**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews and record review the facility failed to report an incident of alleged abuse to the state licensing agency for 1 resident (Resident #30) of 21 sampled residents. Findings include: Per resident interview on 6/19/24 at 11:36 AM Resident #30 stated that a staff member on the overnight shift had made a fist at her/him and stated, You can't even walk. I can knock the shit out of you. Resident #30 stated that s/he had reported this incident to a Licensed Nursing Assistant (LNA) that morning. Per record review of the facility's Abuse, Neglect, and Exploitation policy [last reviewed on 1/27/23], Reporting of all alleged violations are brought to the charge nurse and then the nurse on call. The nurse on call notifies the director of nursing and the administrator. The Director of Nursing, administrator, or designate will notify the state agency ([NAME]), Adult Protective Services [APS] . On 6/19/24 at 12:02 an interview was conducted with the DON [Director of Nursing] and the facility Administrator [ADM]. The DON and facility administrator confirmed that Resident #30 had reported the incident to a staff member and the staff did not inform the DON and ADM. The DON confirmed the incident was not reported as required to APS or the state agency.

Based upon interview and record review, the facility failed to revise resident care plans related to fall prevention for 1 resident [Res.#25] of 21 sampled residents. Findings include: Per review of the facility's Falls-Clinical Protocol policy, the staff and physician will identify pertinent interventions to try to prevent subsequent falls. [Nursing Services Policy and Procedure Manual for Long Term Care- revised March 2018] Review of the facility's Nursing Floor Communication Resource reveals under 'Falls' Update the resident's care plan with a new intervention EVERY time a fall occurs with the resident. An interview was conducted with the facility's Director of Nursing [DON] on 6/19/24 at 9:09 AM. The DON stated that the facility's procedure after a resident fall is to update the resident's care plan with new intervention[s] to prevent future falls. The DON confirmed that incident reports and Nursing Notes documented Res.#25 suffering falls on 12/8/23, 12/10/23, 1/8/24, 1/10/24 and 3/24/24. The DON confirmed that Res.#25's care plan contained no new interventions to prevent future falls after falls on 12/8, 1/8, 1/10. The DON confirmed that after the falls in January with no new interventions, the resident fell again on 3/24/24. Nursing Notes dated 3/24/24 record staff reported to this nurse that resident was lying on the floor of [h/her] room . Did begin to complain of pain in [h/her] Left wrist. Tender to touch or move . DON made aware and an x-ray of Left wrist will be ordered tomorrow (Monday 3/25/24). Nursing Notes dated the next day, 3/25/24, reveal Results of Xray returned and show acute, nondisplaced fracture of the left wrist. Per interview and record review, the DON confirmed that new interventions should have been added to Res.#25's care plan after each fall to prevent future falls and injury but were not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to ensure that records are complete, readily accessible, and systematically organized related to a resident's required pharmacy review for 1 out of 5 sampled residents (Resident # 3). Findings include: Per record review, Resident # 3 was admitted to the facility on [DATE]. There was no evidence in the record that pharmacist conducted a monthly medical record review since admission. During an interview with the Director of Nursing (DON) on 06/18/2024 at approximately 3:30 PM s/he stated that the facility recently changed pharmacy providers. The new pharmacist visited the facility and removed the previous pharmacy recommendations from paper charts and brought them home to review. The DON confirmed at the time of interview that the pharmacy recommendations were not on site or in Resident # 3's medical record. The DON stated that the pharmacist was currently on vacation and was unsure if s/he would be able to obtain the reviews. The DON was able to produce a copy of the pharmacy review form prior to the end of the survey however, s/he did confirm that the pharmacy reviews should have been in the medical record.

Based on interview and record review the facility failed to ensure that 1 of 4 sampled licensed nursing assistants (LNAs) and 2 of 2 sampled Licensed Practical Nurses (LPNs) were assessed for competency in the skills required to care for the resident needs based on resident care plans. Findings include: 1. Review of 1 LNA education and competency file revealed an orientation checklist that was signed off by another LNA; however, there was no evidence that the LNA was assessed for competency by a licensed nurse. 2. Review of the education and competency file for 1 LPN who was hired on 5/29/2024 revealed no evidence that they were assessed for competency in the skills needed to care for the residents. 3. Review of the education and competency file for 1 LPN who was hired on 8/23/17 revealed no evidence of annual competency evaluation of the skills needed to care for the residents. Durning interview on 6/19/2024 at 2:04 PM the Director of Nursing and the Human Resource Director confirmed that there was no evidence that the above LNAs and LPNs had been assessed for competency.

Based on observation, interview, and record review the facility failed to ensure that each resident had access to an effective call system at their bedside for 2 of 21 residents sampled (Resident #1 and #7). This deficient practice has the potential to affect all residents who reside in the facility. Findings include: 1. During unit observations and resident interview on 6/17/24 at 3:03 PM, Resident #1 was observed sitting in a recliner in their room trying to get assistance to go to the bathroom. Resident #1 was asked by the Surveyor if they could ring their call bell to alert staff that s/he needed assistance. The Resident stated that s/he had been ringing and ringing and nobody was coming. The Surveyor pushed the call light button, and nothing happened. Resident #1 was pleading for help to get to the bathroom. The Surveyor went to get a Licensed Nursing Assistant (LNA) to assist. The LNA stated that s/he was not aware that Resident #1 was in need of assistance. The LNA also stated that the call lights don't work a lot of the time, and that the residents have been given hand bells to ring for help if the call light doesn't work. Upon looking for the hand bell in Resident #1's room the LNA discovered and confirmed that there was no hand bell available for Resident #1. The LNA said that s/he would get Resident #1 a hand bell and tell maintenance that the call light was not working after they assisted the resident to the bathroom. Per interview with the Administrator and Director of Nursing on 6/17/24 at approximately 5:15 PM they were unaware of Resident #1's light not working. The Administrator stated that they do have this issue on occasion, and they provide hand bells so the Residents can summon staff. 2. During unit observations on 6/18/24 at 10:44 AM while in Resident #7's room the Surveyor pushed the call light button that was attached to the wall. The call light indicator (a box that lights up when the call button is pushed) in the hall did not light up and there was no audible signal that occurs when the call light is activated. Per interview with the Administrator and the Assistant Administrator on 6/19/24 at 9:00 AM there are times when call lights get pulled from the wall a bit and need to be repositioned to work. When a call bell is not working, and staff are unable to fix it they must complete a TELS (Maintenance) request. The Assistant Administrator stated that about 10 call light checks are done weekly to ensure that they are working, and there has been a significant improvement. However, when asked if there was a system in place to check all call lights to ensure that residents could always call for assistance the Assistant Administrator and Administrator both confirmed that there was not. When asked if staff had made them aware that Resident #1's call light was not working on 6/17/24 the Assistant Administrator confirmed that the LNA had not informed anyone to fix it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary environment, specifically in one shared resident bathroom for 2 of 22 resident rooms. Findings include: During unit observations on 4/18/2022 at 11:45 AM and 3:30 PM, in the bathroom located between rooms [ROOM NUMBERS] there was dried splattered feces on the wall next to the toilet. This was observed again the next day, on 4/19/2022 at 2:24 PM. On 4/19/2022 at 2:24 PM the Environmental Manager (EM) was shown the feces on the wall next to the toilet. The EM stated Okay, the housekeeper has not been in here today because the residents were in and out of the bathroom all day. As you can see the trash is full and has not been emptied. When told that the feces had been there the prior day s/he stated I will get [her/him] in here now to clean this.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation on 4/20/22 10:50 AM - 11:03 AM revealed an unlocked medication cart, and upon the medication cart was noted a 24 hour report that included resident names, and room numbers. A computer that was on top of the medication cart was left open at a the Clinical and Current residents screen. It showed a list of resident names and room numbers - this allowed access to all residents medical records. The nurse was observed behind a tall wall in the nurses station that separated the nurses station from the medication carts and prohibited a constant visual of the medication cart. Upon the nurses return to the medication cart at 11:03 AM, s/he immediately locked the medication cart, closed out of the patient care records screen on the computer and, turned over the 24 hour report sheet so the information on that sheet was not upright and available for others to see. Interview with the nurse at 11:04 AM, confirmed that the medication cart should not have been left unlocked, and all resident information should not have left out in the open for anyone passing by or standing at the medication cart to have easy access to. Based on observation, staff interview, and record review the facility failed to ensure that resident personal and medical information was maintained in a secure and confidential manner, so that others would not have access to it for 1 of 19 sampled residents and 1 of 2 medication carts with identifying information for all residents. Findings include: 1. Per observation on 4/20/2022 at 2:11 PM a sign was posted on the outside of the door, toward the hallway of room [ROOM NUMBER] that stated: Infection Prevention and Control Policy for Suspected or Confirmed Coronavirus (COVID 19); Room log: Residents with suspected or confirmed Coronavirus (COVID 19); Residents name: [The resident's name was written in]; Employee or Visitor Name: Date: Time In: Time Out: An employee had signed in on 4/19/22 at 7:20 AM and 9:30 AM. This sign in sheet was located on the door next to a sign that stated STOP: Modified DROPLET PRECAUTIONS. Visitors MUST report to Nursing Station before entering. visitors and staff must: Wear a mask Wear eye protection (goggles or face shield) when entering room On 4/20/22 at 3:09 PM when asked about the signs and documentation, the Director of Nursing (DNS) stated that the sign in sheet should not be on the door as it is not necessary for staff to sign in and out of the room. The DNS confirmed that the resident's name should not be posted on the sign in sheet for others to see, which discloses a potential health condition.

2. Per observation on 4/18/2022 at 11:52 am, Resident #15 was sitting in the common area in a wheelchair without footrests. A licensed nursing assistant (LNA) asked him/her to pick up his/her feet and began to push the resident to the dining room. The resident lifted his/her feet approximately an inch off the ground for a couple seconds and then began to drag his/her feet while being pushed down the hall. Review of Resident #15's medical record lists history of falling, muscle weakness (generalized), and other abnormalities of gait and mobility as diagnoses. Per review of Resident #15's care plan revealed, the resident is able to complete wheelchair mobility for short distances independently, dependent on staff for purposeful movement and requires vocal cues to lift feet when staff are assisting with WC [wheelchair] mobility. Per review of ADL (Activities of Daily Living) documentation for the month of April, of the 68 instances of locomotion documented for Resident #15, 50 were extensive assistance or total dependence. Per observation on 4/19/2022 at 11:36 AM, Resident #15 was seen sitting in his/her wheelchair and was being pushed to the dining room by a staff member. It was noted that his/her feet were dragging on the floor while being pushed down the hall to the dining room. Per interview on 4/20/2022 at 10:34 AM, a licensed practical nurse (LPN) stated that foot pedals are in the Resident's room. The LPN explained that staff know when to use foot pedals by referring to the sheet on the resident's closet door (Physical Mobility Sheet) and the resident's care plan. Reviewed of Resident #15's Physical Mobility Sheet with the LPN, s/he confirmed the I on Resident #15's Physical Mobility sheet indicated that the resident was independent in his/her wheelchair, and it did not explain when to use foot pedals. Upon review of Resident #15's care plan with this LPN, s/he confirmed that the care plan does not direct staff when to use foot pedals. Per interview on 4/20/2022 at 10:55 AM, a LNA stated that each resident has a mobility sheet on the inside of their closet door that's shows when to use wheelchair foot pedals. S/he would put foot pedals on the wheelchair while bringing a resident for a walk outside, if their feet/legs are swelling, or they can't keep their feet up. Some foot pedals would be considered a restraint. The LNA confirmed that the use of foot pedals would also be in the care plan. On 4/20/2022 at 11:40 AM during an interview with the Director of Nursing (DON), he/she confirmed the use of foot pedals should be on the care plan and that Resident #15's care plan did not provide direction as to when staff would need to use the residents foot pedals. S/he stated that Resident #15's care plan needed to be updated to include when to use foot pedals. Based on observations, interviews, and record reviews, the facility failed to ensure the plan of care for 2 of 19 sampled residents in a standard survey sample were revised to reflect necessary care and services. (Residents #9, and #15). Findings include: 1. Observation on 4/18/2022 at 11:50 am, Resident #9 was sitting in the common area in a wheelchair without footrests. A licensed nursing assistant (LNA) asked her/him to pick up her/his feet and began to push the resident to the dining room. The resident did lift her/his feet up while the LNA pushed her/him to the dining room although she/he did put her/his feet down a few times during the transport. Observation on 4/18/22 at 11:52 AM, revealed a pair of wheelchair foot pedals on top of Resident #9's dresser in her/his room. Review of Resident #9's care plan revealed, has limited physical mobility r/t [related to] Parkinson's Disease, dementia and a non-repaired left hip fracture with the following intervention Resident needs assistance with moving [pronoun omitted] scoot w/c [wheelchair] but can also self-propel short distances. Per interview on 4/20/2022 at 10:34 AM, a licensed practical nurse (LPN) stated that foot pedals are in the resident's room. The LPN explained that staff know when to use foot pedals by referring to the sheet on the resident's closet door (Physical Mobility Sheet) and the resident's care plan. Reviewed of Resident #9's Physical Mobility Sheet with the LPN, s/he confirmed the I on Resident's Physical Mobility sheet indicated that the resident was independent in her/his wheelchair. There was no direction indicated on the Physical Mobility Sheet explaining when to use foot pedals. Upon review of Resident #9's care plan with this LPN, s/he confirmed that the care plan does not direct staff when to use foot pedals. Interview on 4/20/2022 at 10:55 AM, a licensed nurse aid (LNA) stated that each resident has a mobility sheet on the inside of their closet door that's shows when to use wheelchair foot pedals. S/he would put foot pedals on the wheelchair while bringing a resident for a walk outside, if their feet/legs are swelling, or they can't keep their feet up. Some foot pedals would be considered a restraint. The LNA confirmed that the use of foot pedals would also be in the care plan. On 4/20/2022 at 11:40 AM during an interview with the Director of Nursing, she/he confirmed the use of foot pedals should be on the care plan and that Resident #9's care plan did not provide direction as to when staff would need to use the residents foot pedals. S/he stated that Resident #9's care plan needed to be updated to include when to use foot pedals. The DON also confirmed that the use of foot pedals should be listed on the Physical Mobility Sheet, which is on the inside of the residents closet door and on each residents care plan. Review of Resident #9's Physical Mobility Sheet revealed no indication for use of his/her foot pedals and there was no mention of foot pedals on the residents care plan.

Based on observation and interview, the facility failed to ensure drugs and biologicals are stored in accordance with accepted professional standards for 1 of 2 medication carts. Findings include: Observation on 4/20/22 10:50 AM - 11:03 AM revealed an unlocked medication cart. The nurse was observed behind a tall wall in the nurses station that separated the nurses station from the medication carts and prohibited a constant visual of the medication cart. Upon the nurses return to the medication cart at 11:03 AM, s/he immediately locked the medication cart.