**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 28 sampled residents, that the facility did not immediately consult with the resident's physician and notify when there was an accident involving the resident which resulted in injury; a significant change in the resident's physical, mental, or psychosocial status; or a need to alter treatment, or a decision to transfer or discharge the resident from the facility. Specifically, a resident had an injury of unknown origin identified and the physician was not notified. Additionally, the physician was not notified when a resident refused blood draws for laboratory orders. Resident identifiers: 14 and 18. Findings included: 1. Resident 18 was admitted to the facility on [DATE] with diagnoses which consisted of asthma, dementia, hypertension, hyperlipidemia, insomnia, overactive bladder, gastro-esophageal reflux disease, hypokalemia, malignant neoplasm, chronic pain, unspecified protein-calorie malnutrition, anxiety disorder, and major depressive disorder. Resident 18's medical records were reviewed. On 9/4/24 at 7:06 AM, resident 18's nurse note documented, CNAs [Certified Nurse Assistant(s)] found a bruise on the resident's upper thigh area. This appears to be a new bruise. Resident doesn't know how it happened. On 9/9/24, a skin assessment documented no new skin integrity problems. It should be noted that no documentation could be found of an assessment of the identified bruise. Resident 18's care plan for at risk for skin breakdown was initiated on 8/21/24. The care plan goal was that resident 18 would not develop a pressure injury. Interventions identified were do not massage bony prominence and implement weekly skin checks. It should be noted that the care plan did not have interventions related to monitoring, reporting or treating altered skin conditions. On 10/01/24 at 11:39 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that if she identified a newly developed bruise on a resident she would notify the provider, notify the Director of Nursing (DON), document in a progress note and monitor the skin. On 10/01/24 at 11:48 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that CNAs should notify the nurse of any new skin conditions such as a bruise. The DON stated that the licensed nurse needed to assess the skin to see if it was suspicious before reporting it as abuse. The DON stated that the nurse should notify the provider as a non-urgent symptom to review and there was a list in the provider communication book for issues that needed attention by the provider. The DON stated that the licensed nurse sometimes documented in a progress note, but they were not consistently doing that. The DON stated that the licensed nurse should document a progress note that stated the provider was notified of the condition. 2. Resident 14 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included cerebral infarction, hemiplegia and hemiparesis, cognitive communication deficit, chronic obstructive pulmonary disease, pain, major depressive disorder, dementia, insomnia, cervical disc degeneration, spondylosis with myelopathy, alcoholic polyneuropathy, hypertension, osteoarthritis, radiculopathy, cirrhosis of liver, hyperlipidemia, nicotine dependence, alcohol abuse, cannabis abuse, suicide attempt, suicidal ideations, ventral hernia, trochanteric bursitis of left hip, and lesion of ulnar nerve. Resident 14's medical records were reviewed. Resident 14's physician orders revealed the following: a. On 1/18/24, an order for a B-type natriuretic peptide (BNP) and and basic metabolic panel (BMP) was ordered. The order was documented as completed in resident 14's electronic medical records (eMR). b. On 2/22/24, an order for a complete blood count (CBC), a comprehensive metabolic panel (CMP), a thyroid-stimulating hormone (TSH) with reflex thyroxine (T4), a BNP, and a magnesium level (Mg) was ordered. The order was documented as completed in resident 14's eMR. It should be noted that no results could be found for either laboratory order. Review of resident 14's progress notes revealed no documentation of the laboratory results or physician notification. On 10/01/24 at 11:01 AM, an interview was conducted with the DON. The DON stated that on 1/18/24 and 2/22/24 resident 14 refused the lab draw but they did not have documentation of that. The DON stated that the refusal for the blood draws should have been documented in a progress note. The DON stated that the licensed nurse should have notified the physician of resident 14's refusal for the blood draws, and that the refusal and physician notification should have been documented in a progress note.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility did not provide a safe, clean, comfortable, and homelike environment. Specifically, resident restrooms were found to be dirty and there were strong odors of urine in facility restrooms Findings Included: On 10/02/24 at 11:42 AM, an observation was made of the restroom located in room [ROOM NUMBER]. There was a stain surrounding the base of the toilet. On 10/02/24 at 11:45 AM, an observation was made of the restroom located in room [ROOM NUMBER]. There was a strong odor of urine. On 10/02/24 at 11:58 AM, an interview was conducted with the Housekeeper. The Housekeeper stated that the restroom in room [ROOM NUMBER] always smells like mold and mildew. The Housekeeper stated that she tries to get rid of the odor in the restrooms by scrubbing the toilet and shower with disinfectant. The Housekeeper stated that the odor in the restrooms goes away after she cleans the restrooms. The Housekeeper stated that the odor in the restroom is absent for a while after cleaning, but eventually it comes back. The Housekeeper stated that she believes the odor comes from residents urinating outside of the toilet bowl. [Note: The observation of odors in the facility's restrooms occurred after the housekeeper had finished cleaning restrooms for the day.] The Housekeeper stated that she is unable to get to all of her housekeeping duties completed such as washing and cleaning the curtains because the facility reduced the hours of the other housekeeper that works part time in the evenings from 4:00 PM to 8:00 PM. The Housekeeper stated that the last time she was able to wash the curtains was over a month ago. The Housekeeper stated that the part time housekeeper used to work Sunday through Thursday, but now only works Sunday through Wednesday. On 10/02/24 at 11:34 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that he was unaware of how often resident rooms are cleaned, but that the facility has two housekeepers, one during the day and one during the evening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 28 resident's sampled, that the facility did not implement written policies and procedures that ensure reporting of all alleged violations to the Administrator, State Survey Agency (SSA), and Adult Protective Services (APS). Specifically, an allegation of verbal abuse by a facility Certified Nurse Assistant (CNA) towards the resident was not reported to Adult Protective Services. Resident identifier 22. Findings included: Resident 22 was admitted to the facility on [DATE] with diagnoses which included frontotemporal neurocognitive disorder, unspecified mood disorder, impulse disorder, insomnia, disinhibited attachment disorder, asthma, anxiety disorder, chronic respiratory failure, and hepatic encephalopathy. The facility notification to the SSA, form 358, documented an allegation of verbal abuse by CNA 4 towards resident 22. The form documented the details of the incident as, [RA] observed the CNA [name omitted] yelling 'Goodbye' repeatedly in an aggravating and mocking tone to the resident while [name omitted] was passing breakfast trays. Review of the facility abuse investigation revealed no documentation that demonstrated that APS was notified of the incident. On 10/01/24 at 10:07 AM, an interview was conducted with the ADM. The ADM stated that when he was first informed of any allegation of abuse he would immediately check for resident safety. The ADM stated that as soon as the resident was deemed safe he would gather information regarding the incident. The ADM stated that he would gather the details and interview any person who could corroborate the story. The ADM stated that once he obtained a rough timeline of events then he would determine if a staff member needed to be suspended. The ADM stated that they nurse would assess the resident for any injuries. The ADM stated that he would then report the incident to the SSA, Adult Protective Services, and the ombudsman within 2 hours. The facility policy for Resident Abuse Procedural Summary documented that the supervisor will be responsible for taking immediate actions to report the abuse to the appropriate individuals. The Administrator and Director of Nursing will be responsible for reporting the concerns, as required by law, and conducting the investigation. The policy further stated that all employees would be given specific example and measurable limits as to when reporting was required and they could be found contained within the Abuse Policy. The facility policy for Abuse, Neglect, Exploitation and Misappropriation Prevention Program documented that allegations of abuse would be reported within timeframes required by federal requirements. The policy was last revised in April 2024. [Cross-refer F600]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not ensure that recommendations from the pre-admission screening and resident review (PASRR) level II determination and evaluation were implemented and included in the resident assessment, care planning and transitions of care. Specifically, a residents PASRR level II recommendations for specialized services for mental illness was not implemented. Resident identifier 14. Findings included: Resident 14 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included cerebral infarction, hemiplegia and hemiparesis, cognitive communication deficit, chronic obstructive pulmonary disease, pain, major depressive disorder, dementia, insomnia, cervical disc degeneration, spondylosis with myelopathy, alcoholic polyneuropathy, hypertension, osteoarthritis, radiculopathy, cirrhosis of liver, hyperlipidemia, nicotine dependence, alcohol abuse, cannabis abuse, suicide attempt, suicidal ideations, ventral hernia, trochanteric bursitis of left hip, and lesion of ulnar nerve. Resident 14's medical records were reviewed. Resident 14's progress notes revealed the following: a. On 3/7/24 at 2:27 PM, the nurse note documented, Resident is at hospital for trying to hurt himself. b. On 5/31/24 at 3:08 PM, the resident advocate note documented, [Resident 14] has began Mental health therapy with [name omitted] therapy. On 12/29/21, the PASRR level II evaluation documented that in 2018 the resident began to experience increasing depressive symptoms due to his memory loss and due to fears of being put out on the street as he did not have a place to live. He was having suicidal thoughts and eventually cut on both of his wrists; hospital records state that pt reported 'so rather than living on the street, I decided to end it'. After cutting his wrists he fell and hit his head and ribs as well. Pt [patient] was taken to the ER [emergency room] at [hospital name omitted] and had his wrists bandaged, and due to his severe depression he was admitted to [hospital name omitted] for psychiatric evaluation and stabilization. The assessment documented that the resident may be a substantial danger to himself or others. The assessment documented the recommendations as Pt would likely benefit from counseling services to learn ways to cope with his psychiatric sxs [signs and symptoms]. On 5/25/23, resident 14's care plan for meets PASRR level II determination was initiated. The goal was that resident 14 would receive specialized services as recommended by the PASRR level II evaluation. On 5/27/24, an intervention was initiated for PASRR Recommendations for specialized services treatment: Pt would likely benefit from counseling services to learn ways to cope with his psychiatric sxs. On 10/2/24 at 1:14 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 14 was blue sheeted to the hospital a couple of months back. The DON stated that something upset resident 14 and he believed it had to do with the resident being out of cigarettes. The DON stated that resident 14 walked away and said might as well get a body bag. The DON stated that he went and talked to resident 14 and he was holding a butter knife. He looked like he was about to cut himself, one arm extended like he was going to cut himself. The DON asked resident 14 to give him the knife and he did. The DON stated that he asked resident 14 if he was actively suicidal and he responded yes. The DON stated that he asked if he had a plan and resident 14 replied what do you think?. The DON stated that resident 14 did not want to go to the hospital so the provider blue sheeted him. The DON stated that resident 14 did not have a psychosocial assessment after the incident. The DON stated that resident 14 reported to the hospital that he was doing the suicidal ideation behavior in an attempt to obtain cigarettes and that was why they did not admit resident 14 to psychiatric unit. The DON stated that the provider ordered Abilify for resident 14 after his re-admission. The DON stated he could not recall if resident 14 was evaluated by a Social Service Worker (SSW) after his re-admission. The DON stated that a SSW should evaluate a resident after any suicidal ideations or suicidal attempts. The DON stated that resident 14 was receiving behavioral health services but did not know when those services began. On 10/02/24 at 1:37 PM, a telephone interview was conducted with Registered Nurse (RN) 3. RN 3 stated that resident 14 was very depressed, and was trying to hurt himself. RN 3 stated that she was not aware of what happened to initiate the depression. RN 3 stated that resident 14 did not have therapy services prior to being sent to the hospital for suicidal ideations in March 2024. RN 3 stated that she thought resident 14 had therapy since the suicidal ideations but does not know who provided it or the frequency of the visits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not provide routine and emergency drugs and biological to its residents. Specifically, a resident was not provided their psychotropic medications for multiple days due to unavailability from the pharmacy. Resident identifier: 9. Findings included: Resident 9 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included epidural hemorrhage, stable burst fracture of T11-T12, type 2 diabetes mellitus, chronic obstructive pulmonary disease, morbid obesity, contusion of abdominal wall, hypertensive heart disease with heart failure, schizoaffective disorder, post-traumatic stress disorder, spondylolisthesis, insomnia, chronic pain, hypothyroidism, anxiety disorder, spinal stenosis cervical region, osteoarthritis, overactive bladder, history of suicidal behavior, and repeated falls. Resident 9's medical records were reviewed. Resident 9's progress notes revealed the following: a. On 6/4/24 at 7:15 AM, the Orders - Administration Note documented, Lurasidone HCl [hydrochloride] Oral Tablet 120 MG [milligram] Give 120 mg by mouth one time a day for give with food related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE. The note further documented that the medication was on order from the pharmacy. b. On 6/5/24 at 8:21 AM, the Orders - Administration Note documented, Lurasidone HCl Oral Tablet 120 MG Give 120 mg by mouth one time a day for give with food related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE. The note further documented med [medication] on order not availbale (sic) from the pharmacy. c. On 6/10/24 at 11:10 AM, the Orders - Administration Note documented, Lurasidone HCl Oral Tablet 120 MG Give 120 mg by mouth one time a day for give with food related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE. The note further documented Med not available from the pharmacy. d. On 6/10/24 at 6:16 PM, the Orders - Administration Note documented, Haloperidol Oral Tablet 10 MG Give 10 mg by mouth two times a day related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE. The note further documented medication n/a [not available] for dispense from the pharmacy. e. On 6/14/24 at 10:40 AM, the Nurses Note documented, Resident meloxicam and lurasidone will be deliver by this evening as per pharmacy. when I contact them this morning. f. On 6/18/24 at 10:26 AM, the Orders - Administration Note documented, Escitalopram Oxalate Oral Tablet 10 MG Give 1 tablet by mouth one time a day related to GENERALIZED ANXIETY DISORDER. The note further documented med n/a for dispense will f/u [follow-up] c [with] rx [pharmacy]. g. On 6/21/24 at 4:47 PM, the Nurses Note documented, Resident reported to one of the aides that she jabbed another resident with a pen last night 'hard enough to leave a mark' because she is 'fucking psychotic and manic' (referring to herself). Review of the June 2024 Medication Administration Record (MAR) revealed that resident 9's Lurasidone 120 mg was documented as not administered with a code of 9 (see progress note) on 6/4/24, 6/5/24, and 6/10/24. The MAR also documented that resident 9's Escitalopram 10 mg was not administered on 6/18/24 with a code of 9, and the Haloperidol 10 mg was not administered on 6/10/24 with a code of 9. On 6/21/24 at 9:50 PM, the hospital behavioral health intake note documented that another resident with dementia came into her room, touched her things and resident 9 stabbed her with a pencil. Per pt [patient], she was trying to write 'stop it' on the residents arm. Pt told staff, 'I'm fucking psychotic and manic.' Pt stated that facility was unable to get Latuda for a week and a half and restarted four days ago. The note further documented that the resident denied any aggression but did note increased irritability d/t [due to] being off her Latuda. Which isn't my fault, the care facility is supposed to take care of shit like that. That's why people are admitted to that kind of facility Patient reports that while she is still irritable, she is feeling better and far less irritable than she was a week ago. 'I just told them that woman pisses me off and make me want to stab her. There's a lot of shit I want to do and don't do, I'm civilized, but I can still get pissed. When you are off your medication and someone is intentionally pushing your buttons, eventually you will say something and that's all I did. On 9/24/24 at 8:26 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that the process for reordering medication was to pull the sticker off the blister pack and place on a reorder sheet, and that reorder sheet was filled out daily. RN 1 stated that she would also verify in the medication cart if the resident had any additional blister packs that may have been overlooked. RN 1 stated that if a medication was low they would reorder when there were 8-10 pills remaining. RN 1 stated that the pharmacy would take usually 2 days to fill any requested medications unless they were having issues with authorization from the insurance. RN 1 stated that the Latuda was not available in the facility Nexsys system but that Haldol was. RN 1 stated that she documented in the MAR if a medication was not available and was on order from the pharmacy. RN 1 stated that she also called the pharmacy but they were not the best at responding and delivering timely. RN 1 stated that she could recall waiting at least 3 days for medication to be delivered in the past. RN 1 confirmed that she documented that the Latuda was not available on 6/4/24 and 6/5/24. RN 1 stated that n/a in the MAR meant not available. RN 1 stated that resident 9 became manic when she was not provided her antipsychotic medication as prescribed. On 9/24/24 at 1:49 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the process for ordering medication from the pharmacy was to peel the reorder sticker and fax it to the pharmacy daily when that medication had 7 days remaining in the current blister pack. The DON stated that medication deliveries were not consistent, but generally they were delivered by the next day. The DON stated that if a medication was unavailable the staff should look in the Nexsys system, contact the pharmacy for timeframe of delivery, reach out to the provider to notify them, and generally a hold order would be placed until they become available again. The DON stated that the nurses should document this in a progress note. The DON stated that if a resident was not provided their ordered psychotropic medications it could cause an exacerbation of their psychiatric illness. The DON stated that he had read the note that resident 9 had not received their Latuda. The DON stated that he called the pharmacy and balled them out. The DON stated that when he identified that the medication was out of stock he called the pharmacy and they did not provide a good explanation, and that the general explanation was due to a dose change. It should be noted that the June MAR documented that the Lurasidone 120 mg dose was started on 8/5/23 and was discontinued on 6/26/24 and a dose change had not been ordered at the time the medication was unavailable from the pharmacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that for 2 out of 28 sampled residents, the facility did not ensure that resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, the facility did not monitor the blood sugars of a resident receiving insulin, did not administer a resident's thyroid medication, address a resident's continued pain, or use non-pharmacological pain interventions. Resident identifiers: 9, 32. Findings included: 1. Resident 32 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, essential hypertension, hemiplegia and hemiparesis following a cerebral infarction, hyperlipidemia, and chronic obstructive pulmonary disease. Resident 32's medical record was reviewed on 9/22/24. Resident 32's physician orders revealed the following: a. Resident 32's physician's orders dated 6/25/24, documented Insulin Glargine 20 units subcutaneous one time a day. b. Resident 32's physician's orders dated 6/18/24, documented HumaLOG Solution 100 UNIT/ML [milliliter] inject as per sliding scale. This medication was discontinued on 7/22/24. c. Resident 32's physician's orders dated 6/9/24, documented Monitor BG [blood glucose] Q [every] AM [morning]. This order was discontinued on 7/22/24. d. Resident 32's physician' orders dated 9/20/24, documented Daily BG one time a day for 10 days with an end date of 10/1/24. A review of resident 32's Medication Administration Record [MAR] revealed that no blood glucose levels were taken on 6/9/24, 6/10/24, 6/11/24, and 6/12/24. No blood glucose levels were reported from 7/23/24-8/31/24. On 6/27/24 at 1:19 PM, a physician admission history and physical documented, .She is in her bed. says she hates having her fingers poked and wonders when we can stop. She started on jardiance this week and understands that we will lower her insulin slowly. Discussed her care plan and health history. Asked about CGM [continuous glucose monitor] when roommate [sic] mentioned it. On 9/23/24 at 9:50 AM, an interview was conducted with Registered Nurse [RN] 1. RN 1 stated that nurses perform the blood glucose checks on the residents. RN 1 stated that any resident that was prescribed insulin should have their blood glucose levels monitored at least daily, but preferably before every meal. RN 1 stated that if a resident received insulin once a day then the blood glucose level should still be taken. RN 1 stated that an order was required before a blood glucose can be taken and the results were documented in the MAR. On 10/1/24 at 08:31 AM, an interview was conducted with the Director of Nursing [DON]. The DON stated that the facility monitored residents that received insulin based on the medical providers recommendations and the nurses obtained the blood glucose. The DON stated that some residents did not like getting the finger sticks that were required when a blood glucose was obtained. The DON stated that he was unsure if there would be an order for no finger sticks in a resident's medical record. The DON stated that it would be up to the doctor to decide if a blood glucose level was needed. The DON stated that this information would be documented in a physician note at the very least, but preferably would be documented in a progress note. The DON stated he would check the resident's medical chart for documentation or orders for no finger sticks for the resident. No follow up information was provided by the DON.2. Resident 9 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included epidural hemorrhage, stable burst fracture of T11-T12, type 2 diabetes mellitus, chronic obstructive pulmonary disease, morbid obesity, contusion of abdominal wall, hypertensive heart disease with heart failure, schizoaffective disorder, post-traumatic stress disorder, spondylolisthesis, insomnia, chronic pain, hypothyroidism, anxiety disorder, spinal stenosis cervical region, osteoarthritis, overactive bladder, history of suicidal behavior, and repeated falls. Resident 9's medical records were reviewed. Resident 9's September 2024 Medication Administration Record (MAR) revealed the following: a. On 8/5/23, an order was initiated for Levo-T Oral Tablet 100 MCG [micrograms] (Levothyroxine Sodium) Give 100 mcg by mouth one time a day related to HYPOTHYROIDISM, UNSPECIFIED. The order was discontinued on 9/22/24. On 9/18/24, the Levothyroxine was not documented as administered. b. On 12/11/23, an order was initiated for OxyCODONE HCl [hydrochloride] Capsule 5 MG [milligram] Give 1 capsule by mouth every 6 hours as needed for moderate to severe pain. The order was discontinued on 9/22/24. On 9/13/24 at 6:28 PM, the Oxycodone 5 MG was documented as ineffective. On 9/13/24 at 10:09 PM, the Orders - Administration Note documented that the Oxycodone 5 mg was ineffective and the follow-up pain score was a 7 out of 10, with 10 being the worst possible pain. No documentation could be found to indicate that the resident 9's pain was addressed after the oxycodone was documented as ineffective. Additionally, no documentation could be found on the Treatment Administration Record (TAR) to indicate that non-pharmacological interventions were being monitored or implemented for resident 9's pain. On 9/23/24 at 9:47 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that for ineffective pain control she would notify the Director of Nursing (DON) and the provider to see if they could increase the pain medication or administer any additional pain medication. RN 1 stated that it would be documented in a progress note and she would expect to see something documented that other interventions or attempts were made to control the resident's pain. On 10/01/24 at 8:20 AM, an interview was conducted with the DON. The DON stated that the licensed nurse should call the provider if pain medication was documented as ineffective and seek further instruction. The DON stated that the nurse should document in a progress note that the provider was notified. The DON stated that on 9/18/24 the Levothyroxine was not documented as administered, and without it being documented you would not know if the medication was actually administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not ensure that the resident's drug regimen was free from unnecessary psychotropic drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use. Specifically, a resident's psychotropic medications were not monitored for behavioral episodes, non-pharmacological interventions, and adverse side effects of the medications. Resident identifier: 9. Findings included: Resident 9 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included epidural hemorrhage, stable burst fracture of T11-T12, type 2 diabetes mellitus, chronic obstructive pulmonary disease, morbid obesity, contusion of abdominal wall, hypertensive heart disease with heart failure, schizoaffective disorder, post-traumatic stress disorder, spondylolisthesis, insomnia, chronic pain, hypothyroidism, anxiety disorder, spinal stenosis cervical region, osteoarthritis, overactive bladder, history of suicidal behavior, and repeated falls. Resident 9's medical records were reviewed. Resident 9's September 2024 Medication Administration Record (MAR) revealed the following: a. On 5/11/24, an order was initiated for Escitalopram Oxalate Oral Tablet 10 MG [milligram] (Escitalopram Oxalate) Give 1 tablet by mouth one time a day related to GENERALIZED ANXIETY DISORDER. b. On 6/27/24, an order was initiated for Lurasidone HCl [hydrochloride] Oral Tablet (Lurasidone HCl) Give 160 mg by mouth one time a day related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE. c. On 8/8/23, an order was initiated for clonazePAM Oral Tablet 0.5 MG (Clonazepam) Give 0.5 mg by mouth two times a day related to GENERALIZED ANXIETY DISORDER. d. On 8/8/23, an order was initiated for Haloperidol Oral Tablet 10 MG (Haloperidol) Give 10 mg by mouth two times a day related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE. e. On 1/16/24, an order was initiated for BEHAVIOR Antipsychotic medication: Hallucinations/Delusions every shift for Behavior Monitoring. No documentation could be found to indicate that monitoring was conducted for adverse side effects of the antianxiety and antipsychotic medications, or any monitoring for episodes of anxiety. Additionally, no documentation was found of non-pharmacological interventions that were provided prior to the administration of the antianxiety and antipsychotic medications. On 10/01/24 at 8:20 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the licensed nurse should monitor for adverse side effects of the psychotropic medications, effectiveness of medications, and any episodes of behavior. The DON stated that the nurses were typically really good at monitoring in the Treatment Administration Record (TAR).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined for 2 out of 28 sample residents, that the facility did not ensure that it was free of medication error rates of five percent or greater. Observations of 27 medication opportunities, on 9/24/24, revealed two medication errors which resulted in a 7.41% medication error rate. Specifically, wrong doses of medications were given. Resident identifiers: 12, 31. Findings included: 1. Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, traumatic subarachnoid hemorrhage, cerebral infarction, chronic obstructive pulmonary disease, temporal sclerosis, dementia, paranoid schizophrenia, anxiety disorder, and major depressive disorder. On 9/24/24 at 7:15 AM, Registered Nurse (RN) 1 was observed to spill the medication cup across the medication cart that contained resident 12's medications. One tablet of Haloperidol remained in the medication cup. RN 1 replaced two tablets of Haloperidol 1 milligram (mg) and Aripiprazole 30 mg. It was observed that there was an incorrect dosage of Haloperidol in the medication cup. On 9/24/24 07:19 AM, RN 1 was observed to enter resident 12's room when the surveyor stopped RN 1 and asked RN 1 if the medications were correct that she was about to administer to resident 12. RN 1 removed one of the Haloperidol tablets from the cup with a gloved hand and disposed of the medication in a sharps container. RN 1 stated she did not realize that there were 3 tablets in the cup. RN 1 stated she would have given the medication if the surveyor had not intervened. RN 1 stated that in her opinion giving 3 mg of Haloperidol would not have done anything to the resident because the resident took so much medication already. RN 1 stated that she did not know the side effects, signs of overdose, or adverse reactions of Haloperidol. Resident 12's medical record was reviewed for the reconciliation of medication on 9/24/24. According to Physician's orders, resident 12 was to receive Haloperidol Tablet 1 MG: 2 tablets by mouth two times a day. 2. Resident 31 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, bipolar disorder, chronic obstructive pulmonary disease, venous insufficiency, generalized anxiety disorder, post-traumatic stress disorder, diarrhea, gastro-esophageal reflux disease, and obsessive-compulsive disorder. On 9/24/24 at 7:07 AM, RN 1 was observed to prepare and administer medications to resident 31. RN 1 administered one tablet of Loperamide 2 mg to resident 31. Resident 31's medical was reviewed for the reconciliation of medication on 9/24/24. According to Physician's orders, resident 31 was to receive Loperamide HCl Oral Tablet 2 mg: 2 tablets by mouth three times a day (TID) for diarrhea. On 9/24/24 at 7:46 AM, an interview was conducted with RN 1. RN 1 stated that she always double checks the medication cup before she gave residents their medications to prevent errors. RN 1 stated that she checked the medication card and the milligrams of all medications. RN 1 stated that if she gave a wrong dose of medication she would notify the Director of Nursing (DON), notify the provider, monitor the resident, notify the family and follow whatever instructions the provider would want them to do. On 10/1/24 at 9:00 AM, an interview was conducted with the DON. The DON stated that medication errors are classified as the wrong dose, wrong resident, wrong medication, and the wrong route. The DON stated that for all medication errors, once it was identified the nurse should contact the provider first and seek instruction. The DON stated if it was a less urgent medication error then the nurse should just monitor the resident. The DON stated that for all errors alert charting should be started and an incident report completed, but that was not always done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not promptly notify the ordering physician of laboratory results that fall outside of clinical reference ranges, and only obtain laboratory services when ordered by a physician. Specifically, a resident's Basic Metabolic Panel (BMP) and lipid panel had results out of range and the provider was not notified and a BMP and lipid panel were obtained without a physician order. Resident identifier 14. Findings included: Resident 14 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included cerebral infarction, hemiplegia and hemiparesis, cognitive communication deficit, chronic obstructive pulmonary disease, pain, major depressive disorder, dementia, insomnia, cervical disc degeneration, spondylosis with myelopathy, alcoholic polyneuropathy, hypertension, osteoarthritis, radiculopathy, cirrhosis of liver, hyperlipidemia, nicotine dependence, alcohol abuse, cannabis abuse, suicide attempt, suicidal ideations, ventral hernia, trochanteric bursitis of left hip, and lesion of ulnar nerve. Resident 14's medical records were reviewed. On 1/30/24, resident 14 had laboratory results for a BMP and lipid panel. It should be noted that no documentation could be found of a physician order for the laboratory services. On 1/30/24, resident 14's BMP and lipid panel results documented abnormal ranges for Potassium at 5.3 high (H), Chloride at 101 low (L), and total Cholesterol at 112 L. It should be noted that no documentation was found to indicate that resident 14's physician was notified of the results. Additionally, the lab result did not contain any signatures or dates by the provider. On 2/6/24, resident 14's physician ordered a BMP one time only for sodium level. On 2/6/24, resident 14's BMP results documented abnormal ranges for Sodium at 135 L, Potassium at 5.1 H, Chloride at 99 L, and Creatinine at 0.74 L. It should be noted that no documentation was found to indicate that resident 14's physician was notified of the results. Additionally, the lab result did not contain any signatures or dates by the provider. On 9/25/24 at 9:20 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that lab orders were placed by him and he followed-up with the providers. The DON stated that the laboratory process was that the order requisition was placed in the computer system and a resident face sheet was placed in a binder for the phlebotomist. The DON stated that the order requisition did not have a carbon copy for the facility records. The DON stated that the lab placed the results in the portal and it notified him automatically when the results were ready. The DON stated that the lab would call him directly if the labs had critical high or low values. The DON stated that once the provider reviewed the report they would sign the report and then it was scanned into the resident's medical records. The DON stated that he was the only staff that had access to the portal with the laboratory results. The DON stated that the results were also faxed to the facility at the same time they were uploaded into the portal. The DON stated that part of the process was making sure that the nurses were documenting in a progress note that the labs were being done. The DON stated that all labs should have the date and signature of the provider once they have been reviewed. On 10/01/24 at 11:01 AM, a follow-up interview was conducted with the DON. The DON stated that they did not have an order for the labs that were obtained on 1/30/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that for 1 of 28 sampled residents that the facility did not file in the resident's clinical record laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, there were two instances where a resident had physicians orders for a residents lithium levels to be checked, but the results of these lithium level checks were not filed or uploaded in the resident's electronic medical record. Resident Identifier: 31. Findings Included: Resident 31 was admitted [DATE] with diagnoses including bipolar disorder, chronic obstructive pulmonary disease, asthma, venous insufficiency, generalized anxiety disorder, post-traumatic stress disorder, unspecified combined systolic and diastolic heart failure, peripheral vascular disease, unspecified cirrhosis of liver, obsessive-compulsive disorder, and chronic embolism and thrombosis of unspecified deep veins of right lower extremity. Resident 31's medical record was reviewed. The following physician orders were reviewed: a. Lithium level one time a day for Monitoring for 1 day. This order was placed on 5/9/24. There were no lab results uploaded in Resident 31's electronic medical record for this order. The facility was able to provide a copy of the lab results upon request. The results came back on 5/10/24 as a 0.8, indicating that Resident 31's lithium levels were within normal limits. b. Re-check lithium 5/30 one time a day for Monitoring for 1 day. This order was placed on 5/30/24. There were no lab results uploaded in Resident 31's electronic medical record for this order. The facility was able to provide a copy of the lab results upon request. The results came back on 5/30/24 as a 1.0, indicating that Resident 31's lithium levels were within normal limits. On 10/03/24 at 10:35 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the requested lithium labs that were not uploaded into Resident 31's medical record should have been uploaded into Resident 31's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 out of 28 sampled residents, that the facility did not file in the resident's clinical record signed and dated reports of radiologic and other diagnostic services. Specifically, a resident's 12 lead electrocardiogram (EKG) was not in the medical records. Resident identifier 14. Findings included: Resident 14 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included cerebral infarction, hemiplegia and hemiparesis, cognitive communication deficit, chronic obstructive pulmonary disease, pain, major depressive disorder, dementia, insomnia, cervical disc degeneration, spondylosis with myelopathy, alcoholic polyneuropathy, hypertension, osteoarthritis, radiculopathy, cirrhosis of liver, hyperlipidemia, nicotine dependence, alcohol abuse, cannabis abuse, suicide attempt, suicidal ideations, ventral hernia, trochanteric bursitis of left hip, and lesion of ulnar nerve. Resident 14's medical records were reviewed. On 3/15/24, resident 14's physician ordered a 12 lead EKG, one time a day for monitoring for 2 days. No documentation could be found in resident 14's medical records of the EKG reports. On 10/01/24 at 11:01 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the 12 lead EKG report was obtained today. The DON stated that the report was sent to the provider but not to the facility. The DON stated that it would be uploaded into resident 14's records today.

Based on observation, interview, and record review, it was determined that for 2 of 28 sampled residents, that the facility did not ensure that each resident received and the facility provided food prepared by methods that conserve nutritive value, flavor, and appearance; food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, there were resident complaints about the food served at the facility, a test tray was pulled and found to be unappetizing, and there were resident council complaints regarding the food served at the facility. Resident Identifiers: 17 and 30. Findings Included: On 9/22/24 at 12:43 PM, Resident 17 was observed to complain that the lunchtime meal served was too cold during a lunchtime meal observation. At 12:46 PM, Resident 17 further complained that the food served would be good if it was warm. A resident council note dated 9/6/24 documented a resident complaint of pork that was served undercooked and too tough to chew. A resident council note dated 7/17/24 documented a resident complaint of burnt eggs that were frequently served with breakfast meals. On 9/22/24 at 1:26 PM, an interview was conducted with Resident 30. Resident 30 stated that the food served at the facility sucked and that the food was bland. On 9/25/24 at 12:35 PM, a test lunch tray was pulled. The collard greens were found to be soggy and bland. The potatoes had a chunky texture. The corn bread served with the meal was overly salty and was not sweet. The soup served with lunch was overly salty. The apple pie mousse dessert tasted like plain sour yogurt. On 9/25/24 at 1:07 PM, an interview was conducted with the Corporate Dietitian (CD). The CD stated that if residents had food complaints, they could fill out a grievance form. The CD stated that the dietary manager followed up with residents that filed grievances individually and would update their tray tickets.

Based on interview and record review it was determined that the facility did not ensure that the quality assessment and assurance committee met at least quarterly to coordinate and evaluate activities under the Quality Assurance and Performance Improvement (QAPI) program. The Quality Assessment and Assurance (QAA) Committee must be composed of, at a minimum: The Director of Nursing (DON); the Medical Director or his/her designee; at least three other members of the facility staff and one must be the Administrator; and the infection preventionist. Specifically, there was no evidence that the Medical Director participated in the quarterly QAPI meetings. Findings included: Review of the QAPI team revealed that the QAA committee members were the Administrator, the DON, Therapeutic Recreation Specialist (TRS), the Resident Advocate (RA), the Maintenance Director, the Business Office Manager, and the Dietary Manager. The QAA committee did not have the Medical Director listed as a participating member. The facility 2024 Quality Assurance and Performance Improvement (QAPI) Plan was reviewed and documented that the QAPI Committee consisted of the Nursing Home Administrator (NHA), the Director of Nursing (DON), the Medical Director, at least two additional staff members (who can be direct care team members), the Infection Preventionist (effective 2019) and other consultants as deemed necessary by the committee. The plan further documented, The Medical Director is accountable for providing leadership for, and is actively involved in the implementation of, the QAPI program. Performance accountabilities for the Medical Director include, but are not limited to, the following: 1. Validating that quality management initiatives pertaining to the delivery and management of care are clinically sound, promote consumer safety, and are based on current best practices. 2. Participating in and providing support to other committees for the development of appropriate assessment and evaluation efforts, intervention strategies, and corrective action plans. 3. Involving providers and representatives of medical delivery systems in reviewing and planning the QAPI program's core activities. On 10/03/24 at 12:39 PM, an interview was conducted with the Administrator (ADM). The ADM stated that the QAA committee met quarterly but also as needed when issues arise. The ADM stated that if they see something that they could improve they document it, make a plan and talk about it as an Interdisciplinary Team (IDT). The ADM stated that the quarterly meetings were attended by the DON, RA, kitchen staff, TRS, and the ADM. The ADM stated that he would provide the Maintenance Director notes of the meeting. The ADM stated that they invited the Medical Director and tried to have him attend depending on his schedule. The ADM stated that they typically just followed-up with notes to the Medical Director. The ADM stated that the Medical Director did not attend the last quarterly meeting in June 2024, and he was not sure if he attended the prior quarterly meeting in March 2024.

Based on observation and interview it was determined, for 2 out of 28 sampled residents, that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, medications were not administered in a sanitary manner. Resident Identifiers: 12 and 25. Findings included: On 9/24/24 at 7:12 AM, an observation was made of Registered Nurse (RN) 1 during the morning medication pass. RN 1 was observed preparing medications for resident 12. RN 1 did not perform hand hygiene prior to removing the medication from the medication packs. RN 1 was observed to drop medications out of the medication cup onto the medication cart and the floor. RN 1 was observed to scoop up a medication that was half in the medication cup and half on the medication cart. RN 1 was observed to put more medication into the same medication cup and give the medications to resident 12. On 9/24/24 at 7:23 AM, an observation was made of RN 1 during the morning medication pass. RN 1 was observed to drop medication onto the cart and onto the floor. RN 1 was observed to bend down and pick the medication up off the floor, dispose of the medication in the sharps container, and continue to prepare medications for resident 25 without performing hand hygiene. On 9/24/24 at 7:28 AM, an interview was conducted with RN 1. RN 1 stated that she always performed hand hygiene before she began medication pass. RN 1 stated that she sometimes gets distracted by residents that come up to the cart and possibly touches the resident or other things before returning to the medication preparation. RN 1 states that if she dropped medications then she would dispose of them in the sharps container and then continue on with the medication pass. On 10/1/24 at 9:00 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the expectation for staff was to perform appropriate hand hygiene prior to beginning any tasks that involved resident care. The DON stated that nurses should be using hand sanitizer before preparing medications, going into the resident's room, and upon exiting the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not establish an infection prevention and control program (IPCP) that included an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, a resident was receiving an antibiotic for a urinary tract infection and the facility did not follow up with the hospital for the culture and sensitivity results. Resident identifier: 19. Findings included: Resident 19 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included, but not limited to, Alzheimer's Disease, dementia, type 2 diabetes mellitus, bipolar disorder, anxiety disorder, hyperkalemia, peripheral vascular disease, and gastro-esophageal reflux disease without esophagitis. Resident 19's medical record was reviewed on 9/22/24. Resident 19's progress notes were reviewed and revealed the following: a. On 9/4/24 at 3:21 AM, Orders - General Note from eRecord Note Text: Resident returned from the [hospital name]ER department at 0245 [2:45 AM]. She had requested to go to the hospital because she was feeling sick. not feeling well. ER [Emergency Room] department performed the following tests CT [computed tomography]of her brain/head CT maxillofacial w/o [with out]contrast CT spine cervical w/o contrast CBC [complete blood count] w/ auto Diff CMP [comprehensive metabolic panel] Lipase level Urinalysis w[with]/ microscope Everything was found to be unremarkable, except the urinalysis. A urinary tract infection was found, and resident was given a Rocephin shot. b. On 9/11/2024 at 2:37 AM, Alert Note Note Text: ANTIBIOTICS: Since resident returned from the hospital, she hasn't been taking antibiotics. Staff report no foul-smelling order. Resident not verbalizing pain but scored 4/10 on PAINAD [pain assessment in advanced dementia] scale. On 9/24/24 at 1:52 PM, an interview was conducted with the Director of Nursing [DON]. The DON stated that he got orders from the discharge instructions when a resident returned to the facility from the hospital. The DON stated that he reached out to the hospital for culture results and had not had any luck in getting the records. The DON stated that the resident would have the antibiotics administered for the duration the hospital ordered and alert charting would be put in place to monitor the resident for symptoms. On 10/03/24 at 10:05 AM, a follow up interview was conducted with the DON. The DON stated that he did not receive the culture and sensitivity report from the hospital for resident 19. The DON stated that hospital discharge papers showed that a culture and sensitivity was to be performed for resident 19, but was not verified by the DON. The DON stated he would be contacting the hospital for the records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that for 1 of 28 sampled residents, that the facility did not ensure that any individual working in this facility working as a paid feeding assistant had completed a State-approved training program for feeding assistants. Specifically, a staff member who was not a Certified Nursing Assistant (CNA), a Licensed Nurse, or a paid feeding assistant assisted a resident with a feeding. Resident Identifier: 28. Findings Included: Resident 28 was admitted [DATE] with diagnoses including aphasia following cerebrovascular disease, other frontotemporal neurocognitive disorder, moderate protein-calorie malnutrition, vitamin B12 deficiency anemia unspecified, and dementia in other diseases classified elsewhere moderate with agitation. Resident 28's medical record was reviewed. Resident 28's CNA documentation in the Point of Care Response History section was reviewed for the dates of 9/4/24 through 10/2/24. There were 4 occurrences where resident 28 was able to eat independently. There were 8 occurrences where resident 28 required supervision while eating. There were 21 occurrences where resident 28 required limited assistance while eating. There were 16 occurrences where resident 28 required extensive assistance while eating. There were 16 occurrences where resident 28 was totally dependent on staff to eat his meals. On 10/2/24 at 11:58 AM, an interview was conducted with Staff 8. Staff 8 stated that on 10/2/24 around 9:30 AM that they had entered resident 28's room and noticed that resident 28 had not received any dining assistance with his breakfast meal. Staff 8 stated that it appeared resident 28 had not eaten any food, so they assisted resident 28 by feeding him his meal. Staff 8 stated that they were not a CNA. Facility entrance documents stated that the facility does not have any paid feeding assistants. On 10/2/24 at 12:53 PM, an interview was attempted with resident 28. Resident 28 was unable to respond to questions asked. On 9/25/24 at 10:02 AM, an interview was conducted with Nursing Assistant (NA) 1. NA 1 stated that staff can check the facility [NAME] to find out what dining assistance each resident needed. NA 1 stated that staff can also ask their co-workers what assistance residents needed. NA 1 stated that the kitchen staff sent a meal ticket with each resident's meal that specified any allergies, the diet order, and any assistance needed. On 10/2/24 at 2:13 PM, an interview was conducted with Certified Nursing Assistant 1. CNA 1 stated that resident 28 ate finger foods like sandwiches easily, but struggled with foods that required fine motor control such as soup with a spoon. On 10/2/24 at 12:58 PM, an interview was conducted with CNA 2. CNA 2 stated that resident 28 did well with finger foods and that he could use a spoon. CNA 2 stated that resident 28 did not use his right arm and that she was unsure whether or not that was his dominant hand. CNA 2 stated that resident 28 struggled to eat with his left hand. On 10/3/24 at 10:09 AM, an interview was conducted with the Administrator (ADM). The ADM stated that staff who were not CNA's, Nurses, Speech Therapists, or paid feeding assistants should not be assisting residents with feedings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that for 3 of 28 sampled residents, that the facility did not treat each resident with respect and dignity. Specifically, staff at the facility were observed standing next to residents while assisting them with eating, staff were observed using labels instead of resident names when addressing residents, residents were not served meals at the same time, and residents did not receive necessary assistance during dining. Resident identifiers: 11, 18, and 19. Findings included: 1. On 9/22/24 at 12:32 PM, an observation was made of the lunch time dining service. Nursing Assistant (NA) 2 was observed to assist Resident 19 with eating her meal. NA 2 was standing next to Resident 19 while assisting her with eating. 2. On 9/23/24 at 8:09 AM, an observation was made of the breakfast time dining service. The facility had already started to serve meals by the time the observation had started. At 8:17 AM, all residents had been served their meals except for Resident 11. At 8:23 AM, Resident 11 finally received his meal after staff tracked it down from the cart used to deliver meals to residents who eat in their rooms. On 9/25/24 at 10:02 AM, an interview was conducted with NA 1. NA 1 stated that when assisting residents with feedings, staff should sit next to residents to promote dignity. NA 1 stated that the assistance each resident requires varies. NA 1 stated that some residents just need to be coached while others may need to be fed manually. 3. Resident 18 was admitted to the facility on [DATE] with diagnoses which consisted of asthma, dementia, hypertension, hyperlipidemia, insomnia, overactive bladder, gastro-esophageal reflux disease, hypokalemia, malignant neoplasm, chronic pain, unspecified protein-calorie malnutrition, anxiety disorder, and major depressive disorder. Resident 18's medical records were reviewed. Resident 18's diet order was for a no added salt diet, regular texture, regular consistency. On 8/27/24, the Minimum Data Set (MDS) Assessment documented that resident 18 required supervision or touching assistance for eating. On 8/29/24, resident 18's nutritional assessment documented that resident 18 required setup help and supervision for dining. On 9/22/24 at 12:41 PM, an observation was made of resident 18 during the lunch meal service. Resident 18 was observed lifting her fork to her mouth two times without any food on the utensil. Nurse Assistant (NA) 1 was observed to load resident 18's fork with mashed potatoes and beef and attempted to feed the resident while standing at the resident's side. The aide offered the resident a bite of food but did not take the utensil fully to resident 18's mouth. Flies were observed to be hovering and then landing on resident 18's head during the meal. On 10/01/24 at 12:52 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the aides should be seated with the resident when assisting with dining. The DON stated that the aides should load the utensil for the resident, cue the resident to eat, or provide total assistance with feeding the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident 91 was admitted [DATE], readmitted [DATE], and discharged [DATE] with diagnoses including unspecified focal traumatic brain injury with loss of consciousness status unknown sequela, type 2 diabetes mellitus, chronic obstructive pulmonary disease, dementia, generalized anxiety disorder, and major depressive disorder. Resident 92 was admitted [DATE], discharged [DATE] with diagnoses including Alzheimer's disease, dementia, other psychotic disorder, mood disorder, unspecified psychosis, anxiety disorder, and major depressive disorder. Resident 2 was admitted [DATE], readmitted [DATE] with diagnoses including unspecified focal traumatic brain injury with loss of consciousness status unknown sequela, type 2 diabetes, chronic obstructive pulmonary disease, and dementia. On 4/18/24, a facility reported incident was submitted to the state survey agency documenting an allegation of sexual abuse between Resident 91 and Resident 92. The report documented that Resident 91 had kissed Resident 92 on the lips. On 4/19/24, a facility reported incident was submitted to the state survey agency documenting an additional allegation of sexual abuse between Resident 91 and Resident 92. The report documented that Resident 91 had again kissed Resident 92 on the lips. On 3/29/24, a facility reported incident was submitted to the state survey agency documenting an allegation of physical abuse between Resident 91 and Resident 2. The report documented that Resident 91 had punched Resident 2. On 10/2/24 at 9:27 AM, an interview was conducted with the Former Business Office Manager (FBOM) via telephone. The FBOM stated that she witnessed the incident on 4/18/24 between Resident 91 and Resident 92. The FBOM stated that she had been walking to her office in the basement of the facility and had to pass through the facility dining room. The FBOM stated that she saw Resident 91 attempting to kiss Resident 92. The FBOM stated that she separated the two residents and told Resident 91 that it was inappropriate to try and kiss Resident 92. The FBOM stated that after she separated the two residents, she told the RA at the time about the incident. The FBOM provided a written statement that was stored with the facility's investigation for the incident on 4/18/34. The statement documented, At around 1:50 PM today when I was walking towards my office (basement) I saw [Resident 91] holding [Resident 92]'s face and kissing her lips. That happened by the basement door (Kitchen dining room area) I told [Resident 91] that that is wrong and he is not supposed to kiss anyone. I got/took [Resident 92]'s hand and walk away from him. Went to report to Resident's Advocate and nurse in charge. An attempt was made to contact the Former Resident Advocate (FRA) that completed the investigations for the incidents between Resident 91 and Resident 92 by telephone. The FRA's phone number was disconnected. A progress note written by the FRA dated 4/19/23 at 11:04 AM documented, Met with resident to discuss incident that occurred on 4/17/23. Asked resident what led him to kiss female resident. Resident says he meant no harm in kissing female resident and knows he should not have done it. I explained other resident's personal boundaries and asked him not to cross them. He shaked his head yes. Resident was in the dining room asked him to sit in the TV room as female resident was in the same area. He complied. A progress note written by the FRA dated 4/21/24 at 11:41 AM documented, Late entry for 4/18/23. Met with resident to assess for wellbeing changes post incident on 4/17/23. Resident was seen in dining room. She was confused and wandering, which is her baseline. Greeted resident and she smiled. Asked resident how she was feeling, but resident's response was not appropriate to topic. Reviewed nurses charting. Resident has no exhibited any signs or symptoms of distress. On 10/3/24 at 9:52 AM, an interview was conducted with the ADM. The ADM was not the administrator at the time of any of the three incidents involving Resident 91 happened. The ADM stated that Resident 91 kissed Resident 92 on 4/17/23. The ADM stated that there was another incident where Resident 91 kissed Resident 92 on 4/19/23. The ADM stated that two similar incidents occurring in a short period of time was indicative of a behavior that needed to be corrected. The ADM stated that a LCSW came in to assess both residents. The ADM stated that if he had been in the previous administrators shoes, he would have ensured that both residents remained separated, looked to see if there was underlying harm that a lay person could not see, and try to correct any inappropriate behaviors. The ADM stated that it is difficult to determine what he would have done given that Resident 91 and Resident 92 no longer reside at the building. The ADM stated that any interventions after this incident should have been documented in the facility's investigation. A review of the facility policy titled, Identifying Types of Abuse documented the following: Physical abuse includes, but is not limited to hitting, slapping, biting, punching or kicking. and Sexual abuse is non-consensual sexual conduct of any type with a resident. Based on interview and record review it was determined, for 9 out of 28 sampled residents, that the facility did not ensure that the resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Specifically, the facility did not protect residents from abuse following an incident of sexual abuse by a Certified Nurse Assistant (CNA), an incident of verbal abuse by a CNA, multiple incidents of physical abuse following residents to resident altercations, and two incidents of sexual abuse from other residents. Resident identifiers: 2, 7, 9, 14, 22, 85, 86, 91, and 92. Findings included: 1. Resident 7 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of presence of right and left artificial shoulder joint, chronic obstructive pulmonary disease, hypertensive heart disease, pulmonary hypertension, chronic pain syndrome, ventricular premature depolarization, insomnia, nonrheumatic mitral valve insufficiency, history of myocardial infarction, dysphagia, overactive bladder, lesion of ulnar nerve, hypertension, lymphedema, osteoporosis, and hyperlipidemia. On 9/22/24 at 10:15 AM, an interview was conducted with resident 7. Resident 7 stated that CNA 3 was a wonderful aide, he was jovial, he was lovely. Resident 7 stated that one day while talking to CNA 3 he had mentioned that he was going to Kauai, and he told her that he would take her with him. Resident 7 stated that she was not sure how it happened, but CNA 3 said that it would be better if she went as his wife. Resident 7 stated that CNA 3 had told her that he really cared for her. Resident 7 stated that it then felt like manipulation when CNA 3 had asked her to take a photo of her bare breast. Resident 7 stated that she told CNA 3 no and that it was not appropriate. Resident 7 stated that CNA 3 then told her that he must have an obedient wife. Resident 7 stated that she thought it was a ridiculous request and she felt uncomfortable. Resident 7 stated that after CNA 3 was terminated he sent threatening texts to her. Resident 7 stated that the texts said that he could not get a job, that she had ruined his life, and that he was so good to her. Resident 7 stated that she later learned from another aide that CNA 3 was married and had children. Resident 7 stated that she confronted CNA 3 via text, and he replied something nasty and that was the last of it. Resident 7 stated that she showed the text to one of the important people here and then he got fired. Resident 7 stated that CNA 3 was inappropriate, and that was the reason he lost his job and not her. Resident 7 stated She did nothing inappropriate. When you're a married man you don't ask another woman to be your wife. Obviously he has some mental issues and I don't know where he is now. Resident 7 stated that she texted CNA 3 and asked him if he asked her to be his wife so he could get American citizenship and he replied no. Resident 7 stated that she wished he had continued to be a good CNA and that he was a lot of fun. Resident 7 stated that this occurred approximately 6-8 months ago, and she no longer had contact with CNA 3. Resident 7 stated that CNA 3 had called her a silly woman with delusions and denied that it had occurred. Resident 7 stated that was when she handed the text over to the facility staff. Resident 7 stated that she did not have the text messages any longer and that she may have gotten a new phone since this occurred. Resident 7's medical records were reviewed. On 2/14/24, resident 7's Quarterly Minimum Data Set (MDS) Assessment documented that the resident had a Brief Interview for Mental Status (BIMS) score of 15, which would indicate that resident 7 was cognitively intact. On 3/18/24 at 6:11 PM, resident 7's Social Service Note documented, LCSW [Licensed Clinical Social Worker] met with [resident 7] to assess potential indicators of psychosocial distress. [Resident 7] appears friendly, attentive, communicative, well groomed, and happy. She exhibits speech that is normal in rate, volume, and articulation and is coherent and spontaneous. Language skills are intact. Mood presents as normal with no signs of either depression or mood elevation. Affect is appropriate, full range, and congruent with mood. Associations are intact. There were no signs of psychotic symptoms. She denies having suicidal ideas. Homicidal ideas or intentions are denied. Cognitive functioning and fund of knowledge are intact and age appropriate. Short- and long- term memory are intact. This patient is fully oriented. Vocabulary and fund of knowledge indicate cognitive functioning in the normal range. There are no signs of anxiety. There are no signs of hyperactive or attentional difficulties. [Resident 7's] behavior was cooperative and attentive with no gross behavioral abnormalities. When asked about the situation regarding the texts between her and an employee [resident 7] stated 'we were supposed to get married. I don't know why he would ask for pictures. That's not right' and 'he told me he wanted an obedient wife, and I told him children are obedient'. [Resident 7] expressed that 'now he is going to lose his CNA license and I didn't want that to happen.' When LCSW asked her how she was feeling she stated, 'I wish it could go back to how it was before, he was fun and we're not going to talk anymore, he said goodbye'. [Resident 7] was offered mental health services and declined stating 'I'm tired of talking about it.' Screening for s/sxs [signs and symptoms] abuse was negative. Based on review of resident's medical chart, assessments. staff observations, and clinical interview, resident does not appear to be experiencing psychosocial distress. The facility notification to the State Survey Agency (SSA), form 358, documented an allegation of sexual abuse by CNA 3 towards resident 7. The form documented that the Resident Advocate (RA) became aware of the incident on 3/18/24 at 9:22 AM. The details of the incident documented inappropriate phone correspondence between staff and a resident of a sexual nature. The form documented that the incident occurred on 3/14/24. Review of the facility investigation, form 359, revealed an interview that was conducted with resident 7. The interview summary documented, 'He was always very playful and fun with me. He never made any inappropriate comments until he asked to communicate with me through email. I told him that I don't use email well, and we exchanged phone numbers instead. Very early in the conversation, he suddenly said that he wanted me to be his wife. I enjoyed the conversation. Then he started asking me to send him nude photos of my breasts. I was surprised and a little annoyed by that. I told him that he can take them himself the next time he's at work (3/21).' DON [Director of Nursing] offered to assist her with blocking the perpetrator's number and she declined. The next day, upon learning of the investigation, perpetrator sent several frustrated messages to the resident, as divulged by her when DON met with her for the day. Resident expressed that she is not upset by the content of the messages, and when DON again offered to assist her to block the number, she again declined. Resident was not observed displaying any symptoms of distress, physical or psychological harm. She indicated that the two of them had never had any sort of inappropriate physical contact, and a complete skin check revealed no abnormalities. The summary of interviews also documented, No witnesses present with this incident, though the staff member that the resident divulged to read the text messages. The information obtained is quotations from the perpetrator's text messages to the victim: 'Good morning, [resident 7]! I need to get some sleep after my night shift. After that, I will start sending you messages on your cell phone and your email about our future trip to the islands with the aim of your recovery. Have a wonderful day!' '[Resident 7], I just sent a test message to your email. (Kissing emoji)' (The email simply said 'Hello [name omitted], this is a test email' 'Hey [name omitted]! I am so sorry, but I am very busy with my extra work. Don't worry, I am continuing to communicate with you and would like to hug you in a private place. I didn't use a car because public transport in Salt Lake City is perfect. But I understand your desire to make with me always. Would you like to be my wife?' 'Thanks for your amazing messages! But I would like to ask you a simple question: Would you like to be my wife? (Heart emoji)' 'If you are ready to be my wife, then send me a photo fo (sic) your bare breasts. I love you and much!! (Face and heart emoji)' 'Sorry, but you can't see your photo (Heart-eyes emoji)' 'I need an obedient wife, so try to send me your special photo' 'My spoken English is imperfect, so let's correspond .' '[name omitted], do you really love me?' The conclusion of the facility investigation verified the allegation of sexual abuse. The corrective action implemented by the facility was termination of CNA 3. The entry gate code was changed to ensure that CNA 3 had no ability to enter the facility grounds. On 9/30/24 at 2:59 PM, an interview was conducted with the RA. The RA stated that she became aware that resident 7 and CNA 3 had a relationship. The RA stated that it was texting, and she had viewed those text messages. The RA stated that she had taken photos of the text communication between CNA 3 and resident 7 but did not know if she still had those copies. The RA read the text messages that were documented in the facility abuse investigation, form 359, and stated that it was accurate. The RA stated that when she first spoke to resident 7 regarding this incident resident 7 was hinting about it to her. The RA stated that resident 7 seemed happy about the relationship because she thought she had found love. The RA stated that she persuaded resident 7 to show her the text communication with CNA 3. The RA stated that after reading the text messages she explained to resident 7 why it was wrong. The RA stated that she told resident 7 that CNA 3 had professional obligations and could not have relations with any resident, and that it was inappropriate and against the law. The RA stated that resident 7 had reported that nothing physical had happened. The RA stated that resident 7 did not seem upset about the request for nude photos but did state that it was inappropriate. The RA stated that resident 7 had replied that was not who she was, when CNA 3 stated he needed an obedient wife. The RA stated that she reported the incident to the DON immediately. On 10/01/24 at 3:00 PM, an interview was conducted with the Administrator (ADM). The ADM stated that he and the previous ADM conducted the investigation. The ADM stated that CNA 3 had begun texting resident 7. The ADM stated that resident 7 had the right to a romantic relationship but the staff could not have a romantic relationship with residents. The ADM stated that the RA had informed the ADM of the incident. The ADM stated that the RA had informed them of the text messages between resident 7 and CNA 3. The ADM stated that the messages were making resident 7 uncomfortable. The ADM stated it seemed like it was romantic and it went wrong. The ADM stated that he informed CNA 3 by the phone communication app that he was suspended. The ADM stated that they did not speak to CNA 3 and he seemed to avoid all conversation with the facility. The ADM stated that they attempted several times to call CNA 3 but was never able to communicate with him. The ADM stated that they changed the security code to the gate, they communicated with the staff through whats app that CNA 3 was not allowed back in the facility. The ADM stated that when he spoke to resident 7 she was embarrassed about the whole situation. The ADM stated that resident 7 had a good conversation with the RA and DON. The ADM stated We wanted to protect her but wanted to respect her rights. The ADM stated that they asked resident 7 if she wanted to continue talking to CNA 3 after he was terminated or if she wanted them to block his number. The ADM stated that resident 7 did not want to talk to CNA 3 anymore, did not want to respond to his texts, but did not want to block him. The ADM stated that he had viewed the photos of the text messages that the RA had taken. The ADM stated that the text messages included CNA 3 requesting photos of resident 7's bare breasts. The ADM stated that any sort of communication like that was an instant termination. The ADM stated that afterwards they tried to determine if there were any other residents that were involved with CNA 3. The ADM stated that they interviewed 5 other cognitively intact women and asked them if they had ever had any text communication with staff or any request for inappropriate photos from staff. The ADM stated that determined that there were no other incidents of sexual abuse. The ADM stated that they provided staff education after the incident that included professional relationships and what was considered inappropriate. On 10/01/24 at 3:16 PM, an interview was conducted with the DON. The DON stated that they discovered through the RA a relationship between resident 7 and CNA 3. The DON stated that resident 7 had some text messages in which CNA 3 had requested a photo of resident 7's breasts. The DON stated that CNA 3 had texted that he wanted resident 7 to be an obedient wife and it chapped her. The DON stated that resident 7 was a strong willed individual. The DON stated She did not feel victimized, she felt annoyed, and she would not be obedient. The DON stated that resident 7's response to the photo request was come take it yourself. The DON stated that resident 7 did not send a picture, and did not want to be caught up in a photograph. The DON stated that resident 7 was more annoyed by the request. The DON stated that they informed resident 7 of the seriousness and extent of violation that was in healthcare. The DON stated that resident 7 understood and she expressed some sadness because she wanted to be loved. It made her sad. Not because it happened but because it wasn't going to continue. The DON stated that CNA 3 was terminated the same day. The DON stated that he performed a full body skin check on resident 7, and there was no new skin issues. The DON stated that resident 7 adamantly denied anything physical had happened. The DON stated that the incident had occurred the night before. The DON stated resident 7 stated He was playful, flirty and fun and she like it. The DON stated that CNA 3 had tried to initiate email communication, but that resident 7 did not know how to do that. The DON stated that he talked to resident 7 about her emotional status and offered behavioral health services. The DON stated that the LCSW visited resident 7 and assessed her. The DON stated that resident 7 refused to block CNA 3's phone number. She thought it was resolved and he wouldn't continue. The DON stated that resident 7 continued to engage her normal way, but was sad that she did not have that relationship. The DON stated that after CNA 3 was terminated he sent some nasty messages to resident 7, something along the lines of your actions cost me my job. The DON stated that afterwards they initiated an ability to consent by the provider and resident 7 was deemed capable of consenting. The DON stated that even if resident 7 was capable it was not appropriate with a CNA. The DON stated that he called CNA 3 and left a voicemail stating that he was suspended. The DON stated that CNA 3 never called back or texted. The DON stated that corporate human resources called about the termination. The DON stated that they changed the gate code and notified the police department of the incident. The DON stated that they conducted a facility wide sweep to see if any other female residents had any contact with a staff member in an uncomfortable or sexual manner. The DON stated that all responses were negative. The DON stated that they did abuse training and appropriate communication forms afterwards. 2. a. Resident 22 was admitted to the facility on [DATE] with diagnoses which included frontotemporal neurocognitive disorder, unspecified mood disorder, impulse disorder, insomnia, disinhibited attachment disorder, asthma, anxiety disorder, chronic respiratory failure, and hepatic encephalopathy. Resident 9 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included epidural hemorrhage, stable burst fracture of T11-T12, type 2 diabetes mellitus, chronic obstructive pulmonary disease, morbid obesity, contusion of abdominal wall, hypertensive heart disease with heart failure, schizoaffective disorder, post-traumatic stress disorder, spondylolisthesis, insomnia, chronic pain, hypothyroidism, anxiety disorder, spinal stenosis cervical region, osteoarthritis, overactive bladder, history of suicidal behavior, and repeated falls. Resident 22's medical records were reviewed. On 4/25/24, resident 22's MDS Assessment documented that a BIMS could not be conducted because resident 22 was rarely or never understood. The assessment documented that resident 22 Mood Interview was not conducted because resident 22 was rarely or never understood. The Assessment documented that resident 22 did not have hallucinations or delusions, and did not have any physical or verbal behavioral symptoms directed toward others. On 6/21/24 at 11:29 PM, resident 22's Social Service Note documented, LCSW met with resident to assess for potential indicators of psychosocial distress. [Resident 22] appears anxious, distracted, minimally communicative, and casually groomed, which is consistent with her typical daily baseline. She exhibits speech that is fast in rate, normal in volume, is coherent at times and is repetitive. There were no signs of psychotic symptoms. Vocabulary and fund of knowledge indicate cognitive functioning in the below normal range. Insight and judgement into problems appears low. [Resident 22] behavior was uncooperative, and she repeated 'I'm good', and 'goodbye. goodbye'. [Resident 22] also 'fist-bumped' LCSW for the second time as she walked away. Based on a review of resident's medical chart, assessments. staff observations, and clinical interview, her behaviors appear to be within her baseline, and it does not appear that she is experiencing psychosocial harm. On 6/27/24, resident 22's skin assessment documented no new skin problems. It should be noted that no documentation could be found that resident 22's skin was assessed after the incident with resident 9 on 6/21/24. On 6/21/24 at 4:47 PM, resident 9's Nurses Note documented, Resident reported to one of the aides that she jabbed another resident with a pen last night 'hard enough to leave a mark' because she is 'fucking psychotic and manic' (referring to herself). Skin check revealed no significant injury on the other resident. On 6/21/24 at 9:50 PM, resident 9's hospital behavioral health intake notes documented that another resident with dementia came into her room, touched her things and resident 9 stabbed her with a pencil. Per pt [patient], she was trying to write 'stop it' on the resident's arm. Pt told staff, 'I'm fucking psychotic and manic.'. The facility notification to the SSA, form 358, documented an allegation of physical abuse by resident 9 towards resident 22. On 6/21/24 At 1530 [3:30 PM] [CNA 2] was toileting [resident 9]. While washing her hands, [resident 9] stated that she is manic bipolar and that today she 'got so psycho' that she stabbed [resident 22] with a pen for toughing (sic) her things. At 1535 [3:35 PM] [CNA 2] informed [name omitted] (Operations Manager) of what she was told. [ADM] told [CNA 2] to tell the DON [name omitted] and to have [resident 22] get a skin check. They found a pen mark with a skin abrasion at 1538 [3:38 PM]. The form documented that resident 22 sustained a skin abrasion to her left forearm. Review of the facility investigation, form 359, revealed, There were no witnesses to the altercation, but our CNA [name omitted] was providing cares when [resident 9] stated that she was experiencing a manic episode and that she had stabbed [resident 22] with a pen which she attributed to her manic episode. Skin assessment was done with [resident 22] to confirm the story and an abrasion was found and the abrasion did match a scratch with a pen due to the ink line still on the skin. The conclusion of the facility investigation verified the allegation of physical abuse. The corrective action implemented by the facility was a Stop sign installed on resident 9's door to prevent resident 22 from wandering into the room. The systemic changes identified were to in-service the staff to re-direct resident 22 when wandering and resident 9 was referred to physical therapy to help channel excess energy of mania. On 9/24/24 at 1:49 PM, an interview was conducted with the DON. The DON stated that he had read the note that resident 9 had not received her Latuda. The DON stated that he called the pharmacy and balled them out. The DON stated that when he identified that the medication was out of stock, he called the pharmacy and they did not provide a good explanation, and that the general explanation was due to a dose change. The DON stated that if a resident was not provided their ordered psychotropic medications, it could cause an exacerbation of their psychiatric illness. The DON stated that resident 9 had an episode of aggression towards resident 22. The DON stated that resident 22 had wandered into resident 9's room and reached for something. The DON stated that resident 9 shouted and jabbed at resident 22. The DON stated that this resulted in a drawing mark on resident 22 but no broken skin. It should be noted that this contradicted form 358 and form 359 that documented an abrasion to resident 9's left forearm. The DON stated that resident 9 was blue sheeted and sent to the hospital for evaluation. The DON stated that resident 9 returned with a diagnosis of a urinary tract infection. The DON stated that interventions after the incident were to place a stop sign so that resident 22 would not wander into resident 9's room. The DON stated that resident 22 was fixated on food and would wander during mealtimes in search of food. The DON stated that staff were instructed to redirect resident 22 during meals. On 9/25/24 at 1:52 PM, an interview was conducted with CNA 2. CNA 2 stated that resident 9 had reported an incident between her and resident 22. CNA 2 stated that resident 9 had been coloring and writing letters. CNA 2 stated that resident 22 frequently takes other residents belongings. CNA 2 stated that resident 9 reported that resident 22 attempted to take her belongings and she stabbed her with a pen. CNA 2 stated that resident 9 was upset that resident 22 took her stuff, and knew she should not have done what she did. CNA 2 stated she asked resident 9 if she had hurt resident 22 and she replied, I don't think so. CNA 2 stated that she finished resident 9's care and reported the incident to the ADM. CNA 2 stated that she checked resident 22's hand and it had an ink mark but no broken skin. CNA 2 stated that resident 22 did not appear in any distress and was lying in bed when she observed the skin. [Cross-refer to F755] 2. b. On 5/3/24 at 10:28 am, the facility reported to the SSA that on 5/3/24 at 8:05 am, a CNA was observed repeatedly yelling Goodbye in an aggressive and mocking tone towards the resident 22 while passing out breakfast trays in the dining room. The facility notification to the SSA, form 358, documented an allegation of verbal abuse by CNA 4 towards resident 22. The form documented the details of the incident as, [RA] observed the CNA [name omitted] yelling 'Goodbye' repeatedly in an aggravating and mocking tone to the resident while [name omitted] was passing breakfast trays. Another CNA, [name omitted] walked the resident away from the dining room. The RA reported the incident to the DON who informed the ADM. The form documented that the immediate steps taken were suspension of the CNA 4. The RA then spoke to resident 22 who was given a fist bump, a hug, and told [RA] 'I'm good, I'm fine.'. Review of the facility investigation, form 359, documented a summary of the interview with resident 22. Per resident's cognitive and communicative baseline, she does not elaborate deeply into the event or how she's feeling. Her responses are curt, largely consisting of 'I'm good, see you later'. Then a fist bump to the RA, which is a baseline pleasantry exchanged with staff. On 5/3/24, a facility interview with CNA 5 documented, I heard someone shouting 'Goodbye, goodbye' repeatedly and responded to the area to find the perpetrator shouting at the victim because she was looking for food. On her [CNA 4] way out I heard her [CNA 4] threating (sic) that 'They better pay me my money or I am going to come back and shoot this place up' in front of [ADM] office. On 5/3/24, a facility interview with Registered Nurse (RN) 3 documented, I heard [CNA 4] shouting and found her saying 'Goodbye' loudly at the resident because she was out looking for the breakfast tray. On her way out I heard her talking back to us but couldn't hear what she said because I was helping another resident. On 5/3/24, a facility interview with the RA documented, I was sitting in my office and heard what sounded like a staff member shouting 'Goodbye' very loudly and seemingly in a mocking way. I responded to find her shouting it toward a resident's face as the resident was searching for snacks on the breakfast tray, which is a behavior of hers. [CNA 4] has a tendency to be abrupt when redirecting resident behaviors, but has never shown a tendency towards mocking or shouting at residents in the past. I went to [resident 22's] room after to see how she was doing and she told me that she was ok and that she was good. She even gave me a hug and a fist bump. The form 359 documented that resident 22 had a medical history of frontotemporal neurocognitive disorder, impulse control disorder, disinhibited attachment disorder, and behaviors related to binge eating from other resident trays while trays are being passed, resulting in a necessity of redirection. Resident 22 had a BIMS of 0. When staff attempt redirection, she will often say 'I'm good, goodbye', which is assumed by the investigators to be where the repeatedly shouted 'Goodbye' stems from. Resident responds well to calm verbal redirection the majority of the time. The concl[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 out of 28 sampled resident, that the facility did not ensure that all alleged violations involving abuse or injuries of unknown source 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, a resident had a newly identified bruise that was not reported to the SSA and an incident of verbal abuse by a Certified Nurse Assistant (CNA) towards a resident was not reported to APS. Resident identifiers 18 and 22. Findings included: 1. Resident 18 was admitted to the facility on [DATE] with diagnoses which consisted of asthma, dementia, hypertension, hyperlipidemia, insomnia, overactive bladder, gastro-esophageal reflux disease, hypokalemia, malignant neoplasm, chronic pain, unspecified protein-calorie malnutrition, anxiety disorder, and major depressive disorder. Resident 18's medical records were reviewed. On 8/27/24, resident 18's admission Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 1/15, which would indicate a severe cognitive impairment. On 9/2/24, resident 18's Montreal Cognitive Assessment (MOCA) score was a 2/30, which would indicate a severe cognitive impairment. On 9/4/24 at 7:06 AM, resident 18's nurse note documented, CNAs [Certified Nurse Assistant(s)] found a bruise on the resident's upper thigh area. This appears to be a new bruise. Resident doesn't know how it happened. On 9/9/24, a skin assessment documented no new skin integrity problems. It should be noted that no documentation could be found of an assessment of the identified bruise. Resident 18's care plan for at risk for skin breakdown was initiated on 8/21/24. The care plan goal was that resident 18 would not develop a pressure injury. Interventions identified were do not massage bony prominence and implement weekly skin checks. It should be noted that the care plan did not have interventions related to monitoring, reporting or treating altered skin conditions. On 10/01/24 at 11:39 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that if she identified a newly developed bruise on a resident she would notify the provider, notify the Director of Nursing (DON), document in a progress note and monitor the skin. RN 1 stated that she would document an event note to alert other staff and would pass off the information in shift report. RN 1 stated that areas of the body that were suspicious for bruising would be private areas, inner thighs, breast, butt, vagina, back of arm, or face. RN 1 stated that if she identified a new bruise she would document characteristics of the bruise such shape like finger prints, and coloring to date the bruise. RN 1 stated she would also document the exact location on the thigh to indicate if it was the outer or inner thigh. RN 1 stated that she felt like the exact location made a difference in investigating the bruise, especially if the resident was not cognitively aware to describe how it happened, the more details the better. On 10/01/24 at 11:48 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that CNAs should notify the nurse of any new skin conditions such as a bruise. The DON stated that the licensed nurse needed to assess the skin to see if it was suspicious before reporting it as abuse. The DON stated that the nurse should notify the provider as a non-urgent symptom to review and there was a list in the provider communication book for issues that needed attention by the provider. The DON stated that the licensed nurse sometimes documented in a progress note, but they were not consistently doing that. The DON stated that the licensed nurse should document a progress note that stated the provider was notified of the condition. The DON stated that a bruise would be considered suspicious if the size was large, was located in areas of the genitals or anus, and if it appeared like fingerprints or if the resident reported an allegation of abuse. The DON stated that if the resident was not able to report what caused the injury the staff should also consider observations and resident behaviors that may be at cause. The DON was informed of the nurse note identifying a new bruise on resident 18. The DON asked if the bruise was located on the lateral or medial aspect of the thigh. The DON stated that for the lateral aspect of the thigh he would still expect the nursing staff to assess for suspicious circumstances. The DON stated that if the bruise was located on the medial aspect of the thigh it would be considered suspicious and the Administrator (ADM), DON and provider should be notified. The DON stated that if the bruise was located on the inner thigh it could be a possible indicator of abuse. The DON stated that if it was an indicator of abuse, or an injury of unknown origin it should have been notified to the SSA. The DON stated that the note did not contain the precise location or characteristics of the bruise and the licensed nurse should have done a better note. The facility policy on Identifying Types of Abuse documented Possible indicators of physical abuse include an injury that is suspicious because the source of the injury is not observed, the extent or location of the injury is unusual, or because of the number of injuries either at the single point in time or over time. The policy further documented possible examples of injuries that could indicate physical abuse were bruises, including those found in unusual locations such as the head, neck, lateral locations on the arms, or posterior torso and trunk, or bruises in shapes (e.g., finger imprints); The policy was last revised in September 2024. 2. Resident 22 was admitted to the facility on [DATE] with diagnoses which included frontotemporal neurocognitive disorder, unspecified mood disorder, impulse disorder, insomnia, disinhibited attachment disorder, asthma, anxiety disorder, chronic respiratory failure, and hepatic encephalopathy. The facility notification to the SSA, form 358, documented an allegation of verbal abuse by CNA 4 towards resident 22. The form documented the details of the incident as, [RA] observed the CNA [name omitted] yelling 'Goodbye' repeatedly in an aggravating and mocking tone to the resident while [name omitted] was passing breakfast trays. Review of the facility abuse investigation revealed no documentation that demonstrated that APS was notified of the incident. On 10/01/24 at 10:07 AM, an interview was conducted with the ADM. The ADM stated that when he was first informed of any allegation of abuse he would immediately check for resident safety. The ADM stated that as soon as the resident was deemed safe he would gather information regarding the incident. The ADM stated that he would gather the details and interview any person who could corroborate the story. The ADM stated that once he obtained a rough timeline of events then he would determine if a staff member needed to be suspended. The ADM stated that the nurse would assess the resident for any injuries. The ADM stated that he would then report the incident to the SSA, Adult Protective Services, and the ombudsman within 2 hours. The facility policy for Resident Abuse Procedural Summary documented that the supervisor will be responsible for taking immediate actions to report the abuse to the appropriate individuals. The Administrator and Director of Nursing will be responsible for reporting the concerns, as required by law, and conducting the investigation. The policy further stated that all employees would be given specific example and measurable limits as to when reporting was required and they could be found contained within the Abuse Policy. The facility policy for Abuse, Neglect, Exploitation and Misappropriation Prevention Program documented that allegations of abuse would be reported within timeframes required by federal requirements. The policy was last revised in April 2024. [Cross-refer F600]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 3 of 28 sampled residents, that the facility in response to allegations of abuse did not prevent further potential abuse while the investigation was in progress. Specifically, the facility did not put effective measures in place to ensure that abuse did not occur and corrective measure that were identified were not implemented. Resident identifier, 14, 85, and 86. Findings included: 1. a. Resident 86 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which consisted of atrial fibrillation, type I diabetes mellitus, acute respiratory failure, bipolar disorder, hepatic failure, hypertensive heart disease, anxiety disorder, post-traumatic stress disorder, dementia, hepatic encephalopathy, hyperlipidemia, essential tremor, pain, insomnia, major depressive disorder, benign prostatic hyperplasia, osteoarthritis, and age-related cognitive decline. Resident 14 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included cerebral infarction, hemiplegia and hemiparesis, cognitive communication deficit, chronic obstructive pulmonary disease, pain, major depressive disorder, dementia, insomnia, cervical disc degeneration, spondylosis with myelopathy, alcoholic polyneuropathy, hypertension, osteoarthritis, radiculopathy, cirrhosis of liver, hyperlipidemia, nicotine dependence, alcohol abuse, cannabis abuse, suicide attempt, suicidal ideations, ventral hernia, trochanteric bursitis of left hip, and lesion of ulnar nerve. The facility notification to the SSA, form 358, documented an allegation of physical abuse between resident 14 and resident 86. On 9/5/23 at 7:15 PM, the form documented that facility staff became aware of the incident. It is alleged that [resident 86] and [resident 14] were arguing over [resident 14's] radio and both residents were found on the floor. The form documented that the residents were separated and resident 86 was removed to another room. The form documented that resident 14 had a small cut on the top of his left hand and resident 86 had a small cut on his right elbow and his lip. The form 359 documented the corrective actions taken were a room change for resident 86, alert charting, skin assessments, and 15-minute checks on both residents for 24 hours. Med review was requested. It should be noted that no documentation could be found that 15-minute safety checks were completed for resident 86 or resident 14 after the incident occurred. 1. b. Resident 85 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included Alzheimer's disease, pseudobulbar affect, anxiety disorder, anemia, dementia with anxiety and mood disorder, and major depressive disorder. The facility notification to the SSA, form 358, documented an allegation of sexual abuse by resident 86 towards resident 85. The form documented that Licensed Practical Nurse (LPN) 1 witnessed resident 86 seated on the couch next to resident 85. Its reported that [resident 86] was seen with his hand down the front of his pants and his other hand moving up the female residents leg and briefly making contact with her genital area. The residents were quickly separated, and [resident 86] was taken to his apartment. [Resident 85] was assessed and was unable to give any verbal feedback due to significant cognitive deficits, but was not showing signs of distress, pain or discomfort outside of her baseline. The corrective actions documented on form 359 were that resident 86 was placed on 15-minute checks to reduce the risk of continued incidents. [Resident 86's] provider ordered Depo-Provera, in order to reduce continued behaviors of a sexual nature Resident 86's medical records were reviewed. Resident 86's progress notes documented the following: a. On 9/14/23 at 5:07 PM, the Order Note documented, On 9/14, resident's POA [Power of Attorney][name omitted] was contacted following event with a female resident of the community. The provider ordered Depo-Provera in response to the event, and this order was discussed in detail with POA. POA had no concerns with this medication, and provided consent to DON to administer the medication. b. On 9/16/23 at 10:55 AM, the Orders - Administration Note documented that the Depo-Provera Intramuscular injection was unavailable from the pharmacy. Review of resident 86's 15-minute check logs revealed that the visual checks were initiated on 9/15/24 at 12:15 AM and entries continued until 10:00 AM. No documentation was entered on the log from 10:15 AM to 9:45 PM on 9/15/24. On 9/16/24, the 15 minute check log had missing entries from 6:15 AM to 1:45 PM. On 9/17/24, the 15 minute check log had missing entries from 4:00 PM to midnight. It should be noted that no other documentation of 15-minute checks was found. On 10/02/24 at 11:11 AM, an interview was conducted with the DON. The DON stated that to his knowledge resident 86 did not have a history of sexually inappropriate behaviors. The DON stated that resident 86's family member reported a past incident of sexual behavior with the onset of dementia, but nothing at the facility that he was aware of. The DON stated that the provider ordered Depo Provera in response to the incident. The DON stated that they tried to keep the residents separated, and ensure they were not in the common area at the same time. The DON stated 15-minute checks were not typically used as an intervention. The DON stated that with the facility demographic it was difficult to maintain 15-minute checks when you had another 10+ behavioral residents. The DON stated that the staff should have been consistent with the 15-minute checks and filling out the form completely. On 10/03/24 at 9:55 AM, an interview was conducted with the ADM. The ADM stated that 15-minute checks were a poor intervention in the facility. The ADM stated that 15-minute checks were basically a 1:1 staffing situation. The ADM stated that the immediate intervention was to identify what they could do to keep resident 86 and resident 85 separated. The ADM stated that he would expect to see the interventions documented in the facility investigation under corrective measures. The ADM stated that if they could not take measure to keep residents safe then he had to take drastic measures and transfer residents out. [Cross-refer F600]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 8 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included, but not limited to, metabolic encephalopathy, diabetes mellitus, chronic obstructive pulmonary disease, chronic respiratory failure with hypercapnia, pulmonary hypertension, paranoid schizophrenia, and anxiety disorder. Resident 8's medical record was reviewed on 9/22/24. A review of the progress notes documented the following: a. On 1/7/24 at 3:56 AM, Nurses Note Note Text: Resident was re-admited [sic] to facility after being at the hospital. She has been hit and miss with keeping her NC [nasal cannula] on for additional oxygen. She doesn't like wearing it, and will sit in the hallway without it, or sit outside. Resident has not had a fall, [NAME] [sic] she exhibiting involuntary arm movements like before her hospital visit. She is compliant with taking her medications and with her ADLs. [activities of daily living] b. On 1/15/24 at 2:36 AM, Nurses Note Note Text: Late entry for 1-14-2024 @ 1855 [6:55 PM]: Re-admit from [name of hospital] hospital. Arrived back to facility at 1855 in ambulance. DX [diagnosis]; Acute on 1)chronic respiratory failure with hypoxia and hypercapnia 2)Pneumonia. Ambulated from ambulance into facility with assistance from CNA [certified nursing aide] staff. Alert and oriented X3 [times 3] with verbal and nonverbal behavior congruent. New order for BS [blood sugar] checks to be done before and after meals QD [daily]. New order for DME [durable medical equipment] Compressor and for Nebulizer. Order faxed to [name of DME company] medical for DME equipment. VS [vital signs]: Temp [temperature] 97.9, B/P [blood pressure]138/74, Resp [respirations] 20, SPO2 [oxygen saturation] 90% on 3L [liters], Pulse 94. Lungs sounds diminished in all lobes. Wet cough noted with no sputum expelled. c. On 2/22/24 at 2:34 AM, Nurses Note Note Text: [resident 8] voiced she came back to [name of facility] from the hospital today at 4PM. Voiced she is happy to be back and that she missed her friends here. She is alert and oriented X3 and compliant with all meds and cares. Took all HS [bedtime] meds whole with water without any problems. SPO2 90% on 3.5L O2 [oxygen]. Assisted her to call her husband at 2000 [8:00 PM]. She is in bed sleeping without any signs or symptoms of distress. d. On 3/25/24 at 10:44 AM, Nurses Note Note Text: Resident sent to hospital for low 02 saturation. e. On 5/12/24 at 3:56 AM, Incident Note Note Text: At 0250 [2:50 AM], resident was yelling for help, while outside. Staff found the resident away from her walker and lying on the ground. I just fell she told the staff. She also stated, I have too much oxygen. Staff checked and resident's O2 level was 35%. A fewminutes [sic] passed and it jumped to 40%. The resident was helped up to her walker, then walked to her room. Assessment and first set of Neuros were to be started. Resident was placed on 4L of oxygen and only came up to 67%. She was able to answer simple Yes or No questions clearly. However, if she began to explain something, her words became slurred. Staff reported that she had become agitated and raised her fist to staff when told she couldn't go out to smoke. No wounds were visible and resident denied pain. DON [director of nursing] and Administrator were notified at 0257 [2:57 AM]. Because of her low oxygen level and resident's orientation continuing to change when asked questions, 911 was called and she was taken to the [name of hospital] hospital. f. On 6/26/24 at 8:08 AM, Nurses Note Note Text: Resident was sent to the hospital. Resident was lathargic [sic], weak and dizzy, she couldn't stand with out assistance. Residents vitals were b/p- 74/43 T-101.2 HR- 104 O2- 66% Resident was sent to the [name of hospital] g. On 7/7/24 4:10 PM, Nurses Note Note Text: CNA notified me that [resident 8] fell on her face outside on the pavement. When this nurse went outside [resident 8] was laying in supine position. She had blood on the R [right] side of her face and inside her mouth. Noted abrasions to her face, blood in hair and in her mouth and throat. Head to toe assessment done. No hip fx [fracture] upon assessment. Head to toe assessment. Neuro check WNL [within normal limits] , VS:B/P 155/85, Resp, 20, Pulse 88, SPO2 88%. 911 called. Notified DON and guardian [name redacted]. MD [medical doctor] notified. Ambulance took [resident 8] to [name of hospital] hospital. h. On 7/15/24 11:11 PM, Nurses Note Note Text: Resident was struggling to oxygenate, causing ALOC [altered level of consciousness] and confusion, she was cyanotic, very lethargic and weak, unable to sit up long enough to take meds. She agreed to be transported to [name of hospital] for evaluation. Guardian and husband were notified. I called for anupdate [sic], and she has been admitted to [name of hospital] Shock/Trauma unit. Personnel on the unit were unavailable to answer the phone for a status update. Will follow up. i. On 9/28/24 at 9:27 AM Nurses Note Note Text: Resident was sent to the hospital. This morning her oxygen was 60% on 5L. She was not being compliant with keeping her Nasal cannula on. When I ask, she said I am breathing and keep walking. On call NP [nurse practitioner] [name redacted] Notified about patient conditions at 7:39 Am and agree to send her to the hospital. Resident guardian was notified. A hospital history and physical report dated 1/10/24 documented, .Patient comes with no documentation from her care facility, attempted to call with no answer/continuous ringing .unable to obtain further information Review of resident 8's electronic medical record revealed no documentation of a transfer/discharge assessment or paperwork that might have accompanied the resident to the hospital. 4. Resident 19 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included, but not limited to, Alzheimer's Disease, dementia, type 2 diabetes mellitus, bipolar disorder, anxiety disorder, hyperkalemia, peripheral vascular disease, and gastro-esophageal reflux disease without esophagitis. Resident 19's medical record was reviewed on 9/22/24. A review of the progress notes documented the following: a. On 9/4/at 3:21 AM, Orders - General Note from eRecord Note Text: Resident returned from the [name of hospital] ER [emergency room] department at 0245 [2:45 AM]. She had requested to go to the hospital because she was feeling sick. not feeling well. ER department performed the following tests CT [computed tomography] of her brain/head CT maxillofacial w/o [with out] contrast CT spine cervical w/o contrast CBC [complete blood count] w/ auto Diff CMP [comprehensive metabolic panel] Lipase level Urinalysis w/ microscope Everything was found to be unremarkable, except the urinalysis. A urinary tract infection was found, and resident was given a Rocephin shot. The ER sent a script for Keflex 500 mg three times a day for 7 days. Resident was placed in her bed and is sleeping. b. On 9/7/24 at 8:30 AM, Nurses Note Note Text: Patient was transported by EMS [emergency medical services] to [name of hospital] ER. She was drooling while she was waiting which is her primary complaint that her throat is sore enough that she can't swallow. was unable to take her pills due to this. Family, on call provider and DON alerted. Review of resident 19's electronic medical record revealed no documentation of a transfer/discharge assessment or paperwork that might have accompanied the resident to the hospital. On 10/01/24 at 12:57 PM, an interview was conducted with Registered Nurse [RN] 1. RN 1 stated that a face sheet, medication list, and POLST [Physician Orders for Life Sustaining Treatment] form should accompany a resident to the hospital. RN 1 stated that this information was given to the EMTs [emergency medical technicians]. RN 1 stated that the documents needed to be printed and sent with EMS. RN 1 stated that a progress note should be made and the DON should be notified. On 10/02/24 at 11:32 AM, an interview was conducted with the DON. The DON stated that it should be documented in the progress noted that a resident went to the hospital. The DON stated there was something called e-interact that wasn't done as much as he would like the nurses to do to document that the resident had been transferred to the hospital. The DON stated that the progress notes should document the situation as to why the resident needed to go to the hospital, that the provider, DON, and responsible party should have been notified. The DON stated that the resident's medication list and POLST form should accompany the resident to the hospital. Based on interview and record review it was determined, for 4 out of 28 sampled residents, that the facility did not ensure that when the facility transferred or discharged a resident that the transfer or discharge was documented in the resident's medical record and that all the information was communicated to the receiving provider. The information provided to the receiving provider should include contact information of the practitioner responsible for the care of the resident; resident representative information; Advanced Directive information; all special instructions or precautions for ongoing care; comprehensive care plan goals; and all other necessary information to ensure a safe and effective transition of care. Specifically, residents were transferred to the hospital and no documentation could be found to demonstrate what information was communicated to the receiving provider. Resident identifiers 8, 9, 14, and 19. Findings included: 1. Resident 9 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included epidural hemorrhage, stable burst fracture of T11-T12, type 2 diabetes mellitus, chronic obstructive pulmonary disease, morbid obesity, contusion of abdominal wall, hypertensive heart disease with heart failure, schizoaffective disorder, post-traumatic stress disorder, spondylolisthesis, insomnia, chronic pain, hypothyroidism, anxiety disorder, spinal stenosis cervical region, osteoarthritis, overactive bladder, history of suicidal behavior, and repeated falls. Resident 9's medical records were reviewed. On 9/19/2024 at 4:41 PM, resident 9's nurse note documented, Resident was sent to the hospital via gold cross because of hypotension, lethargic and bradycardic. On 9/23/24 at 9:16 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she would document a resident change in condition, everything she did for the resident, and if the resident was transferred to the hospital in a progress note. RN 1 stated that the progress notes would detail the time of transfer, circumstance or details of event, and where they transferred to. RN 1 stated she would send the resident face sheet and medication list with the resident to the hospital. RN 1 stated that they do not send a copy of the resident's Physician Order for Life Sustaining Treatment (POLST) to the hospital. RN 1 reviewed a random resident's face sheet and confirmed that the POLST or Advanced Directives were not listed on the form. RN 1 stated that she would also document in the progress note what was sent with the resident to the hospital. On 9/23/24 at 7:55 PM, a telephone interview was conducted with the RN 3. RN 3 stated that resident 9 was drowsy in the morning when she administered her medication. RN 3 stated that later in the day resident 9's vital signs changed and she had a low blood pressure and a low heart rate. RN 3 stated that she informed the Director of Nursing (DON) and the decision was made to send resident 9 to the emergency department. RN 3 stated that she gave the paramedics a copy of resident 9's medication list and face sheet. RN 3 stated that the paramedics shocked resident 9 before they transported her to the emergency room. On 9/24/24 at 1:49 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 9 had a change in condition in the afternoon on Thursday. The DON stated that Nursing Assistant (NA) 1 brought it to his attention. The DON stated he asked for a full set of vital signs and resident 9 had a heart rate in the high 30's and a blood pressure around 60/40. The DON stated that when the paramedics arrived they took resident 9's vital signs again. The DON stated that the paramedics asked him for a copy of resident 9's POLST form because they were going to start pacing her. It should be noted that no documentation could be found of the transfer paperwork for resident 9 or what information was sent to the receiving provider. 2. Resident 14 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included cerebral infarction, hemiplegia and hemiparesis, cognitive communication deficit, chronic obstructive pulmonary disease, pain, major depressive disorder, dementia, insomnia, cervical disc degeneration, spondylosis with myelopathy, alcoholic polyneuropathy, hypertension, osteoarthritis, radiculopathy, cirrhosis of liver, hyperlipidemia, nicotine dependence, alcohol abuse, cannabis abuse, suicide attempt, suicidal ideations, ventral hernia, trochanteric bursitis of left hip, and lesion of ulnar nerve. Resident 14's medical records were reviewed. On 3/7/24 at 2:27 PM, resident 14's nurse note documented, Resident is at hospital for trying to hurt himself. It should be noted that no documentation could be found of the transfer paperwork for resident 14 or what information was sent to the receiving provider.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined that the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or included the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, in the medication refrigerator, one multi-dose vial was not labeled with an opened date, insulin pens did not have names or dates, one insulin pen was expired with an open date of [DATE], and a Prevnar 13 dose was expired and available to use. Findings included: On [DATE] at 7:35 AM, the medication refrigerator was inspected. A multi-dose vial of Tuberculin was observed open and available for use and an open date was not marked on the vial. A Prevnar 13 vaccine with an expiration date of [DATE] was available for use. A Tresiba insulin pen was observed to have been used with no opened date. A Lantus insulin pen was observed to be available for use with an open date of [DATE]. A Lantus insulin pen was observed to be opened and used with no open date. An aspart insulin flex pen was observed to have been opened and used with no name or open date on it. An insulin glargine pen was observed to be opened and used with no name on it. On [DATE] at 07:36 AM, an interview was conducted with RN 1. RN 1 stated she thought insulin pens were good for 30 days once they were used or at least by the expiration date listed on the pen. RN 1 stated that if she could not read the name or the date on the insulin pen then the pen should be discarded in the sharps container. RN 1 stated that she was unable to see names listed on some of the insulin pens or any opened dates. On [DATE] at 9:00 AM, an interview was conducted with the Director of Nursing (DON). The DON was informed of the expired medication, the medications that were not labeled with expiration dates/opened dates, and the medication not labeled with the resident identifiable information. The DON stated that all medications should be labeled with the resident's name. The DON stated that insulin stored in the refrigerator should be labeled with an open date and the resident's name. The DON stated that once insulin was opened it was good for 30 days. The DON stated that there should not be anything else stored in the refrigerator but medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that for 2 of 28 sample residents, that the facility did not provide or obtain laboratory services to meet the needs of its residents. Specifically, there were at least two instances where the facility did not obtain International Normalized Ratio (INR) labs for a resident despite there being physician orders for the labs to be obtained every 4 weeks and one instance where the facility did not obtain a Basic Metabolic Panel (BMP) for another resident despite there being physician orders for the BMP to be drawn. Resident identifiers: 31 and 9. Findings Included: Resident 31 was admitted [DATE] with diagnoses including bipolar disorder, chronic obstructive pulmonary disease, other asthma, venous insufficiency, generalized anxiety disorder, post-traumatic stress disorder, unspecified combined systolic and diastolic heart failure, peripheral vascular disease, unspecified cirrhosis of liver, obsessive-compulsive disorder, and chronic embolism and thrombosis of unspecified deep veins of right lower extremity. Resident 31's medical record was reviewed. The following Physician's orders were reviewed: Draw INR once every 4 weeks on Thursdays. INR results for the dates of 4/12/24, 7/12/24, 8/27/24, 9/12/24, and 9/19/24 were uploaded into Resident 31's medical record. INR results for the months of May and June were not found in Resident 31's medical record. On 6/10/24, a pharmacy consultant review for the month of May 2024 documented, Nursing-I did not find routine monthly monitoring of PT[prothrombin]/INR values to follow warfarin treatment. He has fluctuating weight and medications which may alter warfarin effectiveness. Recommendation: Check and record PT/INR value at least monthly. On 8/9/24, a pharmacy consultant review for the month of July 2024 documented, .[Resident 31's] PT/INR has been subtherapeutic the last two labs found (April and July). Goal INR is 2-2.5 to provide protection against clotting. Recommendations: 1. Monitor PT/INR at least once a month . On 10/03/24 at 10:35 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that he had reviewed the orders for Resident 31's INR to be checked in May and June of 2024. The DON stated that it was likely that the phlebotomist contracted to work for the facility never obtained the labs for the months of May and June 2024. 2. Resident 9 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included epidural hemorrhage, stable burst fracture of T11-T12, type 2 diabetes mellitus, chronic obstructive pulmonary disease, morbid obesity, contusion of abdominal wall, hypertensive heart disease with heart failure, schizoaffective disorder, post-traumatic stress disorder, spondylolisthesis, insomnia, chronic pain, hypothyroidism, anxiety disorder, spinal stenosis cervical region, osteoarthritis, overactive bladder, history of suicidal behavior, and repeated falls. Resident 9's medical records were reviewed. On 8/13/24, resident 9's physician ordered a Basic Metabolic Panel (BMP). No documentation could be found in resident 9's electronic medical records of the BMP results. On 9/23/24 at 1:56 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the BMP that was ordered on 8/13/24 was missed and not obtained. On 9/25/24 at 9:20 AM, a follow-up interview was conducted with the DON. The DON stated that lab orders were placed by him and he followed-up with the providers. The DON stated that the laboratory process was that the order requisition was placed in the computer system and a resident face sheet was placed in a binder for the phlebotomist. The DON stated that the order requisition did not have a carbon copy for the facility records. The DON stated that the lab placed the results in the portal and it notified him automatically when the results were ready. The DON stated that the lab would call him directly if the labs had critical high or low values. The DON stated that once the provider reviewed the report they would sign the report and then it was scanned into the resident's medical records. The DON stated that he was the only staff that had access to the portal with the laboratory results. The DON stated that the results were also faxed to the facility at the same time they were uploaded into the portal. The DON stated that part of the process was making sure that the nurses were documenting in a progress note that the labs were being done. The DON stated that all labs should have the date and signature of the provider once they have been reviewed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that for 1 out of 28 sampled residents, the facility did not maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized and the facility kept confidential all information contained in the resident's records. Specifically, resident's information was left open on a computer screen unsecured on two different occasions while residents were in the vicinity and no documentation of a resident's hospital visit was found in the medical record. Resident identifier: 14. Findings included: On 9/22/24 at 09:40 AM, an observation was made of Registered Nurse [RN] 4 walk away from the medication cart. The computer on top of the medication cart was left open with resident information available to view. An observation was made of residents 10 and 18 around the medication cart. On 9/22/24 at 12:40 PM, an interview was conducted with RN 4. RN 4 stated that any time the medication cart was left unattended the computer and medication cart should be locked. RN 4 stated that she usually locked the computer screen when she left the cart. On 9/24/24 at 07:50 AM, an observation was made of RN 1 leaving the medication cart unattended with the computer open with resident information visible. Residents 10 and 31 were in the hallway next to the medication cart. On 9/25/24 at 1: 22 PM, an interview was conducted with RN 1. RN 1 stated when she left the medication cart she made sure she locked the cart and the computer so that no information was visible to residents. RN 1 stated she tried to always have her computer screen locked when she was not in the area. On 10/1/24 at 9:00 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the expectation of staff was to keep all identifiable resident information confidential. The DON stated that if a medication cart was left unattended the nurse should lock the computer screen to avoid residents from seeing Health Insurance Portability and Accountability Act (HIPAA) protected information. 2. Resident 14 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included cerebral infarction, hemiplegia and hemiparesis, cognitive communication deficit, chronic obstructive pulmonary disease, pain, major depressive disorder, dementia, insomnia, cervical disc degeneration, spondylosis with myelopathy, alcoholic polyneuropathy, hypertension, osteoarthritis, radiculopathy, cirrhosis of liver, hyperlipidemia, nicotine dependence, alcohol abuse, cannabis abuse, suicide attempt, suicidal ideations, ventral hernia, trochanteric bursitis of left hip, and lesion of ulnar nerve. Resident 14's medical records were reviewed. On 3/7/24 at 2:27 PM, resident 14's nurse note documented, Resident is at hospital for trying to hurt himself. No documentation could be found in resident 14's electronic medical records (eMR) of the hospital history and physical or discharge paperwork following his hospitalization on 3/7/24. On 10/2/24 at 1:14 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 14 was blue sheeted a couple of months back. The DON stated that something upset resident 14 and he believed it had to do with the resident being out of cigarettes. The DON stated that resident 14 walked away and said might as well get a body bag. The DON stated that he went and talked to resident 14 and he was holding a butter knife. He looked like he was about to cut himself, one arm extended like he was going to cut himself. The DON asked resident 14 to give him the knife and he did. The DON stated that he asked resident 14 if he was actively suicidal and he responded yes. The DON stated that he asked if he had a plan and resident 14 replied what do you think?. The DON stated that resident 14 did not want to go to the hospital so the provider blue sheeted him. The DON stated that they should have resident 14's discharge paperwork, and that the hospital did not admit him. On 10/03/24 at 9:28 AM, a follow-up interview was conducted with the DON. The DON stated that he requested the hospital records for resident 14 and the hospital had replied that he was not seen there. The DON stated that he then called the ambulance service and they had a record of the transport. The DON stated that he would follow-up with the hospital again. On 10/8/24 at 4:18 PM, the facility provided the hospital history and physical (H & P) for resident 14's hospitalization on 3/7/24. The DON stated, Here's the H&P for that hospitalization. On review of old messages, I realized a blue sheet wasn't initiated on this resident for this incident. When he made these expressions, the ambulance was contacted without a blue sheet and he agreed to go to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility did not ensure that the resident or resident representative had the opportunity to accept or refuse a COVID-19 vaccine, and that the resident's medical record included documentation that indicated that the resident was provided education regarding the benefits and potential risks associated with the vaccine; documentation of each dose administered; and documentation of declinations or contraindications to the vaccine. Specifically, for 4 out of 5 sampled residents, the facility did not have evidence that each resident was provided education about the COVID-19 vaccine, was provided the COVID-19 vaccine, or declined the COVID-19 vaccine. Resident identifiers: 7, 18, 28, and 30. Findings included: 1. Resident 7 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of presence of right and left artificial shoulder joint, chronic obstructive pulmonary disease, hypertensive heart disease, pulmonary hypertension, chronic pain syndrome, ventricular premature depolarization, insomnia, nonrheumatic mitral valve insufficiency, history of myocardial infarction, dysphagia, overactive bladder, lesion of ulnar nerve, hypertension, lymphedema, osteoporosis, and hyperlipidemia. Resident 7's medical records were reviewed and no documentation could be found of the COVID-19 vaccine education, vaccine administration or vaccine declination. 2. Resident 18 was admitted to the facility on [DATE] with diagnoses which consisted of asthma, dementia, hypertension, hyperlipidemia, insomnia, overactive bladder, gastro-esophageal reflux disease, hypokalemia, malignant neoplasm, chronic pain, unspecified protein-calorie malnutrition, anxiety disorder, and major depressive disorder. Resident 18's medical records were reviewed and no documentation could be found of the COVID-19 vaccine education, vaccine administration or vaccine declination. 3. Resident 28 was admitted to the facility on [DATE] with diagnoses which included aphasia, frontotemporal neurocognitive disorder, insomnia, and dementia. Resident 28's medical records were reviewed and no documentation could be found of the COVID-19 vaccine education, vaccine administration or vaccine declination. 4. Resident 30 was admitted to the facility on [DATE] with diagnoses which included unspecified focal traumatic brain injury, chronic obstructive pulmonary disease, Alzheimer's disease, dementia, hypertension, hyperlipidemia, cognitive communication deficit, chronic pain, and osteoarthritis. Resident 30's medical records were reviewed and no documentation could be found of the COVID-19 vaccine education, vaccine administration or vaccine declination for the current vaccine season. The facility Coronavirus Disease (COVID-19) - Vaccination of Residents policy documented that the resident or resident representative had the opportunity to accept or refuse a COVID-19 vaccine and before the vaccine was offered the resident was provided education regarding the benefits, risks, and potential side effects associated with the vaccine. The policy further stated that residents must sign a consent to vaccinate form prior to receiving the vaccine and a vaccine administration record was filed in the resident record. The policy also stated that if a resident did not receive the COVID-19 vaccine due to medical contraindications or refusal the documentation was made in the resident record. The policy was last revised in August 2024. On 10/3/24 at 10:58 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that he was not sure where the documentation was located for the resident COVID-19 immunization records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined for 1 of 18 sample residents that the facility did not include provisions to inform and provide written information concerning the right to accept or refuse medical or surgical treatment and, at the residents' option formulate an advance directive. Specifically, one resident was not provided the opportunity to document his life-saving preferences. Resident identifier: 2. Findings include: Resident 2 was admitted to the facility on [DATE] with diagnoses which included sequelae of cardiovascular disease, traumatic brain injury, chronic obstructive pulmonary disease, type II diabetes, acute hepatitis c, dysphagia, hypertension, pain and psoriasis. On 2/28/23 resident 2's electronic medical record (EMR) was reviewed. A physician order dated 12/6/21, revealed resident 2 had an order to be a Full Code. There was no advanced directive or physician order for life sustaining treatment (POLST) located in resident 2's EMR. On 3/1/23 at 11:05 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated the POLST is completed on admit by the admitting nurse unless the family needed to sign it then we try to get it done as soon as possible. LPN 1 stated resident 2 was a full code and was unsure where his POLST form was located. LPN 1 stated the code status is found in the orders in the medical record. On 3/1/23 at 2:35 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the resident was unable to make decisions for himself so he could not sign a POLST form. The DON stated that this made him a full code. The DON that the residents knew on admit if a POLST was not signed they were considered a full code. The DON stated the facility had tried to get the resident's family member to sign the POLST form but the family member was not the resident's person of authority (POA) so the family member refused to sign the form. The DON stated the facility was trying to get a State sanctioned guardian put in place for resident 2. The DON stated she would try to provide paperwork regarding the guardian placement process. A review of resident 2's EMR revealed, resident 2's family member was listed as the person responsible for making decisions for resident 2. On 3/1/23, a telephone call was placed to resident 2's family member. There was no answer and no message was left on the unidentified voicemail. On 3/2/23 at 12:40 PM, a follow up interview was conducted with the DON. The DON stated they were still trying to locate the paperwork documenting the placement of resident 2 with a guardian. The DON stated resident 2 had been full code status for over a year and that his family member should not have been listed as his POA. The administrator joined the interview at this time and stated there was a 2 year wait for resident guardianship, but they would try to provide additional information to document the guardianship process was underway. Note: no additional information was provided by the facility documenting the guardianship process had begun or that an advanced directive or POLST had been completed for resident 2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 18 sample residents, that the facility did not coordinate assessments with the pre-admission. Including referring all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. Specifically, after a resident was diagnosed with a mental illness there was no referral for a level II. Resident identifier: 4. Findings include: Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included type II diabetes, hypertension, gastroesophageal reflux disease, bipolar disorder, anxiety, major depressive disorder, obesity and dementia. On 2/28/23 the electronic medical record for resident 4 was reviewed. A review of resident 4's Pre-admission Screening Application/Resident Review (PASRR) dated 4/11/2019 revealed there was no serious mental illness diagnoses. The form revealed, TBI/dementia appears to be primary diagnoses and mood is related to TBI. No level II needed. The diagnoses of bipolar disorder was added to resident 4's medical record on 8/25/21 and reevaluated on 10/12/22. On 3/1/23 at 2:02 PM, an interview was conducted with the Social Worker (SW). The SW stated she was the staff member over the PSARR process. The SW stated when a resident received a new mental diagnoses or had a change in condition a referral was made to the PSARR team. The PSARR team would then schedule a time with the facility to come meet with the resident. The SW stated if a resident had a new diagnoses they were supposed to be reevaluated. The SW stated resident 4 should have been reevaluated when the bipolar disorder diagnoses was given. On 3/2/23 at 1:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 4 had a PSARR completed and a PSARR II was not needed. The DON stated she was unaware of the bipolar diagnoses being added on 8/25/21 and would need to verify with the SW if a new PSARR had been completed. The DON stated resident 4 should have had a new PSARR done if there was a change in condition or if new diagnoses was added.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the residents environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, a resident with multiple falls was not provided an adequate walker, and a resident on supervised smoking was observed smoking outside without staff supervision. Resident identifiers: 29 and 31. Findings include: 1. Resident 29 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, asthma, neuropathy, hypertension, protein-calorie malnutrition, anxiety, schizophrenia, bipolar disorder, muscle weakness, insomnia, chronic pain syndrome, nicotine dependence, and toxic encephalopathy. On 2/27/23 at 10:39 AM an interview with resident 29 was conducted. Resident 29 stated that she had multiple falls at the facility due to being unsteady on her feet. Resident 29 stated that she did not have any serious injuries resulting from her falls. Resident 29 stated that she does not have a walker that she is able to use at the facility. Resident 29 stated that she had brought her own walker to the facility, but it was too small and it wobbled when she used it. Resident 29 stated that she did not feel safe to use her walker. Resident 29 stated that the facility had not assessed her for a new walker. Resident 29 stated that she would likely have less falls if she had a walker that she was able to use. Resident 29's medical record was reviewed. Resident's 29's care plan had a focus, initiated on 1/16/23, that stated, [resident 29] has had an actual fall with no injury. 1/21/23 actual fall with no injury. 1/15/23 actual fall with no injury. 1/21/23 actual fall with no injury. 2/17/23 actual fall with no injury. 2/18/23 actual fall with no injury. The goal, initiated on 1/16/23, stated, [Resident 29] will resume usual activities without further incident through the review date. The interventions revealed the following, a.Continue interventions on the at-risk plan. Initiated 1/16/23. b. Educate resident to ask staff assistance with ADLs [activities of daily living], transfers, ambulation r/t [related to] weakness and unsteady gait. Initiated on 1/22/23. c. Encourage resident to allow staff to clean restroom on a regular schedule Initiated on 2/18/23. d. Encourage resident to use assistive device while ambulating. Initiated on 1/23/23. e. For no apparent acute injury, determine and address causative factors of the fall. Initiated 1/16/23. f. Frequent checks on rounds r/t weakness and unsteady gait. Initiated on 2/17/23. g. Monitor/document/report PRN [as needed] x 72h [hours] to MD [doctor] for s/sx [signs/symptoms]: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Initiated on 2/19/23. h. Obtain radiograph to determine injury Initiated on 1/16/23. i. Resident is in possession of a 4WW [four-wheel walker]. Encourage her to use it when ambulating. Initiated 2/20/23. Resident 29's Quarterly Minimum Data Set (MDS) from 1/20/23 was reviewed. The MDS revealed that resident 29 required limited one person physical assistance with transfers, walking in room, walking in corridor, and locomotion off unit (how residents move to and returns from off-unit location which includes areas set aside for dining, activities, or treatments). On 2/28/23 at 2:38 PM an observation of resident 29 was made outside in the smoking area. Resident 29 was observed walking with no assistive devices from the smoking area to the facility back entrance. Resident 29 was observed to be walking slowly and appeared to be unsteady as her legs were shaking while she walked. Resident 29 then called out for a staff member to assist her with walking up the concrete walkway. A staff member assisted resident 29 to the door of the facility. On 3/1/23 at 9:42 AM an interview with Nursing Assistant (NA) 1 was conducted. NA 1 stated that resident 29 was unsteady on her feet, and resident 29 would usually use the hand rails or hold on to a staff member to get around. NA 1 stated that resident 29 would benefit from using a walker, but currently did not have one. On 3/1/23 at 9:47 AM a follow up interview was conducted with resident 29. Resident 29 stated that she was offered a two-wheeled walker by the facility, but she was physically unable to use it. Resident 29 stated that wanted to be assessed for a new four-wheeled walker. On 3/2/23 at 11:14 AM an interview with the Director of Nursing (DON) was conducted. The DON stated that residents who required a walker were generally evaluated by physical therapy. The DON stated that resident 29 had a four-wheeled walker in her room that had wobbly wheels and resident 29 refused to use the two-wheeled walker at the facility because it hurt her shoulder. The DON stated that the facility would not be able to purchase a new walker for resident 29. On 3/2/23 at 11:54 AM an interview with the Administrator (ADM) was conducted. The ADM stated that he was unaware of resident 29 requiring a new walker. The ADM stated that the facility would be able to purchase her a walker that suited her needs. 2. Resident 31 was initially admitted to the facility on [DATE] and again on 1/30/23 with diagnoses which included pneumonia, acute respiratory failure, sepsis, severe protein-calorie malnutrition, dementia, muscle weakness, unsteadiness on feet, chronic obstructive pulmonary disease, cognitive communication, hypothyroidism, insomnia, chronic pain, major depressive disorder, nicotine dependence, and personal history of suicidal behavior. Resident 31's electric medical record was reviewed. A progress note from 1/20/23 at 3:34 PM stated, . The resident walked out to smoke and was caught by a CNA starting the smoke while on oxygen. She quickly removed the O2 tank from her and brought it to the nurse's station. The O2 tank is now only used under the supervision of the nurse and while the resident is in her room. Other CNA's notified about the use of O2 for [resident 31] and under no circumstances should she be smoking unattended. Resident was educated by DON on how she is cared for in the facility . Resident 31's care plan was reviewed. Resident 31 had a care plan with a focus initiated 2/7/23 which stated, [Resident 31] uses tobacco/cigarettes. The goal initiated 2/7/23 stated, [Resident 31] will not smoke without supervision through the next review date. [Resident 31] will not suffer injury from unsafe smoking practices through the review date. The interventions initiated on 2/7/23 stated, Instruct resident about smoking risks and hazards and about smoking cessation aids that are available. Instruct resident about the facility policy on smoking/vaping locations, times, and safety concerns. Monitor oral hygiene. Notify charge nurse immediately if it is suspected resident has violated smoking policy. Observe clothing and skin for signs of cigarette burns. Resident 31's most recent Smoking Safety Evaluation from 2/21/23 was reviewed. The Smoking Safety Evaluation revealed that, Resident demonstrates impaired orientation in one or more of the following areas: Person, Place, time. Resident has a diagnosis of Neuropathy or other neurological impairment. Resident demonstrates one or more of the following cognitive impairments: Poor safety awareness, impaired short-term memory, impulsiveness. Resident demonstrates non-compliance with smoking policy . The Smoking Safety Evaluation stated, Resident is unable to smoke independently. Resident requires supervision with smoking . On 3/1/23 at 1:09 AM, an observation was made of resident 31 walking outside by herself. The surveyor followed the resident to the smoking gazebo. Resident 31 sat down and pulled a cigarette and a lighter from her coat pocket. Resident 31 then lit her cigarette and started to smoke. No other residents were observed in the gazebo as it was not the regularly scheduled smoking time. The Corporate Nurse followed this surveyor outside and watched as resident 31 lit her cigarette. Resident 31 finished her cigarette, stood up, and pulled another cigarette and lighter out of her pocket and lit the cigarette. The Corporate Nurse went to tell the DON of the situation. The DON came over and attempted to confiscate the cigarette supplies from resident 31. Resident 31 refused to give the cigarettes and lighter to the DON. The Corporate Nurse went inside, and the Human Resources staff member (HR) came outside to stand by resident 31. The DON went inside. Resident 31's guardian was at the facility to visit resident 31 and the guardian came outside to ask resident 31 to give her cigarettes and lighter to the facility staff. Resident 31 again refused to give anyone her cigarettes and lighter. HR left and went inside to get the smoking policy. The resident was observed to be left outside with the guardian and no facility staff. The DON returned and asked resident 31 to go inside because it was not a designated smoking time. Resident 31 refused to go inside. HR returned with the smoking policy and the guardian signed it. Resident 31 was asked if she wanted a snack and resident 31 agreed to go inside for a snack. On 3/2/23 at 11:14 AM, an interview with the DON was conducted. The DON stated that resident 31 was not supposed to have her own cigarettes and lighter. The DON stated that resident 31 continues to refuse to give her smoking supplies to the staff. On 3/2/23 at 11:54 AM, an interview with the ADM was conducted. The ADM stated that he was unaware of resident 31 attempting to smoke with her O2 on outside on 1/20/23. The ADMIN stated that the facility was in the process of creating a safer environment for smokers, including adding a bell on the door to alert staff of residents going outside, collecting all smoking equipment from residents, and creating accommodations for residents who wish to smoke outside the designated smoking times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was revealed that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. Specifically, two residents were receiving blood pressure medications outside of the ordered parameters and a resident had a medication held without orders to hold the medication. Resident identifiers: 19 and 30. Findings include: 1. Resident 30 was initially admitted to the facility on [DATE] and again on 12/16/22 with diagnoses of pneumonia, respiratory syncytial virus, protein calorie malnutrition, metabolic encephalopathy, atrial fibrillation, major depressive disorder, essential hypertension, pain, unspecified dementia, bariatric surgery status, cystitis. On 2/27/22 resident 30's medical records were reviewed. Resident 30 had an order for Furosemide that stated, Give 20 mg [milligrams] by mouth one time a day related to essential (primary) hypertension Hold for BP [Blood pressure] less than 120. The start date for the order was 1/3/23. A review of the Medical Administration Record (MAR) from January 2023 and February 2023 revealed multiple days where the Furosemide medication was given out of the ordered parameters. a. On 1/7/23 resident 30's blood pressure was 119/67 and Furosemide was marked as given b. On 1/23/23 resident 30's blood pressure was 110/69 and Furosemide was marked as given c. On 1/30/23 resident 30's blood pressure was 115/64 and Furosemide was marked as given d. On 2/2/23 resident 30's blood pressure was 118/60 and Furosemide was marked as given e. On 2/5/23 resident 30's blood pressure was 116/74 and Furosemide was marked as given f. On 2/12/23 resident 30's blood pressure was 111/63 and Furosemide was marked as given g. On 2/16/23 resident 30's blood pressure was 116/80 and Furosemide was marked as given h. On 2/26/23 resident 30's blood pressure was 116/55 and Furosemide was marked as given On 2/28/23 resident 30's progress notes were reviewed. A Nurses Note from 2/28/23 at 7:44 PM stated, Error found in BP parameter for Lasix. BP parameter listed in error. Standing BP parameters is 110 SBP [systolic blood pressure]. Resident 30 had an order for Potassium Chloride ER (Extended Release) Tablet 20 MEQ (milliequivalent) that stated, Give 20 mEq by mouth two times a day for Lasix use. The start date for the order was 1/28/22. A review of the February 2023 MAR revealed multiple days where the order was marked as held due to Vitals outside of parameters for administration. A review of resident 30's orders revealed that there were no orders to hold the Potassium Chloride. The following dates reveal Potassium Chloride being held with no order to hold the medication. a. On 2/4/23 resident 30's Potassium Chloride was held in the morning b. On 2/7/23 resident 30's Potassium Chloride was held in the morning c. On 2/10/23 resident 30's Potassium Chloride was held in the morning d. On 2/17/23 resident 30's Potassium Chloride was held in the morning e. On 2/19/23 resident 30's Potassium Chloride was held in the morning On 3/1/23 at 9:26 AM, an interview with Licensed Practical Nurse (LPN) 1 was conducted. LPN 1 stated that resident 30's Furosemide was held if resident 30's blood pressure was less than 110. LPN 1 stated, We usually let the doctor know when we hold the Furosemide, and the doctor will usually tell us if we should hold the Potassium Chloride. LPN 1 stated that she did not know if there was an order to hold the Potassium Chloride. On 3/2/23 at 11:14 AM an interview with the Director of Nursing (DON) was conducted. The DON stated that the order for resident 30's Furosemide had incorrect parameters, and the order should have always been to hold the Furosemide if the BP is less than 110, not 120. The DON stated that she did not know if there was an order to hold the Potassium Chloride for resident 30. The DON stated that there should have been a written order for when the Potassium Chloride should have been held. 2. Resident 19 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included major depressive disorder, dementia, traumatic brain injury, type II diabetes, suicidal ideation, hypertension and pain. On 2/28/23 the medical record for resident 19 was reviewed. A physicians order dated 2/9/23 documented an order for Losartan Potassium oral tablet give 100 mg one time a day. HOLD for SBP less than 110. A physicians order dated 2/16/23 documented at order for at med pass please note new B/P parameter for [resident 19) Hold if SPB is less than 130. Two times a day for monitoring. A review of the February 2023 MAR documented the following entries when resident 19 received the Losartan with a BP less than 130. a. On 2/22/23, resident 19's B/P was 129/87 and Losartan 100 mg was administered. b. On 2/26/23, resident 19's B/P was 120/74 and Losartan 100 mg was administered. On 3/1/23 at 8:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated the nurse should follow the orders given by the doctor. If there are parameters for a medication there was usually a reason and they should be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents medical records included documentation that indicated that the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. Specifically, two residents did not have documentation in their electronic medical record indicating if they had or had not received the pneumococcal vaccine. Resident identifiers: 2 and 29 Findings include: 1. Resident 29 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, asthma, neuropathy, hypertension, protein-calorie malnutrition, anxiety, schizophrenia, bipolar disorder, muscle weakness, insomnia, chronic pain syndrome, nicotine dependence, and toxic encephalopathy. A review of resident 29's medical record was conducted. Resident 29's vaccination records did not show documentation regarding the pneumococcal vaccine. 2. Resident 2 was admitted to the facility on [DATE] with diagnoses which include cerebrovascular disease, history of traumatic brain injury, chronic obstructive pulmonary disease, type 2 diabetes mellitus, dysphagia, liver disease, muscle weakness, and alcohol dependence. A review of resident 2's medical record was conducted. Resident 2's vaccination records did not show documentation regarding the pneumococcal vaccine. On 3/1/23 an interview with the Administration (ADM) was conducted. The ADM stated he would send over any documentation regarding resident 2 and resident 29's pneumococcal vaccination status. Documentation sent by the facility did not contain information regarding resident 2 and resident 29's pneumococcal vaccination status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents medical records included documentation that indicated that the resident either received the COVID-19 immunization or did not receive the COVID-19 immunization due to medical contraindication or refusal. Specifically, one resident did not have documentation in their electronic medical record indicating if the facility offered a resident the COVID-19 vaccination. Resident identifier: 31 Findings Include: 1. Resident 31 was initially admitted to the facility on [DATE] and again on 1/30/23 with diagnoses which included pneumonia, acute respiratory failure, sepsis, severe protein-calorie malnutrition, dementia, muscle weakness, unsteadiness on feet, chronic obstructive pulmonary disease, cognitive communication, hypothyroidism, insomnia, chronic pain, major depressive disorder, nicotine dependence, and personal history of suicidal behavior. Resident 31's electric medical record was reviewed. Resident 31's immunization history, not dated, stated that resident 31 Has not completed a COVID-19 vaccine series. Resident 31's medical record was reviewed and documentation showing that resident 31 was offered a COVID-19 vaccination was not found. On 3/1/23 an interview with the Administrator (ADM) was conducted. The ADM stated he would send over any documentation regarding resident 31's COVID-19 vaccination status. Documentation sent by the facility did not contain information that showed resident 31 was offered the COVID-19 vaccination.

Based on observation and interview, it was determined the facility failed to provide a clean and comfortable homelike environment. Specifically, a continuous high pitched alarm in the dining area, dirt and debris was observed on the resident room doors and bed rails, area of flooring and seating pads of chairs in the dining room were in disrepair, trash and debris blocked the air duct in the facility day room, a set of broken closet doors, and paint peeling from the walls in resident rooms. Residents identifiers: 4, 5, 16, 17, 20, 25, 29, and 30. Findings include: ALARM On 2/27/23 at 10:20 AM, an observation was made of a high pitched alarm going off in the dining room. An immediate interview was conducted with the Administrator (ADM), Chief Operating Officer (COO) and the Activities Coordinator (AC). The ADM stated he was unsure what the sound was but would find out. The AC stated the alarm was from the call lights down the hallway, but it only made noise and did not light up. The ADM, COO and AC were then observed to walk down the hallway and the alarm stopped. The alarm was observed to have alarmed for 24 minutes. Residents were in the dining and day rooms. On 2/28/23 the alarm was observed to alarm for 30 minutes, residents were observed in the dining and day rooms. On 3/1/23 7:03 AM an observation was made of a high pitched alarm going off in the dining room. The alarm was on until 8:01 AM. The alarm was observed to be on again on 3/1/23 at 12:00 PM while resident were gathering in the dining room for lunch. The alarm last 6 minutes. On 3/01/23 at 9:17 AM, an observation was made of a high pitched alarm going off in the dining room for 20 minutes. On 3/01/23 at 12:02 PM, an observation was made of a high pitched alarm in dining area that alarmed for three minutes. On 3/2/23 at 11:10 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated the alarm will alarm in the dining room and it won't turn off until we turn it off. CNA 1 stated the alarm goes off for a long time some times. HOUSEKEEPING An observation was made on 2/27/23 at 10:14 AM of resident 17 's room. The floor was observed to have crumbs and debris on it. The resident's side table had dirt and debris on it. The wall next to resident 17's bed appeared to have dried drips of an unknown liquid. On 2/27/23 at 10:28 AM, an observation was made of the wall by resident 4's bed. Dirt, dried debris and an unknown substance was observed to be on the wall. An observation was made on 2/27/23 at 11:07 AM of resident 20's room. Resident 20's metal bed frame appeared to be visibly dirty with an unknown liquid splattered on it. On 2/28/23 at 12:33 PM, an observation was made of the floor airway duct located on the north wall in the dayroom. Trash to include a plastic spoon, a straw and several candy wrappers were observed to be inside the air duct. An observation was made on 2/28/23 at 1:01 PM of resident 30's room. The inside of the bathroom door in resident 30's was observed to have multiple areas of a dried brown splatter on the lower half of the door. On 3/01/23 at 7:10 AM, an observation was made of resident 16's door. The panel of the door on the inside of the room was observed to have spots of dried food, debris and greasy brown discoloration around the door handle. On 3/1/23 at 12:19 PM, an interview was conducted through the assistance of a telephone translator, with Housekeeping (HSK). HSK stated it is difficult to get to all the rooms when he was the only housekeeper. The HSK stated the residents are messy and sometimes you have to clean up the same mess over and over again. The HSK stated he cleans the walls once a week and vacuums the floors once a week. The HSK stated he thinks they have hired another housekeeper so that should help. The HSK stated he did not clean the beds. The HSK stated he was told by management to make sure the bathrooms are clean, that is the priority. PAINT On 2/27/23 at 10:14 AM, an observation was made of multiple areas of chipped paint on the wall next to resident 17's bed. On 2/27/23 at 10:15 AM, an observation was made of large areas of paint missing from the wall by resident 25's bed. On 2/27/23 at 10:28 AM, an observation was made of large areas of pain missing from the wall by resident 4's bed. An observation was made on 2/27/23 at 10:39 AM of resident 29's room. The wall in resident 29's room was observed to have multiple large areas of chipped paint. On 3/01/23 at 7:15 AM, an observation was made of the closet in resident 5's room. The closet door for was observed to be off the tracks and falling into the closet. On 3/2/23 at 11:00 AM, an interview was conducted with Nursing Assistant (NA) 1. NA 1 stated the staff will fix the problem if something is broken and if we can't fix it then we tell the nurses or we call the maintenance man to come fix it. DINING ROOM An observation was made on 2/28/23 at 12:42 PM in the dining room. The floor had multiple areas of chipped flooring. Five dining room chairs were observed to have cracked and damaged seats. On 3/2/23 at 11:05 AM an attempt to call the two facility maintenance men was made. No answer on either line.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 26 sampled residents, that the facility did not ensure that the appropriate information was communicated to the receiving health care institution when the resident was transferred, and included the basis for the transfer, contact information of the practitioner and resident representative, advanced directive information, instructions or precautions for ongoing care, comprehensive care plan, and any necessary information to ensure a safe and effective transition of care. Specifically, the resident was transferred to the local emergency department (ED) without any transfer documentation to the receiving health care facility. Resident identifier 31. Findings included: Resident 31 was admitted to the facility on [DATE] with diagnoses which consisted of major depressive disorder, dementia, anemia, hypothyroidism, hypertension, hyperlipidemia, anxiety disorder, gastro-esophageal reflux disease, urinary tract infection (UTI), pain and delusional disorder. On 8/15/21 at 10:40 AM, an interview was conducted with resident 31. Resident 31 stated that she was recently hospitalized for a UTI about a month ago and was treated with an antibiotic. On 8/16/21 resident 31's medical records were reviewed. On 7/28/2021 at 1:18 PM, resident 31's progress notes documented that the resident was sent to the ED for evaluation and treatment of altered mental status, agitation, and confusion that was increased from baseline. No other documentation could be found for the transfer paperwork or assessment that was sent to the ED with resident 31. On 8/18/21 at 9:05 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 31 occasionally required assistance with toileting, depending on the level of confusion that day. LPN 1 stated that if resident 31 started having more confusion it was usually the start of a UTI. LPN 1 stated that for any resident transfer to the hospital they printed out a face sheet with the resident diagnoses, contact information, and a list of the resident's medications. LPN 1 stated it was standard practice to send these documents with the resident to the hospital. LPN 1 stated that this was not documented anywhere in the resident's medical record. On 8/18/21 at 10:25 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff were supposed to complete a transfer form with any transfer to the hospital and that it was automatically triggered in the electronic medical records. The DON reviewed resident 31's medical records and confirmed that the resident did not have a transfer form for the ED visit on 7/28/21. The DON stated that the transfer form contained the resident's current demographics, ongoing problems, any current treatments, medications, current situations, vital signs, pain medications given at the time of the event, and any current wounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 out of 26 sampled residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframe's to meet the residents medical, nursing and mental and psychosocial needs. Specifically, a resident who had a history of chronic urinary tract infections (UTI) did not have a current care plan for UTIs. Resident identifier 31. Findings included: Resident 31 was admitted to the facility on [DATE] with diagnoses which consisted of major depressive disorder, dementia, anemia, hypothyroidism, hypertension, hyperlipidemia, anxiety disorder, gastro-esophageal reflux disease, urinary tract infection (UTI), pain and delusional disorder. On 8/15/21 at 10:40 AM, an interview was conducted with resident 31. Resident 31 stated that she was recently hospitalized for a UTI about a month ago and was treated with an antibiotic. On 8/16/21 resident 31's medical records were reviewed. On 7/28/2021 at 1:18 PM, resident 31's progress notes documented that the resident was sent to the emergency department (ED) for evaluation and treatment of altered mental status (AMS), agitation, and confusion that was increased from baseline. On 7/28/21 at 6:07 PM resident 31's progress note documented that the resident returned to the facility from the ED with a diagnosis of a UTI. A new order was received from the ED to start the resident on an antibiotic. Review of resident 31's hospital history and physical on 7/28/21 documented the reason for the visit as AMS. A urinalysis was completed and the clinical impression documented a UTI (cystitis), and cephalexin (Keflex) treatment was ordered. On 11/24/2020 the admission Minimum Data Set (MDS) Care Area Assessment (CAA) triggered a care plan for Urinary Incontinence and Indwelling Catheter. The analysis of the findings indicated delirium with contributing factors of urgency and the need for assistance in toileting. The assessment further documented that the resident was unable to care for herself due to the progression of the disease, generalized weakness and other co-morbidities. Resident 31's care plan revealed a RESOLVED focus area for a UTI on admission. The care plan was initiated on 11/13/2020 and resolved on 2/28/21. The interventions identified were encourage adequate fluid intake, give antibiotic therapy as ordered, monitor for side effects and effectiveness, monitor vital signs, notify Medical Doctor (MD) of abnormalities, monitor/document/report any signs and symptoms of a UTI, obtain and monitor lab/diagnostic work as ordered, and assist the resident with hand hygiene after toileting and before meals. Review of resident 31's care plan revealed a focus area for episodes of incontinence of bowel and bladder and required assistance with toileting cares. The care plan was initiated on 2/28/21. Interventions identified were assist with peri-cares during times of incontinence, clean peri-area with each incontinence episode, encourage and offer assistance to the toilet, ensure an unobstructed path to the toilet, monitor for signs and symptoms of a UTI, and monitor/document/report as needed any possible causes of incontinence. No documentation could be found for a care plan that addressed the UTI on 7/28/21 or a current care plan that addressed resident 31's frequent UTIs. On 8/18/21 at 9:05 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 31 occasionally required assistance with toileting, depending on the resident's level of confusion that day. LPN 1 stated that if resident 31 started having more confusion it was usually the start of a UTI. LPN 1 stated that resident 31 had chronic UTIs. On 8/18/21 at 10:25 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the MDS Coordinator and herself were responsible for updating the resident's care plans. The DON reviewed resident 31's medical records and confirmed that the resident did not have a current care plan for UTIs with interventions in place. The DON stated that resident 31 had chronic UTIs and should have a care plan. The DON stated that they would update the care plan and include the UTI with antibiotic treatment on 7/28/21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 3 out of 26 residents, that the facility did not ensure that each resident was offered an Influenza and Pneumococcal immunization and that the medical record included documentation that the resident either received the immunization or did not due to medical contraindications or refusal. Specifically, residents did not have Influenza and Pneumococcal immunization documentation in the medical records. Resident identifiers: 18, 22, and 27. Findings included: 1. Resident 18 was admitted to the facility on [DATE] with diagnoses which included bipolar disorder, anxiety disorder, opioid dependence, insomnia, pain, hypertension, restless leg syndrome, and obsessive-compulsive disorder. On 8/18/21 resident 18's medical records were reviewed. No documentation could be found that resident 18 had received, been offered, or refused the Pneumococcal immunization. Additionally, no documentation was found to indicate that the Pneumococcal vaccine was contraindicated. 2. Resident 22 was admitted to the facility on [DATE] with diagnoses which included schizophrenia, dementia, and unspecified injury of the left lower leg. On 8/18/21 resident 22's medical records were reviewed. No documentation could be found that resident 22 had received, been offered, or refused the Influenza or Pneumococcal immunization. Additionally, no documentation was found to indicate that the Influenza or Pneumococcal vaccines were contraindicated. 3. Resident 27 was admitted to the facility on [DATE] with diagnoses which included type 1 diabetes mellitus, schizoaffective disorder, osteomyelitis, asthma, post-traumatic stress disorder, anxiety disorder, gastro-esophageal reflux disease, acquired absence of left leg below the knee, and pain. On 8/18/21 resident 27's medical records were reviewed. No documentation could be found that resident 27 had received, been offered, or refused the Influenza or Pneumococcal immunization. Additionally, no documentation was found to indicate that the Influenza or Pneumococcal vaccines were contraindicated. Review of the facility Policy on Adult Vaccination Requirements/-Recommendations stated that the facility would ensure recommended immunizations were offered or available to all facility residents and employees and that accurate documentation of such immunizations would be maintained. The policy was last revised on 2/2016. On 8/18/21 at 12:12 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she kept copies of all the residents vaccination records in a binder in her office. The DON confirmed that she did not have documentation of resident 18's Pneumococcal vaccination or resident 22 and resident 27's Pneumococcal and Influenza vaccination. The Corporate Resource Nurse (CRN) stated that resident 22 had refused the flu and pneumonia vaccine in February 2020 at a sister facility. The CRN stated that the information was not transferred to the current facility for them to have in their medical records. The DON stated that the vaccination information should have been obtained upon admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined, for 9 of 26 sampled residents that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including SARS-CoV-2. Specifically, observations were made of residents not provided with hand hygiene prior to dining, a resident handled a trash bin in order to stabilize himself and was not offered hand hygiene prior to dining, staff were observed passing meal trays to residents in residents' rooms without performing proper hand hygiene between each meal tray pass, staff were observed physically assisting and touching residents without performing hand hygiene between residents, staff were observed with face masks below their nose, staff were observed speaking in close proximity to residents with the staff's mask pulled down below the mouth, staff were observed administering medications without performing hand hygiene in between the administration of medications to different residents, a staff member entered the building without a mask, performed the screening process, then walked down the hall to retrieve a mask, and a resident was observed to utilize another residents bathroom on multiple occasions without the restroom being disinfected afterwards. Resident identifiers: 3, 4, 7, 13 , 15, 16, 21, 24, and 27. Findings included: 1. On 8/15/21 at 8:36 AM, an observation was made upon entrance to the facility of Registered Nurse (RN) 1. RN 1 was seated at the nurse's station and was observed with their surgical mask pulled down below the chin, and the RN's eye protection was placed on top of the head. On 8/15/21 at 8:48 AM, a second observation was made of RN 1 with their surgical mask down below the chin. The RN was near the nurse's station in the resident care area. On 8/15/21 at 9:51 AM, an entrance conference was conducted with the facility Administrator. The Administrator stated that the county positivity rate had been above 5% for about 3 weeks and was currently 9.8%. On 8/15/21 at 10:49 AM, an observation was made of RN 1 at the nurse's station. RN 1 was behind the desk at the nurse's station. RN 1 was observed to pull down her surgical face mask to speak to resident 24. At the time of the observation resident 13 was standing at the nurse's station and was directly in front of RN 1. 2. On 8/15/21 the following observations were made during the lunch meal service: a. At approximately 12:10 PM, resident 4 was observed to walk to the dining room with stand by assistance from the facility Administrator. The resident was observed to stabilize himself by placing his left hand on the lid of the garbage can. Resident 4 was not provided any hand hygiene prior to meal service by the facility staff. b. At 12:18 PM, an observation was made of Certified Nurse Assistant (CNA) 1 serving drinks to the residents seated in the main dining room. CNA 1 did not perform hand hygiene prior to the drink service. c. At 12:25 PM, an observation was made of CNA 1 providing dining assistance to resident 16. At 12:51 PM, CNA 1 stepped away from resident 16 to assist resident 7. CNA 1 was observed to rub resident 7's back and touch the back of resident 7's wheelchair. CNA 1 then returned to resident 16 and proceeded to provide dining assistance again. CNA 1 did not perform any hand hygiene between the residents. d. At 12:20 PM, an observation was made of CNA 3 and CNA 7 delivering meal trays to resident rooms. CNA 3 and CNA 7 did not perform hand hygiene in between taking lunch trays into rooms 111-114. CNA 7 turned the light on in room [ROOM NUMBER] upon exiting the room and hand hygiene was not performed before delivering trays to the remaining residents in room [ROOM NUMBER]. On 8/17/21 at approximately 8:10 AM, an interview was conducted with the Director of Nursing (DON). The DON was observed assisting resident 4 to and from the bathroom. The DON stated that hand hygiene should be provided to residents prior to meal service by the staff, and that alcohol-based hand rub (ABHR) was available. The DON stated that staff should be performing hand hygiene before meal service and between resident contact during meal service. On 8/18/21 at 11:50 AM, an interview was conducted with CNA 5. CNA 5 stated that with every meal service they provide hand hygiene to the residents. They offered hand sanitizer, and if the resident refused it was their right. CNA 5 stated, for example resident 7 would get upset if they gave him ABHR so they did not attempt to do that with him anymore. 3. Resident 4 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure, hypertension, diverticulosis of large intestine, type 2 diabetes mellitus, pain, dementia, amnesia, cataract, presence of cardiac pacemaker, benign prostatic hyperplasia, and hyperlipidemia. On 8/16/21 at 10:20 AM, an observation was made of resident 4 entering room [ROOM NUMBER]. It should be noted that resident 4 did not reside in room [ROOM NUMBER]. room [ROOM NUMBER] was located directly across from the common TV area. Resident 4 was observed, from the hallway, to use the restroom inside room [ROOM NUMBER]. No staff were present to assist resident 4, nor disinfect or clean the bathroom afterwards. On 8/17/21 at 8:05 AM, an observation was made of the DON assisting resident 4 from the main dining room to room [ROOM NUMBER] to utilize the restroom. At the time of the observation the facility was experiencing a power outage. The DON was observed to stay and assist resident 4 with toileting. An immediate interview was conducted with the DON upon exit of room [ROOM NUMBER]. The DON stated that resident 4 was using the bathroom and they were going to disinfect it afterwards. The DON stated that resident 4 used this bathroom when he could not make it to his own room. The DON stated that they disinfected the bathroom after use by resident 4. On 8/17/21 at 12:39 PM, an observation was made of resident 4 entering room [ROOM NUMBER] to utilize the restroom. Resident 4 could be observed from the hallway. Resident 4 was observed to exit room [ROOM NUMBER], close the door behind him and ambulate to a chair in the common area TV room. No staff were present to assist resident 4, nor disinfect or clean the bathroom afterwards. 4. On 8/17/21 at 7:35 AM, observations were made during medication administration with Licensed Practical Nurse (LPN) 1. LPN 1 was observed to draw up resident 15's insulin, and administer the insulin to resident 15. Upon completion of the insulin administration hand hygiene was not performed by LPN 1. At 7:38 AM, LPN 1 proceeded to draw up resident 3's insulin, and administer the insulin to resident 3. Upon completion of the insulin administration hand hygiene was not performed by LPN 1. At 7:43 AM, LPN 1 proceeded to draw up resident 27's insulin, and the syringe was handed to the resident to self administer. LPN 1 retrieved the insulin syringe from resident 27 to discard. LPN 1 was then observed to performed hand hygiene. An immediate interview was conducted with LPN 1. LPN 1 stated that hand hygiene was usually done every time he returned to the medication cart and should be completed after every medication administration. LPN 1 stated that he did not perform hand hygiene after each medication administration. 5. On 8/16/21 at 8:45 AM, the Corporate Resource Nurse (CRN) was observed. The CRN entered the building not wearing a face mask. The CRN performed the health screening process at the entrance of the building, spoke in close proximity to staff, approximately 6-10 inches from the other staff member's faces, then proceeded to an office within the building where she located a mask. 6. On 8/16/21 at 12:03 PM, CNA 4 was observed with her mask down below her mouth. CNA 4 spoke in close proximity to resident 4, and was approximately 6-10 inches away from resident 4. 7. On 8/18/21 at 2:03 PM, CNA 6 was observed with her mask down below her mouth. CNA 6 spoke in close proximity to resident 21, and was approximately 6-10 inches from resident 21's face. Review of the Centers for Disease Control and Prevention (CDC) guidance on Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes stated under Implement Source Control Measures that health care providers (HCP) working in areas with moderate to substantial community transmission were more likely to encounter asymptomatic or pre-symptomatic residents with SARS-CoV-2 infection. Additionally, HCP should wear a N95 respirator or a well fitting facemask with a nose wire to help the facemask conform to the face and eye protection while in the facility. The guidance was last updated on March 29, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html Review of the CDC guidance on Hand Hygiene in Healthcare Settings stated that HCP should use ABHR or wash with soap and water for the following clinical indications: a. Immediately before touching a patient b. Before performing an aseptic task c. Before moving from work on a soiled body site to a clean body site on the same patient d. After touching a patient or the patient's immediate environment e. After contact with blood, body fluids, or contaminated surfaces f. Immediately after glove removal The guidance was last reviewed on January 30, 2020. https://www.cdc.gov/handhygiene/providers/guideline.html On 8/18/21 at approximately 9:48 AM, an interview was conducted with the facility Administrator. The Administrator stated that the facility staff obtained their PPE at the front entrance just inside the doorway when they screened in for their shift. The Administrator stated that extra surgical masks were located there. It should be noted that the employee screening area was directly outside of a resident room and residents were observed to congregate at the front entrance. On 8/18/21 at approximately 12:12 PM, an interview was conducted with the DON and CRN. The DON was informed of the observations pertaining to infection control. No additional information was provided by the DON or CRN.

Based on observation and interview it was determined that for all facility residents, the facility did not provide emergency electrical power and a functioning fire suppression system during a power outage with an emergency generator that was located on the premises. Findings included: On 8/17/21 at 7:45 AM, an observation was made of a power outage in the facility. The exit doors were illuminated by two lights on each exit sign that was above the exit doors. No other lighting was on in the facility. Temperature in the dining room was set for 75 degrees and the temperature read 78 degrees at the time of the power outage. Four residents occupied the dining room with multiple staff members nearby. On 8/17/21 at 7:50, an interview was conducted with the administrator (AD). The AD stated she had called the power company to make them aware of the power outage. On 8/17/21 at 7:59 AM, an observation was made of the dietary manager (DM) and dietary staff (DS). The DM & DS each used a flashlight to illuminate the kitchen and the resident hallways as they walked in the facility. The DM & DS had propped open the back door of the kitchen for more light. On 8/17/21 at 8:01 AM, an interview was conducted with the AD. The AD stated the facility maintenance (FM) would arrive in 10 minutes to hook up the generator. On 8/16/21 at 8:07 AM, an observation was made of the arrival of the FM. The FM went through the kitchen to the backyard of the facility. A plastic storage container was in the corner of the fenced yard. The container was closed with a keyed lock in place. The FM stated no one had the key to the plastic container that was holding the generator. The FM was unsuccessful when he attempted to open the lock with bolt cutters. The DM arrived at the storage container and pulled the door completely off the hinge to open the container. Generac OHV 420cc GP 8000e Power Rush with Cosense technology generator was in the storage container. The generator was attached to the fence behind the container with a cable and another keyed lock. The FM and DM both stated no one in the facility had the key to the lock. The FM and DM attempted to start the generator with no success. On 8/17/21 at 8:10 AM, an interview was conducted with the AD. The AD stated the facility had gotten the generator during the last earthquake. The AD stated the generator had the capacity to run the lights, kitchen appliances, and the air conditioner in the hallway that encompassed the nurses station, kitchen, dining and communal television room but no resident rooms. The AD stated residents would be moved to that section from other areas in the facility, if needed. On 8/17/21 at approximately 8:15 AM, an observation was made of the FM & DM. The FM & DM attempted 7-10 times to start the generator. The AD stated she had called corporate maintenance (CM) to come assist with the generator. Via telephone CM gave DM instructions on how to start the generator with no success. The DM stated he was the only employee in the facility trained by the CM on how to use the generator. On 8/17/21 at approximately 8:17 AM, both the FM and DM stated the generator was out of gasoline. An observation was made of an empty 5 gallon metal gasoline can in the storage container. The cap to the generator gasoline tank was taken off and no gasoline was in the tank. On 8/17/21 at approximately 8:20 AM, the power to the facility returned. The FM stated he was going to the fuel station to get some gasoline. On 8/17/21 at approximately 8:40 AM, an observation was made of the FM. The FM had returned to the facility with a can full of gasoline. The FM poured 2.5 gallons of the gasoline into the generator's gasoline tank. On 8/17/21 at approximately 8:41 AM, an interview was conducted with the FM. The FM stated the generator was completely empty of gasoline. The FM stated corporate does not allow the facility to keep gasoline in the generator's gasoline tank because it can ruin the generator. On 8/17/21 at approximately 8:42 AM, an observation was made of a plastic box sitting next to the generator that held electrical cords. On 8/17/21 at 8:42 AM, an interview was conducted with the DM. The DM stated the generator electrical cords would reach from the generator to the facility even if the generator was not unlocked from the cabinet. The DM was unable to state the length of the electrical cords. The DM stated he was going to get a key from corporate for the generator. The DM stated no one at the facility had a key to the storage container or to the cable that held the generator in place. The DM stated the generator was completely out of gas and would not run without gasoline. On 8/17/21 at approximately 8:43 AM, an interview was conducted with the FM . The FM stated the CM would not let anyone have a key to the generator because in the past the generators had been stolen. On 8/17/21 at 8:44 AM, an observation was made of the DM. The DM attempted to start the generator, generator started with one attempt. On 8/17/21 at approximately 8:50 AM, an observation was made that the generator ran for 2 minutes. The DM stated the generator would only provide power to the refrigerators and freezers in the kitchen, nothing else. The DM stated there were emergency lights in boxes on the ground of the plastic container that were to be used to light the hallways of the facility. On 8/17/21 at 8:51 AM, an observation was made of emergency lights on the floor of the plastic storage container. On 8/17/21 at approximately 8:55 AM, an interview was conducted with the FM. The FM stated the generator would not run the fire safety system, lights or air conditioning for the facility as the generator was too small and did not have enough power. Emergency Preparedness Planning and Resource Manual for facility was reviewed. The manual stated, ensure backup systems (emergency generators, emergency lighting, additional blankets, flashlights, emergency water, emergency food supply, etc.) are available and operating as designed in accordance with requirements. The manual was last revised on October 2012. It should be noted that the emergency generator at the facility was not readily available or operational when power outage occurred.