resident 76's records showed that resident 76 had a stage IV facility acquired (FA) pressure ulcer (PU) on her right buttock. A record review of resident 76's progress notes indicated the following: resident 76's right thigh wound was initially discovered on 11/4/21. The nurse practitioner (NP) and wound nurse (WN) were notified, and the wound was identified as excoriation. An initial order for wound care was written. On 11/11/21 it was documented that the right inner thigh wound continued to be open, but no documentation was found indicating when the wound changed from excoriation to an open wound. On 11/12/21 at 1:33 AM, the WN was notified of resident 76's worsening wound. No documentation was found indicating the NP or WN were notified of the worsening wound prior to this date. On 11/12/21 at 3:23 PM, the WN assessed resident 76's wound and identified it as a deep tissue injury (DTI)-like wound. The WN obtained new wound care orders at that time. See nursing notes below. [Note: A review of resident 76's records indicated the WN was notified of the initial right thigh wound on 11/4/21 but was not notified of worsening condition of right thigh wound until 11/12/21. The worsening right thigh wound was not assessed for 8 days.] [Note: A record review of resident 76's treatment administration record (TAR) indicated nursing staff followed initial wound care orders for excoriation from 11/4/21 until 11/12/21 when new orders were written. The treatment ordered for excoriation was provided to the worsening (open) right thigh wound for 8 days.] Nurses notes for resident 76 were reviewed and revealed the following: a. 11/4/21: Excoriation to right upper thigh. NP and Wound nurse notified. New order to apply Venelex and Calmoseptine ointment to area BID [twice daily] and prn [as needed] until healed. Resident denies pain to area. Will continue to monitor. b. 11/11/21: Open skin area to her R [right] inner thigh continues to be open. Treatment applied as directed. Wound is not improving. Resident continues spending long hours sitting on her powered WC [wheelchair]. Refuses to lay down in bed when asked Currently resting in bed. No distress noted during RN [registered nurse] rounds. Fluids and call light within reach. Will continue to monitor. c. 11/12/21: Resident has a open skin area to her right inner thigh. Ointment applied as directed after brief being changed and hygiene/peri care provided. Open skin area has been worsening. Wound nurse notified. Resident continue to be non compliant with her cares and spending more time in her bed to take pressure from buttocks areas Currently resting in bed. Fluids and call light within reach. Will continue to monitor. d. 11/12/21: Wound to R [right] posterior upper thigh, appears to be a DTI [deep tissue injury] like wound. No signs or symptoms of infection. No odor. New order to cleanse with wound cleanser or NS [normal saline]. Dry with gauze. Apply medi honey to wound bed. Cover with superabsorbent dressing, fix in place with mefix tape to ensure it stays in place d/t [due to] where the wound is located. Encourage and assist [resident 76] to offload from this area to help with wound healing. Wound NP [nurse practitioner] aware of wound and new order for treatment. Author: [wound nurse]. On 3/17/22 at 11:09 AM, interview was conducted with the WN. The WN stated that initially resident 76's buttock wound started as a minor excoriation and the wound care being done was for excoriation. The WN stated he was not notified of the worsening condition of the right buttock wound until 11/12/21 at 1:23 AM. The WN stated he assessed the wound on 11/12/21 where he noted the wound had opened up, appearing to be a DTI-like wound. The WN stated he obtained new orders for wound care for the now open, deteriorating wound. The WN stated the NP was following and adjusting treatments. The WN stated there were not enough staff to manage all the wound care needs within the facility. 3. Resident 194 was admitted to the facility on [DATE] with diagnoses of spinal stenosis, lumbar region, muscle spasms, chronic pain, age-related osteoporosis, radiculopathy lumbar region, encephalopathy, and ground level fall. On 3/16/22 resident 194's medical records were reviewed. On 3/11/22 at 12:41 PM, resident 194's Brief Interview for Mental Status (BIMS) assessment documented a score of 15/15 which indicated resident 194 was cognitively intact. Review of resident 194's physician orders revealed the following: a. Lidocaine Patch 4 %, Apply to Right Biceps topically every 12 hours as needed for pain. The order was initiated on 3/15/2022. b. Acetaminophen Tablet, Give 1000 milligrams (mg) by mouth three times a day for pain. The order was initiated on 3/11/2022. c. Duloxetine Hydrochloride (HCl) Capsule Delayed Release Particles, Give 60 mg by mouth one time a day related to chronic pain. The order was initiated on 3/11/22. d. Gabapentin Capsule, Give 300 mg by mouth three times a day for neuropathy. The order was initiated on 3/8/22. e. Hot pack to residents lower back as needed for Back pain. The order was initiated on 3/10/22. f. Tizanidine HCl Tablet, Give 2 mg by mouth every 8 hours as needed for muscle spasms, do not give more than 3 doses within 24 hours. The order was initiated on 3/9/22. g. Question resident about presence of pain or burning including pressure points every shift. Monitor for pain using 0-10 scale. 0 for no pain, 10 for worst pain possible. If resident was not able to answer, use PAINAD scale. The order was initiated on 3/8/22. h. Record non-pharmacological interventions to pain every shift: 1=repositioning/limb, elevation 2=reassurance/emotional support 3=distraction/diversionary activities 4=ROM/ambulation/stretching 5=rest period/quiet environment 6=deep breathing/relaxation exercises 7=massage/therapeutic touch 8=application of ice/heat pack 9=laughter/socialization 10=Aroma therapy 11=NO PAIN PRESENT. The order was initiated on 3/8/22. i. Meloxicam Tablet, Give 15 mg by mouth at bedtime for hip/back pain, take with food and plenty of water. The order was initiated on 3/8/22. Review of resident 194's March 2022 Medication Administration Record (MAR) revealed that resident 194 had an order for Tramadol HCL Tablet, give 100 mg by mouth every 8 hours as needed for pain for 7 Days. The order was initiated on 3/8/22 and expired on 3/15/22. On 3/16/22 at approximately 1:15 AM, the Administrator (ADM) and Registered Nurse (RN) 8 were speaking at the nurse's station about resident 194. RN 8 stated that resident 194 needs Something done because she had been up all night. The ADM was observed to walk away. RN 8 stated that resident 194 was attention seeking. RN 8 stated that they will go into resident 194's room and help her, and then as soon as they leave the resident will cry out again. RN 8 stated that they were going to talk to the Nurse Practitioner (NP) again tomorrow about resident 194 because she had been constantly calling staff into her room. RN 8 stated that resident 194 had been at the facility before so staff were familiar with her behaviors. On 3/16/22 at 2:14 AM, RN 8 entered resident 194's room. Resident 194 stated that she needed a certain medication. RN 8 stated they could not do anything until morning. Resident 194 stated that she just felt like she needed to run down the hallway. Resident 194 asked if the gabapentin was administered with the medication. RN 8 stated they gave the gabapentin. Resident 194 stated that the medication gets all messed up when she goes into a care facility. Resident 194 stated that her back was killing her, and RN 8 stated they could get her a hot pack. Resident 194 stated that would be wonderful, but the hot pack did not last very long like a heating pad. I know that you think I'm in a panic, but when I talk no one listens. RN 8 stated that she gave her all the medication she could and had done everything she could tonight for her. Resident 194 stated that this was not normal, and her body did not feel right. RN 8 stated that the doctor would come in tomorrow. Resident 194 stated that she was scared and if she moved her neck a certain way then it hurt the rest of her body. Resident 194 stated that she just needed some help. Resident 194 stated Can't stand and can't sit because of the pressure. RN 8 stated It's the middle of the night so I'm not calling her [provider] right now. RN 8 exited the room at 2:19 AM. On 3/16/22 at 2:21 AM, RN 8 spoke to resident 194. RN 8 stated that it was the middle of the night and she had given her everything she could. RN 8 stated that she could not do anything until morning and refused to contact the Medical Doctor (MD) because it was the middle of the night. On 3/16/22 at 3:00 AM, resident 194 placed the call light on and Certified Nurse Assistant (CNA) 16 answered. Resident 194 stated I don't know what's going on. Resident 194 stated she could not wait until tomorrow. Resident 194 stated that she did not have much faith in this place. Resident 194 stated she had a really dumb back and when she sat in the chair her back hurts. Resident 194 stated she could not do this, and she needed to see a doctor. CNA 16 stated that the doctor would be here during the day. Resident 194 stated What am I supposed to do? On 3/16/22 at 3:08 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated he had no issues with notifying a provider at any time there was a need. LPN 1 stated that he could call the MD or NP and if they were not available the facility had an on-call MD service 24 hours a day 7 days a week. LPN 1 stated that he would attempt to contact the MD first with a resident change in condition and then the NP as they were familiar with the residents, but the on-call physician also had access to the resident's electronic medical records. LPN 1 stated that he would not hesitate to call the provider if a resident was experiencing severe pain even if it should have been addressed on the day shift. On 3/16/22 at 3:23 AM, a follow-up interview was conducted with RN 8. RN 8 stated that a lot of it was attention seeking, and this happened a lot. RN 8 stated that resident 194 had Tizanidine for muscle spasms a couple hours ago. RN 8 stated I'm sure she's hurting. RN 8 stated that resident 194 was on gabapentin, Meloxicam, and all medications were for pain. RN 8 stated that resident 194's Tramadol was scheduled now and that resident 194 did have it but that it was not coming up now. RN 8 stated that she had contacted the physician. RN 8 stated that a week ago resident 194 did not have the Meloxicam order, and the Tramadol was a new medication. RN 8 stated that the Lidocaine patch was every 12 hours as needed, so she was going to check to see if it could be administered. RN 8 stated that resident 194 knew that the state surveyors were in the building, so she was crying even more. RN 8 stated that she did not administer the Tramadol to resident 194 because it was not on the MAR. RN 8 stated that she had no idea why it dropped off the MAR and stated, So that could be a factor of why she is hurting. RN 8 stated that she had not given resident 194 any Tramadol during her shift. RN 8 stated And her light is back on again, I just left! On 3/16/22 at 3:27 AM, RN 8 answered resident 194's call light. RN 8 stated that she knew what the physician was going to say, and that the physician would be there in the morning. Resident 194 stated she did not know what to do and was crying and she felt like a complete maniac. Resident 194 stated she has had chronic pain for 8 years and finally got it under control and other people's interruption did not help her. What did I do wrong? Resident 194 was heard crying and speech was indiscernible. Resident 194 asked RN 8 for a shot of muscle relaxer. RN 8 stated she was unable to do that. Resident 194 stated Every single night this happens. RN 8 stated I'll take care of it tonight, I promise. Resident 194 was heard crying from the hallway. RN 8 asked resident 194 to sit in a chair for a while, and the resident stated she just tried that, and it did not work. RN 8 stated that she had to give the patch time to work because it was not magic. RN 8 stated it was not fun for anyone, and It's hard to see you this way. Resident 194 was heard sobbing. On 3/16/22 at 3:32 AM, an interview was conducted with LPN 2. LPN 2 stated that she was with an agency, and this was her first night in the facility. LPN 2 stated that she was being trained by facility LPN 1. LPN 2 stated the first thing she asked LPN 1 was who to call if there was a problem, and she knew to call the MD first, the NP second, and the on-call service next. LPN 2 was able to locate the contact numbers for all the facility providers. LPN 2 stated that she would not hesitate to call a provider if a resident was injured, in severe pain, or needed anything that was serious and could not wait until morning. On 3/16/22 at 3:36 AM, RN 8 was interviewed. RN 8 stated that she could call the MD but that she did not think they would do anything. RN 8 stated that if she called the MD, he would just tell her that the NP was coming in the morning. RN 8 stated that if she called the NP, she would just tell her that she was coming in the morning. RN 8 stated that according to the MAR, resident 194 had not received any Tramadol since 5:45 AM on 3/15/22. RN 8 stated that she would message the NP about restarting the medication. On 3/16/22 at 3:40 AM, RN 8 was interviewed. RN 8 stated, Where's the line with her regarding medication seeking and the resident being in pain. RN 8 stated that she could call the on-call providers if things get really bad, and they will answer. RN 8 stated she could call and ask for Ativan [for anxiety] and possibly get a order for Tramadol. RN 8 was asked how she knew resident 194 was med seeking and RN 8 replied that the nurses that had worked with resident 194 had seen it and will tell each other on the shift-to-shift report. RN 8 stated that if you give in to what resident 194 wanted she just wants more. RN 8 stated that she just tried to stay positive with the resident. RN 8 was asked if the MD or NP had given any direction to the licensed nurses regarding resident 194's medication seeking behaviors and RN 8 replied no. On 3/16/22 at 3:48 AM, RN 8 informed CNA 16 that If she really threatens to go to the hospital, I'll call the on-call and see what they say. On 3/16/22 at 4:04 AM, resident 194 was heard from the hallway exclaiming, Please, I can't, Please, and I want to see a doctor. On 3/16/22 at 4:16 AM, resident 194 was observed ambulating out of her room with a walker. Resident 194 was sobbing and stated, I can't do this. RN 10 was observed to enter resident 194's room. Resident 194 stated that her hips and legs hurt and that she was having spasms with a whole lot of pain. Resident 194 stated that this happened last night and the night before. Resident 194 stated she could not live that way. Resident 194 stated she was not sure when her last pain pill was given. CNA 16 entered and stated that resident 194 had been like this all night, and they did not have anything to give the resident. On 3/16/22 at 4:20 AM, resident 194 was observed inside her room and was heard stating everyone says they are going to get someone, and I never see them again. Resident 194 then walked out of her room breathing heavily and stated, It hurts. I can't sleep or anything. On 3/16/22 at 4:22 AM, an interview was conducted with RN 10. RN 10 stated she informed RN 8 and RN 8 told her that resident 194's Tramadol had run out yesterday and they were going to get her more when the doctor comes in today. On 3/16/22 at 5:04 AM, observed RN 10 inform the ADM that resident 194's Tramadol had expired. An immediate interview was conducted with RN 10. RN 10 stated that the she told RN 8 that resident 194's Tramadol had expired yesterday, and she had to put in a new request in the doctor's book to extend the order. RN 10 stated that there was a MD on-call that the nurse could contact. RN 10 stated that she just let the ADM know and he was going to notify the NP to see if she could prescribe her something for pain. RN 10 stated that after 6 PM they were not supposed to call the NP. RN 10 stated that they could contact the on-call physician for any expired medication orders. RN 10 stated that if they had a resident with uncontrolled pain and was crying all night, she should be calling the on-call MD. On 3/16/22 at 5:12 AM, RN 8 was observed in resident 194's room asking, Are you feeling better? RN 8 was heard telling resident 194 that she had to call and wake people up to get an order for her Tramadol. On 3/16/22 at 5:22 AM, an interview was conducted with resident 194. Resident 194 was observed to be slapping her chest with the palm of her hand. Resident 194 stated that she was in pain all night. Resident 194 stated that they gave her medication during the day, and she suffered all night. Resident 194 stated that this was cruel. Resident 194 stated that she fought this battle every time she went to a new facility, and it hurts the patients, and she was one of them. Resident 194 stated that she was in a whole lot of pain, had been most of the night, could not sit down, and could not stand up. Resident 194 stated that the pain was located in her lower back. Resident 194 stated that she had spinal stenosis, ruptured discs, arthritis, and that her pelvic area was a disaster. Resident 194 stated that the pain radiated down her legs, and she had arthritis in her left knee and she had muscle spasms in her legs. Resident 194 stated that the Tramadol order was not scheduled but instead an as needed order. Resident 194 stated that sometimes the Tramadol was only one pill instead of two. Resident 194 stated that she was her only advocate and had to go to bat for herself. Resident 194 stated that she use to work for the local school of medicine as an administrative assistant and was familiar with doctors. Resident 194 stated I'm not a doctor, I'm a patient, but I've been a patient a long time. Resident 194 stated that she was running off at the mouth and was observed to cry. Resident 194 was pacing in the room during the interview, frequently sitting and standing to find a comfortable position. On 3/16/22 at 6:16 AM, an interview was conducted with RN 8. RN 8 stated that she gave resident 194 Tramadol 100 mg at approximately 5:05 AM. RN 8 stated that resident 194 was attention seeking. RN 8 stated that she did not know that the Tramadol had expired, she was the only nurse on the floor, and she had a new admit. RN 8 stated that resident 194 never specifically asked for a pain medication or a Tramadol. RN 8 stated that resident 194's pain score throughout the night was a 7/10 with a lot of muscle spasms. RN 8 stated that the medication did not alleviate the pain and the pain score remained a 7/10, and then she reassessed the resident at 5 AM and called the NP. RN 8 stated that she could have called the on-call physician, but did not think that it was necessary. RN 8 stated that it was her fault and that she was definitely busy. On 3/16/22 at 5:57 AM, resident 194 was heard sobbing and stated, I just want to die and I need a doctor, I need a doctor, I need a doctor. On 3/16/22 at 8:25 AM, an interview was conducted with the ADM. The ADM stated that he contacted the NP at 5:09 AM and she was responsive. The ADM stated that the nurse's attitude was poor. The ADM stated that he reported to the NP that there was an issue with the resident's pain medication and the NP gave a verbal order to the nurse. The ADM stated that RN 10 informed him of the issue with resident 194's pain. The ADM stated that it was not up to the nurse to determine if the resident was med seeking. The ADM stated that the nurse should be assessing the resident's pain and notifying the MD. On 3/17/22 at 10:43 AM, an interview was conducted with the DON. The DON stated that the on-call physicians would not order narcotics. The DON stated that the MD was good at taking her calls after hours and always returned her calls promptly. The DON stated that she was his agent and had the authority to call any prescriptions into the pharmacy for him. The DON stated that she had the ability to call in a Tramadol order for the expired prescription and that RN 8 was aware of this. The DON stated that all the nursing staff were aware to contact her at any hour for any concerns or change in condition for a resident. The DON stated that she was not sure what was going on with the nurse that night, she knows better. 4. Resident 198 was admitted to the facility on [DATE] with diagnoses of fracture of right humerus, ground level fall, alcohol dependence, type 2 diabetes mellitus, chronic obstructive pulmonary disease, cellulitis of left lower limb, hypertension, hyperlipidemia, hypothyroidism, sleep apnea, dorsalgia, major depressive disorder, anxiety disorder, gastro-esophageal reflux disease, and chronic pain. On 3/14/22 at 1:18 PM, an interview was conducted with resident 198. Resident 198 stated that he had open wounds on the bottom of both feet, and that he had neuropathy. Resident 198 stated that he did not have any wound care for his feet, no dressing changes, no creams or ointments. Resident 198 stated that the wounds were located on the heels and big toes, and would bleed a little bit. Resident 198 stated that he did not think that the facility staff knew about the wounds. On 3/15/22 resident 198's medical records were reviewed. On 3/12/22 at 1:50 PM, resident 198's BIMS assessment documented a score of 12 which would indicate that the resident had a moderate cognitive impairment. Resident 198's skin assessments were reviewed and revealed the following: a. On 3/9/22 at 1:50 PM, the admission Evaluation documented edema on right and left lower extremity. Skin issues were documented as present with skin breaks documented on the right toe, sacrum and sores on left and right heels. b. On 3/9/22 at 2:50 PM, the Braden scale for Predicting Pressure Sore Risk documented a score of 21, which would indicate that resident 198 was at risk for pressure sores. c. On 3/16/22 at 1:50 PM, the skin and wound assessment documented no wounds, the condition was normal, the elasticity was good, skin color was normal for ethnic group, temperature warm (normal), and moisture was normal. Review of resident 198's physician orders revealed no treatment or wound care orders. Review of resident 198's progress notes revealed the following: a. On 3/9/2022 at 5:19 PM, the note documented, .has wounds on both feet and bruising on his R [right] arm. b. On 3/10/2022 at 10:35 AM, the physician/provider note documented, Skin: inspection: no rashes, lesions, normal coloring and complexion, warm and dry. Skin is clean, dry and intact. c. On 3/14/2022 at 6:28 AM, the physician/provider note documented, Skin: inspection: no rashes, lesions, normal coloring and complexion. Review of resident 198's task for skin observation revealed daily documentation since admission that checked None of the above observed. The above were documented as scratched, red area, discoloration, skin tear, and open area. No resident refusals were documented. It should be noted that this task for skin observation was completed daily by the CNAs in their Point of Care (POC) charting. Review of resident 198's care plan revealed a focus area of had the potential for impairment to skin integrity. The care plan was initiated on 3/10/22. The goal identified was that the resident will maintain or develop clean and intact skin by the review date. Interventions identified were to encourage good nutrition and hydration in order to promote healthier skin. On 3/17/22 at 9:23 AM, an interview was conducted with RN 11. RN 11 stated that resident 198 had a head to toe skin check ordered, and she looked at them every day. RN 11 then stated that resident 198 had a head to toe skin assessment completed once a week. RN 11 stated that resident 198 had a skin assessment completed on admission and it could be viewed in evaluations. RN 11 stated we definitely look at them on our shift. RN 11 stated that resident 198 had bruising on his arms, and that she had identified it on the skin assessment she completed yesterday. RN 11 stated that he had sores identified on his feet when he was admitted , but he did not have any treatments ordered for them. RN 11 stated that the wound nurse probably looked at them. RN 11 stated that resident 198 did not want to take off his socks yesterday so she did not look at his feet. RN 11 stated that after admission the wound nurse would come and evaluate the residents, and sometimes it was the same day or the next day. RN 11 stated that the staff nurse should also do a skin assessment. On 3/17/22 at 11:08 AM, an interview was conducted with the wound nurse (WN). The WN stated that when a resident required wound care the staff alerted him to new skin issues verbally or by a secure message in the electronic medical records (EMR). The WN stated he was informed of resident 198's issues with his feet today. The WN stated that resident 198 had eschar to both great toes and cracking to the right heel. The WN stated that he assessed resident 198's feet today, updated the care plan, notified the provider and obtained wound care orders. On 3/17/22 at 4:38 PM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated that the staff nurse conducted weekly skin checks for elasticity, color, temperature, and wounds. UM 1 stated that the staff nurse should document in the evaluation and write a progress note of any identified skin issues, and notify the provider. UM 1 stated that the process of notifying the WN of residents with new or worsening wounds was that the floor nurse completed a weekly head to toe skin assessment, notified the MD and then notified the WN of any identified concerns. 2. Resident 4 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included diabetes mellitus, protein calorie malnutrition, and schizoaffective disorder. On 3/15/22 at 1:06 PM, an interview was conducted with resident 4. Resident 4 stated she had episodes of hypoglycemia at night, even though the physician had been adjusting her insulin dose. Resident 4 stated that she kept candy bars in the bottom drawer of her nightstand to eat when she had a hypoglycemic episode. Resident 4 stated that sometime last week she was having an episode of hypoglycemia and called a staff member to assist her. Resident 4 stated that she asked the staff member to bring her a candy bar while she was in the bathroom. Resident 4 stated that the staff member gave her the candy bar but then left the room to help other residents. Resident 4 stated that she was shaking so hard from the hypoglycemia that she dropped the candy bar on the bathroom floor. Resident 4 stated that she was able to pick it up, but dropped it a second time. The resident stated, Lord help me she was so sick she had to eat the candy bar off the floor. The resident stated that she was disgusted with the fact that she had to eat the candy bar off of the dirty bathroom floor. Resident 4's medical record was reviewed on 3/15/22. Resident 4's February 2022 Medication Administration Record (MAR) was reviewed. a. The MAR indicated that as of 11/24/21, 18 units of insulin glargine was to be administered daily between 6:00 PM and 10:00 PM, and to notify the physician if the blood glucose was less than 60 or over 400. On 2/1/22, resident 4's blood glucose level was 52. The MAR did not indicate any interventions for the low blood glucose level. The nurses progress notes for that date did not indicate the treatment for the low blood glucose level, nor that the physician had been notified. b. The MAR also indicated that as of 7/16/21, an order for 45 units of insulin glargine was to be administered daily at 8:00 AM, and to notify the physician if the blood glucose was less than 60 or over 400. On 2/2/22, resident 4's blood glucose was 52. The MAR indicated that resident 4's insulin was administered, despite the low blood glucose reading. The MAR did not indicate any interventions for the low blood glucose level. The nurses progress notes for that date did not indicate the treatment for the low blood glucose level, nor that the physician had been notified. c. The MAR indicated that resident 4's blood glucose level was to be checked daily between the hours of 6:00 PM and 10:00 PM. The order did not indicate parameters for when the physician should be contacted. The MAR indicated that on 2/24/22, the resident's blood glucose was 54. The nurses progress notes for that date did not indicate that the physician had been notified. The nurses notes indicated that a Boost supplement was provided, but did not indicate if a follow up blood glucose level check was performed. Resident 4's March 2022 MAR was reviewed. The MAR indicated the resident 4's blood glucose level was to be checked daily between the hours of 6:00 PM and 10:00 PM. The order did not indicate parameters for when the physician should be contacted. The MAR indicated that on 3/2/22 between the hours of 6:00 PM to 10:00 PM, the resident's blood glucose level was 52. The MAR did not indicate any interventions for the low blood glucose level. The nurses progress notes for that date did not indicate the treatment for the low blood [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 12 of 51 sample residents, that the facility did not provide a safe, clean, comfortable, and homelike environment, allowing the residents to use his or her personal belongings to the extent possible. Specifically, there were multiple complaints from residents and observations of rooms in the facility that were unclean, needed to be repainted, and had a urine odor. Additionally, certain areas in the facility had holes in the walls, and sinks that did not drain. Resident identifiers: 10, 15, 23, 41, 51, 58, 62, 68, 72, 82, 198 and 200. Findings included: 1. Resident rooms and areas that were not homelike: On 3/14/22 at 7:29 AM, an initial tour of the facility was conducted. The following observations were made: a. The dining room was observed to have open sugar packets on the floor. There were 2 dirty trays on the tables. There was a carton of open milk on a table. The tables were soiled with debris. b. The wall outside rooms [ROOM NUMBERS] were soiled. c. room [ROOM NUMBER] had white spackle on the walls. d. There was debris on the floor in room [ROOM NUMBER]. e. There was drywall damage between rooms [ROOM NUMBERS]. f. There was debris on the floor between rooms [ROOM NUMBERS]. g. There was debris on the floor in room [ROOM NUMBER]. On 3/14/22 at 7:10 AM, an observation was made of the floor by the nurses station at the front of the building. There was a bedside table with crumbs, and debris on the floor around the bedside table. On 3/16/22 at 12:30 PM, an observation was made of the floor by the nurses station at the front of the building. There was a bedside table with crumbs, and debris on the floor around it. On 3/17/22 at 10:05 AM, an observation was made of the floor by the nurses' station at the front of the building. It was observed that the floor by the nurses' station had an area which was covered with what appeared to be food crumbs and a wet, sticky substance. A follow up observation on 3/17/22 at 11:30 AM revealed that the area was still not cleaned. On 3/14/22 at 7:30 AM and 3/17/22 at 10:02 AM, observations were made of the hallway next to the dining room. It was observed that part of the wall was missing and the baseboard was missing. On 3/14/22 at 10:30 AM, an interview with resident 62 was conducted. Resident 62 stated that sometimes the building was too cold, and the walls needed to be repainted. Resident 62 stated that housekeeping needed to come in more often to sweep, mop, and clean the bathroom. Resident 62 stated that the rooms did not get cleaned daily. Resident 62 stated that often rooms were only cleaned twice a week. Resident 62 stated that his curtains were stained. An observation was made of resident 62's privacy curtains. The curtains appeared to have multiple brown stains on them. Resident 62 stated that he did not know where the stains came from. On 3/14/22 at 1:23 PM, an observation was made in resident 198's room. An observation was made of two beds in the room, one bed was occupied by resident 198 and the other bed was vacant. It was observed that the wall behind the vacant bed had a hole in it near the baseboard. The hole was approximately 1 foot long and 2 inches high. An interview with resident 198 was conducted. Resident 198 stated that the sink in his bathroom filled up too quickly and did not drain well. Resident 198 stated that if he had the sink on for too long, the sink would overflow. An observation of the sink was made. After turning on the sink, the water filled up the entire sink within 25 seconds. Once the sink was turned off, the water slowly drained. On 3/14/22 at 1:47 PM, an interview with resident 200 was conducted. Resident 200 stated that staff occasionally cleaned her room. Resident 200 stated that she would have liked it if staff cleaned more often. Resident 200 stated that some of the sinks in the facility drained too slow. It was observed that the walls had white patches of spackle in multiple areas. On 3/15/22 at 9:21 AM, an observation of resident 23's room was made. The floor was dirty and was covered with crumbs, an empty juice cup, small items of trash, and liquids on the floor. At 11:11 AM, an observation was made of resident 23's electric wheelchair. Resident 23's wheelchair was soiled with a white substance and there was debris on the floor in her room. On 3/15/22 at 9:57 AM, an interview with resident 15 was conducted. Resident 15 stated that her room was sometimes dirty. It was observed that there was debris on the floor in her room. On 3/15/22 at 11:05 AM, an observation was made in resident 41's room. There were gashes behind the headboard of her bed. The walls had white patches of spackle in multiple areas. It was observed that resident 41's wheelchair footrests were soiled, and the chair was dirty. An interview with resident 41 was conducted. Resident 41 stated that she would like her room to be cleaned more often. On 3/15/22 at 11:20 AM, an observation was made of resident 72's room. There was a white substance on the floor next to her night stand. There was a strong urine odor in her room. Resident 72 stated that he room smelled like urine all the time. Resident 86 resided in the same room as resident 72. Resident 86 stated her room smelled of urine. On 3/15/22 at 11:25 AM, an observation was made of resident 68's room. Resident 68's room was observed to have debris on the floor. On 3/17/22 at 11:25 AM, it was observed that in room [ROOM NUMBER], there was debris on the floor next to the door, and debris under the bedside table. On 3/15/22 at 11:27 AM, an observation was made of the wall between rooms [ROOM NUMBERS]. There was a substance on the wall and hand rail. On 3/15/22 at 11:34 AM, it was observed that in room [ROOM NUMBER] there were crumbs and debris on the floor by the resident's bed. On 3/15/22 at 11:38 AM, it was observed that in room [ROOM NUMBER] there was debris on the floor. 2. Odors: On 3/14/22 at 10:02 AM, it was observed that in room [ROOM NUMBER] there was an odor which was also observed in the hallway. On 3/14/22 at 10:21 AM, an interview with resident 10 was conducted. Resident 10 stated that he noticed urine odor every day. Resident 10 stated that the odor bothered him. It was observed that there were cookies crumbs on the floor in resident 10's room. On 3/14/22 at 11:22 AM, it was observed that outside of rooms [ROOM NUMBERS] there was a smell of feces in the hallway. On 3/14/22 at 11:56 AM, it was observed that room [ROOM NUMBER] had a urine odor and there was debris on the floor. On 3/14/22 at 12:20 PM, it was observed that in room [ROOM NUMBER] there was a urine odor. Resident 58's bed was observed to be soaked with urine. Resident 58 stated that his bed had been wet since yesterday. On 3/14/22 at 12:30 PM, an interview with resident 51 was conducted. Resident 51 stated that his room sometimes smelled like urine. There were gashes in the dry wall behind his bed in the wall. The walls had white patches of spackle in multiple areas. On 3/14/22 at 10:08 AM, an observation was made of resident 82. Resident 82 was observed to have a urine soaked bed and a strong urine odor was observed. Resident 82 stated that he was changed yesterday but had not been changed since yesterday before going to bed. Resident 82 stated that his room had a urine odor. On 3/15/22 at 11:32 AM, it was observed there was a urine odor in the 300 hallway. On 3/16/22 at 12:49 AM, it was observed there was a urine odor outside of room [ROOM NUMBER]. On 3/17/22 at 9:27 AM, it was observed there was a urine odor in the hallway between rooms 318 through 322. On 3/17/22 a review of the maintenance log was conducted. There was no documentation of the holes in the walls or the white substance on the walls in the maintenance log. On 3/17/22 at 10:10 AM, an interview with the housekeeping staff (HS) 1 was conducted. The HS 1 stated that there were two people who were cleaning today. The HS 1 stated that there were three staff members in housekeeping total. The HS 1 stated that there was too much to clean, and there were not enough housekeepers. On 3/17/22 at 10:20 AM, an interview with the District Manager for Health Care Services (DMHC) was conducted. The DMHC stated that he managed housekeeping. The DMHC stated that they were currently understaffed. On 3/21/22 at 8:30 AM, an interview with the Administrator (ADM) was conducted. The ADM stated that their maintenance director had recently quit. The ADM stated that he was acting as the maintenance director until the new maintenance director started. The ADM stated that the facility had struggled to keep up with maintenance and housekeeping.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 4 of 51 sampled residents, that the facility did not implement written policies and procedures that prohibit and prevent abuse and neglect. Specifically, the facility did not demonstrate implementation of their abuse policy through timely investigation and reporting of suspected abuse to the Administrator (ADM), State Survey Agency (SSA), and Adult Protective Services (APS). Resident identifiers: 15, 19, 194, and 196. Findings included: 1. Resident 19 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included schizoaffective disorder, bipolar disorder, anxiety disorder, major depressive disorder, dementia, history of traumatic brain injury (TBI), cognitive communication deficit, type 2 diabetes mellitus and insomnia. Review of the facility final investigation report for sexual abuse on 3/11/22 documented that on 3/5/22 at 2:00 PM resident 19 reported to Registered Nurse (RN) 5 that she had asked resident 196 to stop kissing her breasts and that he did not immediately stop. RN 5 reported the incident to the facility Administrator (ADM) and an investigation was initiated. Resident 19 reported that she asked resident 196 to stop kissing her breast as it caused her discomfort, and that he did not stop after the first time she asked him to. However resident 19 reported that he did stop after she told him a second time. Resident 19 also reported that resident 196 tried to get her to stick her hand down his pants. Resident 19 stated that initially she had been okay with the encounter and then changed her mind. Resident 19 stated that she did not wish to press charges against resident 196. The final report documented that both resident 19 and resident 196 were alert and oriented times 3 (person, place, and situation) and had the ability to make decisions. Neither resident had a guardian. The final report documented that the investigation did not support the finding of abuse. On 3/5/22 at 3:00 PM, resident 19's witness statement documented, resident states she had a consentual (sic) encounter with [resident 196]. Resident states that she and [resident 196] were kissing, and that [resident 196] was 'sucking on her titty' in the hallway. [Resident 19] stated that [resident 196] was kissing her breast and it hurt, she says she told him to stop, [resident 19] states that [resident 196] did not stop immediately but that she said stop again a second time and that he then stopped. Resident states that [resident 196] also took her hand and tried to put it down his pants and she said no. Resident stated that initially that she was ok with the encounter, but that she told [resident 196] to stop when she felt discomfort. The witness statement was initialed by the facility ADM and documented verbal with resident. On 3/5/22 at 3:00 PM, Certified Nurse Assistant (CNA) 13's witness statement documented, Approx. [approximately] 0600 on 3/5 observed [resident 19] and [resident 196] to be kissing, touching [resident 19] breasts on 500 hall [CNA 13] reports that she intervened and redirected the residents. [CNA 13] reports that she reported this to the nurse ASAP [as soon as possible] - [RN 7]. [CNA 13] observed [resident 19's] hand down [resident 196] pants or in that area. -[Resident 19] stated 'its ok I let him' -We reported immediately to nurse, the residents did not stop kissing when we told them too. [RN 7] was immediately onsite and intervened and separated them. The witness statement was initialed by the facility ADM and another undistinguishable initial. On 3/10/22 at 12:00 PM, RN 7's witness statement documented, 0600 [6:00 AM] shift change; observed Res's [residents] holding hands zero distress, walked by, [CNA 13] approached '[resident 196] is touching [resident 19]' -Found Res's sitting by each other on 500 hall -Redirected Res to separate rooms/areas. -Did not observe any contact other than previous hand holding. -[Resident 19] denied abuse The witness statement was initialed by the facility ADM. On 3/6/22 at 12:00 PM, CNA 12's witness statement documented, states Res [resident] was anxious, talking about how her life 'sucked'. Reported to [RN 5]. On 3/11/22 at 10:32 AM, RN 5's witness statement documented, On 3/5/22 at 6:00 AM I overheard two aides reporting that [resident 19] and [resident 196] were found in the hall having sexual contact. Aides reported when they asked them to separate [resident 19] told them she wanted [resident 196] to touch her. RN 7 gave instruction to separate [resident 19] and [resident 196] and to keep them separate (sic). At 1400 [2:00 PM] [CNA 12] reported to me that [resident 19] was anxious at which time I interviewed [resident 19] and asked her how she felt about the sexual contact. [Resident 19] reported she had asked [resident 196] to stop and told him he was hurting her. [Resident 19] also said she was worried about getting [resident 196] in trouble. The witness statement was signed by RN 5. On 3/16/22 resident 19's medical records were reviewed. On 12/22/21, resident 19's Quarterly Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated an intact cognitive response. The assessment documented a resident mood interview (PHQ-9) score of 00 which would indicate none to minimal depression severity. The assessment also documented no hallucinations or delusions with the behavior marked as not exhibited. On 3/8/22 at 11:33 AM, resident 19 was assessed for a BIMS and scored 15 which would indicate an intact cognitive response. It should be noted that the assessment was completed 3 days post incident. Review of resident 19's Pre-admission Screening Applicant/Resident Review (PASRR) Level I Assessment on 11/10/2020 documented that resident 19 had a Moderate Intellectual Disability. The comment section documented Difficulty interacting with others d/t [due to] developmental delay. On 11/20/21 at 9:46 AM, an email was sent by the PASRR evaluator to the facility that stated that they would be screening resident 19 out for the need of a Level II Intellectual Disability/Related Condition (IDRC) PASRR. The email stated that the referral was made based on the Moderate Intellectual Disability diagnosis listed on the Level I. The evaluator stated that there was no mention of this diagnosis anywhere else in the provided collateral documentation including the history and physical (H & P). The email further stated that resident 19 suffered a TBI after being thrown from a balcony at age [AGE] which resulted in troubles with behaviors and cognition. Review of resident 19's PASRR Level II Assessment on 3/24/21 documented a hospitalization from 3/4/21 through 3/17/21 for Altered Mental Status and was subsequently diagnosed with Encephalopathy. The assessment documented a cognitive decline due to the TBI and a diagnosis of Dementia due to the TBI. In reviewing [resident 19's] previous PASRR's, it appears that her cognition has worsened over the years and she is somewhat of a poor historian at this point It should also be noted that on her most recent BIMS, she scored a 13/15. However, when she admitted to the facility in December she scored a 3/15 [Resident 19] will likely require ongoing skilled nursing care throughout the remainder of her life, as her cognition is likely to continue to decline where it may become primary at some point. The assessment's evaluation of cognitive functioning documented that the resident was alert and oriented to person and place and partially oriented to situation and time. The evaluation further documented that resident 19's judgment was severely impaired with poor insight and recent and remote memory was fair. The assessment obtained resident 19's history of psychiatric symptoms from previous PASRR's completed and the following was a compilation of that history. The PASRR completed in June 2012 documented that resident 19 appeared her stated age but seemed to function at a much younger developmental stage. She repeatedly asked about what time her lunch was and if she could get a smoke break. She seemed to need significant reassurance; almost seeming child-like in her worry about if she was doing things 'right.' When asked routine questions for the evaluation, she was at times unable to answer and at times would answer and then ask, 'Is that ok?' with a very worried expression. Her short term memory seemed significantly impaired. The PASRR completed in May 2015 documented, She has history of some self-harming behaviors when she does not get her way following the Traumatic Brain Injury that seemed indicative of personality changes related to the injury. Self-injurious behaviors were banging her head on the floor when she did not get a cigarette. The current psychiatric functioning documented that resident 19 talked in a childlike manner and appeared to seek reassurance and acceptance. She is aware of her cognitive decline and this is reportedly 'hard'. The assessment recommended continued skilled nursing services with cognitive stimulation, socialization and participation in group activities where allowed. On 3/5/22 at 2:00 PM, the facility incident report documented that resident 19 stated that she was having an inappropriate relationship with a male resident and stated that she had told him no and that she didn't like what he was doing. She stated that it was consensual and that she allowed it to happen but then stated that she didn't like what was happening now. [Resident 19] and the male resident were separated and both pace (sic) on 15 min. checks to monitor for safety to each resident. The immediate action taken documented that resident 15 was placed on 15-minute checks or safety and behavior tracking for emotional distress and a full skin check was completed with no injuries noted. Resident 19 would smoke with the group but resident 196 would smoke with a CNA. Resident 196 was moved away from resident 19. Review of the 15-minute check sheet revealed that resident 19 was placed on 15 minute safety checks beginning on 3/5/22 at 6:00 AM and those checks continued until 3/6/22 at 2:00 PM. It should be noted that the 15-minutes check sheet was contained within 3 separate forms with duplicate forms dated 3/5/22. No documentation could be found for an evaluation of resident 19's capacity to consent to sexual activity. Review of resident 19's progress notes revealed the following: a. On 3/5/22 at 6:13 PM, the nursing note documented, Resident has been placed on 15 min checks to ensure safety due to incident. Resident had a complete skin check done. Resident is still behaving with anxious behaviors. Resident went to the ER (emergency room) last night in a manic state. ER sent her home. Medications review was done today and new orders for medication given to nurse. no other orders at this time. Resident will be placed on daily social service visits to make sure she is having her needs met. b. On 3/6/22 at 8:45 AM, the nursing note documented, Pt (patient) demonstrated anxious episodes during shift change. Pt was re-directed several times, and provided strategies for relaxation i.e. snacks, wipes, and therapeutic talk. Staff set clear expectations of when pt would expect medications, and additional items requested. At some point on hour about 1 hour of interaction, fire department had arrived to facility, and then local police. Fire department evaluated pt, as well as police. Fire department reported having visited facility with same pt for the fourth time within the day. Fire department/ police spoke with pt and then left. Facility admin notified of findings will monitor pt. c. On 3/6/22 at 9:02 PM, the nurse practitioner (NP) documented, 3/5/22 Patient called 911 last night/sister called fire department due to complaints of nausea and vomiting. No reports of nausea or vomiting to staff. She underwent abd [abdominal] CT [computerized tomography] which was normal and she was returned to facility. This morning she again called 911 and reported shortness of breath. She was ordered meds and refused yesterday and this morning. I arrived to facility after ambulance had left and she was seen sitting on her bed and appeared very angry. She agreed to take meds. Phone was removed and it was explained that she can't call 911 for non-emergencies and she need to talk to nurse. Calling 911 is a behavior for attention. Behaviors discussed with [name of psychiatrist], he did not think she was appropriate for admission. [Name of psychiatrist] agreed with plan to start clozaril. 3/6/22 It was reported that [resident 19] and another resident were found in a sexually inappropriate in her room. Both residents were interviewed as well as staff. It is unclear if consent was given due to conflicting stories and because both residents are poor historians. There will be continuing investigations. Residents have been separated for now. [Resident 19] appeared at baseline when seen and was asking for bananas. The physician's exam documented under Psychiatric: judgement and insight: bizarre, impulsive. mood and affect: anxious, nervous, sad, stressed. The physicians assessment and plan documented Hypersexuality (?) - she does like to show breasts to staff members - thinks she has rashes that need to be seen - continuing investigation with recent sexual behavior with another resident . Cognitive impairment - may be genetic (reports sister has a learning disability) vs. [verses] TBI vs. hx (history) of SUD (substance use disorders) -reports fall from 3rd story building - moca [Montreal Cognitive Assessment] 13/30 .panic attacks - encourage exercise -redirect -plan to start clozaril -seroquel 600 mg (milligram) BID (two times a day) -clonazepam 1 mg TID (three times a day) - anafranil 225 mg It should be noted that no documentation could be found of a Montreal Cognitive Assessment (MOCA) assessment for resident 19. However, a score of 13/30 as indicated in the NP note would indicate mild Alzheimer's disease. On 3/16/22 at 8:38 AM, an interview was conducted with the facility Administrator (ADM). The ADM stated that there was a reportable incident between resident 19 and resident 196. The ADM stated that resident 196 was observed kissing resident 19's breast, and they were separated. The ADM stated that resident 19 had indicated that she told resident 196 to stop and he did not. The ADM stated that resident 19 indicated initially that the interaction was consensual and then later it was reported that she did not feel right about it. The ADM stated that they notified the police and adult protective services immediately when he was informed of the incident. It should be noted that the incident was first identified on 3/5/22 at 6:00 AM. At that time the staff separated the residents and initiated 15-minute safety checks for resident 19. Staff did not notify the ADM of the incident until 2:00 PM. On 3/16/22 at 9:34 AM, a follow-up interview was conducted with the ADM. The ADM stated that resident 19 had a relationship with another resident previously that consisted of hand holding only, and that relationship was not sexual in nature. The ADM stated that originally the incident was a concern, but that resident 19 had denied abuse. The ADM stated that resident 19 was not displaying any signs or symptoms of trauma. The ADM stated that both residents were able to consent, and this was based off a BIMS score of 15. The ADM stated that both residents had a significant cognitive impairment, and were alert and oriented times 3 to person, place, and situation. The ADM stated that resident 19 went and grabbed resident 196 and they were making out, resident 196 did not seek resident 19 out. The ADM did not state how he came to this determination. The ADM stated that resident 19 had a history of sexual abuse in the past but did not elaborate on the sexual abuse. It should be noted that no documentation could be found in resident 19's medical record to substantiate this assertion of prior sexual abuse. The ADM stated that they had conducted an assessment for the capacity to consent to sexual activity on both residents and determined that even though they were cognitively impaired they did have the ability to consent. The ADM stated that both residents were their own representative and did not have a legal guardian. The ADM stated that they involved the NP, social worker, and interdisciplinary team try to respect the resident's rights but also protect the residents from abuse. On 3/21/22 at 9:21 AM, an interview was conducted with resident 19 in the hallway at the end of the 500 hall. Resident 19 requested the interview be conducted in the hallway as she was waiting to go outside for a smoke break. The resident stated on the day of the incident she had her breakfast, bought a soda, and was waiting for a smoke break. Resident 19 stated that resident 196 had started kissing her on the mouth and she told him no. Resident 19 stated that resident 196 then started kissing her on the breast and pinched her nipple. Resident 19 stated that it really hurt and she told him to stop. Resident 19 stated that the incident made her feel uncomfortable. Resident 19 stated that this happened by the smoking patio and also by the store on the 500 hall. Resident 19 stated she did not want to get into trouble or get resident 196 into trouble. Resident 19 stated that resident 196 kept on doing it (kissing) and she did not know what to do. Resident 19 stated that she felt like she could not push resident 196 away, the staff were around, and they did not help me, so I did not know what to do. Resident 19 stated that RN 7 was there. Resident 19 stated that she remembered that it happened before the 10 AM smoke break, but that she did not recall the day, month, or year. Resident 19 stated that RN 7 witnessed it happen and told them to go to their rooms. Resident 19 stated that she did not know what happened to resident 196. Resident 19 stated that after the incident she went back to her room. Resident 19 stated that it made her feel uncomfortable, sad, depressed, and used. Resident 19 stated that she did not talk to anyone after the incident because she was too scared to. Resident 19 stated that it had not happened since then, but that it occurred a couple of times with resident 196 in the past. Resident 19 stated she wanted to say something but did not know who to tell. Resident 19 stated she had low self-esteem. Resident 19 stated that she did not talk to anyone at the facility about the incident and how it made her feel. Resident 19 stated that she did not want to get resident 196 into trouble. Resident 19 stated that she would see resident 196 outside smoking and she kept her distance. Resident 19 stated that she did not know what room resident 196 was residing in now, but that she would see him periodically in the building. Resident 19 again stated that she did not want to get into trouble. Resident 19 stated that she did not feel safe at the facility, not really. Resident 19 stated that she felt scared and thought that other people were trying to steal her belongings, stuff. Resident 19 stated that she was schizophrenic and bipolar and that those were just thoughts that she had in her head. Resident 19 stated that she was taking antipsychotic medications and was compliant with taking all the medication. Resident 19 stated that the thoughts were still present and she was not sure if her medication was working. On 3/21/22 at 1:32 PM, a telephone interview was conducted with RN 7. RN 7 stated that his participation in the incident was very little. RN 7 reported that the incident happened at end of his night shift at approximately 6:00 AM on 3/5/22. RN 7 stated that he did not document the events of the incident. RN 7 stated that he was conducting a narcotic count with the oncoming day shift nurse when CNA 13 reported that the residents were kissing and touching. RN 7 stated that he could not recall the exact retelling of the events. RN 7 stated that the residents had just walked by the medication cart holding hands, and approximately 2-3 minutes later the CNA 13 reported the incident. RN 7 stated that he left the other nurse during the narcotic count and went to investigate. RN 7 stated that he located resident 19 and resident 196 on the 500 hallway at the west end by the exit to the smoking patio. RN 7 stated that the residents were seated on the floor next to each other. RN 7 stated that he asked if everything was okay, and they replied yes. They seemed fine. RN 7 stated that he asked the residents to return to their rooms. RN 7 stated that resident 19 requested to stay in the hallway to wait to smoke. RN 7 stated that he reminded resident 19 that it was not time for the scheduled smoke break and that would not be until 9:00 AM. RN 7 stated that at this point he went back and finished the narcotic count with the day shift nurse, RN 5. RN 7 stated that when he approached resident 19 and resident 196, he did not witness any sexual contact. RN 7 stated that he did not recall what was reported to him but that in that hallway things happened so fast with residents, and that was why he responded immediately. RN 7 stated that the ADM interviewed him by phone and took his statement. RN 7 stated that he did not sign the statement and did not review the statement for accuracy. RN 7 was read the statement and he stated that sounded about right. RN 7 stated that he did not report the incident to anyone because RN 5 also heard the aide report the incident. RN 7 stated that when he did not witness anything inappropriate, he did not report the incident. RN 7 stated that the facility abuse coordinator was the ADM. RN 7 stated that any allegations or incidents of abuse were to be reported to the ADM. RN 7 stated that any incidents that they suspected were abuse should be reported as well. RN 7 stated that the process was to document the incident and then inform the Director of Nursing (DON) and ADM. RN 7 confirmed that if the aide reported inappropriate contact between two residents, even though he did not witness the contact, that incident should be reported as a possible allegation of abuse. RN 7 stated that because it was during shift change, and it was reported to both the nurses at the same time, he assumed that the day shift nurse would report the incident to the facility ADM. RN 7 stated that if he was working that shift, he would have separated the residents and made sure they were safe, then notified the ADM, DON, NP, and completed a incident report. RN 7 stated that he would also initiate a 15-minute check for safety. It should be noted that 15 minutes safety checks were initiated on resident 19 at 6:00 AM on 3/5/22. On 3/21/22 at 2:43 PM, an interview was conducted with the Social Service Worker (SSW) 1 and the Master's of Social Work (MSW). The MSW stated that the intellectual function testing used were the MOCA and BIMS. The MSW stated that they did not have anyone in the facility that was certified to conduct a MOCA. The MSW stated that language barriers should be a consideration when conducting the assessment. The MSW stated that the only type of assessment that they provided for cognitive function was a BIMS. The MSW stated that she was not sure if resident 19 and resident 196 were evaluated before the incident for the capacity to consent to sexual activity. The MSW stated that she thought they were both consenting adults. The MSW stated that they had two people with a cognitive/intellectual decline or function, and it could change on a day-to-day basis. The MSW stated that resident 19 had a resident that she previously held hands with, but that it was not a sexual relationship. The MSW stated that they asked resident 19 if she felt safe. The MSW stated that they were not focusing on resident 19's past interactions with other residents when evaluating this incident. The MSW stated that they interacted with resident 19 multiple times on a daily basis. We see her all the time. The MSW stated that the minute she came into the building, resident 19 came right into her office and talked to her about the incident. It should be noted that the MSW documented that she spoke to resident 19 about the incident 2 days after the incident occurred on 3/7/22 per the witness statement. The MSW stated that when interacting with residents with mental health issues, they have to live in their world. The MSW stated the residents have this belief and we are not going to change that, to them it was real. On 3/21/22 at 3:55 PM, an interview was conducted with the Regional Nurse Consultant (RNC) 1. RNC 1 stated that the capacity to consent was addressed in the resident care plan when they addressed if the resident was capable to participate in their own care plan. RNC 1 stated that the Medical Doctor (MD) reviewed the initial assessment by the nurse and either agreed or disagreed with the assessment. RNC 1 stated that the specifics to the resident's capacity to consent to sexual activity were not addressed in the care plan and did not outline what the assessment details included. RNC 1 stated that resident 19 had an assessment for the capacity to consent to sexual activity prior to the incident with resident 196, but it was not address in the care plan. RNC 1 stated that they go off the BIMS scores. RNC 1 agreed that the BIMS score was as a brief snapshot in time for recall and memory and depending on the day that score could change. RNC 1 was asked if the BIMS addressed a resident's capacity to consent to sexual activity. RNC 1 stated that it was a factor in the assessment for the ability to consent. RNC 1 stated that they felt like it was an indicator of the resident function. RNC 1 stated that the capacity to consent assessment had more to it than just the BIMS score. RNC 1 stated that it also included IDT discussion, resident history, diagnoses, intellectual function, Level II PASRR, and physician input. Review of the facility Policy and Procedure on Freedom From Abuse, Neglect and Exploitation documented that the facility will provide a safe environment and protect residents from abuse. The facility will keep residents free from abuse, neglect, misappropriation of resident property, and exploitation. This includes freedom from verbal, mental, sexual or physical abuse The Policy stated under Prevention that staff would intervene and correct a situation in which abuse was more likely to occur; staff would be informed of individual residents' care needs and behavioral symptoms; staff would identify, assess, and monitor residents with needs and behaviors which might lead to conflict or neglect, such as sexually aggressive behavior; and the facility would provide a safe environment that supported a resident's desire to engage in a consensual sexual relationship. The Policy did not state how the facility would determine that the resident had the capacity to consent to a consensual sexual relationship. The Policy stated under Identification that Administration and staff would monitor for signs that abuse may be occurring, including but not limited to a.) a suspicious injury or b.) a sudden or unexplained change in the resident behavior, such as fear of a person or place or feeling of guilt or shame. The Policy stated under Protection that upon suspicion of a potential abuse or neglect, administrative personnel would immediately take measures to protect the alleged victim and integrity of the investigation. The guidance was last updated in November 2017. 2. Resident 196 was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia, unspecified psychosis, insomnia, lack of expected normal physiological development in childhood, type 2 diabetes mellitus, hypertension, and hyperlipidemia. On 3/14/22 at 11:55 AM, an interview was conducted with resident 196 in the main dining room. Resident 196 replied yes and shook his head in the affirmative when asked if he recently moved rooms. Resident 196 stated that he use to reside in room [ROOM NUMBER]. Resident 196 was asked why his room was changed. The resident responded with garbled speech. No discernable explanation was understood. On 3/14/22 resident 196 medical records were reviewed. On 3/5/22 at 6:20 PM, resident 196's progress note documented, Resident has been moved to a new hallway to ensure safety due to incident. Resident has been placed on 15 min check for safety and had been placed on Behavior tracking. Resident will be placed on daily social service visits to ensure that the resident is having his needs be met. MD was notified and no new orders at this time. On 3/14/22 at 12:00 PM, an interview was conducted with RN 9. RN 9 stated that resident 196 was moved to a different room due to behaviors and a resident-to-resident altercation. RN 9 stated that the incident occurred during a smoking break with resident 19. RN 9 stated that the incident was a verbal altercation, the residents were separated, and an investigation was started. On 2/14/22, resident 196's Annual MDS Assessment documented a BIMS score of 9 which would indicate moderately cognitively impaired. On 3/8/22 at 11:59 AM, resident 196 was assessed for a BIMS and scored 15 which would indicate an intact cognitive response. It should be noted that the assessment was completed 3 days post incident. Review of resident 196's PASRR Level II on 12/31/19 documented a history of paranoid schizophrenia with many inpatient hospitalizations. The history documented that resident 196 had become threatening with family and others and had assaulted at least two people in the past. One assault was of another patient with a shovel. Resident 196 also had experienced suicidal ideation and had tried to stab himself in the head. History also documented that resident 196 had experienced paranoid delusions and auditory hallucinations, including command hallucinations to hurt others. Resident 196 could become quite disorganized when psychotic. The medical record also indicated a history of Borderline Intellectual Functioning but did not indicate that formal intellectual testing had been conducted. Current presentation was consistent with a lower intellectual level. His thinking is simplistic, concrete, and immature. He is well aware that some things that he has said and done are not socially acceptable (i.e. gang involvement, threatening family), and he will deny he has done those things, apparently in an attempt to appear in a more favorable light. Later in the interview, however, he would slip up and admit to 'misbehaviors'. He also seems to have a very limited understanding of his health issues as a result of his intellectual deficit. The recommendations for services documented that Long term placement would depend on resident 196's ability to accept his diabetes and manage the treatment. The recommendations further stipulated that consideration should be given to a formal evaluation intellectually for Borderline Intellectual Functioning. Review of resident 196's PASRR Level II on 2/13/2020 documented under current psychiatric functioning that at the time of the interview resident 196 was restless and fidgety, and attributed this to wanting to smoke. He denied any hallucinations, delusions, or paranoia since his psychiatric hospitalization and staff report the same. His behavior is not currently disorganized or catatonic and his speech was fairly simplistic and lacking in clarity, at times (this may be due to a language barrier). Staff report [resident 196] has poor hygiene, and he will go several days without changing his underwear or clothing, unless prompted by staff He denied symptoms of depression and anxiety (with the exception of sleep impairment). A diagnosis of Schizophrenia is upheld. The Diagnostic Formulation documented that Schizophrenia had impaired resident 196's ability to adapt to change, concentrate, and maintain interpersonal funct[TRUNCATED]

Based on interview and record review it was determined, for 3 out of 51 sampled residents, that the facility did not ensure that all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegation was made, to the administrator (ADM) of the facility and to the State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, an incident of sexual abuse, an incident of neglect with verbal abuse, and an incident of physical abuse were not reported to the ADM, SSA or APS within 2 hours after the identification or occurrence of the incident happening. Resident identifiers: 19, 194, and 196. Findings included: 1. Incident of sexual abuse between resident 19 and resident 196. Review of the facility final investigation report for sexual abuse on 3/11/22 documented that on 3/5/22 at 2:00 PM resident 19 reported to Registered Nurse (RN) 5 that she had asked resident 196 to stop kissing her breasts and that he did not immediately stop. RN 5 reported the incident to the facility Administrator (ADM) and an investigation was initiated. Resident 19 reported that she asked resident 196 to stop kissing her breast as it caused her discomfort, and that he did not stop after the first time she asked him to. However resident 19 reported that he did stop after she told him a second time. Resident 19 also reported that resident 196 tried to get her to stick her hand down his pants. Resident 19 stated that initially she had been okay with the encounter and then changed her mind. The report documented that the police were notified on 3/5/22 (by 1600 [4:00 PM]within 2 hours) and the case number was LK2022-7407. The report documented that APS was notified on 3/5/22 (by 1600 within 2 hours) and the case number was 135597. The SSA was notified of the incident on 3/5/22 at 3:57 PM by email verification. On 3/21/22 at 1:32 PM, a telephone interview was conducted with RN 7. RN 7 stated that his participation in the incident was very little. RN 7 reported that the incident happened at end of his night shift at approximately 6:00 AM on 3/5/22. RN 7 stated that he did not document the events of the incident. RN 7 stated that he was conducting a narcotic count with the oncoming day shift nurse when CNA 13 reported that the residents were kissing and touching. RN 7 stated that he could not recall the exact retelling of the events. RN 7 stated that the residents had just walked by the medication cart holding hands, and approximately 2-3 minutes later the CNA 13 reported the incident. RN 7 stated that he left the other nurse during the narcotic count and went to investigate. RN 7 stated that he located resident 19 and resident 196 on the 500 hallway at the west end by the exit to the smoking patio. RN 7 stated that the residents were seated on the floor next to each other. RN 7 stated that he asked if everything was okay, and they replied yes. They seemed fine. RN 7 stated that he asked the residents to return to their rooms. RN 7 stated that when he approached resident 19 and resident 196, he did not witness any sexual contact. RN 7 stated that he did not recall what was reported to him but that in that hallway things happened so fast with residents, and that was why he responded immediately. RN 7 stated that the ADM interviewed him by phone and took his statement. RN 7 stated that he did not sign the statement and did not review the statement for accuracy. RN 7 was read the statement and he stated that sounded about right. RN 7 stated that he did not report the incident to anyone because RN 5 also heard the aide report the incident. RN 7 stated that when he did not witness anything inappropriate, he did not report the incident. RN 7 stated that the facility abuse coordinator was the ADM. RN 7 stated that any allegations or incidents of abuse were to be reported to the ADM. RN 7 stated that any incidents that they suspected were abuse should be reported as well. RN 7 stated that the process was to document the incident and then inform the Director of Nursing (DON) and ADM. RN 7 confirmed that if the aide reported inappropriate contact between two residents, even though he did not witness the contact, that incident should be reported as a possible allegation of abuse. RN 7 stated that because it was during shift change, and it was reported to both the nurses at the same time, he assumed that the day shift nurse would report the incident to the facility ADM. RN 7 stated that if he was working that shift, he would have separated the residents and made sure they were safe, then notified the ADM, DON, NP, and completed a incident report. It should be noted that 9 hours had passed since the time of the witnessed incident and the time that the incident was reported to the ADM. Additionally, 10 hours had passed since the time of the witnessed incident and the time that the incident was reported to the SSA and APS. 2. Incident of neglect with verbal abuse for resident 194 On 3/16/22 at 8:25 AM, an interview was conducted with the ADM. The ADM stated that he contacted the NP at 5:09 AM and she was responsive. The ADM stated that the nurse's attitude was poor. The ADM stated that he reported to the NP that there was an issue with the resident's pain medication and the NP gave a verbal order to the nurse. The ADM stated that RN 10 informed him of the issue with resident 194's pain. The ADM stated that it was not up to the nurse to determine if the resident was med seeking. The ADM stated that the nurse should be assessing the resident's pain and notifying the MD. Review of the facility initial entity report for verbal/mental abuse documented On 3/17/22 at approximately 1200 facility administration was made aware of allegation of possible verbal/mental abuse. APS notified, investigation initiated Review of the ADM witness statement documented, On 3/16/22 at approximately 0500 [5:00 AM] [RN 5] reported to me that resident [resident 19's name] did not have her tramadol in house and that the resident was upset. I immediately approached the Nurse, [RN 8 name]. [RN 8] stated that the resident [resident 19's name] had tramadol in the cart but didn't have a current order. I asked [RN 8] if she had called the physician, she said that she had not. I immediately called [name of NP] on speaker phone and [name of NP] gave verbal order for the medication, this was approximately 0509 [5:09 AM]. The report documented that APS notification was done on 3/17/22 a 1:17 PM. The report documented SSA notification was done on 3/17/22 at 1:15 PM. It should be noted that the ADM was interviewed on 3/16/22 at 8:25 AM and stated that it was not up to the nurse to determine if the resident was med seeking, and the nurse should be assessing the resident's pain and notifying the MD. At this time the ADM also informed the SSA that he was going to place RN 8 on administrative leave for informing us that she was too busy to call the MD. Additionally, the facility investigation only addressed verbal/mental abuse and did not address resident neglect. Approximately 31 hours had lapsed since the ADM was notified of resident 194's reports of uncontrolled pain without timely assessment or treatment. [Cross-refer F600]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 23 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy, paralytic syndrome, age-related osteoporosis, difficulty in walking, mood disorder, cognitive communication deficit, and muscle weakness. On 3/21/22 at 11:39 AM, an interview was conducted with the Director of Therapy (DT). The DT stated that resident 23 had a splint that was ordered and fitted by occupational therapy (OT), but the splint had since disappeared. The DT stated he was in the process of ordering another splint for resident 23. On 3/21/22 at 1:36 PM, a follow up interview was conducted with the DT. The DT stated he was unsure if a splint for resident 23 had been ordered. The DT stated he did not know when the initial splint was ordered, but stated his records showed that when resident 23 was discharged from occupational therapy in July 2021, she had a splint. A care plan dated 7/27/21 revealed that resident 23 had a left wrist contracture. One of the goals was that resident 23 was to remain free of complications related to immobility, thrombus formation, skin breakdown, and fall related injury through the next review date. The interventions developed were to assist resident with television remote control, bed rail to assist with bed mobility, the resident uses a motorized wheel chair, provide gentle range of motion as tolerated with (sic) daily and remind resident to get out of bed slowly when transferring from the bed to the chair. Another intervention sometimes [resident 23] request to have trash liner tied to the door handle to give her easy access to open the door please respect her choice and restorative nursing assistant (RNA) to provide passive range of motion. The care plan did not list a splint/brace as interventions for resident 23's limited range of motion. 3. Resident 76 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included multiple sclerosis, morbid obesity, paraplegia, unspecified cognitive communication deficit, limitation of activities due to disability, schizoaffective disorder, bipolar type, major depressive disorder, muscle weakness, pain in unspecified limb, and borderline personality disorder. Resident 76's medical record was reviewed on 3/14/22. A review of resident 76's medical record indicated the following: resident 76's right thigh wound was initially discovered on 11/4/21. The nurse practitioner (NP) and wound nurse (WN) were notified, and the wound was identified as excoriation. An initial order for wound care was written. Records indicated resident 76's comprehensive care plan was not updated with the new right thigh wound when it was initially discovered on 11/4/21. On 11/11/21 it was documented that the right inner thigh wound continued to be open, but no documentation was found indicating when the wound changed from excoriation to an open wound. On 11/12/21 at 1:33 AM, the WN was notified of resident 76's worsening wound. No documentation was found indicating the NP or WN were notified of the worsening wound prior to this date. On 11/12/21 at 3:23 PM, the WN assessed resident 76's wound and identified it as a deep tissue injury (DTI)-like wound. The WN obtained new wound care orders at that time. Records indicated resident 76's comprehensive care plan was updated to include the deteriorating wound on 11/12/21, identifying it as a pressure wound to right posterior thigh/buttock area. [Note: The initial wound was discovered on 11/4/21 but the comprehensive care plan was not updated until 11/12/21, indicating a delay of 8 days in describing services to be furnished to attain the resident's highest practicable physical, mental, and psychosocial well-being.] Based on observation, interview and record review, it was determined that, for 3 of 51 sampled residents, the facility did not develop and implement a comprehensive person-centered care plan for each resident that described services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Specifically, a resident who was observed to be smoking was not identified as a smoker did not have a smoking care plan. In addition, the facility staff did not update a resident's care plan in a timely manner when a wound requiring treatment was identified and a resident with limited range of motion did not have interventions for therapy and splints on the care plan. In addition, Resident identifiers: 23, 38 and 76. Findings include: 1. Resident 38 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia, schizoaffective disorder, type 2 diabetes mellitus, and obstructive sleep apnea. On 3/14/22 at 11:49 AM, an interview was conducted with resident 38. Resident 38 stated that he did not think restricting his smoking times was allowed. Resident 38 further stated that he had rights and .I intend to use them. I'll smoke when I like! On 3/15/22, at 10:00 AM, an observation was made of resident 38. Resident 38 was observed to be smoking outside the 300 hall on the patio. Resident 38 was observed to not have smoking safety equipment. On 3/21/22 resident 38's medical record was reviewed. Resident 38's Quarterly Minimum Data Set (MDS), dated [DATE], revealed he had a Brief Interview for Mental Status (BIMS) score of 15 which indicated resident 38 was cognitively intact. Resident 38's annual MDS, dated [DATE], revealed that the facility had written, about the resident, under the section titled Nature of Problem/Condition that He is a smoker. Resident 38's care plan did not identify him as a smoker, and no mention of smoking was made within the care plan. Resident 38 had a smoking assessment in his medical record, dated 5/21/21, indicating he smoked 0 cigarettes per day, and needed no further assessment as he was not identified as a smoker. There were no other smoking assessments located in resident 38's medical records. On 3/14/2021 the facility provided a list of residents who smoked cigarettes. Resident 38 was on the list. On 3/17/22 the Administrator (ADM) provided copies of a letter, dated 2/25/22, that had been sent to all of the facility's residents who smoked. The letter was addressed to the resident, their friends, family, and visitors. In the letter it states- In the coming days, facility staff will be approaching residents who smoke, and asking the residents to turn over all smoking materials to staff. We would also ask that if you bring cigarettes/lighter to our residents, please do not give them to the residents. Please give all cigarettes/smoking materials directly to the staff. Facility staff will distribute the cigarettes and will safely supervise all the residents at the same smoking times. The letter was signed by the ADM, had the resident's name handwritten on the top of the letter, and was signed by resident 38. On 3/22/2022 the facility submitted additional information for the survey. Corporate Resource Nurse (CRN) submitted documentation that stated . Upon review it was determined that [Resident 38] does not smoke. Upon interview of the DON (Director of Nursing) it was determined that he was listed in error on our current smoker list. Confirmed with additional interview of Unit Manager (UM). Per UM he doesn't smoke but does have a previous history of smoking. UM interviewed [Resident 38] and he confirmed he hasn't smoked in a long time and no longer smokes. Smoking assessment and care plan would not be needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 4 of 51 sampled residents, that the facility did not provide the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living (ADL's). Specifically, resident showers were not being completed according to their shower schedule. Resident identifiers: 41, 64, 82, 198. Findings include 1. Resident 64 was admitted to the facility on [DATE] with a diagnoses that included Parkinson's Disease, muscle weakness, difficulty in walking, polyneuropathy, and major depressive disorder. On 3/14/22 at 11:36 AM, an interview was conducted with resident 64. Resident 64 stated she had been in clothes since yesterday. Resident 64 stated she woke-up yesterday in urine and bowel. Resident 64 stated she wanted a shower but did not get a shower. On 3/17/22 at 10:45 AM, an interview with resident 64 was conducted. Resident 64 stated that her shower schedule was every Monday, Wednesday, and Friday. Resident 64 stated that her showers had been skipped multiple times. Resident 64 stated that she was upset that her showers have been skipped. A record review of resident 64's medical record was conducted on 3/17/22. Resident 64's minimum data set (MDS) dated [DATE] was reviewed. It was revealed that resident 64 required physical help in part of bathing activity and required a one person physical assist. Resident 64's care plan dated 3/14/22 was reviewed. The focus area in the care plan included ADLs [activities of daily living]: [Resident 64] has an ADL self performance deficit r/t [related to] Parkinson disease, with the goal of, The resident will maintain current level of ADL function through the review date. An intervention provided for this goal included, Bathing/showering: the resident is up to extensive assist of (1) staff to provide bath/shower and as necessary. The Point of Care (POC) Response History for the bathing task was reviewed from 2/16/22. It revealed that resident 64 was scheduled for bathing on Mondays, Wednesdays, and Fridays. A look back of completion of the bathing task for the previous 30 days was reviewed. Note that Physical Help in part of bathing activity indicated that the bathing task was completed. a. 2/16/22 - marked Physical Help in part of bathing activity b. 2/18/22 - marked Not Applicable c. 2/21/22 - marked Physical Help in part of bathing activity d. 2/23/22 - marked Not Applicable e. 2/25/22 - marked Resident Refused f. 2/28/22 - marked Not Applicable g. 3/2/22 - marked Physical Help in part of bathing activity h. 3/4/22 - marked Resident Refused i. 3/7/22 - marked Physical Help in part of bathing activity j. 3/9/22 - marked Not Applicable k. 3/11/22 - marked Physical Help in part of bathing activity l. 3/14/22 - marked Physical Help in part of bathing activity m. 3/16/22 - marked Resident Refused It should be noted that according to the documentation resident 64 was provided 6 showers from 2/16/22 until 3/16/22. Resident 64 was marked as refusing a shower 3 times. Resident 64 was offered a shower 9 times during that 30 day period of time. 3. Resident 198 was admitted to the facility on [DATE] with diagnoses of fracture of right humerus, ground level fall, alcohol dependence, type 2 diabetes mellitus, chronic obstructive pulmonary disease, cellulitis of left lower limb, hypertension, hyperlipidemia, hypothyroidism, sleep apnea, dorsalgia, major depressive disorder, anxiety disorder, gastro-esophageal reflux disease, and chronic pain. On 3/14/22 at 1:18 PM, an interview was conducted with resident 198. Resident 198 stated that he had open wounds on the bottom of both feet, and that he had neuropathy. Resident 198 stated that he did not have any wound care for his feet, no dressing changes, no creams or ointments. Resident 198 stated that the wounds were located on the heels and big toes, and would bleed a little bit. Resident 198 stated that he did not think that the facility staff knew about the wounds. On 3/15/22 resident 198's medical records were reviewed. On 3/12/22 at 1:50 PM, resident 198's BIMS assessment documented a score of 12/15 which would indicate that the resident had a moderate cognitive impairment. Review of resident 198's the bathing task documented that the resident was a total dependence one person physical assist for bathing and received a shower on 3/16/21 at 5:24 PM. The bathing schedule was documented as Monday, Wednesday, and Friday during the day time. It should be noted that this was the first bathing assistance that was provided to resident 198 since admission on [DATE], and no resident refusals were documented. Review of resident 198's care plan revealed a focus area of had an Activities of Daily Living (ADLs) self-care performance deficit related to decreased mobility. The care plan was initiated on 3/9/22. The goal identified was that the resident will improve current level of function through the review date. Interventions identified for bathing/showering were that the resident was a limited assist of 1 staff to provide bath/shower as necessary. On 3/17/22 at 9:03 AM, an interview was conducted with CNA 12. CNA 12 stated that resident 198 was alert and oriented times four to person, place, time, and situation. CNA 12 stated that he was not sure about resident 12's bathing assistance needs as he had not provided him a shower yet. CNA 12 stated that the showers were documented in the tasks under POC charting. CNA 12 stated that resident 198's shower schedule was Monday, Wednesday, and Friday during the day time. On 3/17/22 at 9:14 AM, an interview was conducted with CNA 19. CNA 19 stated that she had not assisted resident 198 with bathing. CNA 19 stated that resident 198 had been in pain and refusing showers. CNA 19 stated that they documented refusals on a sheet, charted in POC under bathing tasks, and notified the nurse. CNA 19 stated that they assessed the residents skin condition during showers and toileting. On 3/17/22 at 9:23 AM, an interview was conducted with Registered Nurse (RN) 11. RN 11 stated that resident 198 was independent with mobility, and required a 1 person assist for toileting and showers. RN 11 stated that the aides supervised more with showers and helped with the areas he could not reach. 4. Resident 82 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy leukemia, schizoaffective disorder, post-traumatic stress disorder and major depressive disorder. On 3/14/22 at 10:04 AM, an interview was conducted with resident 82. Resident 82 stated that he only received showers once a week. Resident 82 stated he would like them twice a week. Resident 82' medical record was reviewed on 3/17/22. A quarterly MDS dated [DATE] revealed that resident 82 was totally dependent with a one person physical assist for bathing. A care plan dated 8/26/21 revealed ADLs: [Resident 82] has an ADL self-care performance deficit r/t (related to) CP (cerebral palsy). The goal was The resident will improve current level of function through the review date. One of the interventions included Bathing/Showering: The resident is up to extensive assist of (1) staff to provide bath/shower and as necessary. A care plan dated 11/9/21 revealed Resident is resistive to cares. The goal was The resident will cooperate with care through the next review date. Interventions included Allow the resident to make decisions about treatment regime, to provide sense of control and Provide resident with opportunities for choice during care provision and Risk vs benefit for refusal of cares. Resident was also educated. The risk verses benefit form dated 11/10/21 revealed two nurses signatures and no resident signature. The form revealed that resident 82 refuses help with ADL's, showering, and hygiene. According to the shower Tasks section from 2/15/22 until 3/12/22, resident 82 was bathed on 2/17/22, 2/19/22, 2/22/22, 2/26/22, 3/3/22, and 3/10/22. It was marked that resident 82 not applicable on 2/15/22, 3/1/22 and 3/5/22. Resident 82 was marked as refused on 3/8/22 and 3/12/22. Resident 82 was scheduled for bathing on Tuesday, Thursday and Saturday mornings. On 3/17/22 at 11:12 AM, an interview was conducted with CNA 1. CNA 1 stated that the computer notified CNAs of which residents received showers each day. CNA 1 stated there were shower sheets completed after the shower and the CNA gave them to the nurse. CNA 1 stated that not applicable should not be marked showers. CNA 1 stated if a resident refused three times then the nurse was notified. CNA 1 stated if a resident refused three times then a form was signed by the CNA and nurse. On 3/17/22 at 2:54 PM, an interivew was conducted with CNA 20. CNA 20 stated she worked for an agency but had worked at the facility for a little over a year. CNA 20 stated the showers were scheduled in the computer system. CNA 20 stated she look the showers at beginning of the shift. CNA 20 stated she notified the residents of their shower day and asked what time they wanted a shower when she completed vital signs. CNA 20 stated if a resident refused she notified the nurse and looked to see how long it had been since they were showered. CNA 20 if it had been a while, then she went back to the resident and offered a bed bath. CNA 20 stated that resident 82 did most things on his own and did not refuse when she offered cares. On 3/17/22 at 4:27 PM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated that residents were scheduled showers for 3 days per based on their preferences. UM 1 stated that the CNA's document under tasks section in the medical record. UM 1 stated if a resident refused, the CNAs were required to ask 3 times before they documented refused. UM 1 stated there was also a book at the nurses station to complete if a resident refused or if the shower was completed. UM 1 stated the form had a notification section regarding skin issues that the nurses had to sign off on that. UM 1 stated the facility had a lot of agency staff in the building and tried to educate as they came in on shift. UM 1 stated agency CNA's might not know the full process of it. UM 1 stated there was a binder at the nurses station that had every step for CNA's to follow of what needed to be completed during their shift. UM 1 stated she did not know what not applicable meant for showers. UM 1 stated that resident 82 had refused cares a lot and had a risk verses benefit signed. UM 1 stated that a CNAs were to continue to ask resident 82 if he wanted to shower even with a risk verses benefit. On 3/17/22 at 3:29 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that showers were scheduled 3 times per week. The DON stated that shower times were in the electronic charting system. The DON stated if a resident refused then the CNA notified the nurse and then the nurse talked to the resident. The DON stated that the problem was frustrating because there were agency CNAs that have been asked not to come back because they were not charting. On 3/21/22 at 12:07 PM, an interview was conducted with the Regional Nurse Consultant (RNC) 1. RNC 1 stated that showers had an audit over the weekend, and they offered those resident that did not have a shower one over the weekend. RNC 1 stated that the CNAs should be offering the residents a shower on their scheduled shower days. RNC 1 stated that if a resident refused a shower the aide was to ask the resident 3 times, and if they still refused they should inform the nurse of the refusal. RNC 1 stated that the nurse could then step in and assist. RNC 1 stated that the CNAs should be documenting in tasks under showers for resident refusals. RNC 1 stated that some of the staff were documenting not applicable (NA), and they were doing it when it was not given or not appropriate on that shift. RNC 1 stated that the aides should not be documenting a refusal there. 2. Resident 41 was admitted to the facility on [DATE] with diagnoses that included left arm fracture, diabetes mellitus, muscle weakness, anemia, atrial fibrillation, end stage renal disease, and protein calorie malnutrition. On 3/15/22 at 12:23 PM, an interview was conducted with resident 41. Resident 41 stated that she wanted to be showered more often. On 3/15/22, resident 41's medical record was reviewed. Resident 41's MDS significant change assessment dated [DATE], resident 41 was assessed as requiring one person physical assist for bathing. Resident 41's care plan dated 12/30/21 indicated that the resident required limited assistance of one staff member to provide bath/shower. Resident 41's shower record in the Tasks portion of the electronic health record was reviewed. The record indicated that resident 41 received a shower on 2/19/22, 2/22/22, 3/5/22, 3/8/22, and 3/12/22. This was a total of 5 times in the previous 30 days. The Tasks record also indicated that resident 41 was marked as not available on one occasion, refused on 3 occasions, and not applicable on 2 occasions.

Based on observation, interview and record review it was determined, for 10 of 51 sample residents, that the facility did not have sufficient nursing staff with the appropriate competencies and skill set to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physicial, mental, and psychosocial well-being of each resident, as determined by resident assessment and individual plans of care and considering the number, acuity and diagnosies of the facility's resident population in accordance with the facility assessment. Specifically, there was no facility asssessment to determine staffing needs for resident. Resident identifiers: 6, 9, 15, 29, 36, 58, 62, 194, 198 and 201. Findings included: 1. On 03/14/22 at 7:41 AM, an interview was conducted with resident 9. Resident 9 stated the response time to call lights depended on who was working. Resident 9 stated that he usually had to wait about 30 minutes for someone to answer his call light. Resident 9 stated in the afternoons was when he had waited the longest for someone to answer his call light. 2. On 3/14/22 at 8:50 AM, an interview was conducted with resident 29. Resident 29 stated she did not think there were enough staff working at the facility. Resident 29 stated she had to wait 2 hours for help and always had to wait to go outside to smoke. Resident 29 stated she had pushed the call light several times since she had been at the facility where no one showed up at all to assist her. Resident 29 stated she did not like to use the call light because it did not do any good. Resident 29 stated instead of using the call light, she left her room to look for staff herself. Resident 29 stated all shifts were short on staff. Resident 29 stated the facility had nowhere near enough staff and that they need to double the number of staff members. 3. On 3/14/22 at 10:45 AM, an interview was conducted with resident 62. Resident 62 stated it had taken a little while for his call light to be answered. Resident 62 stated the longest wait time was 15 minutes. Resident 62 stated he can ambulate to the toilet independently, but if the issue was diarrhea, he had accidents. Resident 62 stated over the last couple of weeks military staff had been here to help. 4. On 3/14/22 at 12:30 PM, an interview was conducted with resident 58. Resident 58 stated that the staff did not respond when he pressed his call light. Resident 58 stated that he had falls and bladder and bowel accidents waiting for staff to answer his call light. Resident 58's bed was observed to be saturated with urine and there was a strong urine odor. Resident 58 stated that he was currently wet and had not been changed since yesterday. (Cross Refer to F690) 5. On 03/14/22 at 1:13 PM, an interview was conducted with resident 198. Resident 198 stated he needed assistance at night transferring out of bed to go to the bathroom. Resident 198 stated getting out of bed on his own caused him pain in his right arm, which was broken. Resident 198 stated the aides were overworked and sometimes there are only 1 to 2 aides on shift at night. Resident 198 stated that after waiting for assistance without getting help, he would often get up by himself even though it was difficult and painful. 6. On 03/14/22 at 1:30 PM, an interview was conducted with resident 15. Resident 15 stated it took a long time for staff to answer her call light. Resident 15 stated that a lot of staff were sick from the virus and were not working in January 2022. 7. On 03/14/22 at 1:48 PM, an interview was conducted with resident 36. Resident 36 stated she did not get a shower because the facility was short staffed. Resident 36 stated she wanted to get out of bed but there were not enough staff to help her get out of bed. (Cross Refer to F677 and F676) 8. On 03/15/22 at 12:37 PM, an interview was conducted with resident 6. Resident 6 stated there were times she could not get help when she wanted to get into bed, even though she had pushed the call light for help. On 03/21/22 at 12:08 PM, an interview was conducted with Regional Nurse Consultant (RNC) 1. The RNC 1 stated a review of resident showers was done for the last 7 days and any resident who had not received a shower was given one over the weekend (3/19/22 - 3/20/22). The RNC 1 stated the audit included a review of the shower task documentation, and education was provided to Certified Nursing Assistants (CNAs) on how to correctly fill out the task form in the electronic health record (EHR). The RNC 1 stated the facility currently does not have a Restorative Nursing Assistant (RNA), but a new RNA had been hired and was to be trained today (3/21/22). The RNC 1 stated the new RNA was a current employee working as a CNA. The RNC 1 stated the new RNA, while working as a CNA, performed an inappropriate transfer which left a bruise on the resident being transferred. On 3/17/22 at 11:09 AM, an interview was conducted with the Wound Nurse (WN). The WN stated there were not enough staff to manage all the wound care needs within the facility. (Cross Refer to F686) On 3/16/22 at 6:16 AM, an interview was conducted with Registered Nurse (RN) 8. RN 8 stated that she gave resident 194 Tramadol 100 mg at approximately 5:05 AM. RN 8 stated that she called the NP at 5:05 AM to obtain the order. RN 8 stated that resident 194 never specifically asked for a pain medication or a Tramadol. RN 8 stated that resident 194's pain score throughout the night was a 7/10 with a lot of muscle spasms. RN 8 stated that the medication did not alleviate the pain and resident 194's pain score remained a 7/10. RN 8 stated she reassessed the resident at 5 AM and called the NP. RN 8 stated that she could have called the on-call physician, but did not think that it was necessary. RN 8 stated that it was her fault and that she was definitely busy. (Cross Refer to F697) On 3/16/22 at 5:01 AM, an interview was conducted with RN 8. RN 8 was asked about resident 201 and the night he left the facility to go to the hospital. RN 8 stated that she did not think resident 201 wanted to go to the hospital, but his family was being very demanding. I had a crazy night, and a readmit, and then the family of this man kept coming out every 5 minutes saying something was wrong with him. RN 8 stated that she had not met resident 201 prior to 3/14/21. RN 8 stated that she and another nurse assessed resident 201 due to his history of multiple strokes and pulmonary embolism. RN 8 could not indicate what she had done to assess resident 201. RN 8 stated that resident 201's left arm was swollen, and the family member was worried about it. RN 8 stated that she called the facility's nurse practitioner, but the nurse practitioner had not seen the resident and referred her to the physician. RN 8 stated that she called the physician, who told her that he had seen resident 201 that morning and he's fine but if they want to send him out it would be against our wishes. RN 8 stated that she spoke with her Director of Nursing (DON), who also stated that if the resident left the facility, it would be considered AMA, and the resident would not be allowed back to the facility because you're discharging yourself. RN 8 stated that facility staff was awaiting the results of a chest x-ray and she felt like I was the pawn between the facility and the family. (Cross refer to F684) On 3/14/22, the facility assessment was requested. The Administrator provided a form with the name of another company on it. The form revealed Naturally Occurring Events with the likelihood of occurrence, alerts, activations, and severity and risk. There was no other information provided. On 3/30/22 at 3:45 PM, the facility assessment was requested via phone from the Administrator in Training (AIT). The AIT stated she would email the facility assessment. The facility assessment was the same information as the above form. The AIT stated that was the full facility assessment.

Based on observations and interview it was determined that, for 12 of 51 sampled residents, that the facility did not provide food prepared by methods that conserve nutritive value, flavor, and appearance; food and drink that was not palatable, attractive, and at a safe and appetizing temperature. Specifically, multiple residents complained about the palatability of the food, appearance of the food, and repetition of meals. Resident identifiers: 4, 10, 15, 32, 36, 48, 51, 58, 62, 64, 80 and 81. Findings include On 3/14/22 at 12:30 PM, an interview with resident 51 was conducted. Resident 51 stated that the food tasted like school lunch, and he refused to eat it. On 3/14/22 at 1:30 PM, an interview with resident 15 was conducted. Resident 15 stated the food was not good. Resident 15 stated that her family member brought in food for her so she did not have to eat the meals provided by the facility. On 3/14/22 at 10:34 AM, an interview with resident 62 was conducted. Resident 62 stated that the food often arrived cold or lukewarm. Resident 62 stated that the facility often did not follow his food preferences listed on his meal ticket. Resident 62 stated that the facility was aware that dairy products would upset his stomach, but foods containing dairy still arrived on his tray. On 3/14/22 at 11:49 AM, an interview with resident 80 was conducted. Resident 80 stated that the food often arrived cold. On 3/14/22 at 11:12 AM, an interview with resident 48 was conducted. Resident 48 stated that the facility used to offer more choices for food. Resident 48 stated the issue about food have been been addressed at resident council, but the issues did not always get resolved. On 3/15/22 at 10:34 AM, an interview with resident 58 was conducted. Resident 58 stated that the food was bad and he could not eat it. Resident 58 stated that food looked like slop that came off the floor. Resident 58 stated that the food was repetitive. Resident 58 stated that he did not eat most of his food and he thought he had lost weight. On 3/14/22 at 11:25 AM, an interview with resident 64 was conducted. Resident 64 stated that the food was sometimes good and sometimes bad. Resident 64 stated that the food usually arrived cold. Resident 64 stated that the meat loaf was good on one occasion, but it was terrible the next time it was served. On 3/14/22 at 10:06 AM, an interview with resident 32 was conducted. Resident 32 stated that the food was always too cold. Resident 32 stated that he often had to ask staff to reheat the food. Resident 32 stated that the oatmeal was sometimes watered down. Resident 32 stated that he spoke with the administrator and the chef, but the issues had not been resolved. On 3/15/22 at 1:26 PM an interview with resident 4 was conducted. Resident 4 stated that the food tasted terrible. On 3/14/22 at 8:15 AM, an observation was made of resident 81. Resident 81 was observed to be delivered her breakfast meal and was observed to walk back out of her room with the meal tray and place it on a chair outside of her room. Resident 81 stated she did not eat the food. On 3/14/22 at 12:30 PM, an interview with resident 81 was conducted. Resident 81 stated that she did not like the food provided and ate her own food instead. On 03/14/22 10:11 AM, an interview with resident 10 was conducted. Resident 10 stated that the eggs were usually cold. Resident 10 stated the food often was cold when it arrived to her room. On 3/14/22 at 1:46 PM, an interview with resident 36 was conducted. Resident 36 stated that the food tasted awful. Resident 36 stated that her family member brought in food so resident 36 would not have to eat the facilities food. On 3/17/22 at 1:25 PM, an observation was made in the kitchen. The menu stated that lunch was rotisserie chicken, broccoli florets, rice pilaf, a dinner roll, and banana pudding parfait. The kitchen ran out of broccoli florets and rice pilaf for the last 5 resident meal trays. The staff in the kitchen used steamed cauliflower and white rice as a substitute. On 3/17/22 at 1:35 PM a test tray was obtained. The food on the test tray was steamed cauliflower, white rice, rotisserie chicken, and a dinner roll. The temperature of the food was appropriate. The food on the test tray were shades of white or brown, lacking any color. The cauliflower was unseasoned and mushy to the taste. The rice was unseasoned, bland to the taste with a mushy/glue like texture. The rotisserie chicken was seasoned with a chewy texture and dry to the taste. On 3/17/22 at 2:30 PM, an interview with the Dietary Manager (DM) was conducted. The DM stated that they offered substitutions for residents who did not want what was on the menu. The DM stated that he conducted biweekly meetings with the residents to talk about food preferences. The DM stated that most of the food was seasoned according to the recipe, however the last few lunch trays for residents had unseasoned cauliflower and rice due to running out of the broccoli and rice pilaf.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Dining Observations: On 3/14/22 at 8:30 AM, observations were made of the breakfast meal service in the 300 and 500 hallway. The cart in the 300 hallway was parked halfway down the hallway. Trays were observed to be transported through the hallway without a condiment cup with syrup covered. At 8:36 AM, an observation was made of the Dietary Manager transporting the 400 hall meal cart to the hallway. There was a tray observed on top with syrup that was uncovered. The meal cart had been transported from the kitchen through the 200 hallway to the 500 hallway without being covered. The cart was placed in the middle of the 400 hallway and the meal tray were transported through with the syrup uncovered. On 3/17/22 at 12:23 PM, observations were made of the lunch meal service on the 300 and then 200 hallway. The first meal cart arrived on the 300 hallway. The cart was parked halfway down the hallway. Trays were obtained from the cart by different staff members and carried to each resident's room. The following observations were made: a. On 3/17/22 at 12:29 PM, an observation was made of Certified Nurse Assistant (CNA) 2 delivering trays to room [ROOM NUMBER] A and 305 B. Both trays were observed with the dessert pudding uncovered. b. On 3/17/22 at 12:33 PM, CNA 2 delivered the meal tray to room [ROOM NUMBER] A. The dessert was uncovered. c. On 3/17/22 at 12:34 PM, CNA 2 delivered the meal tray to room [ROOM NUMBER] B. The dessert was uncovered. d. On 3/17/22 at 12:35 PM, the meal tray was delivered to room [ROOM NUMBER] A. The dessert was uncovered. e. On 3/17/22 at 12:36 PM, CNA 21 delivered the meal tray to room [ROOM NUMBER]. The dessert was uncovered. f. On 3/17/22 at 12:52 PM, CNA 12 delivered the meal tray to room [ROOM NUMBER]. The dessert was uncovered. g. On 3/17/22 at 12:53 PM, CNA 22 delivered the meal tray delivered to room [ROOM NUMBER]. The dessert was uncovered. 2. Transmission Based Precautions (TBP) a. On 3/14/22 at 8:04 AM, an observation was made of CNA 2 was observed to enter room [ROOM NUMBER]. CNA 2 was observed to take a meal tray into the room and place it by the resident. CNA 2 was observed to wear a surgical mask and eye protection. CNA 2 did not change her PPE or put on additional PPE. CNA 2 was immediately interviewed. CNA 2 stated she did not know why the residents in the room were on isolation. An observation was made of signage on door 305. The signage revealed contact droplet precautions When C-PAP is in use apply the proper PPE use Droplet/contact isolation Gown, N95, shield and gloves. b. On 3/14/22 at 7:30 AM, an observation was made of room [ROOM NUMBER]. The door to the room had signs posted that stated that the room was on droplet/contact precautions. The droplet sign stated, EVERYONE MUST: Clean hands, before entering and when leaving the room. [NAME] gloves and gown BEFORE entering the room. Make sure their eyes, nose and mouth are fully covered before entering the room. Remove all protective equipment before exiting the room. The contact precautions sign stated, EVERYONE MUST: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. The door also contained signs that demonstrated the sequence for putting on PPE and how to safely doff PPE. An ABHR dispenser was posted outside of room. The door had a PPE hanging cart that contained disposable gowns, gloves, N95 masks and red biohazard bags. The door to room was observed closed. On 3/14/22 at 7:57 AM, an observation was made of CNA 23. CNA 23 donned a disposable gown, and gloves, in addition to the surgical mask and face shield that was already worn. CNA 23 entered room [ROOM NUMBER] to obtain the resident's vital signs (VS) and carried with her a cloth bag with a wrist blood pressure (BP) cuff and a clip board with a pen and paper. room [ROOM NUMBER] had signs posted for contact and droplet precautions. The PPE cart still contained disposable gowns, gloves, N95 masks, and red biohazard bags. CNA 23 did not donn a N95 mask prior to entering room [ROOM NUMBER]. CNA 23 was observed to doff the gown and gloves outside the resident room upon exit. The face shield was not cleaned upon exit of the room, and hand hygiene was not performed. CNA 23 was observed to walk the doffed PPE all the way down the 100 hallway to the 300 hallway garbage room to dispose of the PPE. On 3/14/22 at 8:08 AM, an interview was conducted with CNA 23. CNA 23 stated that she had to dispose of the PPE in the dirty utility room on the 300 hallway because there was not a disposal bin located in room [ROOM NUMBER]. The CNA was then observed to take the BP cuff to room [ROOM NUMBER] and obtained VS from the resident. The CNA was not observed to clean the VS equipment between resident use, nor perform hand hygiene between resident care. CNA 23 was observed to report the residents VS's to the nurse upon completion of the task. On 3/14/22 at 9:58 AM, an interview was conducted with Registered Nurse (RN) 12. RN 12 stated that room [ROOM NUMBER] was on COVID-19 precautions for 14 days following a new admission, and that the resident did not have their COVID-19 vaccination. RN 12 stated that staff needed to follow all the instructions provided on the door before entering the room. Review of the facility policy and procedure for Infection Prevention and Control Program (IPCP) documented under Transmission-Based Precautions that Disposable or dedicated, non-critical care items will be used for the resident. If equipment is shared, it will be disinfected according to manufacturer's recommendations using an approved disinfectant. On 3/17/22 at 10:43 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility protocol for new admissions was that they tested the resident at the door for COVID-19. Then the resident was placed on isolation with contact/droplet precautions, and it was triggered in the resident's electronic medical record (EMR) as an order for 14 days. The DON stated that she was aware that the Centers for Disease Control and Prevention (CDC) now only required a 10 day isolation precautions period. The DON stated that the resident was tested for COVID-19 again 3-4 days after admission and one more time before they came off isolation precautions. The DON stated that staff were to wear all PPE, and that included a face shield, a N95 mask, gown and gloves while in any room that was designated on contact/droplet precautions. The DON stated that all PPE was available in the hanging cart located outside each room that was on TBP. The DON stated that disposal bins for the PPE were supposed to be located inside the resident rooms, and that staff should be doffing in the room before they exited. The DON stated that staff should be performing hand hygiene, doff the N95 mask, donn a new surgical mask and clean their face shield after they exit a room on TBP. The DON stated that staff should disinfect all reusable care equipment with the Micro Kill germicidal alcohol wipes between resident use. Review of the CDC guidance on Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes documented under Managing New Admissions and Readmissions that all residents who were not up to date with all recommended COVID-19 vaccine doses should be placed in quarantine upon admission. The guidance further stated that Healthcare Personnel (HCP) caring for residents on quarantine should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). The guidance was last updated on February 2, 2022. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#anchor_1631031505598 Based on interview and record review it was determined that the facility failed to establish an infection prevention and control program designed to prevent the development and transmission of COVID-19. Specifically, food was observed to be transported through the hallways uncovered, the staff were observed entering resident rooms without proper Personal Protective Equipment (PPE), and soiled PPE was observed to be transported through the hallways, and resident care equipment was not sanitized. Findings include:

Based on observation and interview it was determined that the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the dishwasher did not meet the required minimum temperatures during the wash cycle. Findings include 1. On 3/14/22 at 7:29 AM, an initial tour of the kitchen was conducted. The dish machine log temperature form was reviewed. The following temperatures were documented: [Note: All temperatures were in degrees Fahrenheit.] a. On 2/21/22, the temperature for dinner dish washing cycle was 118 b. On 2/22/22, the temperature for the dinner dish washing cycle was 119. c. On 3/2/22, the temperature for the dinner dish washing cycle was 115. d. On 3/6/22, the temperature for the dinner dish washing cycle was 116. The bottom of the Dish Machine Log revealed Chemical Sanitizing (Low temp): Wash 120-140 and Rinse 120-140. 2. On 3/17/22 at 2:30 PM, an observation of the dishwasher was made. The wash cycle of the dishwasher reached 111.6 degrees Fahrenheit. The dishwasher was a low temperature dishwasher which required the wash cycle temperature to reach a minimum of 120 degrees Fahrenheit. The dishes washed were observed to be placed with the clean dishes. On 3/21/22 at 10:10 AM an observation of the dishwasher was made. The wash cycle of the dishwasher reached 116.3 degrees Fahrenheit. The dishes washed were observed to be placed with the clean dishes. On 3/21/22 at 10:10 AM an interview with the Dietary Manager (DM) was conducted. The DM stated that he did not think the temperature was too low because the electronic temperature sensor turned red if there was an issue with the dishwasher. The DM stated that the electronic temperature sensor was blue which indicated that there was not an issue with the dishwasher. Although the electronic temperature gauge did not indicate an issue with the dishwasher, the dishwasher was still required to meet a minimum temperature of 120 degrees Fahrenheit during the wash cycle. The DM stated that he would call the manufacturing company for the dishwasher to resolve the issue.

Based on interview and record review, the facility did not conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility assessment must address or include both the number of residents and facility's resident capacity; the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that were present within that population; the staff competencies that were necessary to provide the level and types of care needed for the resident population; the physical environment, equipment, services, and other physical plan considerations that were necessary to care for this population; and any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including but not limited to, activities and food and nutrition services. Specifically, the facility did not have a facility assessment. Findings include: On 3/14/22, the facility assessment was requested. The Administrator provided a form with a Title of another company on it. The form revealed Naturally Occurring Events with the likelihood of occurrence, alerts, activations, and severity and risk on the form. There was no other information provided. On 3/30/22 at 3:45 PM, the facility assessment was requested via phone by the Administrator in Training (AIT). The AIT stated she would email the facility assessment. The facility assessment was the same information as the above form. The AIT stated that was the full facility assessment.